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Baxter MA, Denholm M, Kingdon SJ, Kathirgamakarthigeyan S, Parikh S, Shakir R, Johnson R, Martin H, Walton M, Yao W, Swan A, Samuelson C, Ren X, Cooper A, Gray HL, Clifton S, Ball J, Gullick G, Anderson M, Dodd L, Hayhurst H, Salama M, Shotton R, Britton F, Christodoulou T, Abdul-Hamid A, Eichholz A, Evans RM, Wallroth P, Gibson F, Poole K, Rowe M, Harris J. CAnceR IN PreGnancy (CARING) - a retrospective study of cancer diagnosed during pregnancy in the United Kingdom. Br J Cancer 2024; 130:1261-1268. [PMID: 38383704 PMCID: PMC11014900 DOI: 10.1038/s41416-024-02605-x] [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: 11/24/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND The incidence of cancer diagnosed during pregnancy is increasing. Data relating to investigation and management, as well as maternal and foetal outcomes is lacking in a United Kingdom (UK) population. METHODS In this retrospective study we report data from 119 patients diagnosed with cancer during pregnancy from 14 cancer centres in the UK across a five-year period (2016-2020). RESULTS Median age at diagnosis was 33 years, with breast, skin and haematological the most common primary sites. The majority of cases were new diagnoses (109 patients, 91.6%). Most patients were treated with radical intent (96 patients, 80.7%), however, gastrointestinal cancers were associated with a high rate of palliative intent treatment (63.6%). Intervention was commenced during pregnancy in 68 (57.1%) patients; 44 (37%) had surgery and 31 (26.1%) received chemotherapy. Live births occurred in 98 (81.7%) of the cases, with 54 (55.1%) of these delivered by caesarean section. Maternal mortality during the study period was 20.2%. CONCLUSIONS This is the first pan-tumour report of diagnosis, management and outcomes of cancer diagnosed during pregnancy in the UK. Our findings demonstrate proof of concept that data collection is feasible and highlight the need for further research in this cohort of patients.
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Affiliation(s)
- M A Baxter
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK.
- Tayside Cancer Centre, Ninewells Hospital and Medical School, NHS Tayside, Dundee, UK.
| | - M Denholm
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Early Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, UK
| | - S J Kingdon
- Exeter Oncology Centre, Royal Devon University Hospitals NHS Trust, Exeter, UK
| | | | - S Parikh
- Department of Oncology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R Shakir
- Oncology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Johnson
- Oncology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - H Martin
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Early Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, UK
- Cancer Research UK Cambridge Institute, Cambridge University, Cambridge, UK
| | - M Walton
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - W Yao
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - A Swan
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - C Samuelson
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - X Ren
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - A Cooper
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - H-L Gray
- Tayside Cancer Centre, Ninewells Hospital and Medical School, NHS Tayside, Dundee, UK
| | - S Clifton
- Bristol Haematology and Oncology Centre, Bristol, UK
| | - J Ball
- Bristol Haematology and Oncology Centre, Bristol, UK
| | - G Gullick
- Oncology Department, Royal United Hospitals NHS Foundation Trust, Bath, UK
| | - M Anderson
- Northern Centre for Cancer Care, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, The Newcastle Upon Tyne, UK
| | - L Dodd
- Northern Centre for Cancer Care, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, The Newcastle Upon Tyne, UK
| | - H Hayhurst
- Northern Centre for Cancer Care, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, The Newcastle Upon Tyne, UK
| | - M Salama
- Department of Oncology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R Shotton
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - F Britton
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - T Christodoulou
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - A Abdul-Hamid
- Department of Oncology, Royal Surrey County Hospital NHS Trust, Surrey, UK
| | - A Eichholz
- Department of Oncology, Buckinghamshire Healthcare NHS Trust, Buckinghamshire, UK
| | - R M Evans
- South West Wales Cancer Centre, Swansea Bay NHS Trust, Swansea, UK
| | | | - F Gibson
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - K Poole
- The Institute of Cancer Research, Clinical Trials and Statistics Unit, Belmont, Sutton, Surrey, UK
| | - M Rowe
- Sunrise Oncology Centre, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - J Harris
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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Tembelis M, Frederick-Dyer KC, Dyer JL, Planz VB, Moshiri M. Medicolegal considerations associated with cancer during pregnancy. Abdom Radiol (NY) 2023; 48:1637-1644. [PMID: 36538081 DOI: 10.1007/s00261-022-03776-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 05/01/2023]
Abstract
The management of pregnant patients with cancer is complex and requires a multidisciplinary team to effectively diagnose, stage, and manage the cancer while also being cognizant of the potential harm that diagnosis and treatment may have on the maternal and fetal well-being. Beyond the complex clinical management of these patients is additional medicolegal consideration. Radiologists play a crucial role in the management of these patients as their knowledge of diagnostic and interventional radiology techniques allows for appropriate and safe imaging for both the mother and fetus. In addition, radiologist are able to educate patient on the different imaging modalities and techniques, thus allowing patients to make informed decisions and maintain autonomy over there care. This article will review safety considerations associated with different imaging modalities, contrast agents, interventional radiology procedures and moderate sedation related to the imaging of pregnant patient with cancer with specific attention paid to the medicolegal aspects.
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Affiliation(s)
- Miltiadis Tembelis
- Department of Radiology, NYU Langone Hospital Long Island, Mineola, NY, 11501, USA.
| | - Katherine C Frederick-Dyer
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | | | - Virginia B Planz
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Mariam Moshiri
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
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Li Y, Huang B, Cao J, Fang T, Liu G, Li X, Wu J. ESTIMATING RADIATION DOSE TO MAJOR ORGANS IN DENTAL X-RAY EXAMINATIONS: A PHANTOM STUDY. RADIATION PROTECTION DOSIMETRY 2020; 192:328-334. [PMID: 33320946 DOI: 10.1093/rpd/ncaa196] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/30/2020] [Accepted: 11/05/2020] [Indexed: 06/12/2023]
Abstract
The radiation doses absorbed by major organs of males and females were studied from three types of dental X-ray devices. The absorbed doses from cone-beam computed tomography (CBCT), panoramic and intraoral X-ray machines were in the range of 0.23-1314.85 μGy, and were observed to be high in organs and tissues located in or adjacent to the irradiated area, there were discrepancies in organ doses between male and female. Thyroid, salivary gland, eye lens and brain were the organs that received higher absorbed doses. The organ absorbed doses were considerably lower than the diagnostic reference level for dental radiography in China. The calculated effective radiation doses for males and females were 56.63, 8.15, 2.56 μSv and 55.18, 8.99, 2.39 μSv, respectively, when using CBCT, the panoramic X-ray machine and intraoral X-ray machine. The effective radiation dose caused by CBCT was much higher than those of panoramic and intraoral X-ray machines.
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Affiliation(s)
- Yong Li
- Department of Nuclear Science and Technology, School of Physics and Optoelectronic Engineering, Shenzhen University, Shenzhen 518060, China
| | - Bingsheng Huang
- Medical AI Lab, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen 518071, China
| | - Jun Cao
- Department of Stomatology, Shenzhen University General Hospital, Shenzhen 518055, China
| | - Tianqi Fang
- Medical AI Lab, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen 518071, China
- Shenzhen University General Hospital Clinical Research Center for Neurological Diseases, Shenzhen 518071, China
| | - Guoqing Liu
- Department of Nuclear Science and Technology, School of Physics and Optoelectronic Engineering, Shenzhen University, Shenzhen 518060, China
| | - Xuguang Li
- Department of Stomatology, Shenzhen University General Hospital, Shenzhen 518055, China
| | - Jiabao Wu
- Department of Nuclear Science and Technology, School of Physics and Optoelectronic Engineering, Shenzhen University, Shenzhen 518060, China
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Tester J, Hammerschlag G, Irving L, Pascoe D, Rees M. Investigation and diagnostic imaging of suspected pulmonary embolism during pregnancy and the puerperium: A review of the literature. J Med Imaging Radiat Oncol 2020; 64:505-515. [PMID: 32307898 DOI: 10.1111/1754-9485.13027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 02/16/2020] [Accepted: 02/23/2020] [Indexed: 11/27/2022]
Abstract
Pulmonary embolism (PE) is a leading cause of maternal mortality with women at increased risk of PE during pregnancy and the early postpartum period. Clinical assessment of suspected PE during pregnancy is challenging as signs and symptoms associated with PE overlap with physiological changes of pregnancy. Clinical tests and rules commonly used to assess pre-test probability of PE were historically not well validated in the pregnant population. The challenges of clinical assessment in the pregnant and postpartum population result in a lowered threshold for diagnostic imaging. Computed tomographic pulmonary angiography (CTPA) and nuclear medicine lung scintigraphy or ventilation/perfusion (V/Q) scans are the main types of diagnostic imaging for suspected PE. Both methods are associated with small levels of ionising radiation exposure to mother and foetus. Accuracy of the diagnostic imaging tests is paramount. Haemodynamic changes of pregnancy, including increased heart rate, increased blood volume and altered flow velocity in the pulmonary arteries, may influence the quality of imaging. This comprehensive review examines the literature and evidence for the investigation and diagnostic imaging of suspected pulmonary embolism during pregnancy with CTPA and V/Q. Clinical decision-making tools, biomarkers and diagnostic imaging during pregnancy and postpartum will be considered with a focus on diagnostic accuracy and yield, radiation dose exposure (maternal-foetal) and protocol modifications. Current practice guideline recommendations and recent literature on diagnostic pathways are also presented.
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Affiliation(s)
- Jodie Tester
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Gary Hammerschlag
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Louis Irving
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Diane Pascoe
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Radiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Megan Rees
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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5
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Lowe SA. Ionizing radiation for maternal medical indications. Prenat Diagn 2019; 40:1150-1155. [PMID: 31697844 DOI: 10.1002/pd.5592] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/23/2019] [Accepted: 10/11/2019] [Indexed: 12/21/2022]
Abstract
Ionizing radiation should be considered an avoidable exposure although all pregnant women receive some radiation from their environment. The potential effect of ionizing radiation on the fetus is determined by the dose and the timing of the exposure with growing interest in the potential risks of transgenerational effects of radiation as an epigenetic phenomenon. High dosage exposure is very unlikely in routine situations such as occupational, diagnostic, or therapeutic exposures. Individual diagnostic radiation procedures (fetal dosage <50 mGy), are not associated with any increase in lethality (miscarriage or stillbirth), genetic damage, teratogenicity, growth impairment, mental retardation, or sterility. More recent modeling has suggested that a 10 mGy fetal dose is associated with an excess risk of childhood cancer risk as low as 1 in 4545, well below historical estimates.When the mother's condition necessitates diagnostic radiation it is necessary to balance the risks of the procedure with the benefits to be gained. As almost all diagnostic imaging involves doses below the 50 mGy threshold, clinically indicated investigations should not be withheld because of concerns regarding fetal radiation exposure. Even radiotherapy directed away from the abdomen or pelvis may be considered during pregnancy, if the benefits outweigh the risks and no suitable alternative is available.
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Affiliation(s)
- Sandra A Lowe
- Royal Hospital for Women, University of New South Wales, Sydney, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, Australia
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Lowe S. Diagnostic imaging in pregnancy: Making informed decisions. Obstet Med 2019; 12:116-122. [PMID: 31523267 PMCID: PMC6734637 DOI: 10.1177/1753495x19838658] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/26/2019] [Indexed: 01/03/2023] Open
Abstract
The use of diagnostic imaging involving ionising radiation may be necessary in pregnancy and requires an assessment of the most appropriate and safest imaging modality which will provide the necessary information balanced with the potential risks to the mother and fetus. In most cases, this will involve a potential fetal radiation dose well below 50 mGy. At these doses, there is no risk of lethality, genetic damage/epigenetic change, teratogenicity, growth impairment or sterility. Older epidemiological data indicating a potential increased cancer risk have been contradicted by newer data and better understanding of the biology of low dose radiation. The linear no-threshold rule has been challenged by many and more realistic estimates of oncogenicity risk along with the potential risks of contrast agents are summarised in this review. Imaging in the pregnant population is increasing in both the number of examinations performed and the number of patients being imaged, with the greatest increase being computed tomography scans. Counselling and obtaining informed consent for imaging that involves radiation requires the clinician to communicate with the woman and her family a realistic estimate of the potential radiation dose to herself and her fetus, to describe and quantitate the risks of this estimated dose, to outline the benefits of the imaging procedure and to respond to any questions or concerns. As almost all diagnostic imaging involves doses below the 50 mGy threshold, clinically indicated investigations should not be withheld during pregnancy. All allied staff must also be well informed to ensure the patient receives a consistent message about the risks and benefits of the proposed test.
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Affiliation(s)
- Sandra Lowe
- Royal Hospital for Women and School of Women’s and Children’s Health, University of New South Wales, Sydney, Australia
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7
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Hirshfeld JW, Ferrari VA, Bengel FM, Bergersen L, Chambers CE, Einstein AJ, Eisenberg MJ, Fogel MA, Gerber TC, Haines DE, Laskey WK, Limacher MC, Nichols KJ, Pryma DA, Raff GL, Rubin GD, Smith D, Stillman AE, Thomas SA, Tsai TT, Wagner LK, Samuel Wann L, Januzzi JL, Afonso LC, Everett B, Hernandez AF, Hucker W, Jneid H, Kumbhani D, Edward Marine J, Morris PB, Piana RN, Watson KE, Wiggins BS. 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness. Catheter Cardiovasc Interv 2018; 92:E35-E97. [DOI: 10.1002/ccd.27659] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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8
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Hirshfeld JW, Ferrari VA, Bengel FM, Bergersen L, Chambers CE, Einstein AJ, Eisenberg MJ, Fogel MA, Gerber TC, Haines DE, Laskey WK, Limacher MC, Nichols KJ, Pryma DA, Raff GL, Rubin GD, Smith D, Stillman AE, Thomas SA, Tsai TT, Wagner LK, Wann LS. 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 2018; 71:e283-e351. [PMID: 29729877 DOI: 10.1016/j.jacc.2018.02.016] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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9
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Xie T, Zanotti-Fregonara P, Edet-Sanson A, Zaidi H. Patient-Specific Computational Model and Dosimetry Calculations for PET/CT of a Patient Pregnant with Twins. J Nucl Med 2018; 59:1451-1458. [PMID: 29371408 DOI: 10.2967/jnumed.117.205286] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 01/12/2018] [Indexed: 11/16/2022] Open
Abstract
The radiation dose delivered to pregnant patients during radiologic imaging procedures raises health concerns because the developing embryo and fetus are considered to be highly radiosensitive. To appropriately weigh the diagnostic benefits against the radiation risks, the radiologist needs reasonably accurate and detailed estimates of the fetal dose. Expanding our previously developed series of computational phantoms for pregnant women, we here describe a personalized model for twin pregnancy, based on an actual clinical scan. Methods: The model is based on a standardized hybrid pregnant female and fetus phantom and on a clinical case of a patient who underwent an 18F-FDG PET/CT scan while expecting twins at 25 weeks' gestation. This model enabled us to produce a realistic physical representation of the pregnant patient and to estimate the maternal and fetal organ doses from the 18F-FDG and CT components. The Monte Carlo N-Particle Extended general-purpose code was used for radiation transport simulation. Results: The 18F-FDG doses for the 2 fetuses were 3.78 and 3.99 mGy, and the CT doses were 0.76 and 0.70 mGy, respectively. Therefore, the relative contribution of 18F-FDG and CT to the total dose to the fetuses was about 84% and 16%, respectively. Meanwhile, for 18F-FDG, the calculated personalized absorbed dose was about 40%-50% higher than the doses reported by other dosimetry computer software tools. Conclusion: Our approach to constructing personalized computational models allows estimation of a patient-specific radiation dose, even in cases with unusual anatomic features such as a twin pregnancy. Our results also show that, even in twins, the fetal organ doses from both 18F-FDG and CT present a certain variability linked to the anatomic characteristics. The CT fetal dose is smaller than the 18F-FDG PET dose.
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Affiliation(s)
- Tianwu Xie
- Division of Nuclear Medicine and Molecular Imaging, Geneva University Hospital, Geneva, Switzerland
| | | | | | - Habib Zaidi
- Division of Nuclear Medicine and Molecular Imaging, Geneva University Hospital, Geneva, Switzerland .,Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, Netherlands.,Geneva University Neurocenter, University of Geneva, Geneva, Switzerland; and.,Department of Nuclear Medicine, University of Southern Denmark, Odense, Denmark
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