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Jensen SB, Jæhger DE, Serrano-Chávez E, Halldórsdóttir HR, Engel TB, Jørgensen JS, Björgvinsdóttir UJ, Kostrikov S, Scheeper MJ, Ringgaard L, Bruun LM, Stavnsbjerg C, Christensen E, Bak M, Thuroczy J, Balogh L, Jensen ATI, Melander F, Kjaer A, Henriksen JR, Hansen AE, Andresen TL. An in situ depot for the sustained release of a TLR7/8 agonist in combination with a TGFβ inhibitor promotes anti-tumor immune responses. Nat Commun 2024; 15:7687. [PMID: 39227589 PMCID: PMC11371921 DOI: 10.1038/s41467-024-50967-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 07/26/2024] [Indexed: 09/05/2024] Open
Abstract
Cancer curing immune responses against heterogeneous solid cancers require that a coordinated immune activation is initiated in the antigen avid but immunosuppressive tumor microenvironment (TME). The plastic TME, and the poor systemic tolerability of immune activating drugs are, however, fundamental barriers to generating curative anticancer immune responses. Here, we introduce the CarboCell technology to overcome these barriers by forming an intratumoral sustained drug release depot that provides high payloads of immune stimulatory drugs selectively within the TME. The CarboCell thereby induces a hot spot for immune cell training and polarization and further drives and maintains the tumor-draining lymph nodes in an anticancer and immune activated state. Mechanistically, this transforms cancerous tissues, consequently generating systemic anticancer immunoreactivity. CarboCell can be injected through standard thin-needle technologies and has inherent imaging contrast which secure accurate intratumoral positioning. In particular, here we report the therapeutic performance for a dual-drug CarboCell providing sustained release of a Toll-like receptor 7/8 agonist and a transforming growth factor-β inhibitor in preclinical tumor models in female mice.
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Affiliation(s)
- Sophie B Jensen
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Ditte E Jæhger
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Elizabeth Serrano-Chávez
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Hólmfríður R Halldórsdóttir
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Trine B Engel
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Jennifer S Jørgensen
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Unnur J Björgvinsdóttir
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Serhii Kostrikov
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Marouschka J Scheeper
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Lars Ringgaard
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Linda M Bruun
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Camilla Stavnsbjerg
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Esben Christensen
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Martin Bak
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | | | | | - Andreas T I Jensen
- Department of Health Technology, Center for Nanomedicine and Theranostics, Technical University of Denmark, Roskilde, Denmark
| | - Fredrik Melander
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Andreas Kjaer
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital, Copenhagen, Denmark
- Cluster for Molecular Imaging, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonas R Henriksen
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Anders E Hansen
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Thomas L Andresen
- Department of Health Technology, Biotherapeutic Engineering and Drug Targeting, Technical University of Denmark, Kgs. Lyngby, Denmark.
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Bleeker M, Hulshof MCCM, Bel A, Sonke JJ, van der Horst A. Stomach Motion and Deformation: Implications for Preoperative Gastric Cancer Radiation Therapy. Int J Radiat Oncol Biol Phys 2024; 118:543-553. [PMID: 37633498 DOI: 10.1016/j.ijrobp.2023.08.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 08/10/2023] [Accepted: 08/17/2023] [Indexed: 08/28/2023]
Abstract
PURPOSE Selection and development of image guided strategies for preoperative gastric radiation therapy requires quantitative knowledge of the various sources of anatomic changes of the stomach. This study aims to investigate the magnitude of interfractional and intrafractional stomach motion and deformation using fiducial markers and 4-dimensional (4D) imaging. METHODS AND MATERIALS Fourteen patients who underwent preoperative gastric cancer radiation therapy received 2 to 6 fiducial markers distributed throughout the stomach (total of 54 markers) and additional imaging (ie, 1 planning 4D computed tomography [pCT], 20-25 pretreatment 4D cone beam [CB] CTs, 4-5 posttreatment 4D CBCTs). Marker coordinates on all end-exhale (EE) and end-inhale (EI) scans were obtained after a bony anatomy match. Interfractional marker displacements (ie, between EE pCT and all EE CBCTs) were evaluated for 5 anatomic regions (ie, cardia, small curvature, proximal and distal large curvature, and pylorus). Motion was defined as displacement of the center-of-mass of available markers (COMstomach), deformation as the average difference in marker-pair distances. Interfractional (ie, between EE pCT and all EE CBCTs), respiratory (between EE and EI pCT and CBCTs), and pre-post (pre- and posttreatment EE CBCTs) motion and deformation were quantified. RESULTS The interfractional marker displacement varied per anatomic region and direction, with systematic and random errors ranging from 1.6-8.8 mm and 2.2-8.2 mm, respectively. Respiratory motion varied per patient (median, 3-dimensional [3D] amplitude 5.2-20.0 mm) and day (interquartile range, 0.8-4.2 mm). Regarding COMstomach motion, respiratory motion was larger than interfractional motion (median, 10.9 vs 8.9 mm; P < .0001; Wilcoxon rank-sum), which was larger than pre-post motion (3.6 mm; P < .0001). Interfractional deformations (median, 5.8 mm) were significantly larger than pre-post deformations (2.6 mm; P < .0001), which were larger than respiratory deformation (1.8 mm; P < .0001). CONCLUSIONS The demonstrated sizable stomach motions and deformations during radiation therapy stress the need for generous nonuniform planning target volume margins for preoperative gastric cancer radiation therapy. These margins can be decreased by daily image guidance and adaptive radiation therapy.
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Affiliation(s)
- Margot Bleeker
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Astrid van der Horst
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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Brown K, Ghita M, Prise KM, Butterworth KT. Feasibility and guidelines for the use of an injectable fiducial marker (BioXmark ®) to improve target delineation in preclinical radiotherapy studies using mouse models. F1000Res 2023; 12:526. [PMID: 38799243 PMCID: PMC11116939 DOI: 10.12688/f1000research.130883.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Preclinical models of radiotherapy (RT) response are vital for the continued success and evolution of RT in the treatment of cancer. The irradiation of tissues in mouse models necessitates high levels of precision and accuracy to recapitulate clinical exposures and limit adverse effects on animal welfare. This requirement has been met by technological advances in preclinical RT platforms established over the past decade. Small animal RT systems use onboard computed tomography (CT) imaging to delineate target volumes and have significantly refined radiobiology experiments with major 3Rs impacts. However, the CT imaging is limited by the differential attenuation of tissues resulting in poor contrast in soft tissues. Clinically, radio-opaque fiducial markers (FMs) are used to establish anatomical reference points during treatment planning to ensure accuracy beam targeting, this approach is yet to translate back preclinical models. METHODS We report on the use of a novel liquid FM BioXmark ® developed by Nanovi A/S (Kongens Lyngby, Denmark) that can be used to improve the visualisation of soft tissue targets during beam targeting and minimise dose to surrounding organs at risk. We present descriptive protocols and methods for the use of BioXmark ® in experimental male and female C57BL/6J mouse models. RESULTS These guidelines outline the optimum needle size for uptake (18-gauge) and injection (25- or 26-gauge) of BioXmark ® for use in mouse models along with recommended injection volumes (10-20 µl) for visualisation on preclinical cone beam CT (CBCT) scans. Injection techniques include subcutaneous, intraperitoneal, intra-tumoral and prostate injections. CONCLUSIONS The use of BioXmark ® can help to standardise targeting methods, improve alignment in preclinical image-guided RT and significantly improve the welfare of experimental animals with the reduction of normal tissue exposure to RT.
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Affiliation(s)
- Kathryn Brown
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, BT9 7AE, UK
| | - Mihaela Ghita
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, BT9 7AE, UK
| | - Kevin M Prise
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, BT9 7AE, UK
| | - Karl T Butterworth
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, BT9 7AE, UK
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Moreau M, Richards G, Yasmin-Karim S, Narang A, Deville C, Ngwa W. A liquid immunogenic fiducial eluter for image-guided radiotherapy. Front Oncol 2022; 12:1020088. [PMID: 36620560 PMCID: PMC9812550 DOI: 10.3389/fonc.2022.1020088] [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: 08/15/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Fiducials are routinely used to provide image-guidance during radiotherapy. Here, a new nanoparticle-based liquid immunogenic fiducial is investigated for its potential to provide image-guidance, while also enhancing treatment outcomes. Methods This fiducial, liquid immunogenic fiducial eluter (LIFE) biomaterial, is formulated with natural biodegradable polymers, chitosan and sodium alginate with radio-sensitizing nanoparticles, and immunoadjuvant like anti-CD40 monoclonal antibody. Once administered intra-tumorally, this liquid smart radiotherapy biomaterial congeals within the calcium rich tumor microenvironment. The potential use of LIFE biomaterial for providing image guidance in magnetic resonance imaging (MRI) and computed tomography (CT) was investigated over different time period in a pre-clinical tumored mouse model. Results Results showed that the LIFE biomaterial can provide both MRI contrast and CT imaging contrast over 3-weeks, with gradual decrease of the contrast over time, as the LIFE biomaterial biodegrades. Results also showed the LIFE biomaterial significantly slowed tumor growth and prolonged mice survival (p < 0.0001) over time. Discussion The results highlight the potential use of the LIFE biomaterial as a multi-functional smart radiotherapy biomaterial that could be developed and optimized for hypo-fractionated radiotherapy applications and combining radiotherapy with immunoadjuvants.
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Affiliation(s)
- Michele Moreau
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States,Department of Radiation Oncology and Molecular Radiation Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, United States,Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States,*Correspondence: Michele Moreau, ; Wilfred Ngwa,
| | - Geraud Richards
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - Sayeda Yasmin-Karim
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - Amol Narang
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Curtiland Deville
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Wilfred Ngwa
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States,Department of Radiation Oncology and Molecular Radiation Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, United States,Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States,*Correspondence: Michele Moreau, ; Wilfred Ngwa,
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Be KH, Khor R, Lim Joon D, Starvaggi B, Chao M, Ng SP, Ng M, Zorron Cheng Tao Pu L, Efthymiou M, Vaughan R, Chandran S. Long-term clinical outcomes of lipiodol marking using standard gastroscopy for image-guided radiotherapy of upper gastrointestinal cancers. World J Gastroenterol 2021; 27:7387-7401. [PMID: 34876797 PMCID: PMC8611208 DOI: 10.3748/wjg.v27.i42.7387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/26/2021] [Accepted: 10/27/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Image-guided radiotherapy (IGRT) has significantly improved the precision in which radiotherapy is delivered in cancer treatment. Typically, IGRT uses bony landmarks and key anatomical structures to locate the tumor. Recent studies have demonstrated the feasibility of peri-tumor fiducials in enabling even more accurate delineation of target and normal tissue. The use of gold coils as fiducials in gastrointestinal tumors has been extensively studied. However, placement requires expertise and specialized endoscopic ultrasound equipment. This article reports the long-term outcomes of using a standard gastroscopy to inject liquid fiducials for the treatment of oesophageal and gastric tumors with IGRT.
AIM To assess the long-term outcomes of liquid fiducial-guided IGRT in a cohort of oesophageal and gastric cancer patients.
METHODS A retrospective cohort study of consecutive adults with Oesophagogastric cancers referred for liquid fiducial placement before definitive/neo-adjuvant or palliative IGRT between 2013 and 2021 at a tertiary hospital in Melbourne, Australia was conducted. Up to four liquid fiducials were inserted per patient, each injection consisting of 0.2-0.5mL of a 1:1 mixture of iodized oil (Lipiodol; Aspen Pharmacare) and n-butyl 2-cyanoacrylate (Histoacryl®; B. Braun). A 23-gauge injector (Cook Medical) was used for the injection. All procedures were performed by or under the supervision of a gastroenterologist. Liquid fiducial-based IGRT (LF-IGRT) consisted of computer-assisted direct matching of the fiducial region on cone-beam computerised tomography at the time of radiotherapy. Patients received standard-IGRT (S-IGRT) if fiducial visibility was insufficient, consisting of bone match as a surrogate for tumor position. Radiotherapy was delivered to 54Gy in 30 fractions for curative patients and up to 45Gy in 15 fractions for palliative treatments.
RESULTS 52 patients were referred for liquid fiducial placement within the study period. A total of 51 patients underwent liquid fiducial implantation. Of these a total of 31 patients received radiotherapy. Among these, the median age was 77.4 years with a range between 57.5 and 88.8, and 64.5% were male. Twenty-seven out of the 31 patients were able to have LF-IGRT while four had S-IGRT. There were no complications after endoscopic implantation of liquid fiducials in our cohort. The cohort overall survival (OS) post-radiotherapy was 19 mo (range 0 to 87 mo). Whilst the progression-free survival (PFS) post-radiotherapy was 13 mo (range 0 to 74 mo). For those treated with curative intent, the median OS was 22.0 mo (range 0 to 87 mo) with a PFS median of 14.0 mo (range 0 to 74 mo). Grade 3 complication rate post-radiotherapy was 29%.
CONCLUSION LF-IGRT is feasible in 87.1% of patients undergoing liquid fiducial placement through standard gastroscopy injection technique. Our cohort has an overall survival of 19 mo and PFS of 13 mo. Further studies are warranted to determine the long-term outcomes of liquid-fiducial based IGRT.
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Affiliation(s)
- Kim Hay Be
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Richard Khor
- Department of Radiation Oncology, Austin Health, Heidelberg 3084, Victoria, Australia
- School of Cancer Medicine, La Trobe University, Melbourne 3086, Victoria, Australia
| | - Daryl Lim Joon
- Department of Radiation Oncology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Ben Starvaggi
- Department of Radiation Oncology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Michael Chao
- Department of Radiation Oncology, Austin Health, Heidelberg 3084, Victoria, Australia
- Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Sweet Ping Ng
- Department of Radiation Oncology, Austin Health, Heidelberg 3084, Victoria, Australia
- School of Cancer Medicine, La Trobe University, Melbourne 3086, Victoria, Australia
- Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Michael Ng
- Genesis Care, East Melbourne 3002, Victoria, Australia
| | | | - Marios Efthymiou
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Rhys Vaughan
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Sujievvan Chandran
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville 3010, Victoria, Australia
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Steybe D, Poxleitner P, Voss PJ, Metzger MC, Schmelzeisen R, Bamberg F, Kim S, Russe MF. Evaluation of computed tomography settings in the context of visualization and discrimination of low dose injections of a novel liquid soft tissue fiducial marker in head and neck imaging. BMC Med Imaging 2021; 21:157. [PMID: 34702192 PMCID: PMC8549337 DOI: 10.1186/s12880-021-00689-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/18/2021] [Indexed: 11/25/2022] Open
Abstract
Background Intraoperative incorporation of radiopaque fiducial markers at the tumor resection surface can provide useful assistance in identifying the tumor bed in postoperative imaging for RT planning and radiological follow-up. Besides titanium clips, iodine containing injectable liquid fiducial markers represent an option that has emerged more recently for this purpose. In this study, marking oral soft tissue resection surfaces, applying low dose injections of a novel Conformité Européenne (CE)-marked liquid fiducial marker based on sucrose acetoisobutyrate (SAIB) and iodinated SAIB (x-SAIB) was investigated. Methods Visibility and discriminability of low dose injections of SAIB/x-SAIB (10 µl, 20 µl, 30 µl) were systematically studied at different kV settings used in clinical routine in an ex-vivo porcine mandible model. Transferability of the preclinical results into the clinical setting and applicability of DE-CT were investigated in initial patients.
Results Markers created by injection volumes as low as 10 µl were visible in CT imaging at all kV settings applied in clinical routine (70–120 kV). An injection volume of 30 µl allowed differentiation from an injection volume of 10 µl. In a total of 118 injections performed in two head and neck cancer patients, markers were clearly visible in 83% and 86% of injections. DE-CT allowed for differentiation between SAIB/x-SAIB markers and other hyperdense structures. Conclusions Injection of low doses of SAIB/x-SAIB was found to be a feasible approach to mark oral soft tissue resection surfaces, with injection volumes as low as 10 µl found to be visible at all kV settings applied in clinical routine. With the application of SAIB/x-SAIB reported for tumors of different organs already, mostly applying relatively large volumes for IGRT, this study adds information on the applicability of low dose injections to facilitate identification of the tumor bed in postoperative CT and on performance of the marker at different kV settings used in clinical routine.
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Affiliation(s)
- David Steybe
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Albert-Ludwigs University Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
| | - Philipp Poxleitner
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Albert-Ludwigs University Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.,Berta-Ottenstein-Programme for Clinician Scientists, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Pit Jacob Voss
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Albert-Ludwigs University Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Marc Christian Metzger
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Albert-Ludwigs University Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Rainer Schmelzeisen
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Albert-Ludwigs University Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Fabian Bamberg
- Department of Diagnostic and Interventional Radiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Suam Kim
- Department of Diagnostic and Interventional Radiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maximilian Frederik Russe
- Department of Diagnostic and Interventional Radiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Steybe D, Russe MF, Ludwig U, Sprave T, Vach K, Semper-Hogg W, Schmelzeisen R, Voss PJ, Poxleitner P. Intraoperative marking of the tumour resection surface for improved radiation therapy planning in head and neck cancer: preclinical evaluation of a novel liquid fiducial marker. Dentomaxillofac Radiol 2021; 50:20200290. [PMID: 32915672 DOI: 10.1259/dmfr.20200290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To evaluate a novel liquid fiducial marker for intraoperative marking of the tumour resection surface in oral cancer patients to facilitate precise postoperative delineation of the interface between the tumour resection border and reconstructed tissue for intensity-modulated radiation therapy. METHODS A total of 200 markers were created by injecting the volumes of 10 µl, 20 µl, 30 µl, 40 µl and 50 µl of a liquid marker composed of sucrose acetoisobutyrate (SAIB) and iodinated sucrose acetoisobutyrate (x-SAIB) into the soft tissue of porcine mandible segments. Visibility of the resulting markers was quantified by threshold-based segmentation of the marker volume in CT- and CBCT imaging and by a comparison of signal intensities in MRI. RESULTS Even the lowest volume of SAIB-/x-SAIB investigated (10 µl) resulted in a higher visibility (CTSoft tissue: 88.18 ± 13.23 µl; CTBone: 49.55 ± 7.62 µl; CBCT: 54.65 ± 12.58 µl) than observed with the incorporation of titanium ligature clips (CTSoft tissue: 50.15 ± 7.50 mm3; CTBone: 23.90 ± 3.39 mm3; CBCT: 33.80 ± 9.20 mm3). Markers created by the injection of 10 µl and 20 µl could reliably be delineated from markers created by the injection of higher volumes. CONCLUSION SAIB/x-SAIB, which has recently become available as a Conformité Européenne (CE)-marked fiducial marker, provides an option for fast and reliable production of markers with excellent visibility in imaging modalities used in oral cancer radiation therapy (RT) planning routine.
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Affiliation(s)
- David Steybe
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maximilian Frederik Russe
- Department of Diagnostic and Interventional Radiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ute Ludwig
- Medical Physics, Department of Radiology, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Tanja Sprave
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kirstin Vach
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Wiebke Semper-Hogg
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Rainer Schmelzeisen
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Pit Jacob Voss
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philipp Poxleitner
- Department of Oral and Maxillofacial Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Berta-Ottenstein-Programme for Clinician Scientists, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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8
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Hansen AE, Henriksen JR, Jølck RI, Fliedner FP, Bruun LM, Scherman J, Jensen AI, Munck af Rosenschöld P, Moorman L, Kurbegovic S, de Blanck SR, Larsen KR, Clementsen PF, Christensen AN, Clausen MH, Wang W, Kempen P, Christensen M, Viby NE, Persson G, Larsen R, Conradsen K, McEvoy FJ, Kjaer A, Eriksen T, Andresen TL. Multimodal soft tissue markers for bridging high-resolution diagnostic imaging with therapeutic intervention. SCIENCE ADVANCES 2020; 6:eabb5353. [PMID: 32875113 PMCID: PMC7438096 DOI: 10.1126/sciadv.abb5353] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/07/2020] [Indexed: 05/11/2023]
Abstract
Diagnostic imaging often outperforms the surgeon's ability to identify small structures during therapeutic procedures. Smart soft tissue markers that translate the sensitivity of diagnostic imaging into optimal therapeutic intervention are therefore highly warranted. This paper presents a unique adaptable liquid soft tissue marker system based on functionalized carbohydrates (Carbo-gel). The liquid state of these markers allows for high-precision placement under image guidance using thin needles. Based on step-by-step modifications, the image features and mechanical properties of markers can be optimized to bridge diagnostic imaging and specific therapeutic interventions. The performance of Carbo-gel is demonstrated for markers that (i) have radiographic, magnetic resonance, and ultrasound visibility; (ii) are palpable and visible; and (iii) are localizable by near-infrared fluorescence and radio guidance. The study demonstrates encouraging proof of concept for the liquid marker system as a well-tolerated multimodal imaging marker that can improve image-guided radiotherapy and surgical interventions, including robotic surgery.
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Affiliation(s)
- Anders E. Hansen
- DTU Health Technology, Section for Biotherapeutic Engineering and Drug Targeting, Center for Nanomedicine and Theranostics, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Jonas R. Henriksen
- DTU Health Technology, Section for Biotherapeutic Engineering and Drug Targeting, Center for Nanomedicine and Theranostics, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Rasmus I. Jølck
- DTU Health Technology, Section for Biotherapeutic Engineering and Drug Targeting, Center for Nanomedicine and Theranostics, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Frederikke P. Fliedner
- Dept. of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Dept. of Biomedical Sciences, Copenhagen University Hospital (Rigshospitalet) and University of Copenhagen, Copenhagen, DK-2200, Denmark
| | - Linda M. Bruun
- DTU Health Technology, Section for Biotherapeutic Engineering and Drug Targeting, Center for Nanomedicine and Theranostics, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Jonas Scherman
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund SE-222 42, Sweden
| | - Andreas I. Jensen
- DTU Health Technology, The Hevesy Laboratory, Technical University of Denmark, Roskilde DK-4000, Denmark
| | - Per. Munck af Rosenschöld
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund SE-222 42, Sweden
| | - Lilah Moorman
- Department of Veterinary Clinical and Animal Sciences, University of Copenhagen, Frederiksberg DK-1870, Denmark
| | - Sorel Kurbegovic
- Dept. of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Dept. of Biomedical Sciences, Copenhagen University Hospital (Rigshospitalet) and University of Copenhagen, Copenhagen, DK-2200, Denmark
| | - Steen R. de Blanck
- Department of Oncology, Copenhagen University Hospital (Rigshospitalet), Copenhagen DK-2100, Denmark
| | - Klaus R. Larsen
- Department of Respiratory Medicine, Copenhagen University Hospital (Bispebjerg and Frederiksberg Hospital), Copenhagen DK-2400, Denmark
| | - Paul F. Clementsen
- Copenhagen Academy for Medical Education and Simulation (CAMES), Department of Internal Medicine, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, DK-2100, Denmark
| | - Anders N. Christensen
- DTU Compute, Section for Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Mads H. Clausen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital (Rigshospitalet), Copenhagen DK-2100, Denmark
| | - Wenbo Wang
- DTU Health Technology, Section for Biotherapeutic Engineering and Drug Targeting, Center for Nanomedicine and Theranostics, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Paul Kempen
- DTU Health Technology, Section for Biotherapeutic Engineering and Drug Targeting, Center for Nanomedicine and Theranostics, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Merete Christensen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital (Rigshospitalet), Copenhagen DK-2100, Denmark
| | - Niels-Erik Viby
- Department of Cardiothoracic Surgery, Copenhagen University Hospital (Rigshospitalet), Copenhagen DK-2100, Denmark
| | - Gitte Persson
- Department of Oncology, Herlev-Gentofte Hospital, Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen DK-2200, Denmark
| | - Rasmus Larsen
- DTU Compute, Section for Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Knut Conradsen
- DTU Compute, Section for Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
| | - Fintan J. McEvoy
- Department of Veterinary Clinical and Animal Sciences, University of Copenhagen, Frederiksberg DK-1870, Denmark
| | - Andreas Kjaer
- Dept. of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Dept. of Biomedical Sciences, Copenhagen University Hospital (Rigshospitalet) and University of Copenhagen, Copenhagen, DK-2200, Denmark
| | - Thomas Eriksen
- Department of Veterinary Clinical and Animal Sciences, University of Copenhagen, Frederiksberg DK-1870, Denmark
| | - Thomas L. Andresen
- DTU Health Technology, Section for Biotherapeutic Engineering and Drug Targeting, Center for Nanomedicine and Theranostics, Technical University of Denmark, Kgs. Lyngby DK-2800, Denmark
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Evaluation of a Novel Liquid Fiducial Marker, BioXmark ®, for Small Animal Image-Guided Radiotherapy Applications. Cancers (Basel) 2020; 12:cancers12051276. [PMID: 32443537 PMCID: PMC7280978 DOI: 10.3390/cancers12051276] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 12/17/2022] Open
Abstract
BioXmark® (Nanovi A/S, Denmark) is a novel fiducial marker based on a liquid, iodine-based and non-metallic formulation. BioXmark® has been clinically validated and reverse translated to preclinical models to improve cone-beam CT (CBCT) target delineation in small animal image-guided radiotherapy (SAIGRT). However, in phantom image analysis and in vivo evaluation of radiobiological response after the injection of BioXmark® are yet to be reported. In phantom measurements were performed to compare CBCT imaging artefacts with solid fiducials and determine optimum imaging parameters for BioXmark®. In vivo stability of BioXmark® was assessed over a 5-month period, and the impact of BioXmark® on in vivo tumour response from single-fraction and fractionated X-ray exposures was investigated in a subcutaneous syngeneic tumour model. BioXmark® was stable, well tolerated and detectable on CBCT at volumes ≤10 µL. Our data showed imaging artefacts reduced by up to 84% and 89% compared to polymer and gold fiducial markers, respectively. BioXmark® was shown to have no significant impact on tumour growth in control animals, but changes were observed in irradiated animals injected with BioXmark® due to alterations in dose calculations induced by the sharp contrast enhancement. BioXmark® is superior to solid fiducials with reduced imaging artefacts on CBCT. With minimal impact on the tumour growth delay, BioXmark® can be implemented in SAIGRT to improve target delineation and reduce set-up errors.
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Schneider S, Aust DE, Brückner S, Welsch T, Hampe J, Troost EGC, Hoffmann AL. Detectability and structural stability of a liquid fiducial marker in fresh ex vivo pancreas tumour resection specimens on CT and 3T MRI. Strahlenther Onkol 2019; 195:756-763. [PMID: 31143995 DOI: 10.1007/s00066-019-01474-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 05/03/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE To test the detectability of a liquid fiducial marker injected into ex vivo pancreas tumour tissue on magnetic resonance imaging (MRI) and computed tomography (CT). Furthermore, its injection performance using different needle sizes and its structural stability after fixation in formaldehyde were investigated. METHODS Liquid fiducial markers with a volume of 20-100 µl were injected into freshly resected pancreas specimens of three patients with suspected adenocarcinoma. X‑ray guided injection was performed using different needle sizes (18 G, 22 G, 25 G). The specimens were scanned on MRI and CT with clinical protocols. The markers were segmented on CT by signal thresholding. Marker detectability in MRI was assessed in the registered segmentations. Marker volume on CT was compared to the injected volume as a measure of backflow. RESULTS Markers with a volume ≥20 µl were detected as hyperintensity on X‑ray and CT. On T1- and T2-weighted 3T MRI, marker sizes ranging from 20-100 µl were visible as hypointensity. Since most markers were non-spherical, MRI detectability was poor and their differentiation from hypointensities caused by air cavities or surgical clips was only feasible with a reference CT. Marker backflow was only observed when using an 18-G needle. A volume decrease of 6.6 ± 13.0% was observed after 24 h in formaldehyde and, with the exception of one instance, no wash-out occurred. CONCLUSIONS The liquid fiducial marker injected in ex vivo pancreatic resection specimen was visible as hyperintensity on kV X‑ray and CT and as hypointensity on MRI. The marker's size was stable in formaldehyde. A marker volume of ≥50 µL is recommended in clinically used MRI sequences. In vivo injection is expected to improve the markers sphericity due to persisting metabolism and thereby enhance detectability on MRI.
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Affiliation(s)
- Sergej Schneider
- Institute of Radiooncology-OncoRay, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany. .,OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Fetscherstraße 74, PF 41, 01307, Dresden, Germany.
| | - Daniela E Aust
- Institute of Pathology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Stefan Brückner
- Medical Department 1, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jochen Hampe
- Medical Department 1, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Esther G C Troost
- Institute of Radiooncology-OncoRay, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Fetscherstraße 74, PF 41, 01307, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), partner site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden; and Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Aswin L Hoffmann
- Institute of Radiooncology-OncoRay, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Fetscherstraße 74, PF 41, 01307, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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11
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The State of the Hybrid Operating Room: Technological Acceleration at the Pinnacle of Collaboration. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0229-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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