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Ishaque AH, Alvi MA, Pedro K, Fehlings MG. Imaging protocols for non-traumatic spinal cord injury: current state of the art and future directions. Expert Rev Neurother 2024; 24:691-709. [PMID: 38879824 DOI: 10.1080/14737175.2024.2363839] [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: 10/13/2023] [Accepted: 05/31/2024] [Indexed: 06/21/2024]
Abstract
INTRODUCTION Non-traumatic spinal cord injury (NTSCI) is a term used to describe damage to the spinal cord from sources other than trauma. Neuroimaging techniques such as computerized tomography (CT) and magnetic resonance imaging (MRI) have improved our ability to diagnose and manage NTSCIs. Several practice guidelines utilize MRI in the diagnostic evaluation of traumatic and non-traumatic SCI to direct surgical intervention. AREAS COVERED The authors review practices surrounding the imaging of various causes of NTSCI as well as recent advances and future directions for the use of novel imaging modalities in this realm. The authors also present discussions around the use of simple radiographs and advanced MRI modalities in clinical settings, and briefly highlight areas of active research that seek to advance our understanding and improve patient care. EXPERT OPINION Although several obstacles must be overcome, it appears highly likely that novel quantitative imaging features and advancements in artificial intelligence (AI) as well as machine learning (ML) will revolutionize degenerative cervical myelopathy (DCM) care by providing earlier diagnosis, accurate localization, monitoring for deterioration and neurological recovery, outcome prediction, and standardized practice. Some intriguing findings in these areas have been published, including the identification of possible serum and cerebrospinal fluid biomarkers, which are currently in the early phases of translation.
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Affiliation(s)
- Abdullah H Ishaque
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Karlo Pedro
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
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Sacino AN, Chen H, Sahgal A, Bettegowda C, Rhines LD, Maralani P, Redmond KJ. Stereotactic body radiation therapy for spinal metastases: A new standard of care. Neuro Oncol 2024; 26:S76-S87. [PMID: 38437670 PMCID: PMC10911798 DOI: 10.1093/neuonc/noad225] [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] [Indexed: 03/06/2024] Open
Abstract
Advancements in systemic therapies for patients with metastatic cancer have improved overall survival and, hence, the number of patients living with spinal metastases. As a result, the need for more versatile and personalized treatments for spinal metastases to optimize long-term pain and local control has become increasingly important. Stereotactic body radiation therapy (SBRT) has been developed to meet this need by providing precise and conformal delivery of ablative high-dose-per-fraction radiation in few fractions while minimizing risk of toxicity. Additionally, advances in minimally invasive surgical techniques have also greatly improved care for patients with epidural disease and/or unstable spines, which may then be combined with SBRT for durable local control. In this review, we highlight the indications and controversies of SBRT along with new surgical techniques for the treatment of spinal metastases.
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Affiliation(s)
- Amanda N Sacino
- Department of Neurosurgery, John Hopkins University, Baltimore, Maryland, USA
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chetan Bettegowda
- Department of Neurosurgery, John Hopkins University, Baltimore, Maryland, USA
| | - Laurence D Rhines
- Department of Neurosurgery, MD Anderson Cancer Center, Houston, Texas, USA
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kristin J Redmond
- Department of Radiation and Molecular Oncology, John Hopkins University, Baltimore, Maryland, USA
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Yildirim O, Peck KK, Saha A, Karimi S, Lis E. Dynamic Contrast Enhanced MR Perfusion and Diffusion-Weighted Imaging of Marrow-Replacing Disorders of the Spine: A Comprehensive Review. Radiol Clin North Am 2024; 62:287-302. [PMID: 38272621 DOI: 10.1016/j.rcl.2023.09.004] [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] [Indexed: 01/27/2024]
Abstract
Significant advancements in cancer treatment have led to improved survival rates for patients, particularly in the context of spinal metastases. However, early detection and monitoring of treatment response remain crucial for optimizing patient outcomes. Although conventional imaging methods such as bone scan, PET, MR imaging, and computed tomography are commonly used for diagnosing and monitoring treatment, they present challenges in differential diagnoses and treatment response monitoring. This review article provides a comprehensive overview of the principles, applications, and practical uses of dynamic contrast-enhanced MR imaging and diffusion-weighted imaging in the assessment and monitoring of marrow-replacing disorders of the spine.
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Affiliation(s)
- Onur Yildirim
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| | | | - Atin Saha
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Sasan Karimi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Eric Lis
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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Burgess L, Nguyen E, Tseng CL, Guckenberger M, Lo SS, Zhang B, Nielsen M, Maralani P, Nguyen QN, Sahgal A. Practice and principles of stereotactic body radiation therapy for spine and non-spine bone metastases. Clin Transl Radiat Oncol 2024; 45:100716. [PMID: 38226025 PMCID: PMC10788412 DOI: 10.1016/j.ctro.2023.100716] [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: 09/12/2023] [Revised: 11/23/2023] [Accepted: 12/16/2023] [Indexed: 01/17/2024] Open
Abstract
Radiotherapy is the dominant treatment modality for painful spine and non-spine bone metastases (NSBM). Historically, this was achieved with conventional low dose external beam radiotherapy, however, stereotactic body radiotherapy (SBRT) is increasingly applied for these indications. Meta-analyses and randomized clinical trials have demonstrated improved pain response and more durable tumor control with SBRT for spine metastases. However, in the setting of NSBM, there is limited evidence supporting global adoption and large scale randomized clinical trials are in need. SBRT is technically demanding requiring careful consideration of organ at risk tolerance, and strict adherence to technical requirements including immobilization, simulation, contouring and image-guidance procedures. Additional considerations include follow up practices after SBRT, with appropriate imaging playing a critical role in response assessment. Finally, there is renewed research into promising new technologies that may further refine the use of SBRT in both spinal and NSBM in the years to come.
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Affiliation(s)
- Laura Burgess
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eric Nguyen
- Department of Radiation Oncology, Walker Family Cancer Centre, St. Catharines, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States
| | - Beibei Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Nielsen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, MD Anderson Cancer Centre, University of Texas, Houston, TX, United States
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Griffith JF, Yip SWY, van der Heijden RA, Valenzuela RF, Yeung DKW. Perfusion Imaging of the Musculoskeletal System. Magn Reson Imaging Clin N Am 2024; 32:181-206. [PMID: 38007280 DOI: 10.1016/j.mric.2023.07.004] [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] [Indexed: 11/27/2023]
Abstract
Perfusion imaging is the aspect of functional imaging, which is most applicable to the musculoskeletal system. In this review, the anatomy and physiology of bone perfusion is briefly outlined as are the methods of acquiring perfusion data on MR imaging. The current clinical indications of perfusion related to the assessment of soft tissue and bone tumors, synovitis, osteoarthritis, avascular necrosis, Keinbock's disease, diabetic foot, osteochondritis dissecans, and Paget's disease of bone are reviewed. Challenges and opportunities related to perfusion imaging of the musculoskeletal system are also briefly addressed.
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Affiliation(s)
- James F Griffith
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong.
| | - Stefanie W Y Yip
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong
| | - Rianne A van der Heijden
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Raul F Valenzuela
- Department of Musculoskeletal Imaging, The University of Texas, MD Anderson Cancer Center, USA
| | - David K W Yeung
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong
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Behar M, Peck KK, Yildirim O, Tisnado J, Saha A, Arevalo-Perez J, Lis E, Yamada Y, Holodny AI, Karimi S. T1-Weighted, Dynamic Contrast-Enhanced MR Perfusion Imaging Can Differentiate between Treatment Success and Failure in Spine Metastases Undergoing Radiation Therapy. AJNR Am J Neuroradiol 2023; 44:1451-1457. [PMID: 38049990 PMCID: PMC10714859 DOI: 10.3174/ajnr.a8057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 10/05/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND AND PURPOSE Current imaging techniques have difficulty differentiating treatment success and failure in spinal metastases undergoing radiation therapy. This study investigated the correlation between changes in dynamic contrast-enhanced MR imaging perfusion parameters and clinical outcomes following radiation therapy for spinal metastases. We hypothesized that perfusion parameters will outperform traditional size measurements in discriminating treatment success and failure. MATERIALS AND METHODS This retrospective study included 49 patients (mean age, 63 [SD, 13] years; 29 men) with metastatic lesions treated with radiation therapy who underwent dynamic contrast-enhanced MR imaging. The median time between radiation therapy and follow-up dynamic contrast-enhanced MR imaging was 62 days. We divided patients into 2 groups: clinical success (n = 38) and failure (n = 11). Failure was defined as PET recurrence (n = 5), biopsy-proved (n = 1) recurrence, or an increase in tumor size (n = 7), while their absence defined clinical success. A Mann-Whitney U test was performed to assess differences between groups. RESULTS The reduction in plasma volume was greater in the success group than in the failure group (-57.3% versus +88.2%, respectively; P < .001). When we assessed the success of treatment, the sensitivity of plasma volume was 91% (10 of 11; 95% CI, 82%-97%) and the specificity was 87% (33 of 38; 95% CI, 73%-94%). The sensitivity of size measurements was 82% (9 of 11; 95% CI, 67%-90%) and the specificity was 47% (18 of 38; 95% CI, 37%-67%). CONCLUSIONS The specificity of plasma volume was higher than that of conventional size measurements, suggesting that dynamic contrast-enhanced MR imaging is a powerful tool to discriminate between treatment success and failure.
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Affiliation(s)
- Mark Behar
- From the Department of Radiology (M.B., K.K.P., O.Y., J.T., A.S., J.A.-P., E.L., A.I.H., S.K.), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kyung K Peck
- From the Department of Radiology (M.B., K.K.P., O.Y., J.T., A.S., J.A.-P., E.L., A.I.H., S.K.), Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medical Physics (K.K.P.), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Onur Yildirim
- From the Department of Radiology (M.B., K.K.P., O.Y., J.T., A.S., J.A.-P., E.L., A.I.H., S.K.), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jamie Tisnado
- From the Department of Radiology (M.B., K.K.P., O.Y., J.T., A.S., J.A.-P., E.L., A.I.H., S.K.), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Atin Saha
- From the Department of Radiology (M.B., K.K.P., O.Y., J.T., A.S., J.A.-P., E.L., A.I.H., S.K.), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Julio Arevalo-Perez
- From the Department of Radiology (M.B., K.K.P., O.Y., J.T., A.S., J.A.-P., E.L., A.I.H., S.K.), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eric Lis
- From the Department of Radiology (M.B., K.K.P., O.Y., J.T., A.S., J.A.-P., E.L., A.I.H., S.K.), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yoshiya Yamada
- Department of Radiation Oncology (Y.Y.), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrei I Holodny
- From the Department of Radiology (M.B., K.K.P., O.Y., J.T., A.S., J.A.-P., E.L., A.I.H., S.K.), Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiology (A.I.H.), Weill Medical College of Cornell University, New York, New York
- Department of Neuroscience (A.I.H.), Weill-Cornell Graduate School of the Medical Sciences, New York, New York
| | - Sasan Karimi
- From the Department of Radiology (M.B., K.K.P., O.Y., J.T., A.S., J.A.-P., E.L., A.I.H., S.K.), Memorial Sloan Kettering Cancer Center, New York, New York
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Mulyadi R, Putri PP, Handoko, Zairinal RA, Prihartono J. Dynamic contrast-enhanced magnetic resonance imaging parameter changes as an early biomarker of tumor responses following radiation therapy in patients with spinal metastases: a systematic review. Radiat Oncol J 2023; 41:225-236. [PMID: 38185927 PMCID: PMC10772591 DOI: 10.3857/roj.2023.00290] [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: 04/12/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 01/09/2024] Open
Abstract
PURPOSE This systematic review aims to assess and summarize the clinical values of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) parameter changes as early biomarkers of tumor responses following radiation therapy (RT) in patients with spinal metastases. MATERIALS AND METHODS A systematic search was conducted on five electronic databases: PubMed, Scopus, Science Direct, Cochrane, and Embase. Studies were included if they mentioned DCE-MRI parameter changes before and after RT in patients with spinal metastases with a correlation to tumor responses based on clinical and imaging criteria. The Quality Assessment of Diagnostic Accuracy Studies 2 was used to assess study quality. RESULTS This systematic review included seven studies involving 107 patients. All seven studies evaluated the transfer constant (Ktrans), six studies evaluated the plasma volume fraction (Vp), three studies evaluated the extravascular extracellular space volume fraction, and two studies evaluated the rate constant. There were variations in the type of primary cancer, RT techniques used, post-treatment scan time, and median follow-up time. Despite the variations, however, the collected evidence generally suggested that significant differences could be detected in DCE-MRI parameters between before and after RT, which might reflect treatment success or failures in long-term follow-up. Responders showed higher reduction and lower values of Ktrans and Vp after RT. DCE-MRI parameters showed changes and detectable recurrences significantly earlier (up to 6 months) than conventional MRI with favorable diagnostic values. CONCLUSION The results of this systematic review suggested that DCE-MRI parameter changes in patients with spinal metastases could be a promising tool for treatment-response assessment following RT. Lower values and higher reduction of Ktrans and Vp after treatment demonstrated good prediction of local control. Compared to conventional MRI, DCE-MRI showed more rapid changes and earlier prediction of treatment failure.
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Affiliation(s)
- Rahmad Mulyadi
- Department of Radiology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Pungky Permata Putri
- Department of Radiology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Handoko
- Department of Radiation Oncology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | | | - Joedo Prihartono
- Department of Community Medicine Pre Clinic, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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Gibbs WN, Basha MM, Chazen JL. Management Algorithm for Osseous Metastatic Disease: What the Treatment Teams Want to Know. Neuroimaging Clin N Am 2023; 33:487-497. [PMID: 37356864 DOI: 10.1016/j.nic.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
Radiologists play a primary role in identifying, characterizing, and classifying spinal metastases and can play a lifesaving role in the care of these patients by triaging those with instability to urgent spine surgery consultation. For this reason, an understanding of current treatment algorithms and principles of spinal stability in patients with cancer is vital for all who interpret spine studies. In addition, advances in imaging allow radiologists to provide more accurate diagnoses and characterize pathology, thereby improving patient safety.
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Affiliation(s)
- Wende N Gibbs
- Barrow Neurological Institute, Department of Neuroradiology, St. Joseph's Hospital and Medical Center, 350 West Thomas Road, Phoenix, AZ 85013, USA.
| | - Mahmud Mossa Basha
- University of Washington School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - J Levi Chazen
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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Saha A, Peck KK, Karimi S, Lis E, Holodny AI. Dynamic Contrast-Enhanced MR Perfusion: Role in Diagnosis and Treatment Follow-Up in Patients with Vertebral Body Tumors. Neuroimaging Clin N Am 2023; 33:477-486. [PMID: 37356863 DOI: 10.1016/j.nic.2023.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
Recent therapeutic advances have led to increased survival times for patients with metastatic disease. Key to survival is early diagnosis and subsequent treatment as well as early detection of treatment failure allowing for therapy modifications. Conventional MR imaging techniques of the spine can be at times suboptimal for identifying viable tumor, as structural changes and imaging characteristics may not differ pretreatment and posttreatment. Advanced imaging techniques such as DCE-MRI can allow earlier and more accurate noninvasive assessment of viable disease by characterizing physiologic changes and tumor microvasculature.
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Affiliation(s)
- Atin Saha
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Department of Radiology, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA.
| | - Kyung K Peck
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Sasan Karimi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Department of Radiology, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
| | - Eric Lis
- Department of Radiology, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
| | - Andrei I Holodny
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA. https://twitter.com/AndreiHolodny
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Camelo F, Peck KK, Saha A, Arevalo-Perez J, Lyo JK, Tisnado J, Lis E, Karimi S, Holodny AI. Delay of Aortic Arterial Input Function Time Improves Detection of Malignant Vertebral Body Lesions on Dynamic Contrast-Enhanced MRI Perfusion. Cancers (Basel) 2023; 15:cancers15082353. [PMID: 37190282 DOI: 10.3390/cancers15082353] [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: 01/27/2023] [Revised: 04/03/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023] Open
Abstract
Dynamic contrast-enhanced MRI (DCE) is an emerging modality in the study of vertebral body malignancies. DCE-MRI analysis relies on a pharmacokinetic model, which assumes that contrast uptake is simultaneous in the feeding of arteries and tissues of interest. While true in the highly vascularized brain, the perfusion of the spine is delayed. This delay of contrast reaching vertebral body lesions can affect DCE-MRI analyses, leading to misdiagnosis for the presence of active malignancy in the bone marrow. To overcome the limitation of delayed contrast arrival to vertebral body lesions, we shifted the arterial input function (AIF) curve over a series of phases and recalculated the plasma volume values (Vp) for each phase shift. We hypothesized that shifting the AIF tracer curve would better reflect actual contrast perfusion, thereby improving the accuracy of Vp maps in metastases. We evaluated 18 biopsy-proven vertebral body metastases in which standard DCE-MRI analysis failed to demonstrate the expected increase in Vp. We manually delayed the AIF curve for multiple phases, defined as the scan-specific phase temporal resolution, and analyzed DCE-MRI parameters with the new AIF curves. All patients were found to require at least one phase-shift delay in the calculated AIF to better visualize metastatic spinal lesions and improve quantitation of Vp. Average normalized Vp values were 1.78 ± 1.88 for zero phase shifts (P0), 4.72 ± 4.31 for one phase shift (P1), and 5.59 ± 4.41 for two phase shifts (P2). Mann-Whitney U tests obtained p-values = 0.003 between P0 and P1, and 0.0004 between P0 and P2. This study demonstrates that image processing analysis for DCE-MRI in patients with spinal metastases requires a careful review of signal intensity curve, as well as a possible adjustment of the phase of aortic AIF to increase the accuracy of Vp.
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Affiliation(s)
- Felipe Camelo
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- Weill Cornell Medicine, 1300 York Avenue, New York, NY 10065, USA
| | - Kyung K Peck
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Atin Saha
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Julio Arevalo-Perez
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - John K Lyo
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Jamie Tisnado
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Eric Lis
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Sasan Karimi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- Department of Radiology, Weill Medical College of Cornell University, 525 East 68th Street, New York, NY 10065, USA
| | - Andrei I Holodny
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- Department of Radiology, Weill Medical College of Cornell University, 525 East 68th Street, New York, NY 10065, USA
- Department of Neuroscience, Weill Cornell Graduate School of Medical Sciences, 1300 York Avenue, New York, NY 10065, USA
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11
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Bone marrow MR perfusion imaging and potential for tumor evaluation. Skeletal Radiol 2023; 52:477-491. [PMID: 36271181 DOI: 10.1007/s00256-022-04202-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 09/19/2022] [Accepted: 10/04/2022] [Indexed: 02/02/2023]
Abstract
The physiology of bone perfusion is reviewed outlining how it can be measured with dynamic contrast-enhanced MRI as well as intravoxel incoherent imaging. Evaluation of bone perfusion provides a potential means of assessing tumor activity and treatment response beyond that possible with standard MR imaging.
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12
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Quantifying the changes in the tumour vascular micro-environment in spinal metastases treated with stereotactic body radiotherapy - a single arm prospective study. Radiol Oncol 2022; 56:525-534. [PMID: 36503714 PMCID: PMC9784370 DOI: 10.2478/raon-2022-0046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/29/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The primary objective was to quantify changes in vascular micro-environment in spinal metastases (SM) patients treated with stereotactic body radiotherapy (SBRT) with multi-parametric dynamic contrast enhanced (DCE) magnetic resonance imaging (MRI). The secondary objective was to study plasma biomarkers related to endothelial apoptosis. PATIENTS AND METHODS Patients were imaged with DCE-MRI at baseline/1-week/12-weeks post-SBRT. Metrics including normalised time-dependent leakage (Ktrans), permeability surface product (PS), fractional plasma volume (Vp), extracellular volume (Ve) and perfusion (F) were estimated using distributed parameter model. Serum acid sphingomyelinase (ASM) and sphingosine-1-phosphate (S1P) were quantified using ELISA. Clinical outcomes including physician-scored and patient-reported toxicity were collected. RESULTS Twelve patients (with varying primary histology) were recruited, of whom 10 underwent SBRT. Nine patients (with 10 lesions) completed all 3 imaging assessment timepoints. One patient died due to pneumonia (unrelated) before follow-up scans were performed. Median SBRT dose was 27 Gy (range: 24-27) over 3 fractions (range: 2-3). Median follow-up for alive patients was 42-months (range: 22.3-54.3), with local control rate of 90% and one grade 2 or higher toxicity (vertebral compression fracture). In general, we found an overall trend of reduction at 12-weeks in all parameters (Ktrans/PS/Vp/Ve/F). Ktrans and PS showed a reduction as early as 1-week. Ve/Vp/F exhibited a slight rise 1-week post-SBRT before reducing below the baseline value. There were no significant changes, post-SBRT, in plasma biomarkers (ASM/S1P). CONCLUSIONS Tumour vascular micro-environment (measured by various metrics) showed a general trend towards downregulation post-SBRT. It is likely that vascular-mediated cell killing contributes to excellent local control rates seen with SBRT. Future studies should evaluate the effect of SBRT on primary-specific spinal metastases (e.g., renal cell carcinoma).
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Roth SG, Chambless LB. Editorial. Assessing treatment response following stereotactic body radiotherapy for spinal metastases. Neurosurg Focus 2022; 53:E11. [DOI: 10.3171/2022.8.focus22438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Steven G. Roth
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lola B. Chambless
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Harel R, Kaisman-Elbaz T, Emch T, Elson P, Chao ST, Suh JH, Angelov L. A quantitative and comparative evaluation of stereotactic spine radiosurgery local control: proposing a consistent measurement methodology. Neurosurg Focus 2022; 53:E10. [DOI: 10.3171/2022.8.focus22363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 08/03/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE
Stereotactic body radiotherapy (SBRT) is a precise and conformal treatment modality used in the management of metastatic spine tumors. Multiple studies have demonstrated its safety and efficacy for pain and tumor control. However, no uniform quantitative imaging methodology exists to evaluate response to treatment in these patients. This study presents radiographic local control rates post-SBRT, systematically compares measurements acquired according to WHO and Response Evaluation Criteria in Solid Tumors (RECIST) criteria, and explores the relationship to patient outcome.
METHODS
The authors performed a retrospective review of prospectively obtained data from a cohort of 59 consecutive patients (81 metastatic isocenters) treated with SBRT and followed with serial MRI scans. Measurements were performed by a neuroradiologist blinded to the patients’ clinical course. Local control status was determined according to both WHO and RECIST measurements, and agreement between the measuring methodologies was calculated and reported.
RESULTS
Eighty-one isocenters (111 vertebral bodies) were treated with SBRT. The mean treatment dose was 13.96 Gy and the median follow-up duration was 10.8 months, during which 408 MRI scans were evaluated with both WHO and RECIST criteria for each scan point. Imaging demonstrated a mean unidimensional size decrease of 0.2 cm (p = 0.14) and a mean area size decrease of 0.99 cm2 (p = 0.03). Although 88% of the case classifications were concordant and the agreement was significant, WHO criteria were found to be more sensitive to tumor size change. The local control rates according to WHO and RECIST were 95% and 98%, respectively.
CONCLUSIONS
Although WHO volumetric measurements are admittedly superior for tumor size measurement, RECIST is simpler, reproducible, and for the first time is shown here to be comparable to WHO criteria. Thus, the application of RECIST methodology appears to be a suitable standard for evaluating post-SBRT treatment response. Moreover, using comprehensive and consistent measuring approaches, this study substantiates the efficacy of SBRT in the treatment of spine metastases.
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Affiliation(s)
- Ran Harel
- Department of Neurosurgery, Sheba Medical Center Affiliated to Tel-Aviv University, Tel-Aviv, Israel
| | - Tehila Kaisman-Elbaz
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
| | - Todd Emch
- Imaging Institute, Cleveland Clinic, Cleveland
| | - Paul Elson
- Quantitative Health Sciences, Cleveland Clinic, Cleveland; and
| | - Samuel T Chao
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - John H Suh
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
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15
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Bahouth SM, Yeboa DN, Ghia AJ, Tatsui CE, Alvarez-Breckenridge CA, Beckham TH, Bishio AJ, Li J, McAleer MF, North RY, Rhines LD, Swanson TA, Chenyang W, Amini B. Multidisciplinary management of spinal metastases: what the radiologist needs to know. Br J Radiol 2022; 95:20220266. [PMID: 35856792 PMCID: PMC9815745 DOI: 10.1259/bjr.20220266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/17/2022] [Accepted: 07/11/2022] [Indexed: 01/13/2023] Open
Abstract
The modern management of spinal metastases requires a multidisciplinary approach that includes radiation oncologists, surgeons, medical oncologists, and diagnostic and interventional radiologists. The diagnostic radiologist can play an important role in the multidisciplinary team and help guide assessment of disease and selection of appropriate therapy. The assessment of spine metastases is best performed on MRI, but imaging from other modalities is often needed. We provide a review of the clinical and imaging features that are needed by the multidisciplinary team caring for patients with spine metastases and stress the importance of the spine radiologist taking responsibility for synthesizing imaging features across multiple modalities to provide a report that advances patient care.
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Affiliation(s)
- Sarah M Bahouth
- Musculoskeletal Imaging and Intervention Department, Brigham and Women’s Hospital, Boston MA, USA
| | - Debra N Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudio E Tatsui
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Thomas H Beckham
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Bishio
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert Y North
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laurence D Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Todd A Swanson
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wang Chenyang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Behrang Amini
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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16
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Kuah T, Vellayappan BA, Makmur A, Nair S, Song J, Tan JH, Kumar N, Quek ST, Hallinan JTPD. State-of-the-Art Imaging Techniques in Metastatic Spinal Cord Compression. Cancers (Basel) 2022; 14:cancers14133289. [PMID: 35805059 PMCID: PMC9265325 DOI: 10.3390/cancers14133289] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/24/2022] [Accepted: 06/28/2022] [Indexed: 12/23/2022] Open
Abstract
Metastatic Spinal Cord Compression (MSCC) is a debilitating complication in oncology patients. This narrative review discusses the strengths and limitations of various imaging modalities in diagnosing MSCC, the role of imaging in stereotactic body radiotherapy (SBRT) for MSCC treatment, and recent advances in deep learning (DL) tools for MSCC diagnosis. PubMed and Google Scholar databases were searched using targeted keywords. Studies were reviewed in consensus among the co-authors for their suitability before inclusion. MRI is the gold standard of imaging to diagnose MSCC with reported sensitivity and specificity of 93% and 97% respectively. CT Myelogram appears to have comparable sensitivity and specificity to contrast-enhanced MRI. Conventional CT has a lower diagnostic accuracy than MRI in MSCC diagnosis, but is helpful in emergent situations with limited access to MRI. Metal artifact reduction techniques for MRI and CT are continually being researched for patients with spinal implants. Imaging is crucial for SBRT treatment planning and three-dimensional positional verification of the treatment isocentre prior to SBRT delivery. Structural and functional MRI may be helpful in post-treatment surveillance. DL tools may improve detection of vertebral metastasis and reduce time to MSCC diagnosis. This enables earlier institution of definitive therapy for better outcomes.
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Affiliation(s)
- Tricia Kuah
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Correspondence: ; Tel.: +65-6779-5555
| | - Balamurugan A. Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore 119074, Singapore;
| | - Andrew Makmur
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - Shalini Nair
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
| | - Junda Song
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
| | - Jiong Hao Tan
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, 1E Lower Kent Ridge Road, Singapore 119228, Singapore; (J.H.T.); (N.K.)
| | - Naresh Kumar
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, 1E Lower Kent Ridge Road, Singapore 119228, Singapore; (J.H.T.); (N.K.)
| | - Swee Tian Quek
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - James Thomas Patrick Decourcy Hallinan
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
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17
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Guo L, Ke L, Zeng Z, Yuan C, Wu Z, Chen L, Lu L. Stereotactic body radiotherapy for spinal metastases: a review. Med Oncol 2022; 39:103. [DOI: 10.1007/s12032-021-01613-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/19/2021] [Indexed: 02/05/2023]
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18
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Kim CH, Lee JH, Lee JW, Kim E, Choi SH. Introducing a New Biomarker Named R2*-BOLD-MRI Parameter to Assess Treatment Response in Osteosarcoma. J Magn Reson Imaging 2021; 56:538-546. [PMID: 34888987 DOI: 10.1002/jmri.28023] [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: 09/15/2021] [Revised: 11/25/2021] [Accepted: 11/29/2021] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND While histologic response to neoadjuvant chemotherapy (NChT) is the major prognostic factor for osteosarcoma treatment, evaluating that response is difficult. PURPOSE To evaluate the feasibility of the blood oxygen level-dependent (BOLD) technique to assess the response to NChT. STUDY TYPE Prospective. POPULATION Twelve patients with osteosarcoma undergoing NChT. FIELD STRENGTH/SEQUENCE 3 T; T2*-weighted BOLD, dynamic contrast-enhanced (DCE) and diffusion-weighted (DW) (b values of 0, 400, and 1400 seconds/mm2 ) sequences. ASSESSMENT Examination was performed before treatment (first), after each cycle of treatment (second and third). At each time point, spin dephasing rates (R2*) from BOLD magnetic resonance imaging (MRI), parameters from DCE-MRI (volume transfer constant [Ktrans ], reflux rate [kep ], volume fraction of the extravascular extracellular matrix [ve ], and blood plasma volume [vp ]), and the apparent diffusion coefficient (ADC) from DW-MRI were measured. STATISTICAL TESTS Wilcoxon's signed rank test, Spearman's correlation coefficient (ρ) were used. A P-value of <0.05 was considered statistically significant. RESULTS The difference and relative difference of the R2* values between the first/third MRIs in the extraosseous portion were statistically significant. Only the differences in the kep values between the first/second and between the first/third MRIs in the extraosseous portion were significant. The differences in the ADCs in the extraosseous and osseous portions were not statistically significant (P = 0.151, P = 0.733 each in extraosseous portion and P = 0.569, P = 0.129 each in osseous portion). The relative difference in R2* values in the extraosseous portion between the first/third MRI (ρ = 0.706) was significantly better correlated with the pathologic grade than those of kep and ADC over the same period (ρ = 0.286 and ρ = -0.091, respectively). DATA CONCLUSION The R2* from the BOLD MRI technique could be a useful biomarker for evaluating treatment response in osteosarcoma treated with NchT. LEVEL OF EVIDENCE 5 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Chu Hyun Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ji Hyun Lee
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ji Won Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Eunju Kim
- Department of Clinical Science, MR, Philips Healthcare Korea, Seoul, South Korea
| | - Sang-Hee Choi
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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19
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Verma M, Sood S, Singh B, Thakur M, Sharma S. Dynamic contrast-enhanced magnetic resonance perfusion volumetrics can differentiate tuberculosis of the spine and vertebral malignancy. Acta Radiol 2021; 63:1504-1512. [PMID: 34806421 DOI: 10.1177/02841851211043838] [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: 11/16/2022]
Abstract
BACKGROUND There is considerable overlap in radiologic features of tubercular and malignant spinal lesions on conventional magnetic resonance imaging (MRI). PURPOSE To evaluate the role of dynamic contrast-enhanced (DCE) MRI perfusion parameters in differentiating vertebral malignancy from spinal tuberculosis. MATERIAL AND METHODS This was a prospective study and we enrolled consecutive patients presenting with a clinical/radiologic evidence of vertebral lesions. DCE-MRI of the spine was performed using 3D volume interpolated breath-hold examination (VIBE) sequence after intravenously injecting 0.1 mmol/kg body weight of gadopentetate dimeglumine. We used Tofts model to calculate DCE parameters that included Ktrans (transfer constant), kep (rate constant), ve (fractional volume of extracellular extravascular space), and iAUC (initial area under the curve). We compared the mean value of each perfusion parameter by type of lesion (tubercular/malignant) at 0.05 significance level and performed receiver operating characteristic curve analysis. RESULTS We could confirm histologic/cytologic diagnosis in 35 of the 45 patients recruited. Of these, 19 were tubercular and 16 were malignant lesions. The mean (± standard deviation) of kep (min-1) was significantly higher (2.89 ± 3.3) in malignant compared to tubercular lesions (0.81 ± 0.19), whereas ve was significantly lower in malignant (0.27 ± 0.13 mL/g) compared to benign lesions (0.47 ± 0.12 mL/g) at 0.05 significance level. kep cutoff of ≥1.17 min-1 had a sensitivity of 93.8% and specificity of 100% with a diagnostic accuracy of 94.4% in detecting malignant disease. CONCLUSION High kep is the single best predictor of malignant vertebral lesions. We recommend kep cutoff value of ≥1.17 min-1 that has high diagnostic accuracy in identifying malignant lesions.
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Affiliation(s)
- Mansi Verma
- Department of Radiodiagnosis, Indira Gandhi Medical College, Shimla, India
| | - Shikha Sood
- Department of Radiodiagnosis, Indira Gandhi Medical College, Shimla, India
| | - Balraj Singh
- Department of Community Medicine, Indira Gandhi Medical College, Shimla, India
| | - Manoj Thakur
- Department of Orthopaedics, Indira Gandhi Medical College, Shimla, India
| | - Sudershan Sharma
- Department of Pathology, Indira Gandhi Medical College, Shimla, India
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20
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Chen Y, Zhang E, Wang Q, Yuan H, Zhuang H, Lang N. Use of dynamic contrast-enhanced MRI for the early assessment of outcome of CyberKnife stereotactic radiosurgery for patients with spinal metastases. Clin Radiol 2021; 76:864.e1-864.e6. [PMID: 34404514 DOI: 10.1016/j.crad.2021.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
AIM To explore the value of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for evaluating early outcomes of CyberKnife radiosurgery for spinal metastases. MATERIALS AND METHODS Patients with spinal metastases who were treated with CyberKnife radiosurgery from July 2018 to December 2020 were enrolled. Conventional MRI and DCE-MRI were performed before treatment and at 3 months after treatment. Patients showing disease progression were defined as the progressive disease (PD) group and those showing complete response, partial response, and stable disease were defined as the non-PD group. The haemodynamic parameters (volume transfer constant [Ktrans], rate constant [Kep], and extravascular space [Ve]) before and after treatment between the groups were analysed. Area under the curve (AUC) values were calculated. RESULTS A total of 27 patients with 39 independent spinal lesions were included. The median follow-up time was 18.6 months (6.2-36.4 months). There were 27 lesions in the non-PD group and 12 lesions in the PD group. Post-treatment Kep, ΔKtrans and ΔKep in the non-PD group (0.959/min, - 32.6% and -41.1%, respectively) were significantly lower than the corresponding values in PD group (1.429/min, 20.4% and -6%; p<0.05). Post-treatment Ve and ΔVe (0.223 and 27.8%, respectively) in the non-PD group were significantly higher than that of the PD group (0.165 and -13.5%, p<0.05). ΔKtrans showed the highest diagnostic efficiency, with an AUC of 0.821. CONCLUSIONS DCE-MRI parameters change significantly at an early stage after CyberKnife stereotactic radiosurgery for spinal metastases. DCE-MRI may be of value in determining the early treatment response.
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Affiliation(s)
- Y Chen
- Department of Radiology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, PR China
| | - E Zhang
- Department of Radiology, Peking University International Hospital, 1 Life Science Park, Life Road, Haidian District, Beijing, 102206, PR China
| | - Q Wang
- Department of Radiology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, PR China
| | - H Yuan
- Department of Radiology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, PR China
| | - H Zhuang
- Department of Radiotherapy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, PR China
| | - N Lang
- Department of Radiology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, PR China.
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21
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Lee JH, Yoo GS, Yoon YC, Park HC, Kim HS. Diffusion-weighted and dynamic contrast-enhanced magnetic resonance imaging after radiation therapy for bone metastases in patients with hepatocellular carcinoma. Sci Rep 2021; 11:10459. [PMID: 34001997 PMCID: PMC8128906 DOI: 10.1038/s41598-021-90065-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/04/2021] [Indexed: 12/24/2022] Open
Abstract
The objectives of this study were to assess changes in apparent diffusion coefficient (ADC) and dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) parameters after radiation therapy (RT) for bone metastases from hepatocellular carcinoma (HCC) and to evaluate their prognostic value. This prospective study was approved by the Institutional Review Board. Fourteen patients with HCC underwent RT (30 Gy in 10 fractions once daily) for bone metastases. The ADC and DCE-MRI parameters and the volume of the target lesions were measured before (baseline) and one month after RT (post-RT). The Wilcoxon signed-rank test was used to compare the parameters between the baseline and post-RT MRI. The parameters were compared between patients with or without disease progression in RT fields using the Mann–Whitney test. Intraclass correlation coefficients were used to evaluate the interobserver agreement. The medians of the ADC, rate constant [kep], and volume fraction of the extravascular extracellular matrix [ve] in the baseline and post-RT MRI were 0.67 (range 0.61–0.72) and 0.75 (range 0.63–1.43) (× 10–3 mm2/s) (P = 0.027), 836.33 (range 301.41–1082.32) and 335.80 (range 21.86–741.87) (× 10–3/min) (P = 0.002), and 161.54 (range 128.38–410.13) and 273.99 (range 181.39–1216.95) (× 10–3) (P = 0.027), respectively. The medians of the percent change in the ADC of post-RT MRI in patients with progressive disease and patients without progressive disease were − 1.35 (range − 6.16 to 6.79) and + 46.71 (range 7.71–112.81) (%) (P = 0.011), respectively. The interobserver agreements for all MRI parameters were excellent (intraclass correlation coefficients > 0.8). In conclusion, the ADC, kep, and ve of bone metastases changed significantly after RT. The percentage change in the ADC was closely related to local tumor progression.
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Affiliation(s)
- Ji Hyun Lee
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Gyu Sang Yoo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Young Cheol Yoon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
| | - Hyun Su Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
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22
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Guan Y, Peck KK, Lyo J, Tisnado J, Lis E, Arevalo-Perez J, Yamada Y, Hameed MR, Karimi S, Holodny A. T1-weighted Dynamic Contrast-enhanced MRI to Differentiate Nonneoplastic and Malignant Vertebral Body Lesions in the Spine. Radiology 2020; 297:382-389. [PMID: 32870135 DOI: 10.1148/radiol.2020190553] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Dynamic contrast agent-enhanced (DCE) perfusion MRI may help differentiate between nonneoplastic and malignant lesions in the spine. Purpose To investigate the correlation between fractional plasma volume (Vp), a parameter derived from DCE perfusion MRI, and histopathologic diagnosis for spinal lesions. Materials and Methods In this retrospective study, patients who underwent DCE perfusion MRI and lesion biopsy between May 2015 and May 2018 were included. Inclusion criteria were short time interval (<30 days) between DCE perfusion MRI and biopsy, DCE perfusion MRI performed before biopsy, and DCE perfusion MRI performed at the same spine level as biopsy. Exclusion criteria were prior radiation treatment on vertebrae of interest, poor DCE perfusion MRI quality, nondiagnostic biopsy, and extensive spinal metastasis or prior kyphoplasty. One hundred thirty-four lesions were separated into a nonneoplastic group (n = 51) and a malignant group (n = 83) on the basis of histopathologic analysis. Two investigators manually defined regions of interest in the vertebrae. DCE perfusion MRI parameter Vp was calculated by using the Tofts pharmacokinetic two-compartment model. Vp was quantified, normalized to adjacent normal vertebrae, and compared between the two groups. A Mann-Whitney U test and receiver operating characteristic analysis was performed to verify the difference in Vp between the nonneoplastic and malignant groups. Reproducibility was assessed by calculating the Cohen κ coefficient. Results One hundred patients (mean age, 65 years ± 11 [standard deviation]; 52 men) were evaluated. Vp was lower in nonneoplastic lesions versus malignant lesions (1.6 ± 1.3 vs 4.2 ± 3.0, respectively; P < .001). The sensitivity of Vp was 93% (77 of 83; 95% confidence interval [CI]: 85%, 97%), specificity was 78% (40 of 51; 95% CI: 65%, 89%), and area under the receiver operating characteristic curve was 0.88 (95% CI: 0.82, 0.95). Cohen κ coefficient suggested substantial agreement in both intra- (κ = 0.72) and interreader (κ = 0.70) reproducibility. Conclusion This study indicated that dynamic contrast agent-enhanced perfusion MRI parameter, fractional plasma volume, was able to differentiate between nonneoplastic spinal lesions and malignant lesions. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Haller in this issue.
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Affiliation(s)
- Youxin Guan
- From the Departments of Radiology (Y.G., K.K.P., J.L., J.T., E.L., J.A.P., S.K., A.H.), Medical Physics (K.K.P.), Radiation Oncology (Y.Y.), and Pathology (M.R.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021; Department of Radiology, Weill Medical College of Cornell University, New York, NY (A.H.); and Department of Neuroscience, Weill-Cornell Graduate School of the Medical Sciences, New York, NY (A.H.)
| | - Kyung K Peck
- From the Departments of Radiology (Y.G., K.K.P., J.L., J.T., E.L., J.A.P., S.K., A.H.), Medical Physics (K.K.P.), Radiation Oncology (Y.Y.), and Pathology (M.R.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021; Department of Radiology, Weill Medical College of Cornell University, New York, NY (A.H.); and Department of Neuroscience, Weill-Cornell Graduate School of the Medical Sciences, New York, NY (A.H.)
| | - John Lyo
- From the Departments of Radiology (Y.G., K.K.P., J.L., J.T., E.L., J.A.P., S.K., A.H.), Medical Physics (K.K.P.), Radiation Oncology (Y.Y.), and Pathology (M.R.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021; Department of Radiology, Weill Medical College of Cornell University, New York, NY (A.H.); and Department of Neuroscience, Weill-Cornell Graduate School of the Medical Sciences, New York, NY (A.H.)
| | - Jamie Tisnado
- From the Departments of Radiology (Y.G., K.K.P., J.L., J.T., E.L., J.A.P., S.K., A.H.), Medical Physics (K.K.P.), Radiation Oncology (Y.Y.), and Pathology (M.R.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021; Department of Radiology, Weill Medical College of Cornell University, New York, NY (A.H.); and Department of Neuroscience, Weill-Cornell Graduate School of the Medical Sciences, New York, NY (A.H.)
| | - Eric Lis
- From the Departments of Radiology (Y.G., K.K.P., J.L., J.T., E.L., J.A.P., S.K., A.H.), Medical Physics (K.K.P.), Radiation Oncology (Y.Y.), and Pathology (M.R.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021; Department of Radiology, Weill Medical College of Cornell University, New York, NY (A.H.); and Department of Neuroscience, Weill-Cornell Graduate School of the Medical Sciences, New York, NY (A.H.)
| | - Julio Arevalo-Perez
- From the Departments of Radiology (Y.G., K.K.P., J.L., J.T., E.L., J.A.P., S.K., A.H.), Medical Physics (K.K.P.), Radiation Oncology (Y.Y.), and Pathology (M.R.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021; Department of Radiology, Weill Medical College of Cornell University, New York, NY (A.H.); and Department of Neuroscience, Weill-Cornell Graduate School of the Medical Sciences, New York, NY (A.H.)
| | - Yoshiya Yamada
- From the Departments of Radiology (Y.G., K.K.P., J.L., J.T., E.L., J.A.P., S.K., A.H.), Medical Physics (K.K.P.), Radiation Oncology (Y.Y.), and Pathology (M.R.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021; Department of Radiology, Weill Medical College of Cornell University, New York, NY (A.H.); and Department of Neuroscience, Weill-Cornell Graduate School of the Medical Sciences, New York, NY (A.H.)
| | - Meera R Hameed
- From the Departments of Radiology (Y.G., K.K.P., J.L., J.T., E.L., J.A.P., S.K., A.H.), Medical Physics (K.K.P.), Radiation Oncology (Y.Y.), and Pathology (M.R.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021; Department of Radiology, Weill Medical College of Cornell University, New York, NY (A.H.); and Department of Neuroscience, Weill-Cornell Graduate School of the Medical Sciences, New York, NY (A.H.)
| | - Sasan Karimi
- From the Departments of Radiology (Y.G., K.K.P., J.L., J.T., E.L., J.A.P., S.K., A.H.), Medical Physics (K.K.P.), Radiation Oncology (Y.Y.), and Pathology (M.R.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021; Department of Radiology, Weill Medical College of Cornell University, New York, NY (A.H.); and Department of Neuroscience, Weill-Cornell Graduate School of the Medical Sciences, New York, NY (A.H.)
| | - Andrei Holodny
- From the Departments of Radiology (Y.G., K.K.P., J.L., J.T., E.L., J.A.P., S.K., A.H.), Medical Physics (K.K.P.), Radiation Oncology (Y.Y.), and Pathology (M.R.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021; Department of Radiology, Weill Medical College of Cornell University, New York, NY (A.H.); and Department of Neuroscience, Weill-Cornell Graduate School of the Medical Sciences, New York, NY (A.H.)
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O'Sullivan S, McDermott R, Keys M, O'Sullivan M, Armstrong J, Faul C. Imaging response assessment following stereotactic body radiotherapy for solid tumour metastases of the spine: Current challenges and future directions. J Med Imaging Radiat Oncol 2020; 64:385-397. [PMID: 32293114 DOI: 10.1111/1754-9485.13032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 03/09/2020] [Indexed: 01/01/2023]
Abstract
Patients with metastatic disease are routinely serially imaged to assess disease burden and response to systemic and local therapies, which places ever-expanding demands on our healthcare resources. Image interpretation following stereotactic body radiotherapy (SBRT) for spine metastases can be challenging; however, appropriate and accurate assessment is critical to ensure patients are managed correctly and resources are optimised. Here, we take a critical review of the merits and pitfalls of various imaging modalities, current response assessment guidelines, and explore novel imaging approaches and the potential for radiomics to add value in imaging assessment.
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Affiliation(s)
- Siobhra O'Sullivan
- St Luke's Institute of Cancer Research, St Luke's Radiation Oncology Network, Dublin 6, Ireland.,Department of Radiation Oncology, St Luke's Radiation Oncology Network, Dublin 6, Ireland
| | - Ronan McDermott
- St Luke's Institute of Cancer Research, St Luke's Radiation Oncology Network, Dublin 6, Ireland.,Department of Radiation Oncology, St Luke's Radiation Oncology Network, Dublin 6, Ireland
| | - Maeve Keys
- Department of Radiation Oncology, St Luke's Radiation Oncology Network, Dublin 6, Ireland
| | - Maeve O'Sullivan
- Department of Radiology, Beaumont Hospital, Royal College of Surgeons of Ireland, Dublin 9, Ireland
| | - John Armstrong
- Department of Radiation Oncology, St Luke's Radiation Oncology Network, Dublin 6, Ireland
| | - Clare Faul
- Department of Radiation Oncology, St Luke's Radiation Oncology Network, Dublin 6, Ireland
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Gong Y, Xu L, Zhuang H, Jiang L, Wei F, Liu Z, Li Y, Yu M, Ni K, Liu X. Efficacy and safety of different fractions in stereotactic body radiotherapy for spinal metastases: A systematic review. Cancer Med 2019; 8:6176-6184. [PMID: 31489788 PMCID: PMC6797563 DOI: 10.1002/cam4.2546] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/28/2019] [Accepted: 08/23/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In the treatment of spinal metastases, stereotactic body radiotherapy (SBRT) delivers precise, high-dose radiation to the target region while sparing the spinal cord. A range of doses and fractions had been reported; however, the optimal prescribed scheme remains unclear. METHODS Two reviewers performed independent literature searches of the PubMed, EMBASE, Cochrane Database, and Web of Science databases. Articles were divided into one to five fractions groups. The Methodological Index for Non-randomized Studies (MINORS) was used to assess the quality of studies. Local control (LC) and overall survival (OS) were presented for the included studies and a pooled value was calculated by the weighted average. RESULTS The 38 included studies comprised 3,754 patients with 4,731 lesions. The average 1-year LCs for the one to five fractions were 92.7%, 84.6%, 86.8%, 82.6%, and 80.6%, respectively. The average 1-year OS for the one to five fractions were 53.0%, 70.4%, 60.1%, 48%, and 80%, respectively. The 24 Gy/single fraction scheme had a higher 1-year LC (98.1%) than those of 24 Gy/two fractions (85.4%), 27 Gy/three fractions (84.9%), and 24 Gy/three fractions (89.0%). The incidence of vertebral compression fracture was 10.3%, with 10.7% in the single-fraction group and 10.1% in the multi-fraction group. The incidence of radiation-induced myelopathy was 0.19%; three and two patients were treated with single-fraction and multi-fraction SBRT, respectively. The incidence of radiculopathy was 0.30% and all but one patient were treated with multi-fraction SBRT. CONCLUSIONS SBRT provided satisfactory efficacy and acceptable safety for spinal metastases. Single-fraction SBRT demonstrated a higher local control rate than those of the other factions, especially the 24 Gy dose. The risk of vertebral compression fracture (VCF) was slightly higher in single-fraction SBRT and more patients developed radiculopathy after multi-fraction SBRT.
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Affiliation(s)
- Yining Gong
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Lingyi Xu
- Eight-Year-Program, Grade 2015, Health Science Center, Peking University, Beijing, China
| | - Hongqing Zhuang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Liang Jiang
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Feng Wei
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Zhongjun Liu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Yan Li
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Miao Yu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Kaiwen Ni
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Xiaoguang Liu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
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25
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Mossa-Basha M, Gerszten PC, Myrehaug S, Mayr NA, Yuh WT, Jabehdar Maralani P, Sahgal A, Lo SS. Spinal metastasis: diagnosis, management and follow-up. Br J Radiol 2019; 92:20190211. [PMID: 31322920 DOI: 10.1259/bjr.20190211] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Spine metastatic disease is an increasingly common occurrence in cancer patients due to improved patient survival. Close proximity of the bony spinal column to the spinal cord limits many conventional treatments for metastatic disease. In the past decade, we have witnessed dramatic advancements in therapies, with improvements in surgical techniques and recent adoption of spine stereotactic radiotherapy techniques leading to improved patient outcomes. Multidisciplinary approaches to patient evaluation, treatment and follow-up are essential. Imaging plays an ever increasing role in disease detection, pre-treatment planning and assessment of patient outcomes. It is important for the radiologist to be familiar with imaging algorithms, best practices for surgery and/or radiotherapy and imaging findings in the post-treatment period that may indicate disease recurrence. In this review, we present a multidisciplinary discussion of spine metastases, with specific focus on pre-treatment imaging, planning, current treatment approaches, and post-treatment assessment.
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Affiliation(s)
| | - Peter C Gerszten
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Nina A Mayr
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - William Tc Yuh
- Department of Radiology, University of Washington, Seattle, WA
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA
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Neuroimaging and Stereotactic Body Radiation Therapy (SBRT) for Spine Metastasis. Top Magn Reson Imaging 2019; 28:85-96. [PMID: 31022051 DOI: 10.1097/rmr.0000000000000199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Historically, management options for spinal metastases include surgery for stabilization and decompression and/or external beam radiation therapy (EBRT). EBRT is palliative in nature, as it lacks accurate targeting such that the prescribed radiation doses must be limited in order to maintain safety. Modern advancement in imaging and radiotherapy technology have facilitated the development of stereotactic body radiation therapy (SBRT), which provides increased targeted precision for radiation delivery to tumors resulting in lower overall toxicity, particularly to regional structures such as the spinal cord and esophagus, while delivering higher, more effective, and radically ablative radiation doses.Over the past decade, SBRT has been increasingly utilized as a method of treating spinal metastases either as the primary modality or following surgical intervention in both de novo and reirradiation setting. Numerous studies suggest that SBRT is associated with an 80% to 90% rate of 1-year local control across clinical scenarios. For example, studies of SBRT as the primary treatment modality suggest long-term local control rate of 80% to 95% for spinal metastases. Similarly, SBRT in the adjuvant setting following surgery is associated with local control rates ranging from 70% to 100%. Furthermore, because SBRT allows for lower dose to the spinal cord, it has also been used in patients who have had prior radiation therapy, with studies showing 66% to 93% local control in this scenario.
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Özdemir Y, Torun N, Topkan E. Stereotaktik radyocerrahi uygulanan vertebra metastazlarında yanıt değerlendirmesinde PET-BT’nin yeri. CUKUROVA MEDICAL JOURNAL 2019. [DOI: 10.17826/cumj.453287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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