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Stokke C, Gnesin S, Tran-Gia J, Cicone F, Holm S, Cremonesi M, Blakkisrud J, Wendler T, Gillings N, Herrmann K, Mottaghy FM, Gear J. EANM guidance document: dosimetry for first-in-human studies and early phase clinical trials. Eur J Nucl Med Mol Imaging 2024; 51:1268-1286. [PMID: 38366197 PMCID: PMC10957710 DOI: 10.1007/s00259-024-06640-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/04/2024] [Indexed: 02/18/2024]
Abstract
The numbers of diagnostic and therapeutic nuclear medicine agents under investigation are rapidly increasing. Both novel emitters and novel carrier molecules require careful selection of measurement procedures. This document provides guidance relevant to dosimetry for first-in human and early phase clinical trials of such novel agents. The guideline includes a short introduction to different emitters and carrier molecules, followed by recommendations on the methods for activity measurement, pharmacokinetic analyses, as well as absorbed dose calculations and uncertainty analyses. The optimal use of preclinical information and studies involving diagnostic analogues is discussed. Good practice reporting is emphasised, and relevant dosimetry parameters and method descriptions to be included are listed. Three examples of first-in-human dosimetry studies, both for diagnostic tracers and radionuclide therapies, are given.
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Affiliation(s)
- Caroline Stokke
- Department of Diagnostic Physics and Computational Radiology, Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.
- Department of Physics, University of Oslo, Oslo, Norway.
| | - Silvano Gnesin
- Institute of Radiation Physics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Johannes Tran-Gia
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Francesco Cicone
- Nuclear Medicine Unit, Department of Experimental and Clinical Medicine, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Søren Holm
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Marta Cremonesi
- Department of Medical Imaging and Radiation Sciences, European Institute of Oncology, IRCCS, Milan, Italy
| | - Johan Blakkisrud
- Department of Diagnostic Physics and Computational Radiology, Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Thomas Wendler
- Computer-Aided Medical Procedures and Augmented Reality, Technische Universität München, Munich, Germany
- Clinical Computational Medical Imaging Research, Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Nic Gillings
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ken Herrmann
- Department of Nuclear Medicine, University of Duisburg-Essen, and German Cancer Consortium (DKTK)-University Hospital Essen, Essen, Germany
- National Center for Tumor Diseases (NCT), NCT West, Heidelberg, Germany
| | - Felix M Mottaghy
- Department of Radiology and Nuclear Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Nuclear Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Jonathan Gear
- Joint Department of Physics, Royal Marsden NHSFT & Institute of Cancer Research, Sutton, UK
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Bette S, Canalini L, Feitelson LM, Woźnicki P, Risch F, Huber A, Decker JA, Tehlan K, Becker J, Wollny C, Scheurig-Münkler C, Wendler T, Schwarz F, Kroencke T. Radiomics-Based Machine Learning Model for Diagnosis of Acute Pancreatitis Using Computed Tomography. Diagnostics (Basel) 2024; 14:718. [PMID: 38611632 PMCID: PMC11011980 DOI: 10.3390/diagnostics14070718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
In the early diagnostic workup of acute pancreatitis (AP), the role of contrast-enhanced CT is to establish the diagnosis in uncertain cases, assess severity, and detect potential complications like necrosis, fluid collections, bleeding or portal vein thrombosis. The value of texture analysis/radiomics of medical images has rapidly increased during the past decade, and the main focus has been on oncological imaging and tumor classification. Previous studies assessed the value of radiomics for differentiating between malignancies and inflammatory diseases of the pancreas as well as for prediction of AP severity. The aim of our study was to evaluate an automatic machine learning model for AP detection using radiomics analysis. Patients with abdominal pain and contrast-enhanced CT of the abdomen in an emergency setting were retrospectively included in this single-center study. The pancreas was automatically segmented using TotalSegmentator and radiomics features were extracted using PyRadiomics. We performed unsupervised hierarchical clustering and applied the random-forest based Boruta model to select the most important radiomics features. Important features and lipase levels were included in a logistic regression model with AP as the dependent variable. The model was established in a training cohort using fivefold cross-validation and applied to the test cohort (80/20 split). From a total of 1012 patients, 137 patients with AP and 138 patients without AP were included in the final study cohort. Feature selection confirmed 28 important features (mainly shape and first-order features) for the differentiation between AP and controls. The logistic regression model showed excellent diagnostic accuracy of radiomics features for the detection of AP, with an area under the curve (AUC) of 0.932. Using lipase levels only, an AUC of 0.946 was observed. Using both radiomics features and lipase levels, we showed an excellent AUC of 0.933 for the detection of AP. Automated segmentation of the pancreas and consecutive radiomics analysis almost achieved the high diagnostic accuracy of lipase levels, a well-established predictor of AP, and might be considered an additional diagnostic tool in unclear cases. This study provides scientific evidence that automated image analysis of the pancreas achieves comparable diagnostic accuracy to lipase levels and might therefore be used in the future in the rapidly growing era of AI-based image analysis.
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Affiliation(s)
- Stefanie Bette
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, 86156 Augsburg, Germany; (S.B.); (L.C.); (L.-M.F.); (A.H.); (J.A.D.); (K.T.); (J.B.); (C.W.); (C.S.-M.); (T.W.)
| | - Luca Canalini
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, 86156 Augsburg, Germany; (S.B.); (L.C.); (L.-M.F.); (A.H.); (J.A.D.); (K.T.); (J.B.); (C.W.); (C.S.-M.); (T.W.)
| | - Laura-Marie Feitelson
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, 86156 Augsburg, Germany; (S.B.); (L.C.); (L.-M.F.); (A.H.); (J.A.D.); (K.T.); (J.B.); (C.W.); (C.S.-M.); (T.W.)
| | - Piotr Woźnicki
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, University of Würzburg, 97080 Würzburg, Germany;
| | - Franka Risch
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, 86156 Augsburg, Germany; (S.B.); (L.C.); (L.-M.F.); (A.H.); (J.A.D.); (K.T.); (J.B.); (C.W.); (C.S.-M.); (T.W.)
| | - Adrian Huber
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, 86156 Augsburg, Germany; (S.B.); (L.C.); (L.-M.F.); (A.H.); (J.A.D.); (K.T.); (J.B.); (C.W.); (C.S.-M.); (T.W.)
| | - Josua A. Decker
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, 86156 Augsburg, Germany; (S.B.); (L.C.); (L.-M.F.); (A.H.); (J.A.D.); (K.T.); (J.B.); (C.W.); (C.S.-M.); (T.W.)
| | - Kartikay Tehlan
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, 86156 Augsburg, Germany; (S.B.); (L.C.); (L.-M.F.); (A.H.); (J.A.D.); (K.T.); (J.B.); (C.W.); (C.S.-M.); (T.W.)
| | - Judith Becker
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, 86156 Augsburg, Germany; (S.B.); (L.C.); (L.-M.F.); (A.H.); (J.A.D.); (K.T.); (J.B.); (C.W.); (C.S.-M.); (T.W.)
| | - Claudia Wollny
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, 86156 Augsburg, Germany; (S.B.); (L.C.); (L.-M.F.); (A.H.); (J.A.D.); (K.T.); (J.B.); (C.W.); (C.S.-M.); (T.W.)
| | - Christian Scheurig-Münkler
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, 86156 Augsburg, Germany; (S.B.); (L.C.); (L.-M.F.); (A.H.); (J.A.D.); (K.T.); (J.B.); (C.W.); (C.S.-M.); (T.W.)
| | - Thomas Wendler
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, 86156 Augsburg, Germany; (S.B.); (L.C.); (L.-M.F.); (A.H.); (J.A.D.); (K.T.); (J.B.); (C.W.); (C.S.-M.); (T.W.)
- Institute of Digital Health, University Hospital Augsburg, Faculty of Medicine, University of Augsburg, 86356 Neusaess, Germany
- Computer-Aided Medical Procedures and Augmented Reality, School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei Muenchen, Germany
| | - Florian Schwarz
- Centre for Diagnostic Imaging and Interventional Therapy, Donau-Isar-Klinikum, 94469 Deggendorf, Germany;
| | - Thomas Kroencke
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, 86156 Augsburg, Germany; (S.B.); (L.C.); (L.-M.F.); (A.H.); (J.A.D.); (K.T.); (J.B.); (C.W.); (C.S.-M.); (T.W.)
- Centre for Advanced Analytics and Predictive Sciences (CAAPS), University of Augsburg, 86159 Augsburg, Germany
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Pisano G, Wendler T, Valdés Olmos RA, Garganese G, Rietbergen DDD, Giammarile F, Vidal-Sicart S, Oonk MHM, Frumovitz M, Abu-Rustum NR, Scambia G, Rufini V, Collarino A. Molecular image-guided surgery in gynaecological cancer: where do we stand? Eur J Nucl Med Mol Imaging 2024:10.1007/s00259-024-06604-1. [PMID: 38233609 DOI: 10.1007/s00259-024-06604-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/04/2024] [Indexed: 01/19/2024]
Abstract
PURPOSE The aim of this review is to give an overview of the current status of molecular image-guided surgery in gynaecological malignancies, from both clinical and technological points of view. METHODS A narrative approach was taken to describe the relevant literature, focusing on clinical applications of molecular image-guided surgery in gynaecology, preoperative imaging as surgical roadmap, and intraoperative devices. RESULTS The most common clinical application in gynaecology is sentinel node biopsy (SNB). Other promising approaches are receptor-target modalities and occult lesion localisation. Preoperative SPECT/CT and PET/CT permit a roadmap for adequate surgical planning. Intraoperative detection modalities span from 1D probes to 2D portable cameras and 3D freehand imaging. CONCLUSION After successful application of radio-guided SNB and SPECT, innovation is leaning towards hybrid modalities, such as hybrid tracer and fusion of imaging approaches including SPECT/CT and PET/CT. Robotic surgery, as well as augmented reality and virtual reality techniques, is leading to application of these innovative technologies to the clinical setting, guiding surgeons towards a precise, personalised, and minimally invasive approach.
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Affiliation(s)
- Giusi Pisano
- Section of Nuclear Medicine, University Department of Radiological Sciences and Haematology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Thomas Wendler
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
- Chair for Computer-Aided Medical Procedures and Augmented Reality, Technical University of Munich, Garching, Near Munich, Germany
| | - Renato A Valdés Olmos
- Interventional Molecular Imaging Laboratory & Section Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Giorgia Garganese
- Gynecologic Oncology Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Section of Obstetrics and Gynecology, University Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Daphne D D Rietbergen
- Interventional Molecular Imaging Laboratory & Section Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Francesco Giammarile
- Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Sergi Vidal-Sicart
- Nuclear Medicine Department, Hospital Clinic Barcelona, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Barcelona, Spain
| | - Maaike H M Oonk
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Michael Frumovitz
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Giovanni Scambia
- Gynecologic Oncology Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Section of Obstetrics and Gynecology, University Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vittoria Rufini
- Section of Nuclear Medicine, University Department of Radiological Sciences and Haematology, Università Cattolica del Sacro Cuore, Rome, Italy
- Nuclear Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Angela Collarino
- Nuclear Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
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Miederer I, Rogasch JMM, Wendler T. AI in Nuclear Medicine - a review of the current situation. Nuklearmedizin 2023; 62:332-333. [PMID: 37995705 DOI: 10.1055/a-2198-0614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Affiliation(s)
- Isabelle Miederer
- Department of Nuclear Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Julian Manuel Michael Rogasch
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Wendler
- Clinical Computational Medical Imaging Research, Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
- Computer-Aided Medical Procedures and Augmented Reality, School of Computation, Information and Technology, Technical University of Munich, Munich, Germany
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Wendler T, Kreissl MC, Schemmer B, Rogasch JMM, De Benetti F. Artificial Intelligence-powered automatic volume calculation in medical images - available tools, performance and challenges for nuclear medicine. Nuklearmedizin 2023; 62:343-353. [PMID: 37995707 PMCID: PMC10667065 DOI: 10.1055/a-2200-2145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/26/2023] [Indexed: 11/25/2023]
Abstract
Volumetry is crucial in oncology and endocrinology, for diagnosis, treatment planning, and evaluating response to therapy for several diseases. The integration of Artificial Intelligence (AI) and Deep Learning (DL) has significantly accelerated the automatization of volumetric calculations, enhancing accuracy and reducing variability and labor. In this review, we show that a high correlation has been observed between Machine Learning (ML) methods and expert assessments in tumor volumetry; Yet, it is recognized as more challenging than organ volumetry. Liver volumetry has shown progression in accuracy with a decrease in error. If a relative error below 10 % is acceptable, ML-based liver volumetry can be considered reliable for standardized imaging protocols if used in patients without major anomalies. Similarly, ML-supported automatic kidney volumetry has also shown consistency and reliability in volumetric calculations. In contrast, AI-supported thyroid volumetry has not been extensively developed, despite initial works in 3D ultrasound showing promising results in terms of accuracy and reproducibility. Despite the advancements presented in the reviewed literature, the lack of standardization limits the generalizability of ML methods across diverse scenarios. The domain gap, i. e., the difference in probability distribution of training and inference data, is of paramount importance before clinical deployment of AI, to maintain accuracy and reliability in patient care. The increasing availability of improved segmentation tools is expected to further incorporate AI methods into routine workflows where volumetry will play a more prominent role in radionuclide therapy planning and quantitative follow-up of disease evolution.
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Affiliation(s)
- Thomas Wendler
- Clinical Computational Medical Imaging Research, Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Germany
- Institute of Digital Medicine, Universitätsklinikum Augsburg, Germany
- Computer-Aided Medical Procedures and Augmented Reality School of Computation, Information and Technology, Technical University of Munich, Munich, Germany
| | | | | | - Julian Manuel Michael Rogasch
- Department of Nuclear Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin,Germany
| | - Francesca De Benetti
- Computer-Aided Medical Procedures and Augmented Reality School of Computation, Information and Technology, Technical University of Munich, Munich, Germany
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Miederer I, Shi K, Wendler T. Machine learning methods for tracer kinetic modelling. Nuklearmedizin 2023; 62:370-378. [PMID: 37820696 DOI: 10.1055/a-2179-5818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Tracer kinetic modelling based on dynamic PET is an important field of Nuclear Medicine for quantitative functional imaging. Yet, its implementation in clinical routine has been constrained by its complexity and computational costs. Machine learning poses an opportunity to improve modelling processes in terms of arterial input function prediction, the prediction of kinetic modelling parameters and model selection in both clinical and preclinical studies while reducing processing time. Moreover, it can help improving kinetic modelling data used in downstream tasks such as tumor detection. In this review, we introduce the basics of tracer kinetic modelling and present a literature review of original works and conference papers using machine learning methods in this field.
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Affiliation(s)
- Isabelle Miederer
- Department of Nuclear Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Kuangyu Shi
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
- Chair for Computer-Aided Medical Procedures and Augmented Reality, Technical University of Munich, Garching near Munich, Germany
| | - Thomas Wendler
- Chair for Computer-Aided Medical Procedures and Augmented Reality, Technical University of Munich, Garching near Munich, Germany
- Department of diagnostic and interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
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Keicher M, Burwinkel H, Bani-Harouni D, Paschali M, Czempiel T, Burian E, Makowski MR, Braren R, Navab N, Wendler T. Multimodal graph attention network for COVID-19 outcome prediction. Sci Rep 2023; 13:19539. [PMID: 37945590 PMCID: PMC10636061 DOI: 10.1038/s41598-023-46625-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 11/03/2023] [Indexed: 11/12/2023] Open
Abstract
When dealing with a newly emerging disease such as COVID-19, the impact of patient- and disease-specific factors (e.g., body weight or known co-morbidities) on the immediate course of the disease is largely unknown. An accurate prediction of the most likely individual disease progression can improve the planning of limited resources and finding the optimal treatment for patients. In the case of COVID-19, the need for intensive care unit (ICU) admission of pneumonia patients can often only be determined on short notice by acute indicators such as vital signs (e.g., breathing rate, blood oxygen levels), whereas statistical analysis and decision support systems that integrate all of the available data could enable an earlier prognosis. To this end, we propose a holistic, multimodal graph-based approach combining imaging and non-imaging information. Specifically, we introduce a multimodal similarity metric to build a population graph that shows a clustering of patients. For each patient in the graph, we extract radiomic features from a segmentation network that also serves as a latent image feature encoder. Together with clinical patient data like vital signs, demographics, and lab results, these modalities are combined into a multimodal representation of each patient. This feature extraction is trained end-to-end with an image-based Graph Attention Network to process the population graph and predict the COVID-19 patient outcomes: admission to ICU, need for ventilation, and mortality. To combine multiple modalities, radiomic features are extracted from chest CTs using a segmentation neural network. Results on a dataset collected in Klinikum rechts der Isar in Munich, Germany and the publicly available iCTCF dataset show that our approach outperforms single modality and non-graph baselines. Moreover, our clustering and graph attention increases understanding of the patient relationships within the population graph and provides insight into the network's decision-making process.
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Affiliation(s)
- Matthias Keicher
- Computer Aided Medical Procedures and Augmented Reality, School of Computation, Information and Technology, Technical University of Munich, Boltzmannstr. 3, 85748, Garching, Germany.
| | - Hendrik Burwinkel
- Computer Aided Medical Procedures and Augmented Reality, School of Computation, Information and Technology, Technical University of Munich, Boltzmannstr. 3, 85748, Garching, Germany
| | - David Bani-Harouni
- Computer Aided Medical Procedures and Augmented Reality, School of Computation, Information and Technology, Technical University of Munich, Boltzmannstr. 3, 85748, Garching, Germany
| | - Magdalini Paschali
- Computer Aided Medical Procedures and Augmented Reality, School of Computation, Information and Technology, Technical University of Munich, Boltzmannstr. 3, 85748, Garching, Germany
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, 94304, USA
| | - Tobias Czempiel
- Computer Aided Medical Procedures and Augmented Reality, School of Computation, Information and Technology, Technical University of Munich, Boltzmannstr. 3, 85748, Garching, Germany
| | - Egon Burian
- Department of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Marcus R Makowski
- Department of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Rickmer Braren
- Department of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Nassir Navab
- Computer Aided Medical Procedures and Augmented Reality, School of Computation, Information and Technology, Technical University of Munich, Boltzmannstr. 3, 85748, Garching, Germany
| | - Thomas Wendler
- Computer Aided Medical Procedures and Augmented Reality, School of Computation, Information and Technology, Technical University of Munich, Boltzmannstr. 3, 85748, Garching, Germany
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Clinical Computational Medical Imaging Research, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
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Miederer I, Rogasch JMM, Fischer R, Fuchs T, Lapa C, Lohmann P, Shi K, Tran-Gia J, Wendler T, Hellwig D. The Medical Informatics Initiative and the Network University Medicine - Perspectives for Nuclear Medicine. Nuklearmedizin 2023; 62:276-283. [PMID: 37683678 DOI: 10.1055/a-2067-7642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Digitization in the healthcare sector and the support of clinical workflows with artificial intelligence (AI), including AI-supported image analysis, represent a great challenge and equally a promising perspective for preclinical and clinical nuclear medicine. In Germany, the Medical Informatics Initiative (MII) and the Network University Medicine (NUM) are of central importance for this transformation. This review article outlines these structures and highlights their future role in enabling privacy-preserving federated multi-center analyses with interoperable data structures harmonized between site-specific IT infrastructures. The newly founded working group "Digitization and AI" in the German Society of Nuclear Medicine (DGN) as well as the Fach- und Organspezifische Arbeitsgruppe (FOSA, specialty- and organ-specific working group) founded for the field of nuclear medicine (FOSA Nuklearmedizin) within the NUM aim to initiate and coordinate measures in the context of digital medicine and (image-)data-driven analyses for the DGN.
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Affiliation(s)
- Isabelle Miederer
- Department of Nuclear Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Julian Manuel Michael Rogasch
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Regina Fischer
- Department of Nuclear Medicine, University Hospital Regensburg, Regensburg, Germany
- Bavarian Center for Cancer Research (BZKF), Partner Site Regensburg, Regensburg, Germany
- Medical Data Integration Center MEDIZUKR, University Hospital Regensburg, Regensburg, Germany
| | - Timo Fuchs
- Department of Nuclear Medicine, University Hospital Regensburg, Regensburg, Germany
- Bavarian Center for Cancer Research (BZKF), Partner Site Regensburg, Regensburg, Germany
- Medical Data Integration Center MEDIZUKR, University Hospital Regensburg, Regensburg, Germany
| | - Constantin Lapa
- Nuclear Medicine, Medical Faculty, University of Augsburg, Augsburg, Germany
- Bavarian Center for Cancer Research (BZKF), Partner Site Augsburg, Augsburg, Germany
| | - Philipp Lohmann
- Institute of Neuroscience and Medicine (INM-4), Research Center Juelich (FZJ), Juelich, Germany
| | - Kuangyu Shi
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johannes Tran-Gia
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
- Bavarian Center for Cancer Research (BZKF), Partner Site Würzburg, Würzburg, Germany
| | - Thomas Wendler
- Chair for Computer-Aided Medical Procedures and Augmented Reality, Technical University of Munich, Munich, Germany
| | - Dirk Hellwig
- Department of Nuclear Medicine, University Hospital Regensburg, Regensburg, Germany
- Bavarian Center for Cancer Research (BZKF), Partner Site Regensburg, Regensburg, Germany
- Medical Data Integration Center MEDIZUKR, University Hospital Regensburg, Regensburg, Germany
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Ashtari Esfahani A, Böser S, Buzinsky N, Carmona-Benitez MC, Claessens C, de Viveiros L, Doe PJ, Fertl M, Formaggio JA, Gaison JK, Gladstone L, Grando M, Guigue M, Hartse J, Heeger KM, Huyan X, Johnston J, Jones AM, Kazkaz K, LaRoque BH, Li M, Lindman A, Machado E, Marsteller A, Matthé C, Mohiuddin R, Monreal B, Mueller R, Nikkel JA, Novitski E, Oblath NS, Peña JI, Pettus W, Reimann R, Robertson RGH, Rosa De Jesús D, Rybka G, Saldaña L, Schram M, Slocum PL, Stachurska J, Sun YH, Surukuchi PT, Tedeschi JR, Telles AB, Thomas F, Thomas M, Thorne LA, Thümmler T, Tvrznikova L, Van De Pontseele W, VanDevender BA, Weintroub J, Weiss TE, Wendler T, Young A, Zayas E, Ziegler A. Tritium Beta Spectrum Measurement and Neutrino Mass Limit from Cyclotron Radiation Emission Spectroscopy. Phys Rev Lett 2023; 131:102502. [PMID: 37739382 DOI: 10.1103/physrevlett.131.102502] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/26/2023] [Accepted: 07/17/2023] [Indexed: 09/24/2023]
Abstract
The absolute scale of the neutrino mass plays a critical role in physics at every scale, from the subatomic to the cosmological. Measurements of the tritium end-point spectrum have provided the most precise direct limit on the neutrino mass scale. In this Letter, we present advances by Project 8 to the cyclotron radiation emission spectroscopy (CRES) technique culminating in the first frequency-based neutrino mass limit. With only a cm^{3}-scale physical detection volume, a limit of m_{β}<155 eV/c^{2} (152 eV/c^{2}) is extracted from the background-free measurement of the continuous tritium beta spectrum in a Bayesian (frequentist) analysis. Using ^{83m}Kr calibration data, a resolution of 1.66±0.19 eV (FWHM) is measured, the detector response model is validated, and the efficiency is characterized over the multi-keV tritium analysis window. These measurements establish the potential of CRES for a high-sensitivity next-generation direct neutrino mass experiment featuring low background and high resolution.
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Affiliation(s)
- A Ashtari Esfahani
- Center for Experimental Nuclear Physics and Astrophysics and Department of Physics, University of Washington, Seattle, Washington 98195, USA
| | - S Böser
- Institute for Physics, Johannes Gutenberg University Mainz, 55128 Mainz, Germany
| | - N Buzinsky
- Laboratory for Nuclear Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
| | - M C Carmona-Benitez
- Department of Physics, Pennsylvania State University, University Park, Pennsylvania 16802, USA
| | - C Claessens
- Center for Experimental Nuclear Physics and Astrophysics and Department of Physics, University of Washington, Seattle, Washington 98195, USA
- Institute for Physics, Johannes Gutenberg University Mainz, 55128 Mainz, Germany
| | - L de Viveiros
- Department of Physics, Pennsylvania State University, University Park, Pennsylvania 16802, USA
| | - P J Doe
- Center for Experimental Nuclear Physics and Astrophysics and Department of Physics, University of Washington, Seattle, Washington 98195, USA
| | - M Fertl
- Institute for Physics, Johannes Gutenberg University Mainz, 55128 Mainz, Germany
| | - J A Formaggio
- Laboratory for Nuclear Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
| | - J K Gaison
- Pacific Northwest National Laboratory, Richland, Washington 99354, USA
| | - L Gladstone
- Department of Physics, Case Western Reserve University, Cleveland, Ohio 44106, USA
| | - M Grando
- Pacific Northwest National Laboratory, Richland, Washington 99354, USA
| | - M Guigue
- Laboratoire de Physique Nucléaire et de Hautes Énergies, Sorbonne Université, Université Paris Cité, CNRS/IN2P3, 75005 Paris, France
| | - J Hartse
- Center for Experimental Nuclear Physics and Astrophysics and Department of Physics, University of Washington, Seattle, Washington 98195, USA
| | - K M Heeger
- Wright Laboratory and Department of Physics, Yale University, New Haven, Connecticut 06520, USA
| | - X Huyan
- Pacific Northwest National Laboratory, Richland, Washington 99354, USA
| | - J Johnston
- Laboratory for Nuclear Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
| | - A M Jones
- Pacific Northwest National Laboratory, Richland, Washington 99354, USA
| | - K Kazkaz
- Lawrence Livermore National Laboratory, Livermore, California 94550, USA
| | - B H LaRoque
- Pacific Northwest National Laboratory, Richland, Washington 99354, USA
| | - M Li
- Laboratory for Nuclear Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
| | - A Lindman
- Institute for Physics, Johannes Gutenberg University Mainz, 55128 Mainz, Germany
| | - E Machado
- Center for Experimental Nuclear Physics and Astrophysics and Department of Physics, University of Washington, Seattle, Washington 98195, USA
| | - A Marsteller
- Center for Experimental Nuclear Physics and Astrophysics and Department of Physics, University of Washington, Seattle, Washington 98195, USA
| | - C Matthé
- Institute for Physics, Johannes Gutenberg University Mainz, 55128 Mainz, Germany
| | - R Mohiuddin
- Department of Physics, Case Western Reserve University, Cleveland, Ohio 44106, USA
| | - B Monreal
- Department of Physics, Case Western Reserve University, Cleveland, Ohio 44106, USA
| | - R Mueller
- Department of Physics, Pennsylvania State University, University Park, Pennsylvania 16802, USA
| | - J A Nikkel
- Wright Laboratory and Department of Physics, Yale University, New Haven, Connecticut 06520, USA
| | - E Novitski
- Center for Experimental Nuclear Physics and Astrophysics and Department of Physics, University of Washington, Seattle, Washington 98195, USA
| | - N S Oblath
- Pacific Northwest National Laboratory, Richland, Washington 99354, USA
| | - J I Peña
- Laboratory for Nuclear Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
| | - W Pettus
- Center for Exploration of Energy and Matter and Department of Physics, Indiana University, Bloomington, Indiana 47405, USA
| | - R Reimann
- Institute for Physics, Johannes Gutenberg University Mainz, 55128 Mainz, Germany
| | - R G H Robertson
- Center for Experimental Nuclear Physics and Astrophysics and Department of Physics, University of Washington, Seattle, Washington 98195, USA
| | - D Rosa De Jesús
- Pacific Northwest National Laboratory, Richland, Washington 99354, USA
| | - G Rybka
- Center for Experimental Nuclear Physics and Astrophysics and Department of Physics, University of Washington, Seattle, Washington 98195, USA
| | - L Saldaña
- Wright Laboratory and Department of Physics, Yale University, New Haven, Connecticut 06520, USA
| | - M Schram
- Pacific Northwest National Laboratory, Richland, Washington 99354, USA
| | - P L Slocum
- Wright Laboratory and Department of Physics, Yale University, New Haven, Connecticut 06520, USA
| | - J Stachurska
- Laboratory for Nuclear Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
| | - Y-H Sun
- Department of Physics, Case Western Reserve University, Cleveland, Ohio 44106, USA
| | - P T Surukuchi
- Wright Laboratory and Department of Physics, Yale University, New Haven, Connecticut 06520, USA
| | - J R Tedeschi
- Pacific Northwest National Laboratory, Richland, Washington 99354, USA
| | - A B Telles
- Wright Laboratory and Department of Physics, Yale University, New Haven, Connecticut 06520, USA
| | - F Thomas
- Institute for Physics, Johannes Gutenberg University Mainz, 55128 Mainz, Germany
| | - M Thomas
- Pacific Northwest National Laboratory, Richland, Washington 99354, USA
| | - L A Thorne
- Institute for Physics, Johannes Gutenberg University Mainz, 55128 Mainz, Germany
| | - T Thümmler
- Institute of Astroparticle Physics, Karlsruhe Institute of Technology, 76021 Karlsruhe, Germany
| | - L Tvrznikova
- Lawrence Livermore National Laboratory, Livermore, California 94550, USA
| | - W Van De Pontseele
- Laboratory for Nuclear Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
| | - B A VanDevender
- Center for Experimental Nuclear Physics and Astrophysics and Department of Physics, University of Washington, Seattle, Washington 98195, USA
- Pacific Northwest National Laboratory, Richland, Washington 99354, USA
| | - J Weintroub
- Center for Astrophysics, Harvard & Smithsonian, Cambridge, Massachusetts 02138, USA
| | - T E Weiss
- Wright Laboratory and Department of Physics, Yale University, New Haven, Connecticut 06520, USA
| | - T Wendler
- Department of Physics, Pennsylvania State University, University Park, Pennsylvania 16802, USA
| | - A Young
- Center for Astrophysics, Harvard & Smithsonian, Cambridge, Massachusetts 02138, USA
| | - E Zayas
- Laboratory for Nuclear Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
| | - A Ziegler
- Department of Physics, Pennsylvania State University, University Park, Pennsylvania 16802, USA
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Zhou M, Hennerkes F, Liu J, Jiang Z, Wendler T, Nasseri MA, Iordachita I, Navab N. Theoretical error analysis of spotlight-based instrument localization for retinal surgery. ROBOTICA 2023; 41:1536-1549. [PMID: 37982126 PMCID: PMC10655674 DOI: 10.1017/s0263574722001862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Retinal surgery is widely considered to be a complicated and challenging task even for specialists. Image-guided robot-assisted intervention is among the novel and promising solutions that may enhance human capabilities therein. In this paper, we demonstrate the possibility of using spotlights for 5D guidance of a microsurgical instrument. The theoretical basis of the localization for the instrument based on the projection of a single spotlight is analyzed to deduce the position and orientation of the spotlight source. The usage of multiple spotlights is also proposed to check the possibility of further improvements for the performance boundaries. The proposed method is verified within a high-fidelity simulation environment using the 3D creation suite Blender. Experimental results show that the average positioning error is 0.029 mm using a single spotlight and 0.025 mm with three spotlights, respectively, while the rotational errors are 0.124 and 0.101, which shows the application to be promising in instrument localization for retinal surgery.
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Affiliation(s)
- Mingchuan Zhou
- College of Biosystems Engineering and Food Science, Zhejiang University, Hangzhou, China
| | - Felix Hennerkes
- Chair for Computer Aided Medical Procedures and Augmented Reality, Computer Science Department, Technische Universität München, Munchen, Germany
| | - Jingsong Liu
- Chair for Computer Aided Medical Procedures and Augmented Reality, Computer Science Department, Technische Universität München, Munchen, Germany
| | - Zhongliang Jiang
- Chair for Computer Aided Medical Procedures and Augmented Reality, Computer Science Department, Technische Universität München, Munchen, Germany
| | - Thomas Wendler
- Chair for Computer Aided Medical Procedures and Augmented Reality, Computer Science Department, Technische Universität München, Munchen, Germany
| | - M Ali Nasseri
- Augenklinik und Poliklinik, Klinikum rechts der Isar der Technische Universität München, München, Germany
| | - Iulian Iordachita
- Department of Mechanical Engineering and Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Baltimore, MD, USA
| | - Nassir Navab
- Chair for Computer Aided Medical Procedures and Augmented Reality, Computer Science Department, Technische Universität München, Munchen, Germany
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Ansari MY, Yang Y, Balakrishnan S, Abinahed J, Al-Ansari A, Warfa M, Almokdad O, Barah A, Omer A, Singh AV, Meher PK, Bhadra J, Halabi O, Azampour MF, Navab N, Wendler T, Dakua SP. A lightweight neural network with multiscale feature enhancement for liver CT segmentation. Sci Rep 2022; 12:14153. [PMID: 35986015 PMCID: PMC9391485 DOI: 10.1038/s41598-022-16828-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 07/18/2022] [Indexed: 11/18/2022] Open
Abstract
Segmentation of abdominal Computed Tomography (CT) scan is essential for analyzing, diagnosing, and treating visceral organ diseases (e.g., hepatocellular carcinoma). This paper proposes a novel neural network (Res-PAC-UNet) that employs a fixed-width residual UNet backbone and Pyramid Atrous Convolutions, providing a low disk utilization method for precise liver CT segmentation. The proposed network is trained on medical segmentation decathlon dataset using a modified surface loss function. Additionally, we evaluate its quantitative and qualitative performance; the Res16-PAC-UNet achieves a Dice coefficient of 0.950 ± 0.019 with less than half a million parameters. Alternatively, the Res32-PAC-UNet obtains a Dice coefficient of 0.958 ± 0.015 with an acceptable parameter count of approximately 1.2 million.
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12
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Metzner F, Neupetsch C, Carabello A, Pietsch M, Wendler T, Drossel WG. Biomechanical validation of additively manufactured artificial femoral bones. BMC Biomed Eng 2022; 4:6. [PMID: 35927720 PMCID: PMC9354338 DOI: 10.1186/s42490-022-00063-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/21/2022] [Indexed: 01/15/2023] Open
Abstract
Replicating the mechanical behavior of human bones, especially cancellous bone tissue, is challenging. Typically, conventional bone models primarily consist of polyurethane foam surrounded by a solid shell. Although nearly isotropic foam components have mechanical properties similar to cancellous bone, they do not represent the anisotropy and inhomogeneity of bone architecture. To consider the architecture of bone, models were developed whose core was additively manufactured based on CT data. This core was subsequently coated with glass fiber composite. Specimens consisting of a gyroid-structure were fabricated using fused filament fabrication (FFF) techniques from different materials and various filler levels. Subsequent compression tests showed good accordance between the mechanical behavior of the printed specimens and human bone. The unidirectional fiberglass composite showed higher strength and stiffness than human cortical bone in 3-point bending tests, with comparable material behaviors being observed. During biomechanical investigation of the entire assembly, femoral prosthetic stems were inserted into both artificial and human bones under controlled conditions, while recording occurring forces and strains. All of the artificial prototypes, made of different materials, showed analogous behavior to human bone. In conclusion, it was shown that low-cost FFF technique can be used to generate valid bone models and selectively modify their properties by changing the infill.
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Affiliation(s)
- F. Metzner
- grid.9647.c0000 0004 7669 9786ZESBO Centre for Research on Musculoskeletal Systems, Leipzig University, Semmelweisstraße 14, 04103 Leipzig, Germany ,grid.9647.c0000 0004 7669 9786Department of Orthopaedics, Trauma and Plastic Surgery, Leipzig University, Leipzig, Germany
| | - C. Neupetsch
- grid.9647.c0000 0004 7669 9786Department of Orthopaedics, Trauma and Plastic Surgery, Leipzig University, Leipzig, Germany ,grid.461651.10000 0004 0574 2038Fraunhofer Institute for Machine Tools and Forming Technology, Dresden, Germany ,grid.6810.f0000 0001 2294 5505Professorship of Adaptronics and Lightweight Design, Chemnitz Universtiy of Technology, Chemnitz, Germany
| | - A. Carabello
- grid.461651.10000 0004 0574 2038Fraunhofer Institute for Machine Tools and Forming Technology, Dresden, Germany ,grid.6810.f0000 0001 2294 5505Professorship of Adaptronics and Lightweight Design, Chemnitz Universtiy of Technology, Chemnitz, Germany
| | - M. Pietsch
- grid.461651.10000 0004 0574 2038Fraunhofer Institute for Machine Tools and Forming Technology, Dresden, Germany
| | - T. Wendler
- grid.9647.c0000 0004 7669 9786ZESBO Centre for Research on Musculoskeletal Systems, Leipzig University, Semmelweisstraße 14, 04103 Leipzig, Germany ,grid.9647.c0000 0004 7669 9786Department of Orthopaedics, Trauma and Plastic Surgery, Leipzig University, Leipzig, Germany
| | - W.-G. Drossel
- grid.461651.10000 0004 0574 2038Fraunhofer Institute for Machine Tools and Forming Technology, Dresden, Germany ,grid.6810.f0000 0001 2294 5505Professorship of Adaptronics and Lightweight Design, Chemnitz Universtiy of Technology, Chemnitz, Germany
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Krönke M, Eilers C, Dimova D, Köhler M, Buschner G, Schweiger L, Konstantinidou L, Makowski M, Nagarajah J, Navab N, Weber W, Wendler T. Tracked 3D ultrasound and deep neural network-based thyroid segmentation reduce interobserver variability in thyroid volumetry. PLoS One 2022; 17:e0268550. [PMID: 35905038 PMCID: PMC9337648 DOI: 10.1371/journal.pone.0268550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/02/2022] [Indexed: 11/29/2022] Open
Abstract
Thyroid volumetry is crucial in the diagnosis, treatment, and monitoring of thyroid diseases. However, conventional thyroid volumetry with 2D ultrasound is highly operator-dependent. This study compares 2D and tracked 3D ultrasound with an automatic thyroid segmentation based on a deep neural network regarding inter- and intraobserver variability, time, and accuracy. Volume reference was MRI. 28 healthy volunteers (24—50 a) were scanned with 2D and 3D ultrasound (and by MRI) by three physicians (MD 1, 2, 3) with different experience levels (6, 4, and 1 a). In the 2D scans, the thyroid lobe volumes were calculated with the ellipsoid formula. A convolutional deep neural network (CNN) automatically segmented the 3D thyroid lobes. 26, 6, and 6 random lobe scans were used for training, validation, and testing, respectively. On MRI (T1 VIBE sequence) the thyroid was manually segmented by an experienced MD. MRI thyroid volumes ranged from 2.8 to 16.7ml (mean 7.4, SD 3.05). The CNN was trained to obtain an average Dice score of 0.94. The interobserver variability comparing two MDs showed mean differences for 2D and 3D respectively of 0.58 to 0.52ml (MD1 vs. 2), −1.33 to −0.17ml (MD1 vs. 3) and −1.89 to −0.70ml (MD2 vs. 3). Paired samples t-tests showed significant differences for 2D (p = .140, p = .002 and p = .002) and none for 3D (p = .176, p = .722 and p = .057). Intraobsever variability was similar for 2D and 3D ultrasound. Comparison of ultrasound volumes and MRI volumes showed a significant difference for the 2D volumetry of all MDs (p = .002, p = .009, p <.001), and no significant difference for 3D ultrasound (p = .292, p = .686, p = 0.091). Acquisition time was significantly shorter for 3D ultrasound. Tracked 3D ultrasound combined with a CNN segmentation significantly reduces interobserver variability in thyroid volumetry and increases the accuracy of the measurements with shorter acquisition times.
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Affiliation(s)
- Markus Krönke
- Department of Radiology and Nuclear Medicine, German Heart Center, Technical University of Munich, Munich, Germany
- Department of Nuclear Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Christine Eilers
- Chair for Computer Aided Medical Procedures and Augmented Reality, Department of Computer Science, Technical University of Munich, Garching Near Munich, Germany
- * E-mail:
| | - Desislava Dimova
- Chair for Computer Aided Medical Procedures and Augmented Reality, Department of Computer Science, Technical University of Munich, Garching Near Munich, Germany
| | - Melanie Köhler
- Chair for Computer Aided Medical Procedures and Augmented Reality, Department of Computer Science, Technical University of Munich, Garching Near Munich, Germany
- Medical Faculty, Technical University of Munich, Munich, Germany
| | - Gabriel Buschner
- Department of Nuclear Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Lilit Schweiger
- Department of Nuclear Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Lemonia Konstantinidou
- Chair for Computer Aided Medical Procedures and Augmented Reality, Department of Computer Science, Technical University of Munich, Garching Near Munich, Germany
| | - Marcus Makowski
- Department of Radiology, School of Medicine, Technical University of Munich, Munich, Germany
| | - James Nagarajah
- Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nassir Navab
- Chair for Computer Aided Medical Procedures and Augmented Reality, Department of Computer Science, Technical University of Munich, Garching Near Munich, Germany
- Chair for Computer Aided Medical Procedures, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States of America
| | - Wolfgang Weber
- Department of Nuclear Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Thomas Wendler
- Chair for Computer Aided Medical Procedures and Augmented Reality, Department of Computer Science, Technical University of Munich, Garching Near Munich, Germany
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Wang M, Cui B, Shan Y, Yang H, Yan Z, Sundar LKS, Alberts I, Rominger A, Wendler T, Shi K, Ma Y, Jiang J, Lu J. Non-invasive Glucose Metabolism Quantification Method Based on Unilateral ICA Image Derived Input Function by Hybrid PET/MR in Ischemic Cerebrovascular Disease. IEEE J Biomed Health Inform 2022; 26:5122-5129. [PMID: 35867365 DOI: 10.1109/jbhi.2022.3193190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The non-invasive quantification of the cerebral metabolic rate for glucose (CMRGlc) and the characterization of cerebral metabolism in the cerebrovascular territories are helpful in understanding ischemic cerebrovascular disease (ICVD). Firstly, we investigated a non-invasive quantification approach based on an image-derived input function (IDIF) in ICVD. Second, we studied the metabolic changes in CMRGlc after surgical intervention. We evaluated the hypothesis that the IDIF method based on the unilateral internal carotid artery could address challenges in ICVD quantification. The CMRGlc and standardized uptake value ratio (SUVR) were used to measure glucose metabolism activity. Healthy controls showed no significant differences in CMRGlc values between bilateral and unilateral IDIF measurements (intraclass correlation coefficient [ICC]: 0.91-0.98). Patients with ICVD showed significantly increased CMRGlc values after surgical intervention for all territories (percentage changes: 7.4%-22.5%). In contrast, SUVR showed minor differences between postoperative and preoperative patients, indicating that it was a poor biomarker for the diagnosis of ICVD. A significant association between CMRGlc and the National Institutes of Health Stroke Scale (NIHSS) scores was observed (r=-0.54). Our findings suggested that IDIF could be a valuable tool for CMRGlc quantification in patients with ICVD and may advance personalized precision interventions.
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Bi Y, Jiang Z, Gao Y, Wendler T, Karlas A, Navab N. VesNet-RL: Simulation-Based Reinforcement Learning for Real-World US Probe Navigation. IEEE Robot Autom Lett 2022. [DOI: 10.1109/lra.2022.3176112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yuan Bi
- Chair for Computer-Aided Medical Procedures and Augmented Reality, Technical University of Munich, Garching bei München, Germany
| | - Zhongliang Jiang
- Chair for Computer-Aided Medical Procedures and Augmented Reality, Technical University of Munich, Garching bei München, Germany
| | - Yuan Gao
- Chair for Computer-Aided Medical Procedures and Augmented Reality, Technical University of Munich, Garching bei München, Germany
| | - Thomas Wendler
- Chair for Computer-Aided Medical Procedures and Augmented Reality, Technical University of Munich, Garching bei München, Germany
| | - Angelos Karlas
- Institute of Biological and Medical Imaging, Helmholtz Zentrum München, München, Germany
| | - Nassir Navab
- Chair for Computer-Aided Medical Procedures and Augmented Reality, Technical University of Munich, Garching bei München, Germany
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17
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Wendler T, van Leeuwen FWB, Navab N, van Oosterom MN. How molecular imaging will enable robotic precision surgery : The role of artificial intelligence, augmented reality, and navigation. Eur J Nucl Med Mol Imaging 2021; 48:4201-4224. [PMID: 34185136 PMCID: PMC8566413 DOI: 10.1007/s00259-021-05445-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 06/01/2021] [Indexed: 02/08/2023]
Abstract
Molecular imaging is one of the pillars of precision surgery. Its applications range from early diagnostics to therapy planning, execution, and the accurate assessment of outcomes. In particular, molecular imaging solutions are in high demand in minimally invasive surgical strategies, such as the substantially increasing field of robotic surgery. This review aims at connecting the molecular imaging and nuclear medicine community to the rapidly expanding armory of surgical medical devices. Such devices entail technologies ranging from artificial intelligence and computer-aided visualization technologies (software) to innovative molecular imaging modalities and surgical navigation (hardware). We discuss technologies based on their role at different steps of the surgical workflow, i.e., from surgical decision and planning, over to target localization and excision guidance, all the way to (back table) surgical verification. This provides a glimpse of how innovations from the technology fields can realize an exciting future for the molecular imaging and surgery communities.
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Affiliation(s)
- Thomas Wendler
- Chair for Computer Aided Medical Procedures and Augmented Reality, Technische Universität München, Boltzmannstr. 3, 85748 Garching bei München, Germany
| | - Fijs W. B. van Leeuwen
- Department of Radiology, Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, The Netherlands
- Department of Urology, The Netherlands Cancer Institute - Antonie van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Orsi Academy, Melle, Belgium
| | - Nassir Navab
- Chair for Computer Aided Medical Procedures and Augmented Reality, Technische Universität München, Boltzmannstr. 3, 85748 Garching bei München, Germany
- Chair for Computer Aided Medical Procedures Laboratory for Computational Sensing + Robotics, Johns-Hopkins University, Baltimore, MD USA
| | - Matthias N. van Oosterom
- Department of Radiology, Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, The Netherlands
- Department of Urology, The Netherlands Cancer Institute - Antonie van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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19
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Segato A, Di Vece C, Zucchelli S, Marzo MD, Wendler T, Azampour MF, Galvan S, Secoli R, De Momi E. Position-Based Dynamics Simulator of Brain Deformations for Path Planning and Intra-Operative Control in Keyhole Neurosurgery. IEEE Robot Autom Lett 2021. [DOI: 10.1109/lra.2021.3090016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kogler AK, Polemi AM, Nair S, Majewski S, Dengel LT, Slingluff CL, Kross B, Lee SJ, McKisson JE, McKisson J, Weisenberger AG, Welch BL, Wendler T, Matthies P, Traub J, Witt M, Williams MB. Evaluation of camera-based freehand SPECT in preoperative sentinel lymph node mapping for melanoma patients. EJNMMI Res 2020; 10:139. [PMID: 33175204 PMCID: PMC7658290 DOI: 10.1186/s13550-020-00729-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/29/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Assessment of lymphatic status via sentinel lymph node (SLN) biopsy is an integral and crucial part of melanoma surgical oncology. The most common technique for sentinel node mapping is preoperative planar scintigraphy of an injected gamma-emitting lymphatic tracer followed by intraoperative node localization using a non-imaging gamma probe with auditory feedback. In recent years, intraoperative visualization of SLNs in 3D has become possible by coupling the probe to an external system capable of tracking its location and orientation as it is read out, thereby enabling computation of the 3D distribution of the tracer (freehand SPECT). In this project, the non-imaging probe of the fhSPECT system was replaced by a unique handheld gamma camera containing an array of sodium iodide crystals optically coupled to an array of silicon photomultipliers (SiPMs). A feasibility study was performed in which preoperative SLN mapping was performed using camera fhSPECT and the number of detected nodes was compared to that visualized by lymphoscintigraphy, probe fhSPECT, and to the number ultimately excised under non-imaging probe guidance. RESULTS Among five subjects, SLNs were detected in nine lymphatic basins, with one to five SLNs detected per basin. A basin-by-basin comparison showed that the number of SLNs detected using camera fhSPECT exceeded that using lymphoscintigraphy and probe fhSPECT in seven of nine basins and five of five basins, respectively. (Probe fhSPECT scans were not performed for four basins.) It exceeded the number excised under non-imaging probe guidance for seven of nine basins and equaled the number excised for the other two basins. CONCLUSIONS Freehand SPECT using a prototype SiPM-based gamma camera demonstrates high sensitivity for detection of SLNs in a preoperative setting. Camera fhSPECT is a potential means for efficiently obtaining real-time 3D activity distribution maps in applications such as image-guided percutaneous biopsy, and surgical SLN biopsy or radioguided tumor excision.
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Affiliation(s)
- Annie K Kogler
- Department of Physics, University of Virginia, Charlottesville, VA, USA
| | - Andrew M Polemi
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, USA
| | - Surabhi Nair
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Stanislaw Majewski
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Lynn T Dengel
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Craig L Slingluff
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Brian Kross
- Thomas Jefferson National Accelerator Facility, Newport News, VA, USA
| | - S J Lee
- Thomas Jefferson National Accelerator Facility, Newport News, VA, USA
| | - J E McKisson
- Thomas Jefferson National Accelerator Facility, Newport News, VA, USA
| | - John McKisson
- Thomas Jefferson National Accelerator Facility, Newport News, VA, USA
| | | | | | | | | | | | | | - Mark B Williams
- Department of Physics, University of Virginia, Charlottesville, VA, USA. .,Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, USA. .,Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA.
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Cipriani C, Desantis M, Dahlhoff G, Brown SD, Wendler T, Olmeda M, Pietsch G, Eberlein B. Personalized irradiation therapy for NMSC by rhenium-188 skin cancer therapy: a long-term retrospective study. J DERMATOL TREAT 2020; 33:969-975. [PMID: 32648530 DOI: 10.1080/09546634.2020.1793890] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study aimed to provide long-term clinical data about an innovative epidermal radioisotope therapy called Rhenium-SCT® (Skin Cancer Therapy) for non-melanoma skin cancer (NMSC), based on the use of the non-sealed beta emitter rhenium-188. MATERIAL AND METHODS 52 NMSC patients with a mean age of 71.7 years were treated with rhenium-188 skin cancer therapy between the years 2005 and 2014. An acryl matrix containing rhenium-188 was applied on a plastic foil covering the tumor. The treatment time for reaching a radiation dose of 50 Gy was calculated by a software program. Patients' characteristics and clinical follow-up data were collected and retrospectively analyzed. RESULTS Overall 55 lesions (32 BCC, 19 SCC, 2 M. Bowen and 2 extramammary Paget's disease (EMPD)) mainly in the head and neck region (72.3%) were treated. The average size of the irradiation area was 9.79 cm2 and the mean treatment time 46.35 min. All lesions showed a complete remission after a follow-up period between 3 and more than 12 months. No complications or other post-interventional problems were reported. CONCLUSIONS Rhenium-SCT® is considered as an effective, rapid, safe, painless treatment mostly performed in a single therapeutic session, regardless of the shape complexity, anatomical site and number of lesions.
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Affiliation(s)
| | - Maria Desantis
- Nuclear Medicine Division, AlGa Institute, Celano, Italy
| | | | | | | | | | - Gunilla Pietsch
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Bernadette Eberlein
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
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van Oosterom MN, Meershoek P, Welling MM, Pinto F, Matthies P, Simon H, Wendler T, Navab N, van de Velde CJH, van der Poel HG, van Leeuwen FWB. Extending the Hybrid Surgical Guidance Concept With Freehand Fluorescence Tomography. IEEE Trans Med Imaging 2020; 39:226-235. [PMID: 31247546 DOI: 10.1109/tmi.2019.2924254] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Within image-guided surgery, 'hybrid' guidance technologies have been used to integrate the complementary features of radioactive guidance and fluorescence guidance. Here, we explore how the generation of a novel freehand fluorescence (fhFluo) imaging approach complements freehand SPECT (fhSPECT) in a hybrid setup. Near-infrared optical tracking was used to register the position and the orientation of a hybrid opto-nuclear detection probe while recording its readings. Dedicated look-up table models were used for 3D reconstruction. In phantom and excised tissue settings (i.e., flat-surface human skin explants), fhSPECT and fhFluo were investigated for image resolution and in-tissue signal penetration. Finally, the combined potential of these freehand technologies was evaluated on prostate and lymph node specimens of prostate cancer patients receiving prostatectomy and sentinel lymph node dissection (tracers: indocyanine green (ICG) +99m Tc-nanocolloid or ICG-99mTc-nanocolloid). After hardware and software integration, the hybrid setup created 3D nuclear and fluorescence tomography scans. The imaging resolution of fhFluo (1 mm) was superior to that of fhSPECT (6 mm). Fluorescence modalities were confined to a maximum depth of 0.5 cm, while nuclear modalities were usable at all evaluated depths (<2 cm). Both fhSPECT and fhFluo enabled augmented- and virtual-reality navigation toward segmented image hotspots, including relative hotspot quantification with an accuracy of 3.9% and 4.1%. Imaging in surgical specimens confirmed these trends (fhSPECT: in-depth detectability, low resolution, and fhFluo: superior resolution, superficial detectability). Overall, when radioactive and fluorescent tracer signatures are used, fhFluo has complementary value to fhSPECT. Combined the freehand technologies render a unique hybrid imaging and navigation modality.
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Zagni F, Lima G, Farina A, Castellucci P, Savoia F, Kirikova A, Wendler T, Fanti S, Marengo M. 361. A new therapy with 188Re for non-melanoma skin cancers. First experiences. Phys Med 2018. [DOI: 10.1016/j.ejmp.2018.04.369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Wendler T, Lennertz A, Heinemann O, Duhr C, Samtleben W, Bosch T. Heparin-Free DALI LDL-Apheresis in Hyperlipidemic Patients: Efficacy, Safety and Biocompatibility. Int J Artif Organs 2018. [DOI: 10.1177/039139880002301009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and Aim of Study In routine DALI apheresis - the first technique for direct adsorption of lipoproteins from whole blood - heparin plus citrate (ACD-A) is used as anticoagulation regimen. However, recently several publications have warned of heparin-induced thrombocytopenia as a rare but potentially life-threatening complication of heparin administration (HIT type 2). The aim of the present study was therefore to test the efficacy and biocompatibility of DALI using a heparin-free anticoagulation regimen consisting exclusively of citrate. Methods Four symptomatic hypercholesterolemic patients on regular DALI apheresis were switched to the heparin-free protocol for two sessions each. Two of the patients were on oral anticoagulation using phenprocoumon. In the weekly sessions, 1.3 patient blood volumes were processed at a blood flow rate of 60 ml/min using ACD-A at a ratio of 1:20 (v/v) during adsorber priming and the session. Results Clinically, all sessions were essentially uneventful. Uncorrected lipoprotein reductions amounted to 65% for LDL-C, 62% for Lp(a), 53% for VLDL-C, 24% for HDL-C, 17% for triglycerides and 19% for fibrinogen. Cell counts remained virtually constant. No signs of hemolysis or clotting could be detected. Thromboplastin time (Quick) was slightly prolonged and partial thromboplastin time (PTT) moderately elevated in all patients. In constrast, whole blood coagulation time acc. to Lee-White and activated clotting times were increased only in orally anticoagulated patients. Biocompatibility in terms of complement, leukocyte and thrombocyte activation was excellent. Bradykinin activation was moderate peaking at 3038 pg/ml in the efferent line. Systemic thrombin-antithrombin complex (TAT) reflected perfect anticoagulation in orally anticoagulated patients and adequate anticoagulation in the patients without phenprocoumon. Conclusion In this pilot study, heparin-free DALI apheresis was safe and effective and may thus be performed in LDL-apheresis dependent patients who suffer from heparin intolerance.
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Affiliation(s)
- T. Wendler
- Nephrology Division, Department of Internal Medicine I, Klinikum Großhadern, University of Munich, Munich - Germany
| | - A. Lennertz
- Nephrology Division, Department of Internal Medicine I, Klinikum Großhadern, University of Munich, Munich - Germany
| | - O. Heinemann
- Nephrology Division, Department of Internal Medicine I, Klinikum Großhadern, University of Munich, Munich - Germany
| | - C. Duhr
- Nephrology Division, Department of Internal Medicine I, Klinikum Großhadern, University of Munich, Munich - Germany
| | - W. Samtleben
- Nephrology Division, Department of Internal Medicine I, Klinikum Großhadern, University of Munich, Munich - Germany
| | - T. Bosch
- Nephrology Division, Department of Internal Medicine I, Klinikum Großhadern, University of Munich, Munich - Germany
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Abstract
OBJECTIVE We developed and implemented two predictor-corrector methods for the classification of two-channel EEG data into sleep stages. APPROACH The sequence of sleep stages over the night is modeled by a Markov chain of first and second order, resulting in an informative prior distribution for the new state, given the distribution of the current one. The correction step is realized by applying a Bayes classifier using the (preprocessed) data and this prior. The preprocessing step consists of a frequency analysis, a log transformation and a dimensionality reduction via principal component analysis. MAIN RESULTS The software automatically generates sleep profiles in which it detects wakeful phases as well as the different sleep stages with error rates of 16.5%-31.9% (n = 8, healthy subjects, mean age ± SD: 39 ± 8.1 years, five females), where we compared our results to those of a certified polysomnographic technologist, who used a full polysomnograph and rated according to the American Academy of Sleep Medicine (AASM) criteria. SIGNIFICANCE The method presented relies on considerably less information than visual scoring and is done automatically. Furthermore, the error is comparable to visual scoring, where the inter-rater variability lies around 82%. Therefore, it has the potential to lessen the overheads associated with sleep diagnostics.
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Wendler T, Paepke S. Axillary sentinel node aspiration biopsy: towards minimally invasive lymphatic staging in breast cancer. Clin Transl Imaging 2016. [DOI: 10.1007/s40336-016-0205-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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van Oosterom MN, Engelen MA, van den Berg NS, KleinJan GH, van der Poel HG, Wendler T, van de Velde CJH, Navab N, van Leeuwen FWB. Navigation of a robot-integrated fluorescence laparoscope in preoperative SPECT/CT and intraoperative freehand SPECT imaging data: a phantom study. J Biomed Opt 2016; 21:86008. [PMID: 27548770 DOI: 10.1117/1.jbo.21.8.086008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 07/25/2016] [Indexed: 06/06/2023]
Abstract
Robot-assisted laparoscopic surgery is becoming an established technique for prostatectomy and is increasingly being explored for other types of cancer. Linking intraoperative imaging techniques, such as fluorescence guidance, with the three-dimensional insights provided by preoperative imaging remains a challenge. Navigation technologies may provide a solution, especially when directly linked to both the robotic setup and the fluorescence laparoscope. We evaluated the feasibility of such a setup. Preoperative single-photon emission computed tomography/X-ray computed tomography (SPECT/CT) or intraoperative freehand SPECT (fhSPECT) scans were used to navigate an optically tracked robot-integrated fluorescence laparoscope via an augmented reality overlay in the laparoscopic video feed. The navigation accuracy was evaluated in soft tissue phantoms, followed by studies in a human-like torso phantom. Navigation accuracies found for SPECT/CT-based navigation were 2.25 mm (coronal) and 2.08 mm (sagittal). For fhSPECT-based navigation, these were 1.92 mm (coronal) and 2.83 mm (sagittal). All errors remained below the <1-cm detection limit for fluorescence imaging, allowing refinement of the navigation process using fluorescence findings. The phantom experiments performed suggest that SPECT-based navigation of the robot-integrated fluorescence laparoscope is feasible and may aid fluorescence-guided surgery procedures.
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Affiliation(s)
- Matthias Nathanaël van Oosterom
- Leiden University Medical Center, Department of Surgery, Albinusdreef 2, Leiden 2333 ZA, The NetherlandsbLeiden University Medical Center, Department of Radiology, Interventional Molecular Imaging Laboratory, Albinusdreef 2, Leiden 2333 ZA, The Netherlands
| | - Myrthe Adriana Engelen
- Leiden University Medical Center, Department of Radiology, Interventional Molecular Imaging Laboratory, Albinusdreef 2, Leiden 2333 ZA, The Netherlands
| | - Nynke Sjoerdtje van den Berg
- Leiden University Medical Center, Department of Radiology, Interventional Molecular Imaging Laboratory, Albinusdreef 2, Leiden 2333 ZA, The NetherlandscThe Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Department of Urology, Plesmanlaan 121, Amsterdam 1066 CX, The Netherlands
| | - Gijs Hendrik KleinJan
- Leiden University Medical Center, Department of Radiology, Interventional Molecular Imaging Laboratory, Albinusdreef 2, Leiden 2333 ZA, The NetherlandscThe Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Department of Urology, Plesmanlaan 121, Amsterdam 1066 CX, The Netherlands
| | - Henk Gerrit van der Poel
- The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Department of Urology, Plesmanlaan 121, Amsterdam 1066 CX, The Netherlands
| | - Thomas Wendler
- Technische Universität München, Computer Aided Medical Procedures, Institut für Informatik, I16, Boltzmannstr. 3, Garching bei München 85748, GermanyeSurgicEye GmbH, Friedenstraße 18A, München 81671, Germany
| | | | - Nassir Navab
- Technische Universität München, Computer Aided Medical Procedures, Institut für Informatik, I16, Boltzmannstr. 3, Garching bei München 85748, GermanyfJohns Hopkins University, Computer Aided Medical Procedures, 3400 North Charles Street, Hackerman 200, Baltimore, Maryland 21218, United States
| | - Fijs Willem Bernhard van Leeuwen
- Leiden University Medical Center, Department of Radiology, Interventional Molecular Imaging Laboratory, Albinusdreef 2, Leiden 2333 ZA, The NetherlandscThe Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Department of Urology, Plesmanlaan 121, Amsterdam 1066 CX, The Netherlands
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KleinJan GH, van den Berg NS, van Oosterom MN, Wendler T, Miwa M, Bex A, Hendricksen K, Horenblas S, van Leeuwen FWB. Toward (Hybrid) Navigation of a Fluorescence Camera in an Open Surgery Setting. J Nucl Med 2016; 57:1650-1653. [PMID: 27230927 DOI: 10.2967/jnumed.115.171645] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/11/2016] [Indexed: 01/15/2023] Open
Abstract
With the introduction of the hybrid tracer indocyanine green (ICG)-99mTc-nanocolloid, a direct relation between preoperative imaging and intraoperative fluorescence guidance was established. However, fluorescence guidance remains limited by its superficial nature. This study evaluated the feasibility of a nuclear medicine-based navigation concept that allowed intraoperative positioning of a fluorescence camera (FC) in the vicinity of preoperatively defined ICG-99mTc-nanocolloid containing sentinel nodes (SNs). METHODS Five patients with penile cancer scheduled for SN biopsy were injected with ICG-99mTc-nanocolloid followed by preoperative SPECT/CT imaging. The navigation device was used to provide a real-time augmented reality overlay of the SPECT/CT images and video output of the FC. This overlay was then used for FC navigation. RESULTS SPECT/CT identified 13 SNs in 9 groins. FC navigation was successful for all 12 intraoperatively evaluated SNs (average error, 8.8 mm; range, 0-20 mm). CONCLUSION This study reveals the potential benefits of FC navigation during open surgery procedures.
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Affiliation(s)
- Gijs H KleinJan
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands Department of Nuclear Medicine, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Nynke S van den Berg
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Matthias N van Oosterom
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas Wendler
- Institut für Informatik, Computer Aided Medical Procedures (CAMP), Technische Universität München, Munich, Germany SurgicEye GmbH, Munich, Germany; and
| | - Mitsuharu Miwa
- Business Incubator, Development Center, Hamamatsu Photonics K.K., Hamamatsu City, Japan
| | - Axel Bex
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Kees Hendricksen
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Simon Horenblas
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Fuerst B, Sprung J, Pinto F, Frisch B, Wendler T, Simon H, Mengus L, van den Berg NS, van der Poel HG, van Leeuwen FWB, Navab N. First Robotic SPECT for Minimally Invasive Sentinel Lymph Node Mapping. IEEE Trans Med Imaging 2016; 35:830-838. [PMID: 26561283 DOI: 10.1109/tmi.2015.2498125] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
In this paper we present the usage of a drop-in gamma probe for intra-operative Single-Photon Emission Computed Tomography (SPECT) imaging in the scope of minimally invasive robot-assisted interventions. The probe is designed to be inserted and reside inside the abdominal cavity during the intervention. It is grasped during the procedure using a robotic laparoscopic gripper enabling full six degrees of freedom handling by the surgeon. We demonstrate the first deployment of the tracked probe for intra-operative in-patient robotic SPECT enabling augmented-reality image guidance. The hybrid mechanical- and image-based in-patient probe tracking is shown to have an accuracy of 0.2 mm. The overall system performance is evaluated and tested with a phantom for gynecological sentinel lymph node interventions and compared to ground-truth data yielding a mean reconstruction accuracy of 0.67 mm.
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Paepke S, Pfob CH, Ohlinger R, Gruber I, Thill M, Blohmer JU, Kuehn T, Hahn M, Kiechle M, Wendler T. Abstract P3-01-16: Can sentinel node staging be performed using a minimally invasive needle-biopsy? Results of German multicentric pilot study. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p3-01-16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
AIM
Evaluate within a pilot setup feasibility and safety of minimally invasive needle-biopsy of sentinel nodes guided by SPECT/US as compared to surgical removal while defining optimal needle for follow-up trial.
METHOD AND MATERIALS
As pretrial test phase of the MinimalSNB study, 38 breast cancer patients (6 centers) were taken a needle-biopsy of their sentinel lymph nodes (SLNs) under guidance of SPECT/US (SentiGuide by SurgicEye, Munich, DE). All patients were indicated for a surgical SLN biopsy which was performed immediately after the needle-biopsy. For the test phase, 4 different biopsy systems were tested: HistoCore 14G (BIP, Tuerkenfeld, DE), elite 10G and 13G (Mammotome, Cincinnati, OH, US) and CASSI II 10G (Scion Medical Technologies, Boston, MA, US). Histopathological examination (H&E, step-sectioning) of needle-biopsies and surgically removed SLNs were compared.
RESULTS
No single complication was reported. Occasionally, small hematomas could be found close to the SLN during surgery. Duration of complete procedure (imaging, needle placement, biopsy) took in average 17min. A learning curve was observed in duration (average after 5 biopsies 12min). 1-14 samples were taken of each SLN (average 5 samples). Final pathological examination of material harvested with both methods matched in 34 cases (33 negatives, 1 positive). The needle biopsy failed to detect metastases in 2 pN1 SLNs. In 1 case, the surgically resected tissue did not contain lymph nodes and the needle biopsy remained the only information on nodal status. In 1 case a metastasis found in needle-biopsy motivated a second reading of an originally negative SLN which resulted in the upstaging of the patient. In both cases a metastases was missed by needle-biopsy, the retrieved lymph tissue was minimal (1x 14G sample, 1x 10G sample tangential to node).
CONCLUSION
SPECT/US showed to be a valid method for percutaneous detection of SLNs and needle-guidance. Sampling SLNs with a needle seems safe and feasible. However it requires proper training and user experienced with axillary needle-biopsies. Retrieving more tissue (more cores and larger lumen needles) improves diagnostic power of needle-biopsy. These considerations will be taken within the upcoming MinimalSNB trial.
CLINICAL RELEVANCE
Sentinel lymph biopsy today is a surgical diagnostic procedure with an nonzero morbidity. Moving it out of the operating theatre to a needle-based intervention has a huge impact on the burden of this procedure for the patient as well as relevant improvements in logistics, workflow and radiation burden.
Citation Format: Paepke S, Pfob CH, Ohlinger R, Gruber I, Thill M, Blohmer JU, Kuehn T, Hahn M, Kiechle M, Wendler T. Can sentinel node staging be performed using a minimally invasive needle-biopsy? Results of German multicentric pilot study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-01-16.
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Affiliation(s)
- S Paepke
- Technische Universitaet Muenchen, Munich, Germany; Ernst Moritz Arndt Universitaet Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany; Universitaetsklinikum Tuebingen, Tuebingen, Baden-Wuerttemberg, Germany; Agaplesion Markus Krankenhaus, Frankfurt, Hessen, Germany; Charite – Universitaetsmedizin Berlin, Berlin, Germany; Klinikum Esslingen, Esslingen, Baden-Wuerttemberg, Germany
| | - CH Pfob
- Technische Universitaet Muenchen, Munich, Germany; Ernst Moritz Arndt Universitaet Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany; Universitaetsklinikum Tuebingen, Tuebingen, Baden-Wuerttemberg, Germany; Agaplesion Markus Krankenhaus, Frankfurt, Hessen, Germany; Charite – Universitaetsmedizin Berlin, Berlin, Germany; Klinikum Esslingen, Esslingen, Baden-Wuerttemberg, Germany
| | - R Ohlinger
- Technische Universitaet Muenchen, Munich, Germany; Ernst Moritz Arndt Universitaet Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany; Universitaetsklinikum Tuebingen, Tuebingen, Baden-Wuerttemberg, Germany; Agaplesion Markus Krankenhaus, Frankfurt, Hessen, Germany; Charite – Universitaetsmedizin Berlin, Berlin, Germany; Klinikum Esslingen, Esslingen, Baden-Wuerttemberg, Germany
| | - I Gruber
- Technische Universitaet Muenchen, Munich, Germany; Ernst Moritz Arndt Universitaet Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany; Universitaetsklinikum Tuebingen, Tuebingen, Baden-Wuerttemberg, Germany; Agaplesion Markus Krankenhaus, Frankfurt, Hessen, Germany; Charite – Universitaetsmedizin Berlin, Berlin, Germany; Klinikum Esslingen, Esslingen, Baden-Wuerttemberg, Germany
| | - M Thill
- Technische Universitaet Muenchen, Munich, Germany; Ernst Moritz Arndt Universitaet Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany; Universitaetsklinikum Tuebingen, Tuebingen, Baden-Wuerttemberg, Germany; Agaplesion Markus Krankenhaus, Frankfurt, Hessen, Germany; Charite – Universitaetsmedizin Berlin, Berlin, Germany; Klinikum Esslingen, Esslingen, Baden-Wuerttemberg, Germany
| | - JU Blohmer
- Technische Universitaet Muenchen, Munich, Germany; Ernst Moritz Arndt Universitaet Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany; Universitaetsklinikum Tuebingen, Tuebingen, Baden-Wuerttemberg, Germany; Agaplesion Markus Krankenhaus, Frankfurt, Hessen, Germany; Charite – Universitaetsmedizin Berlin, Berlin, Germany; Klinikum Esslingen, Esslingen, Baden-Wuerttemberg, Germany
| | - T Kuehn
- Technische Universitaet Muenchen, Munich, Germany; Ernst Moritz Arndt Universitaet Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany; Universitaetsklinikum Tuebingen, Tuebingen, Baden-Wuerttemberg, Germany; Agaplesion Markus Krankenhaus, Frankfurt, Hessen, Germany; Charite – Universitaetsmedizin Berlin, Berlin, Germany; Klinikum Esslingen, Esslingen, Baden-Wuerttemberg, Germany
| | - M Hahn
- Technische Universitaet Muenchen, Munich, Germany; Ernst Moritz Arndt Universitaet Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany; Universitaetsklinikum Tuebingen, Tuebingen, Baden-Wuerttemberg, Germany; Agaplesion Markus Krankenhaus, Frankfurt, Hessen, Germany; Charite – Universitaetsmedizin Berlin, Berlin, Germany; Klinikum Esslingen, Esslingen, Baden-Wuerttemberg, Germany
| | - M Kiechle
- Technische Universitaet Muenchen, Munich, Germany; Ernst Moritz Arndt Universitaet Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany; Universitaetsklinikum Tuebingen, Tuebingen, Baden-Wuerttemberg, Germany; Agaplesion Markus Krankenhaus, Frankfurt, Hessen, Germany; Charite – Universitaetsmedizin Berlin, Berlin, Germany; Klinikum Esslingen, Esslingen, Baden-Wuerttemberg, Germany
| | - T Wendler
- Technische Universitaet Muenchen, Munich, Germany; Ernst Moritz Arndt Universitaet Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany; Universitaetsklinikum Tuebingen, Tuebingen, Baden-Wuerttemberg, Germany; Agaplesion Markus Krankenhaus, Frankfurt, Hessen, Germany; Charite – Universitaetsmedizin Berlin, Berlin, Germany; Klinikum Esslingen, Esslingen, Baden-Wuerttemberg, Germany
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Matthies P, Okur A, Wendler T, Navab N, Friebe M. Combination of intra-operative freehand SPECT imaging with MR images for guidance and navigation. Annu Int Conf IEEE Eng Med Biol Soc 2015; 2013:3383-6. [PMID: 24110454 DOI: 10.1109/embc.2013.6610267] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Nowadays for clinical applications such as sentinel lymph node biopsy in breast or prostate cancer, only pre-operative image data is used for navigation, i.e. CT, SPECT/CT or PET/CT. Freehand SPECT and freehand PET provide intra-operative functional imaging techniques that can be complemented with pre- and intra-operative MR imaging to allow for better planning, navigation and guidance. In this paper we propose a method to enable navigation based on pre- or intra-operatively acquired MR images. A fully MR compatible phantom and a dedicated MR compatible optical tracking target with MR markers is built for this study. PET/MR, SPECT/CT and freehand SPECT scans of the phantom are performed. Registration is done using point based registration of the known marker and target geometries and a ground truth is obtained from a SPECT/CT and an MR image that are directly registered. The RMS errors was 0.31 mm for the ground truth and 3.29 mm when using segmentation of the MR markers and their spatial relationship with the optical tracking spheres of the dedicated target. Thus, the freehand SPECT can be registered easily by this approach without the need of any additional CT scans and therefore without any additional radiation dose for the patient. This enables intra-operative fusion of the pre- or intra-operatively acquired MR data, which could provide valuable additional information for intra-operative applications such as guidance based on accurate anatomy or verifying exact tumor location in combination with detailed morphological patient data.
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Brouwer OR, van den Berg NS, Mathéron HM, Wendler T, van der Poel HG, Horenblas S, Valdés Olmos RA, van Leeuwen FW. Feasibility of Intraoperative Navigation to the Sentinel Node in the Groin Using Preoperatively Acquired Single Photon Emission Computerized Tomography Data: Transferring Functional Imaging to the Operating Room. J Urol 2014; 192:1810-6. [DOI: 10.1016/j.juro.2014.03.127] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2014] [Indexed: 11/15/2022]
Affiliation(s)
- Oscar R. Brouwer
- Department of Nuclear Medicine, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nynke S. van den Berg
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hanna M. Mathéron
- Department of Nuclear Medicine, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas Wendler
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
- SurgicEye GmBH, Munich, Germany
| | - Henk G. van der Poel
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Simon Horenblas
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Renato A. Valdés Olmos
- Department of Nuclear Medicine, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Fijs W.B. van Leeuwen
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Head and Neck Surgery and Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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Castillo Morales V, Martin MR, Diaz Laugart E, De Jesus M, Diez Jimenez L, Wendler T, Diez AC. 372. Intraoperative Demonstration of 3D Tumor Localization Using Freehand SPECT in a Duodenum NET Patient. Eur J Surg Oncol 2012. [DOI: 10.1016/j.ejso.2012.06.347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Martignoni M, Rieger A, Saeckl J, Hein R, Okur A, Wendler T, Scheidhauer K, Schuster T, Friess H. 91. Transferring innovative freehand SPECT to the operating room – First experiences with sentinel lymphonodectomy in malignant melanoma. Eur J Surg Oncol 2012. [DOI: 10.1016/j.ejso.2012.06.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Brouwer OR, Buckle T, Bunschoten A, Kuil J, Vahrmeijer AL, Wendler T, Valdés-Olmos RA, van der Poel HG, van Leeuwen FWB. Image navigation as a means to expand the boundaries of fluorescence-guided surgery. Phys Med Biol 2012; 57:3123-36. [PMID: 22547491 DOI: 10.1088/0031-9155/57/10/3123] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hybrid tracers that are both radioactive and fluorescent help extend the use of fluorescence-guided surgery to deeper structures. Such hybrid tracers facilitate preoperative surgical planning using (3D) scintigraphic images and enable synchronous intraoperative radio- and fluorescence guidance. Nevertheless, we previously found that improved orientation during laparoscopic surgery remains desirable. Here we illustrate how intraoperative navigation based on optical tracking of a fluorescence endoscope may help further improve the accuracy of hybrid surgical guidance. After feeding SPECT/CT images with an optical fiducial as a reference target to the navigation system, optical tracking could be used to position the tip of the fluorescence endoscope relative to the preoperative 3D imaging data. This hybrid navigation approach allowed us to accurately identify marker seeds in a phantom setup. The multispectral nature of the fluorescence endoscope enabled stepwise visualization of the two clinically approved fluorescent dyes, fluorescein and indocyanine green. In addition, the approach was used to navigate toward the prostate in a patient undergoing robot-assisted prostatectomy. Navigation of the tracked fluorescence endoscope toward the target identified on SPECT/CT resulted in real-time gradual visualization of the fluorescent signal in the prostate, thus providing an intraoperative confirmation of the navigation accuracy.
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Affiliation(s)
- Oscar R Brouwer
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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Valdivia Vega RP, Perez Carlos J, LI X, LI X, Xu X, Zhang W, Ren H, Chen N, Yorioka N, Doi T, Hirashio S, Arita M, Hirabayashi A, Tilkiyan E, Chonova E, Ronchev Y, Kumchev E, Giamalis P, Spartalis M, Stangou M, Tsouchnikas I, Moysiades D, Dimopoulou D, Garyfalos A, Efstratiadis G, Memmos D, Schonermarck U, Eichhorn P, Sitter T, Wendler T, Vielhauer V, Lederer S, Fechner K, Fischereder M, Bantis C, Heering P, Kouri NM, Stangou M, Schwandt C, Kuhr N, Ivens K, Rump LC, Matta V, Melis P, Conti M, Cao R, Binda V, Altieri P, Asunis AM, Catani W, Floris M, Angioi A, Congia M, Cucca F, Minerba L, Peri M, Pani A, Beck LH, Fervenza FC, Fervenza FC, Bomback AS, Ayalon R, Irazabal MV, Eirin A, Cattran DC, Appel GB, Salant DJ, Santoro D, Postorino A, Costantino G, Bellinghieri G, Savica V, Weiner M, Goh SM, Mohammad A, Eriksson P, Westman K, Selga D, Salama A, Segelmark M, Chocova Z, Hruskova Z, Mareckova H, Svobodova B, Jancova E, Bednarova V, Rysava R, Tesar V, Hruskova Z, Jancova E, Hanzal V, Zamboch K, Grussmannova M, Svojanovsky J, Klaboch J, Kubisova M, Sevcik J, Olsanska R, Sobotkova M, Becvar R, Nemec P, Kodeda M, Jilek D, Chocova Z, Tesar V, Hussain M, Dhaygude A, Cartery C, Cartery C, Huart A, Plaisier E, Bongard V, Montastruc F, Ronco P, Pourrat J, Chauveau D, Prasad N, Gurjar D, Bhadauria D, Sharma RK, Gupta A, Kaul A, Jain M, Venning M, Brown N, Bruce I, Noor S, Dhaygude A, Bekker P, Potarca A, Dairaghi D, Miao S, Powers JP, Jaen JC, Schall TJ, Kalavrizioti D, Kalavrizioti D, Gerolymos M, Komninakis D, Rodi M, Mouzaki A, Kalliakmani P, Goumenos D, Choi BS, Choi BS, Park CW, Kim YS, Yang CW, Sun IO, Qin W, Xie L, Tan C, Qin W, Mian W, Fu P, Tan C, Kaminskyy V, Bantis C, Heering P, Kouri NM, Kuhr N, Schwandt C, Ivens K, Rump LC, Hao X, Hao X, Ren H, Wang W, Chen N, Cengiz C, Nur C, Nurdan Y, Selman G, Pinar T, Mehmet T, Lale S, Caliskan S, Shinzawa M, Yamamoto R, Nagasawa Y, Oseto S, Mori D, Niihata K, Fukunaga M, Yamauchi A, Tsubakihara Y, Rakugi H, Isaka Y, Chen JS, Lin YF, Lin WY, Shu KH, Chen HH, Wu CJ, Yang CS, Tseng TL, Zaza G, Bernich P, Lupo A, Panizo N, Rivera F, Lopez Gomez JM, Regn SROG, Ceresini G, Vaglio A, Urban ML, Corradi D, Usberti E, Palmisano A, Buzio C, Vaglio A, Zineb H, Ramdani B, Marques LPJ, Rioja LDS, Rocco R, Nery ACF, Novaes BC, Bridoux F, Sicard A, Labatut D, Touchard G, Sarkozy C, Vanhille P, Callard P, Essig M, Provot F, Nony A, Ronco P, Karras A, Agustin CP, M Belen HR, Carmen CP, Eliana O, Elisa P, Luis P, Alberto MC, Javier N, Isabel F, Cao R, Conti M, Atzeni A, Fois A, Piras D, Maxia S, Angioi A, Binda V, Melis P, Sau G, Pili G, Floris M, Asunis AM, Porcu M, Derudas D, Angelucci E, Ledda A, La Nasa G, Pani A, Ossareh S, Asgari M, Savaj S, Ataipour Y, Abdi E, Malakoutian T, Rajaa R, Berkchi FZ, Haffane L, Squalli Z, Rouass L, Al Hamany Z, Ezzaitouni F, Benamar L, Bayahya R, Ouzeddoun N, Gao-Yuan H, Yao X, Xin C, Zhen C, Yong-Chun G, Qing-Wen W, Hui-Ping C, Da-XI J, De-Hua G, Wei-Xin H, Zhi-Hong L, Rajaa R, Fatima Zahra B, Laila H, Zoubair S, Rouass L, Al Hamany Z, Ezzaitouni F, Benamar L, Bayahya R, Naima O, Smykal-Jankowiak K, Niemir Z, Polcyn-Adamczak M, Szramka-Pawlak B, Zaba R, Zhang C, Zhang C, Ren H, MA Y, Wang W, Zhang W, Shen P, Chen N, Ouyang Y, Ouyang Y, Pan X, Wang Z, Feng X, Shen P, Ren H, Ni L, Zhang W, Chen N. Primary and secondary glomerulonephritis II. Nephrol Dial Transplant 2012. [DOI: 10.1093/ndt/gfs239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Rieger A, Saeckl J, Belloni B, Hein R, Okur A, Scheidhauer K, Wendler T, Traub J, Friess H, Martignoni ME. First Experiences with Navigated Radio-Guided Surgery Using Freehand SPECT. Case Rep Oncol 2011; 4:420-5. [PMID: 21941492 PMCID: PMC3177799 DOI: 10.1159/000330273] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Sentinel lymph node biopsy (SLNB) in melanoma using one-dimensional gamma probes is a standard of care worldwide. Reports on the performance are claimed by most groups to successfully detect the SLNs during the surgical procedure in almost 100% of the patients. In clinical practice, however, several issues remain which are usually not addressed: the difficulty of intraoperative detection of deeply located nodes, SLN detection in obese patients or in the groin and the impossibility to make a scan of the entire wound after SLN resection to avoid false negative testing for eventually remaining SLNs. Materials and Methods The concept behind freehand SPECT is to combine a gamma probe as used for conventional radio-guided surgery with a tracking system as used in neurosurgical navigation. From this combination and a proper algorithm framework the 3D reconstruction of radioactivity distributions and displaying these intraoperatively is possible. Conclusion In summary, the feasibility of freehand SPECT could be shown and provides an image-guided SLNB and a truly minimally invasive and optimized surgical procedure.
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Affiliation(s)
- A Rieger
- Department of Surgery, Technische Universität München, and, Munich, Germany
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Vetter C, Lasser T, Wendler T, Navab N. 1D-3D registration for functional nuclear imaging. Med Image Comput Comput Assist Interv 2011; 14:227-234. [PMID: 22003621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Functional nuclear imaging systems like PET or SPECT provide unique information that is used extensively in diagnosis, but it has also proven very useful for image-guided interventions. In the case of SPECT and radio-guided surgeries, 1D gamma detectors called gamma probes are routinely used during interventions to localize hotspots in conjunction with pre-operative SPECT images, or more recently, intraoperative SPECT images. As the tissue is being manipulated during surgery, these SPECT images quickly lose their validity, necessitating either new scans, which is in most cases unfeasible, or requiring the surgeon to do a mental update of the available imagery. In this paper, we present a novel 1D-3D registration procedure for functional nuclear imaging that registers tracked intra-operative 1D probe readings to a pre- or intra-operatively acquired 3D functional image. This procedure allows incorporating prior knowledge during radio-guided surgeries, enabling rapid updates of the visualization in the case of tissue deformation without the overhead of an additional complete scan. We show results using phantom data as well as patient data.
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Affiliation(s)
- Christoph Vetter
- Chair for Computer Aided Medical Procedures (CAMP), Technische Universität München, Germany
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Wendler T, Herrmann K, Schnelzer A, Lasser T, Traub J, Kutter O, Ehlerding A, Scheidhauer K, Schuster T, Kiechle M, Schwaiger M, Navab N, Ziegler SI, Buck AK. First demonstration of 3-D lymphatic mapping in breast cancer using freehand SPECT. Eur J Nucl Med Mol Imaging 2010; 37:1452-61. [PMID: 20354851 DOI: 10.1007/s00259-010-1430-4] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Accepted: 02/24/2010] [Indexed: 12/16/2022]
Abstract
PURPOSE Freehand SPECT is a 3-D tomographic imaging modality based on data acquisition with a hand-held detector that is moved freely, in contrast to conventional, fixed gamma camera systems. In this pilot study, the feasibility of freehand SPECT for 3-D lymphatic mapping in breast cancer was evaluated. METHODS A total of 85 patients (age: 29-88 years) with an initial diagnosis of invasive breast cancer and no clinical evidence of nodal involvement prospectively underwent sentinel lymph node (SLN) biopsy. Preoperative lymphatic mapping (35-87 MBq (99m)Tc-Nanocoll) included tomographic imaging with a SPECT/CT device (Siemens Symbia T6) serving as reference. Initially, the freehand SPECT approach was assessed in a pilot study consisting of 50 patients. The quality of each freehand SPECT acquisition was assessed and ranked as good, intermediate or poor. In another series comprising a further 35 patients (validation study), a guidance system for the acquisition was implemented based on the results of the pilot study, ensuring acquisitions with good quality. For 3-D tomographic image reconstruction, ad hoc models and iterative reconstruction algorithms were used in all 85 patients. To allow for adequate comparison, SPECT/CT data and freehand SPECT data were registered within the same coordinate system. RESULTS In the pilot study, freehand SPECT enabled mapping of 24 of 83 SLNs in 20 of 44 patients (3 dropouts, 3 patients without SLN either in SPECT/CT or in freehand SPECT). Using SPECT/CT as reference, the accuracy of freehand SPECT was 77.8% (7/9 nodes) in scans with good quality, while for intermediate and poor quality scans, the accuracy was reduced to 34.3 and 12.8%, respectively. In the validation study, quality feedback improved the results significantly and freehand SPECT enabled the mapping of at least one SLN in 87.5% of the patients (28/32 - 3 dropouts). Compared to the reference method, freehand SPECT showed a sensitivity of 83.3% (35/42 nodes). False-negative findings were related to insufficient scanning time, insufficient coverage of the axillary region, close proximity of the SLN to the injection site and low tracer uptake in the SLNs. CONCLUSION In this preliminary study, we could demonstrate that 3-D localization of SLNs is feasible using freehand SPECT technology. Prerequisites for acquisition of a good scan quality, most likely allowing precise SLN mapping, have been defined. This approach has high potential to allow image-guided biopsy and further standardization of SLN dissection, thus bringing 3-D nuclear imaging into the operating room.
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Affiliation(s)
- Thomas Wendler
- Technische Universität München, Boltzmannstr. 3, 85748 Garching bei Muenchen, Germany.
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Schnelzer A, Wendler T, Herrmann K, Lasser T, Traub J, Kutter O, Scheidhauer K, Schuster T, Kiechle M, Schwaiger M, Navab N, Ziegler SI, Buck AK. Klinische Einführung des freehand SPECT zur 3D-unterstützten Sentinellymphknotenbiopsie beim Mammakarzinom. Geburtshilfe Frauenheilkd 2009. [DOI: 10.1055/s-0029-1239017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Spekowius G, Wendler T, Matthews R, Relan N. Advances in Healthcare Technology: Shaping the Future of Medical Care. J Nucl Med 2008. [DOI: 10.2967/jnumed.107.047688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
In minimally invasive tumor resection, the desirable goal is to perform a minimal but complete removal of cancerous cells. In the last decades interventional nuclear medicine probes supported the detection of remaining tumor cells. However, scanning the patient with an intraoperative probe and applying the treatment are not done simultaneously. The main contribution of this work is to extend the one dimensional signal of a beta-probe to a four dimensional signal including the spatial information of the distal end of the probe. We generate a color encoded surface map of the scanned activity and guide any tracked surgical instrument back to the regions with measured activity. For navigation, we implement an augmented reality visualization that superimposes the acquired surface on a visual image of the real anatomy. Alternatively, a simulated beta-probe count rate in the tip of a tracked therapeutic instrument is simulated showing the count number and coding it as an acoustic signal. Preliminary tests were performed showing the feasibility of the new designed system and the viability of such a three dimensional intraoperative molecular imaging modality.
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Wendler T, Feuerstein M, Traub J, Lasser T, Vogel J, Daghighian F, Ziegler SI, Navab N. Real-time fusion of ultrasound and gamma probe for navigated localization of liver metastases. Med Image Comput Comput Assist Interv 2007; 10:252-60. [PMID: 18044576 DOI: 10.1007/978-3-540-75759-7_31] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Liver metastases are an advanced stage of several types of cancer, usually treated with surgery. Intra-operative localization of these lesions is currently facilitated by intra-operative ultrasound (IOUS) and palpation, yielding a high rate of false positives due to benign abnormal regions. In this paper we present the integration of functional nuclear information from a gamma probe with IOUS, to provide a synchronized, real-time visualization that facilitates the detection of active metastases intra-operatively. We evaluate the system in an ex-vivo setup employing a group of physicians and medical technicians and show that the addition of functional imaging improves the accuracy of localizing and identifying malignant and benign lesions significantly. Furthermore we are able to demonstrate that the inclusion of an advanced, augmented visualization provides more reliability and confidence on classifying these lesions in the presented evaluation setup.
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Affiliation(s)
- Thomas Wendler
- Computer Aided Medical Procedures (CAMP), TUM, Munich, Germany
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Wendler T, Schilling R, Lennertz A, Sodemann K, Kleophas W, Messner H, Riechers G, Wagner J, Keller C, Bosch T. Efficacy and safety of DALI LDL-apheresis at high blood flow rates: A prospective multicenter study. J Clin Apher 2003; 18:157-66. [PMID: 14699591 DOI: 10.1002/jca.10071] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Direct adsorption of lipids (DALI) is the first LDL-apheresis method compatible with whole blood. Usually, the blood flow rate is adjusted at 60-80 ml/min, which results in session times of about 2 hr. The present study was performed to test the safety and efficacy of low-density lipoprotein cholesterol (LDL-C) and lipoprotein (a) [Lp(a)] removal by DALI at high blood flow rates in order to reduce treatment time. Thirteen chronic DALI patients in seven centers suffering from hypercholesterolemia (LDL-C 162 +/- 42 mg/dl at baseline) and coronary artery disease were treated on a weekly or biweekly basis by DALI apheresis. The blood flow rate QB was held constant for at least two sessions, respectively, and was increased from 60 to 80, 120, 160, 200, and 240 ml/min. All patients had pre-existing av-fistulas. The anticoagulation was performed by a heparin bolus plus ACD-A at a ratio of citrate:blood ranging from 1:20 to 1:90. Clinically, the sessions were well tolerated and only 26/201 sessions (12%) of the treatments were fraught with minor adverse events. Acute LDL-C reductions (derived from LDL-C levels determined by lipoprotein electrophoresis) averaged 72/66/60/53/50/48% for QB=60/80/120/160/200/240 ml/min. Lp(a) reductions were 68/67/62/60/58/56%, whereas HDL-C losses were < or =10%. Routine blood chemistries and blood cell counts remained in the normal range. Treatment times averaged 142/83/45 min at Qb=60/120/240 ml/min. On average, DALI LDL-apheresis could be performed safely and effectively at high blood flow rates up to at least 120 ml/min in patients with good blood access, which significantly reduced treatment time from 142 to 83 min (-42%).
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Affiliation(s)
- T Wendler
- Department I of Internal Medicine, Nephrology Division, University Hospital, Munich-Grosshadern, Munich, Germany
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Abstract
Beta2-microglobulin (beta2-m) is an 11.8 kD protein that is excreted by the kidneys. In renal insufficiency, it accumulates in the body and can result in AB amyloidosis with bone and joint destruction. Four modifications of a new beta2-m adsorbent material were tested for biocompatibility with human whole blood. 500 ml of heparinized blood from healthy human donors was perfused ex vivo through minicolumns (adsorber beads: divinylbenzene with different biocompatible coatings) in the single-pass mode. Blood samples were taken from the antecubital vein before and at the column outlet during the 50 min test runs. Red and white cell counts remained virtually constant. No signs of hemolysis could be detected. Thrombogenicity of the columns was low as shown by the insignificant platelet loss, only slight platelet activation and moderate thrombin-antithrombin formation. There was no activation of leukocytes nor monocytes. Complement and bradykinin activation was minimal. Electrolyte concentrations and pH remained essentially constant. In conclusion, this new beta2-m adsorbent material exhibited favorable biocompatibility features in our ex vivo model and is thus a promising candidate for future clinical beta2-m hemoperfusion studies in patients.
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Affiliation(s)
- T Wendler
- Nephrology Division, Department of Internal Medicine I, Klinikum Grosshadern, University of Munich, Munich, Germany
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Bosch T, Wendler T, Maschke H. Modified DALI LDL-apheresis using trisodium citrate anticoagulation plus bicarbonate or lactate-buffered hemofiltration substitution fluids as primers. Artif Organs 2003; 27:555-64. [PMID: 12780510 DOI: 10.1046/j.1525-1594.2003.07104.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND DALI (direct adsorption of lipids) is the first LDL-apheresis technique able to adsorb low-density lipoprotein (LDL) and lipoproteina) directly from whole blood. In the standard procedure, acid citrate dextrose (ACD-A) is used as anticoagulation and the adsorber is rinsed with a specially manufactured priming solution (PS). Using neutral trisodium citrate (TSC) instead of ACD-A might improve the acid-base homeostasis during DALI apheresis; moreover, applying wholesale hemofiltration solutions instead of the special PS might avoid the use of two separate solutions for both priming before and reinfusion after the treatment, thus simplifiying the procedure. AIM The present study was performed to test the effect of neutral (TSC) anticoagulation and of two different commercially available hemofiltration (HF) priming solutions on the efficacy and biocompatibility of DALI apheresis. MATERIALS AND METHODS Five hypercholesterolemic chronic DALI patients were treated prospectively, on a weekly or biweekly basis, 3 times each by standard DALI-apheresis (A). by DALI using 4% TSC and bicarbonate-buffered HF BIC35-210 priming (B). as well as by DALI using 4% TSC and lactate-buffered HF 23 priming (C). After the sessions, the extracorporeal circuit (ECC) was rinsed with saline in study arm A and with the corresponding HF solutions in study arms B and C, respectively. RESULTS Acute LDL-cholesterol reductions in the study arms A/B/C averaged 64/64/63%, for Lp(a) 62/64/62%, respectively (n=15). Clinically, all sessions were essentially uneventful and no clots were observed in the ECC. No major differences were found between the 3 study arms with respect to biocompatibility (elastase, C3a, thrombin-antithrombin, beta-thromboglobulin, bradykinin). CONCLUSION DALI apheresis using TSC anticoagulation and HF solutions for both priming and reinfusion proved to be as safe and effective as the standard DALI apheresis. These modifications, however, further simplify the procedure.
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Affiliation(s)
- T Bosch
- Department of Internal Medicine, University Hospital Munich-Grosshadern, Munich, Germany.
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Bosch T, Wendler T, Jaeger BR, Samtleben W. Improvement of hemorheology by DALI apheresis: acute effects on plasma viscosity and erythrocyte aggregation in hypercholesterolemic patients. Ther Apher 2001; 5:372-6. [PMID: 11778922 DOI: 10.1046/j.1526-0968.2001.00368.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Plasma viscosity (PV) and erythrocyte aggregation (EA) are determinants of microcirculation, especially under the compromised hemodynamic conditions resulting from atherosclerosis. Direct adsorption of lipoproteins (DALI) apheresis is the first method for direct adsorption of lipoproteins; it drastically reduces low-density lipoprotein (LDL)-cholesterol and lipoprotein (a) (Lp[a]), and may therefore improve PV and EA. The current study was performed to test the effect of DALI on hemorheology. Six hypercholesterolemic patients who had been on regular LDL apheresis for at least several months were treated on a weekly or biweekly basis, on average 5 times each by DALI. Before and after each session, PV was measured by a capillary tube plasma viscosimeter and EA by rotational aggregometry. Single DALI sessions (n = 31) acutely decreased PV from 1.18 +/- 0.04 to 1.06 +/- 0.3 mPa (-10%) while EA improved from 22.8 +/- 4.4 to 13.3 +/- 4.5 (arbitrary units) (-42%). LDL-cholesterol, Lp(a), and very-low-density lipoprotein (VLDL)-cholesterol were effectively reduced while the decrease of triglycerides and fibrinogen was only moderate. DALI apheresis exerted an acute positive effect on blood hemorheology which may have beneficial effects on microcirculation. This hypothesis is in accordance with the clinical observation that in some patients, improvement of angina and/or exercise tolerance can be observed after only a few DALI sessions where changes of coronary stenoses cannot be expected yet.
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Affiliation(s)
- T Bosch
- Department I of Internal Medicine, Klinikum Grosshadern, Munich University Hospital, Germany.
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Bosch T, Wendler T. Extracorporeal plasma treatment in primary and recurrent focal segmental glomerular sclerosis: a review. Ther Apher 2001; 5:155-60. [PMID: 11467750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
This review summarizes the state of the art of apheresis in focal segmental sclerosing glomerulonephritis (FSGS) based on the current literature. FSGS is a major cause of nephrotic syndrome and renal insufficiency and has a high tendency to recur after renal transplantation. In many instances, treatment with steroids and/or immunosuppressive agents is without effect. Therapeutic plasma exchange (as well as immunoadsorption in some instances) was performed in primary (pFSGS) and recurrent (rFSGS) FSGS. Proteinuria could be improved and renal function was stabilized in 58% of rFSGS adults, in 74% of rFSGS children, and in 44% of pFSGS in adults. Treatment was successful if implemented early, i.e., in the stage of minimal change glomerulopathy before significant sclerosis had developed. This approach will probably be realistic only in the regular follow-up after transplantation. Furthermore, some patients with full-blown pFSGS were treated successfully in a prophylactic indication immediately prior to transplantation which decreased the incidence of recurrence to 26% in treated patients versus 54% in controls. Due to the uncontrolled study design and small patient cohorts in most trials, the major disadvantage of the reports currently available on the use of apheresis in FSGS is their low level of evidence from which the previous conclusions had to be drawn. Large prospective, controlled and randomized clinical trials are urgently needed for recommendations based on high-level evidence.
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Affiliation(s)
- T Bosch
- Department of Internal Medicine I, Klinikum Grosshadern, University of Munich, Germany.
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Bosch T, Wendler T. Extracorporeal plasma treatment in thrombotic thrombocytopenic purpura and hemolytic uremic syndrome: a review. Ther Apher 2001; 5:182-5. [PMID: 11467754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
This review summarizes the state of the art of apheresis in hemolytic uremic syndrome (HUS) and in thrombotic thrombocytopenic purpura (TTP). Both entities are characterized by thrombotic microangiopathy, hemolytic anemia, and thrombocytopenia. While HUS often presents with renal insufficiency, cerebral involvement is more common in TTP. Recently, in TTP, a primary or secondary lack of activity of a von Willebrand factor (vWF) degrading enzyme was made responsible for the presence of unusually large vWF multimers causing platelet aggregation and thrombus formation in the microvasculature. In contrast, in familial HUS, a factor H deficiency with uninhibited complement activation seems to play a role. Therapeutic plasma exchange (TPE) using fresh frozen plasma or cryosupernatant as the substitution fluid is indicated in acute TTP and atypical HUS without antecedent diarrhea. As a rule, it will show good effectiveness, especially in the former entity. HUS in pregnancy should be treated by instant delivery whereas postpartum HUS may resolve using protracted courses of TPE. In contrast, in thrombotic microangiopathy after bone marrow transplantation as well as in HUS due to cancer, mitomycin C, or after renal transplantation, TPE is of questionable value and indicated only as a last resort treatment.
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Affiliation(s)
- T Bosch
- Department of Internal Medicine I, Klinikum Grosshadern, University of Munich, Germany.
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Bosch T, Heinemann O, Duhr C, Wendler T, Keller C, Fink E, Kirschner T, Klebert S, Samtleben W. Effect of low-dose citrate anticoagulation on the clinical safety and efficacy of direct adsorption of lipoproteins (DALI apheresis) in hypercholesterolemic patients: a prospective controlled clinical trial. Artif Organs 2000; 24:790-6. [PMID: 11091168 DOI: 10.1046/j.1525-1594.2000.06647.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Direct adsorption of lipoproteins (DALI) is the first lipid apheresis system compatible with whole blood with the advantage of a very simple procedure. A mixture of heparin plus citrate (ACD-A) is used for the anticoagulation regimen (AR). A clinical, prospective, controlled crossover study was performed to test the safety and efficacy of low-dose citrate (LDC) anticoagulation in DALI. Five chronic DALI patients suffering from coronary heart disease and hypercholesterolemia underwent 3 DALI sessions each using the LDC anticoagulation regimen (60 IU heparin/kg body weight as initial bolus; 1:40 ACD-A: blood as perfusion). This was compared to 3 sessions per patient with the standard AR (bolus of 20 IU heparin/kg, 1:20 ACD-A as perfusion). Patient blood volumes (1.6; average of 7,040 ml) were treated with 750 ml adsorber gel per session at a blood flow rate of 60 ml/min. Mean LDL and Lp(a) reductions exceeded 60% with both AR. No clinical side effects were observed. Both AR controlled the coagulation well as evidenced by a sufficient prolongation of the partial prothrombin time (PTT) and activated clotting time as well as low thrombin-antithrombin (TAT) formation. Biocompatibility parameters exhibited favorable results (low activation of complement and cells, and only slight formation of C3a, C5a, beta-thromboglobulin, elastase, and TNF-alpha). The asymptomatic bradykinin generation was comparable in both study arms. LDC optimized the ionized calcium levels and pH in the efferent blood postadsorber. LDC anticoagulation was safe and effective, and may further improve the tolerance of DALI apheresis in hypercholesterolemic patients.
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Affiliation(s)
- T Bosch
- Nephrology Division, Medical Clinic I, Klinikum Grosshadern, University of Munich, Germany.
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