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Ingenerf M, Auernhammer C, Lorbeer R, Winkelmann M, Mansournia S, Mansour N, Hesse N, Heinrich K, Ricke J, Berger F, Schmid-Tannwald C. Utility of clinical and MR imaging parameters for prediction and monitoring of response to capecitabine and temozolomide (CAPTEM) therapy in patients with liver metastases of neuroendocrine tumors. Radiol Oncol 2024; 58:196-205. [PMID: 38613843 PMCID: PMC11165981 DOI: 10.2478/raon-2024-0024] [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: 12/08/2023] [Accepted: 02/20/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND This study explores the predictive and monitoring capabilities of clinical and multiparametric MR parameters in assessing capecitabine and temozolomide (CAPTEM) therapy response in patients with neuroendocrine tumors (NET). PATIENTS AND METHODS This retrospective study (n = 44) assessed CAPTEM therapy response in neuroendocrine liver metastases (NELM) patients. Among 33 monitored patients, as a subgroup of the overall study cohort, pretherapeutic and follow-up MRI data (size, apparent diffusion coefficient [ADC] values, and signal intensities), along with clinical parameters (chromogranin A [CgA] and Ki-67%), were analyzed. Progression-free survival (PFS) served as the reference. Responders were defined as those with PFS ≥ 6 months. RESULTS Most patients were male (75%) and had G2 tumors (76%) with a pancreatic origin (84%). Median PFS was 5.7 months; Overall Survival (OS) was 25 months. Non-responders (NR) had higher Ki-67 in primary tumors (16.5 vs. 10%, p = 0.01) and increased hepatic burden (20% vs. 5%, p = 0.007). NR showed elevated CgA post-treatment, while responders (R) exhibited a mild decrease. ADC changes differed significantly between groups, with NR having decreased ADCmin (-23%) and liver-adjusted ADCmean/ADCmean liver (-16%), compared to R's increases of ADCmin (50%) and ADCmean/ADCmean liver (30%). Receiver operating characteristic (ROC) analysis identified the highest area under the curve (AUC) (0.76) for a single parameter for ∆ ADC mean/liver ADCmean, with a cut-off of < 6.9 (76% sensitivity, 75% specificity). Combining ∆ Size NELM and ∆ ADCmin achieved the best balance (88% sensitivity, 60% specificity) outperforming ∆ Size NELM alone (69% sensitivity, 65% specificity). Kaplan-Meier analysis indicated significantly longer PFS for ∆ ADCmean/ADCmean liver < 6.9 (p = 0.024) and ∆ Size NELM > 0% + ∆ ADCmin < -2.9% (p = 0.021). CONCLUSIONS Survival analysis emphasizes the need for adapted response criteria, involving combined evaluation of CgA, ADC values, and tumor size for monitoring CAPTEM response in hepatic metastasized NETs.
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Affiliation(s)
- Maria Ingenerf
- Department of Radiology, University Hospital, LMU Munich, Germany
| | - Christoph Auernhammer
- ENETS Centre of Excellence, Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System at the University Hospital of Munich (GEPNET-KUM), University Hospital of Munich, Munich, Germany
- Department of Internal Medicine 4, University Hospital, LMU Munich, Munich, Germany
| | - Roberto Lorbeer
- Department of Radiology, University Hospital, LMU Munich, Germany
| | | | - Shiwa Mansournia
- Department of Radiology, University Hospital, LMU Munich, Germany
| | - Nabeel Mansour
- Department of Radiology, University Hospital, LMU Munich, Germany
| | - Nina Hesse
- Department of Radiology, University Hospital, LMU Munich, Germany
| | - Kathrin Heinrich
- Department of Medicine III, University Hospital, University of Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Germany
- ENETS Centre of Excellence, Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System at the University Hospital of Munich (GEPNET-KUM), University Hospital of Munich, Munich, Germany
| | - Frank Berger
- Department of Radiology, University Hospital, LMU Munich, Germany
| | - Christine Schmid-Tannwald
- Department of Radiology, University Hospital, LMU Munich, Germany
- ENETS Centre of Excellence, Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System at the University Hospital of Munich (GEPNET-KUM), University Hospital of Munich, Munich, Germany
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Horng A, Ingenerf M, Berger F, Steffinger D, Rübenthaler J, Zacherl M, Wenter V, Ricke J, Schmid-Tannwald C. Synchronous neuroendocine liver metastases in comparison to primary pancreatic neuroendocrine tumors on MRI and SSR-PET/CT. Front Oncol 2024; 14:1352538. [PMID: 38884077 PMCID: PMC11179428 DOI: 10.3389/fonc.2024.1352538] [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: 12/08/2023] [Accepted: 05/17/2024] [Indexed: 06/18/2024] Open
Abstract
Background The study aimed to compare and correlate morphological and functional parameters in pancreatic neuroendocrine tumors (pNET) and their synchronous liver metastases (NELM), while also assessing prognostic imaging parameters. Methods Patients with G1/G2 pNET and synchronous NELM underwent pretherapeutic abdominal MRI with DWI and 68Ga-DOTATATE/TOC PET/CT were included. ADC (mean, min), SNR_art and SNT_T2 (SNR on arterial phase and on T2) and SUV (max, mean) for three target NELM and pNET, as well as tumor-free liver and spleen (only in PET/CT) were measured. Morphological parameters including size, location, arterial enhancement, cystic components, T2-hyperintensity, ductal dilatation, pancreatic atrophy, and vessel involvement were noted. Response evaluation used progression-free survival (PFS) with responders (R;PFS>24 months) and non-responders (NR;PFS ≤ 24 months). Results 33 patients with 33 pNETs and 95 target NELM were included. There were no significant differences in ADC and SUV values between NELM and pNET. 70% of NELM were categorized as hyperenhancing lesions, whereas the pNETs exhibited significantly lower rate (51%) of hyperenhancement (p<0.01) and significant lower SNR_art. NELM were qualitatively and quantitatively (SNR_T2) significantly more hyperintense on T2 compared to pNET (p=0.01 and p<0.001). NELM of R displayed significantly lower ADCmean value in comparison to the ADC mean value of pNET (0.898 versus 1.037x10-3mm²/s,p=0.036). In NR, T2-hyperintensity was notably higher in NELM compared to pNET (p=0.017). The hepatic tumor burden was significantly lower in the R compared to the NR (10% versus 30%). Conclusions Arterial hyperenhancement and T2-hyperintensity differ between synchronous NELM and pNET. These findings emphasize the importance of a multifaceted approach to imaging and treatment planning in patients with these tumors as well as in predicting treatment responses.
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Affiliation(s)
- Annie Horng
- Department of Radiology, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Maria Ingenerf
- Department of Radiology, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Frank Berger
- Department of Radiology, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Denise Steffinger
- Department of Radiology, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Johannes Rübenthaler
- Department of Radiology, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Matthias Zacherl
- Department of Nuclear Medicine, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Vera Wenter
- Department of Nuclear Medicine, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
- European Neuroendocrine Tumor Society (ENETS) Centre of Excellence, Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System at the University Hospital of Munich (GEPNET-KUM), University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Christine Schmid-Tannwald
- Department of Radiology, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
- European Neuroendocrine Tumor Society (ENETS) Centre of Excellence, Interdisciplinary Center of Neuroendocrine Tumours of the GastroEnteroPancreatic System at the University Hospital of Munich (GEPNET-KUM), University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
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Karim S, Seidensticker R, Seidensticker M, Ricke J, Schinner R, Treitl K, Rübenthaler J, Ingenerf M, Schmid-Tannwald C. Role of diffusion-weighted imaging in response prediction and evaluation after high dose rate brachytherapy in patients with colorectal liver metastases. Radiol Oncol 2024; 58:33-42. [PMID: 38378033 PMCID: PMC10878766 DOI: 10.2478/raon-2024-0017] [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: 11/10/2023] [Accepted: 01/04/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND The aim of the study was to assess the role of diffusion-weighted imaging (DWI) to evaluate treatment response in patients with liver metastases of colorectal cancer. PATIENTS AND METHODS In this retrospective, observational cohort study, we included 19 patients with 18 responding metastases (R-Mets; follow-up at least one year) and 11 non-responding metastases (NR-Mets; local tumor recurrence within one year) who were treated with high-dose-rate brachytherapy (HDR-BT) and underwent pre- and post-interventional MRI. DWI (qualitatively, mean apparent diffusion coefficient [ADCmean], ADCmin, intraindividual change of ADCmean and ADCmin) were evaluated and compared between pre-interventional MRI, first follow-up after 3 months and second follow-up at the time of the local tumor recurrence (in NR-Mets, mean: 284 ± 122 d) or after 12 months (in R-Mets, mean: 387+/-64 d). Sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs) for detection of local tumor recurrence were calculated on second follow up, evaluating (1) DWI images only, and (2) DWI with Gd-enhanced T1-weighted images on hepatobiliary phase (contrast-enhanced [CE] T1-weight [T1w] hepatobiliary phase [hb]). RESULTS ADCmean significantly increased 3 months after HDR-BT in both groups (R-Mets: 1.48 ± 0.44 and NR-Mets: 1.49 ± 0.19 x 10-3 mm2;/s, p < 0.0001 and p = 0.01), however, intraindividual change of ADCmean (175% vs.127%, p = 0.03) and ADCmin values (0.44 ± 0.24 to 0.82 ± 0.58 x 10-3 mm2/s) significantly increased only in R-Mets (p < 0.0001 and p < 0.001). ADCmin was significant higher in R-Mets compared to NR-Mets on first follow-up (p = 0.04). Sensitivity (1 vs. 0.72), specificity (0.94 vs. 0.72), PPV (0.91 vs. 0.61) and NPV (1 vs. 0.81) could be improved by combining DWI with CE T1w hb compared to DWI only. CONCLUSIONS DW-MRI seems to be helpful in the qualitative and quantitative evaluation of treatment response after HDR-BT of colorectal metastases in the liver.
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Affiliation(s)
- Salma Karim
- Department of Radiology, University Hospital, LMU Munich, Germany
| | | | - Max Seidensticker
- Department of Radiology, University Hospital, LMU Munich, Germany
- ENETS Centre of Excellence, Interdisciplinary Center of Neuroendocrine Tumours of the GastroEntero-Pancreatic System at the University Hospital of Munich (GEPNET KUM), University Hospital of Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Germany
- ENETS Centre of Excellence, Interdisciplinary Center of Neuroendocrine Tumours of the GastroEntero-Pancreatic System at the University Hospital of Munich (GEPNET KUM), University Hospital of Munich, Munich, Germany
| | - Regina Schinner
- Department of Radiology, University Hospital, LMU Munich, Germany
| | - Karla Treitl
- Department of Radiology, University Hospital, LMU Munich, Germany
| | - Johannes Rübenthaler
- Department of Radiology, University Hospital, LMU Munich, Germany
- ENETS Centre of Excellence, Interdisciplinary Center of Neuroendocrine Tumours of the GastroEntero-Pancreatic System at the University Hospital of Munich (GEPNET KUM), University Hospital of Munich, Munich, Germany
| | - Maria Ingenerf
- Department of Radiology, University Hospital, LMU Munich, Germany
| | - Christine Schmid-Tannwald
- Department of Radiology, University Hospital, LMU Munich, Germany
- ENETS Centre of Excellence, Interdisciplinary Center of Neuroendocrine Tumours of the GastroEntero-Pancreatic System at the University Hospital of Munich (GEPNET KUM), University Hospital of Munich, Munich, Germany
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Ingenerf M, Grawe F, Winkelmann M, Karim H, Ruebenthaler J, Fabritius MP, Ricke J, Seidensticker R, Auernhammer CJ, Zacherl MJ, Seidensticker M, Schmid-Tannwald C. Neuroendocrine liver metastases treated using transarterial radioembolization: Identification of prognostic parameters at 68Ga-DOTATATE PET/CT. Diagn Interv Imaging 2024; 105:15-25. [PMID: 37453859 DOI: 10.1016/j.diii.2023.06.007] [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: 04/03/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE To identify prognostic clinical and imaging parameters for patients with neuroendocrine liver metastases (NELMs) undergoing transarterial radioembolization (TARE). MATERIALS AND METHODS Forty-seven patients (27 men; mean age, 64 years) with NELMs who received TARE, along with pre-procedure liver MRI and 68Ga-DOTATATE positron emission tomography/computed tomography were included. Apparent diffusion coefficient and standardized uptake value (SUV) of three liver metastases, normal spleen and liver were measured. SUVmax or SUVmean were used for the calculation of tumor-to-organ ratios (tumor-to-spleen and tumor-to-liver ratios) using all possible combinations (including SUVmax/SUVmax, SUVmax/SUVmean, and SUVmean/SUVmean). Clinical parameters (hepatic tumor-burden, presence of extra-hepatic metastases, chromograninA, Ki-67 and bilirubin levels) were assessed. Overall survival, progression-free survival (PFS) and hepatic progression-free survival (HPFS) were calculated using Kaplan-Meier curves. RESULTS Median overall survival, PFS and HPFS were 49.6, 13.1 and 28.3 months, respectively. In multivariable Cox regression analysis, low Ki-67 (≤ 5%), low hepatic tumor-burden (< 10%), absence of extrahepatic metastases, and increased Tmean/Lmax ratio were significant prognostic factors of longer overall survival and HPFS. High baseline chromograninA (> 1330 ng/mL) was associated with shorter HPFS. Tmean/Lmax > 1.9 yielded a median overall survival of 69 vs. 33 months (P < 0.04), and a median HPFS of 30 vs. 19 months (P = 0.09). For PFS, high baseline SUVmax of NELMs was the single significant parameter in the multivariable model. SUVmax > 28 resulted in a median PFS of 16.9 vs. 6.5 months, respectively (P = 0.001). CONCLUSION High preinterventional Tmean/Lmax ratios, and high SUVmax on 68Ga-DOTATATE positron emission tomography/computed tomography seem to have prognostic value in patients with NELMs undergoing TARE, potentially aiding patient selection and management alongside conventional variables.
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Affiliation(s)
- Maria Ingenerf
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany.
| | - Freba Grawe
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; Department of Nuclear Medicine, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Michael Winkelmann
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Homeira Karim
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Johannes Ruebenthaler
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; Interdisciplinary Centre of Neuroendocrine Tumors of the GastroEnteroPancreatic System (GEPNET-KUM), University Hospital, LMU Munich, 81377 Munich, Germany
| | | | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; Interdisciplinary Centre of Neuroendocrine Tumors of the GastroEnteroPancreatic System (GEPNET-KUM), University Hospital, LMU Munich, 81377 Munich, Germany
| | | | - Christoph Josef Auernhammer
- Department of Internal Medicine 4, University Hospital, LMU Munich, 81377 Munich, Germany; Interdisciplinary Centre of Neuroendocrine Tumors of the GastroEnteroPancreatic System (GEPNET-KUM), University Hospital, LMU Munich, 81377 Munich, Germany
| | | | - Max Seidensticker
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; Interdisciplinary Centre of Neuroendocrine Tumors of the GastroEnteroPancreatic System (GEPNET-KUM), University Hospital, LMU Munich, 81377 Munich, Germany
| | - Christine Schmid-Tannwald
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; Interdisciplinary Centre of Neuroendocrine Tumors of the GastroEnteroPancreatic System (GEPNET-KUM), University Hospital, LMU Munich, 81377 Munich, Germany
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Microspheres as a Carrier System for Therapeutic Embolization Procedures: Achievements and Advances. J Clin Med 2023; 12:jcm12030918. [PMID: 36769566 PMCID: PMC9917963 DOI: 10.3390/jcm12030918] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 01/27/2023] Open
Abstract
The targeted delivery of anti-cancer drugs and isotopes is one of the most pursued goals in anti-cancer therapy. One of the prime examples of such an application is the intra-arterial injection of microspheres containing cytostatic drugs or radioisotopes during hepatic embolization procedures. Therapy based on the application of microspheres revolves around vascular occlusion, complemented with local therapy in the form of trans-arterial chemoembolization (TACE) or radioembolization (TARE). The broadest implementation of these embolization strategies currently lies within the treatment of untreatable hepatocellular cancer (HCC) and metastatic colorectal cancer. This review aims to describe the state-of-the-art TACE and TARE technologies investigated in the clinical setting for HCC and addresses current trials and new developments. In addition, chemical properties and advancements in microsphere carrier systems are evaluated, and possible improvements in embolization therapy based on the modification of and functionalization with therapeutical loads are explored.
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Treatment Assessment of pNET and NELM after Everolimus by Quantitative MRI Parameters. Biomedicines 2022; 10:biomedicines10102618. [PMID: 36289880 PMCID: PMC9599819 DOI: 10.3390/biomedicines10102618] [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: 08/25/2022] [Revised: 10/01/2022] [Accepted: 10/11/2022] [Indexed: 11/17/2022] Open
Abstract
Assessment of treatment response to targeted therapies such as everolimus is difficult, especially in slow-growing tumors such as NETs. In this retrospective study, 17 patients with pancreatic neuroendocrine tumors (pNETs) and hepatic metastases (NELMs) (42 target lesions) who received everolimus were analyzed. Intralesional signal intensities (SI) of non-contrast T1w, T2w and DCE imaging, and apparent diffusion coefficients (ADCmean and ADCmin) of DWI, were measured on baseline and first follow-up MRI after everolimus initiation. Response assessment was categorized according to progression-free survival (PFS), with responders (R) showing a PFS of ≥11 months. ADCmin of NELMs decreased in Rs whereas it increased in non-responders (NR). Percentual changes of ADCmin and ADCmean differed significantly between response groups (p < 0.03). By contrast, ADC of the pNETs tended to increase in Rs, while there was no change in NRs. Tumor-to-liver (T/L) ratio of T1 SI of NELMs increased in Rs and decreased in NRs, and percentual changes differed significantly between response groups (p < 0.02). T1 SI of the pNETs tended to decrease in Rs and increase in Ns. The quotient of pretherapeutic and posttherapeutic ADCmin values (DADCmin) and length of everolimus treatment showed significant association with PFS in univariable Cox analysis. In conclusion, quantitative MRI, especially DWI, seems to allow treatment assessment of pNETs with NELMs under everolimus. Interestingly, the responding NELMs showed decreasing ADC values, and there might be an opposite effect on ADC and T1 SI between NELMs and pNETs.
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Ramachandran A, Madhusudhan KS. Advances in the imaging of gastroenteropancreatic neuroendocrine neoplasms. World J Gastroenterol 2022; 28:3008-3026. [PMID: 36051339 PMCID: PMC9331531 DOI: 10.3748/wjg.v28.i26.3008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/30/2021] [Accepted: 06/20/2022] [Indexed: 02/06/2023] Open
Abstract
Gastroenteropancreatic neuroendocrine neoplasms comprise a heterogeneous group of tumors that differ in their pathogenesis, hormonal syndromes produced, biological behavior and consequently, in their requirement for and/or response to specific chemotherapeutic agents and molecular targeted therapies. Various imaging techniques are available for functional and morphological evaluation of these neoplasms and the selection of investigations performed in each patient should be customized to the clinical question. Also, with the increased availability of cross sectional imaging, these neoplasms are increasingly being detected incidentally in routine radiology practice. This article is a review of the various imaging modalities currently used in the evaluation of neuroendocrine neoplasms, along with a discussion of the role of advanced imaging techniques and a glimpse into the newer imaging horizons, mostly in the research stage.
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Affiliation(s)
- Anupama Ramachandran
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Kumble Seetharama Madhusudhan
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi 110029, India
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