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Krishnan G, van den Berg NS, Nishio N, Kapoor S, Pei J, Freeman L, Lee YJ, Zhou Q, van Keulen S, Farkurnejad S, Condon J, Baik FM, Martin BA, Rosenthal EL. Fluorescent Molecular Imaging Can Improve Intraoperative Sentinel Margin Detection in Oral Squamous Cell Carcinoma. J Nucl Med 2022; 63:1162-1168. [PMID: 35027369 PMCID: PMC9364343 DOI: 10.2967/jnumed.121.262235] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 11/16/2021] [Indexed: 02/03/2023] Open
Abstract
In head and neck cancer, a major limitation of current intraoperative margin analysis is the ability to detect areas most likely to be positive based on specimen palpation, especially for larger specimens where sampling error limits detection of positive margins. This study aims to prospectively examine the clinical value of fluorescent molecular imaging to accurately identify "the sentinel margin," the point on a specimen at which the tumor lies closest to the resected edge in real-time during frozen section analysis. Methods: Eighteen patients with oral squamous cell carcinoma were enrolled into a prospective clinical trial and infused intravenously with 50 mg of panitumumab-IRDye800CW 1-5 d before surgery. Resected specimens were imaged in a closed-field near-infrared optical imaging system in near real-time, and custom-designed software was used to identify locations of highest fluorescence on deep and peripheral margins. The surgeon identified the sentinel margin masked to optical specimen mapping, and then the regions of highest fluorescence were identified and marked for frozen analysis. Final pathology based on specimen reconstruction was used as reference standard. Results: Resected specimens were imaged in the operating room, and fluorescence had a higher interobserver agreement with pathology (Cohen κ value 0.96) than the surgeon (Cohen κ value of 0.82) for the location of the closest margin. Plotting margin distance at the predicted sentinel margin location of each observer versus the actual closest margin distance at pathology demonstrated best correlation between fluorescence and pathology (R2 = 0.98) with surgeon (R2 = 0.75). Conclusion: Fluorescence imaging can improve identification of the sentinel margin in head and neck cancer resections, holding promise for rapid identification of positive margins and improved oncologic outcomes.
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Affiliation(s)
- Giri Krishnan
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California;,Department of Otolaryngology, Head and Neck Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Nynke S. van den Berg
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Naoki Nishio
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California;,Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Shrey Kapoor
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Jaqueline Pei
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Laura Freeman
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Yu-Jin Lee
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Quan Zhou
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Stan van Keulen
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Shayan Farkurnejad
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - James Condon
- Department of Public Health, School of Medicine, The University of Adelaide, Adelaide, SA, Australia; and
| | - Fred M. Baik
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Brock A. Martin
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Eben L. Rosenthal
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
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Pal R, Hom M, van den Berg NS, Lwin TM, Lee YJ, Prilutskiy A, Faquin W, Yang E, Saladi SV, Varvares MA, Rosenthal EL, Kumar ATN. First Clinical Results of Fluorescence Lifetime-enhanced Tumor Imaging Using Receptor-targeted Fluorescent Probes. Clin Cancer Res 2022; 28:2373-2384. [PMID: 35302604 PMCID: PMC9167767 DOI: 10.1158/1078-0432.ccr-21-3429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/23/2021] [Accepted: 03/15/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE Fluorescence molecular imaging, using cancer-targeted near infrared (NIR) fluorescent probes, offers the promise of accurate tumor delineation during surgeries and the detection of cancer specific molecular expression in vivo. However, nonspecific probe accumulation in normal tissue results in poor tumor fluorescence contrast, precluding widespread clinical adoption of novel imaging agents. Here we present the first clinical evidence that fluorescence lifetime (FLT) imaging can provide tumor specificity at the cellular level in patients systemically injected with panitumumab-IRDye800CW, an EGFR-targeted NIR fluorescent probe. EXPERIMENTAL DESIGN We performed wide-field and microscopic FLT imaging of resection specimens from patients injected with panitumumab-IRDye800CW under an FDA directed clinical trial. RESULTS We show that the FLT within EGFR-overexpressing cancer cells is significantly longer than the FLT of normal tissue, providing high sensitivity (>98%) and specificity (>98%) for tumor versus normal tissue classification, despite the presence of significant nonspecific probe accumulation. We further show microscopic evidence that the mean tissue FLT is spatially correlated (r > 0.85) with tumor-specific EGFR expression in tissue and is consistent across multiple patients. These tumor cell-specific FLT changes can be detected through thick biological tissue, allowing highly specific tumor detection and noninvasive monitoring of tumor EFGR expression in vivo. CONCLUSIONS Our data indicate that FLT imaging is a promising approach for enhancing tumor contrast using an antibody-targeted NIR probe with a proven safety profile in humans, suggesting a strong potential for clinical applications in image guided surgery, cancer diagnostics, and staging.
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Affiliation(s)
- Rahul Pal
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 13 Street, Building 149, Charlestown MA 02129
| | - Marisa Hom
- Department of Otolaryngology, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232
| | | | - Thinzar M Lwin
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston MA
| | - Yu-Jin Lee
- Department of Otolaryngology, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford CA
| | - Andrey Prilutskiy
- Department of Pathology, University of Wisconsin School of Medicine and Public Health, Madison WI
| | - William Faquin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston MA
| | - Eric Yang
- Department of Pathology, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford CA
| | - Srinivas V. Saladi
- Department of Otolaryngology and Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, 55 Fruit Street, Boston MA
| | - Mark A. Varvares
- Department of Otolaryngology and Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, 55 Fruit Street, Boston MA
| | - Eben L. Rosenthal
- Department of Otolaryngology, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232
| | - Anand T. N. Kumar
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 13 Street, Building 149, Charlestown MA 02129
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Helfen A, Rieß J, Fehler O, Stölting M, An Z, Kocman V, Schnepel A, Geyer C, Gerwing M, Masthoff M, Vogl T, Höltke C, Roth J, Ng T, Wildgruber M, Eisenblätter M. In vivo imaging of microenvironmental and anti-PD-L1-mediated dynamics in cancer using S100A8/S100A9 as an imaging biomarker. Neoplasia 2022; 28:100792. [PMID: 35367789 PMCID: PMC8983428 DOI: 10.1016/j.neo.2022.100792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/22/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE As a promotor of tumor invasion and tumor microenvironment (TME) formation, the protein complex S100A8/S100A9 is associated with poor prognosis. Our aim was to further evaluate its origin and regulatory effects, and to establish an imaging biomarker for TME activity. METHODS S100A9-/-cells (ko) were created from syngeneic murine breast cancer 4T1 (high malignancy) and 67NR (low malignancy) wildtype (wt) cell lines and implanted into either female BALB/c wildtype or S100A9-/- mice (n = 10 each). Anti-S100A9-Cy5.5-targeted fluorescence reflectance imaging was performed at 0 h and 24 h after injection. Potential early changes of S100A9-presence under immune checkpoint inhibition (anti-PD-L1, n = 7 vs. rat IgG2b as isotype control, n = 3) were evaluated. RESULTS In S100A9-/-mice contrast-to-noise-ratios were significantly reduced for wt and S100A9-/-tumors. No significant differences were detected for 4T1 ko and 67NR ko cells as compared to wildtype cells. Under anti-PD-L1 treatment S100A9 presence significantly decreased compared with the control group. CONCLUSION Our results confirm a secretion of S100A8/S100A9 by the TME, while tumor cells do not apparently release the protein. Under immune checkpoint inhibition S100A9-imaging reports an early decrease of TME activity. Therefore, S100A9-specific imaging may serve as an imaging biomarker for TME formation and activity.
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Affiliation(s)
- Anne Helfen
- Department of Radiology, University Hospital Muenster, University of Muenster, D-48149 Muenster, Germany.
| | - Jan Rieß
- Department of Radiology, University Hospital Muenster, University of Muenster, D-48149 Muenster, Germany
| | - Olesja Fehler
- Institute of Immunology, University of Muenster, D-48149 Muenster, Germany
| | - Miriam Stölting
- Department of Radiology, University Hospital Muenster, University of Muenster, D-48149 Muenster, Germany
| | - Zhengwen An
- The CRUK City of London Cancer Centre, SE1 9RT London, UK
| | - Vanessa Kocman
- Department of Radiology, University Hospital Muenster, University of Muenster, D-48149 Muenster, Germany
| | - Annika Schnepel
- Department of Radiology, University Hospital Muenster, University of Muenster, D-48149 Muenster, Germany
| | - Christiane Geyer
- Department of Radiology, University Hospital Muenster, University of Muenster, D-48149 Muenster, Germany
| | - Mirjam Gerwing
- Department of Radiology, University Hospital Muenster, University of Muenster, D-48149 Muenster, Germany
| | - Max Masthoff
- Department of Radiology, University Hospital Muenster, University of Muenster, D-48149 Muenster, Germany
| | - Thomas Vogl
- Institute of Immunology, University of Muenster, D-48149 Muenster, Germany
| | - Carsten Höltke
- Department of Radiology, University Hospital Muenster, University of Muenster, D-48149 Muenster, Germany
| | - Johannes Roth
- Institute of Immunology, University of Muenster, D-48149 Muenster, Germany
| | - Tony Ng
- The CRUK City of London Cancer Centre, SE1 9RT London, UK; UCL Cancer Institute, University College London, SE1 9RT London, UK; School of Cancer and Pharmaceutical Sciences, King´s College London, SE1 9RT London, UK
| | - Moritz Wildgruber
- Department of Radiology, University Hospital Muenster, University of Muenster, D-48149 Muenster, Germany; Department for Radiology, LMU Munich, D-81377 Munich, Germany
| | - Michel Eisenblätter
- Department of Radiology, University Hospital Muenster, University of Muenster, D-48149 Muenster, Germany; Department of Diagnostic and Interventional Radiology, Medical Center - University of Freiburg, D-79106 Freiburg, Germany
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Lee YJ, van den Berg NS, Orosco RK, Rosenthal EL, Sorger JM. A narrative review of fluorescence imaging in robotic-assisted surgery. LAPAROSCOPIC SURGERY 2021; 5. [PMID: 34549180 PMCID: PMC8452263 DOI: 10.21037/ls-20-98] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Objective In this review, we provide examples of applications of fluorescence imaging in urologic, gynecologic, general, and endocrine surgeries. Background While robotic-assisted surgery has helped increase the availability of minimally invasive procedures across surgical specialties, there remains an opportunity to reduce adverse events associated with open, laparoscopic, and robotic-assisted methods. In 2011, fluorescence imaging was introduced as an option to the da Vinci Surgical System, and has been standard equipment since 2014. Without interfering with surgical workflow, this fluorescence technology named Firefly® allows for acquisition and display of near-infrared fluorescent signals that are co-registered with white light endoscopic images. As a result, robotic surgeons of all specialties have been able to explore the clinical utility of fluorescence guided surgery. Methods Literature searches were performed using the PubMed and MEDLINE databases using the keywords "robotic-assisted fluorescence surgery", "ICG robotic surgery", and "fluorescence guided surgery" covering the years 2011-2020. Conclusions Real-time intraoperative fluorescence guidance has shown great potential in helping guide surgeons in both simple and complex surgical interventions. Indocyanine green is one of the most widely-used imaging agents in fluorescence guided surgery, and other targeted, near-infrared imaging agents are in various stages of development. Fluorescence is becoming a reliable tool that can help surgeons in their decision-making process in some specialties, while explorations continue in others.
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Affiliation(s)
- Yu-Jin Lee
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, CA, USA
| | | | - Ryan K Orosco
- Moores Cancer Center, La Jolla, CA, USA.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California, San Diego, San Diego, CA, USA
| | - Eben L Rosenthal
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, CA, USA
| | - Jonathan M Sorger
- Department of Research, Intuitive Surgical, Inc., Sunnyvale, CA, USA
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Krishnan G, Berg NSVD, Nishio N, Juniper G, Pei J, Zhou Q, Lu G, Lee YJ, Ramos K, Iagaru AH, Baik FM, Colevas AD, Martin BA, Rosenthal EL. Metastatic and sentinel lymph node mapping using intravenously delivered Panitumumab-IRDye800CW. Theranostics 2021; 11:7188-7198. [PMID: 34158844 PMCID: PMC8210603 DOI: 10.7150/thno.55389] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/07/2021] [Indexed: 12/19/2022] Open
Abstract
Rationale: Sentinel lymph node biopsy (SLNB) is a well-established minimally invasive staging procedure that maps the spread of tumour metastases from their primary site to the regional lymphatics. Currently, the procedure requires the local peri-tumoural injection of radiolabelled and/or optical agents, and is therefore operator dependent, disruptive to surgical workflow and restricted largely to a small subset of malignancies that can be readily accessed externally for local tracer injection. The present study set out to determine whether intravenous (IV) infusion of a tumor-targeted tracer could identify sentinel and metastatic lymph nodes (LNs) in order to overcome these limitations. Methods: We examined 27 patients with oral squamous cell carcinoma (OSCC), 18 of whom were clinically node negative (cN0). Patients were infused intravenously with 50mg of Panitumumab-IRDye800CW prior to surgical resection of their primary tumour with neck dissection and/or SLNB. Lymphadenectomy specimens underwent fluorescence molecular imaging to evaluate tracer distribution to LNs. Results: A total of 960 LNs were analysed, of which 34 (3.5%) contained metastatic disease. Panitumumab-IRDye800CW preferentially localized to metastatic and sentinel LNs as evidenced by a higher fluorescent signal relative to other lymph nodes. The median MFI of metastatic LNs was significantly higher than the median MFI of benign LNs (0.06 versus 0.02, p < 0.05). Furthermore, selecting the highest five fluorescence intensity LNs from individual specimens resulted in 100% sensitivity, 85.8% specificity and 100% negative predictive value (NPV) for the detection of occult metastases and 100% accuracy for clinically staging the neck. In the cN+ cohort, assessment of the highest 5 fluorescence LNs per patient had 87.5% sensitivity, 93.2% specificity and 99.1% NPV for the detection of metastatic nodes. Conclusion: When intravenously infused, a tumour-targeted tracer localized to sentinel and metastatic lymph nodes. Further validation of an IV tumor-targeted tracer delivery approach for SLNB could dramatically change the practice of SLNB, allowing its application to other malignancies where the primary tumour is not accessible for local tracer injection.
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Zhou Q, van den Berg NS, Rosenthal EL, Iv M, Zhang M, Vega Leonel JCM, Walters S, Nishio N, Granucci M, Raymundo R, Yi G, Vogel H, Cayrol R, Lee YJ, Lu G, Hom M, Kang W, Hayden Gephart M, Recht L, Nagpal S, Thomas R, Patel C, Grant GA, Li G. EGFR-targeted intraoperative fluorescence imaging detects high-grade glioma with panitumumab-IRDye800 in a phase 1 clinical trial. Theranostics 2021; 11:7130-7143. [PMID: 34158840 PMCID: PMC8210618 DOI: 10.7150/thno.60582] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/24/2021] [Indexed: 12/12/2022] Open
Abstract
Rationale: First-line therapy for high-grade gliomas (HGGs) includes maximal safe surgical resection. The extent of resection predicts overall survival, but current neuroimaging approaches lack tumor specificity. The epidermal growth factor receptor (EGFR) is a highly expressed HGG biomarker. We evaluated the safety and feasibility of an anti-EGFR antibody, panitumuab-IRDye800, at subtherapeutic doses as an imaging agent for HGG. Methods: Eleven patients with contrast-enhancing HGGs were systemically infused with panitumumab-IRDye800 at a low (50 mg) or high (100 mg) dose 1-5 days before surgery. Near-infrared fluorescence imaging was performed intraoperatively and ex vivo, to identify the optimal tumor-to-background ratio by comparing mean fluorescence intensities of tumor and histologically uninvolved tissue. Fluorescence was correlated with preoperative T1 contrast, tumor size, EGFR expression and other biomarkers. Results: No adverse events were attributed to panitumumab-IRDye800. Tumor fragments as small as 5 mg could be detected ex vivo and detection threshold was dose dependent. In tissue sections, panitumumab-IRDye800 was highly sensitive (95%) and specific (96%) for pathology confirmed tumor containing tissue. Cellular delivery of panitumumab-IRDye800 was correlated to EGFR overexpression and compromised blood-brain barrier in HGG, while normal brain tissue showed minimal fluorescence. Intraoperative fluorescence improved optical contrast in tumor tissue within and beyond the T1 contrast-enhancing margin, with contrast-to-noise ratios of 9.5 ± 2.1 and 3.6 ± 1.1, respectively. Conclusions: Panitumumab-IRDye800 provided excellent tumor contrast and was safe at both doses. Smaller fragments of tumor could be detected at the 100 mg dose and thus more suitable for intraoperative imaging.
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Affiliation(s)
- Quan Zhou
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Nynke S. van den Berg
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Eben L. Rosenthal
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cancer Center, Stanford University, Stanford, CA, USA
| | - Michael Iv
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Shannon Walters
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Naoki Nishio
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Monica Granucci
- Cancer Clinical Trials Office, Stanford University School of Medicine, Stanford, CA, USA
| | - Roan Raymundo
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Cancer Clinical Trials Office, Stanford University School of Medicine, Stanford, CA, USA
| | - Grace Yi
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Cancer Clinical Trials Office, Stanford University School of Medicine, Stanford, CA, USA
| | - Hannes Vogel
- Department of Neuropathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Romain Cayrol
- Department of Neuropathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Yu-Jin Lee
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Guolan Lu
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Marisa Hom
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Wenying Kang
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Larry Recht
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Seema Nagpal
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Reena Thomas
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Chirag Patel
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gerald A. Grant
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
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