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Malarkey M, Toscano AP, Bagheri MH, Solomon J, Machado LB, LoRusso P, Chen A, Folio LR, Goncalves PH. A pilot study of volumetric and density tumor analysis of ACC patients treated with vorinostat in a phase II clinical trial. Heliyon 2023; 9:e18680. [PMID: 37593628 PMCID: PMC10428039 DOI: 10.1016/j.heliyon.2023.e18680] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 06/23/2023] [Accepted: 07/25/2023] [Indexed: 08/19/2023] Open
Abstract
Rationale and objectives Adenoid cystic carcinoma (ACC) is a rare salivary gland cancer. The vast majority of clinical trials evaluating systemic therapy efficacy in solid tumors use the Response Evaluation Criteria in Solid Tumors (RECIST) to measure response that is limited to 2 dimensional only evaluations, not taking volume or density into account. The indolent behavior ACC represents a challenge toward an appropriate evaluation of therapy response. Objectives: 1) To describe and contrast volumetric and density changes at each time-point, including changes noted from baseline to best response, to currently used 2 dimensional-only criteria (RECIST) and 2) To report the coefficient of variation in volume measurement among three reviewers on a subset of ACC patients. Materials and methods We retrospectively assessed a cohort of 18 prospectively treated patients with ACC in a phase 2 trial with vorinostat using a volumetric (viable tumor volume, VTV) and density criteria. Three independent and blinded observers segmented target lesions across a sample of randomly selected computed tomography (CT) exams to examine inter-observer variation. Results We found that the average coefficient of variation among observers for all target lesions was 16.1%, with lung lesions displaying a smaller variation at 14.0% (p-value >0.17). We describe examples of decrease in volume and density in several lesions despite stable disease by RECIST. Conclusion This pilot study demonstrates that two-dimensional criteria such as RECIST may not be the best criteria to assess response to therapy, especially with evolving tools within picture archiving and communication system (PACS) that can assess volumetric size, density and texture, however, this should be prospectively studied.
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Affiliation(s)
- Molly Malarkey
- National Institutes of Health, 10 Center Drive, Building 10, Room 1C 340, Bethesda, MD, 20892, USA
| | - Alex P. Toscano
- National Institutes of Health, 10 Center Drive, Building 10, Room 1C 340, Bethesda, MD, 20892, USA
| | - Mohammad Hadi Bagheri
- Radiology and Imaging Sciences Clinical Center, National Institutes of Health, 10 Center Drive, Bldg. 10, Room 1C342, Bethesda, MD, 20892, USA
| | - Jeffrey Solomon
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, 21702, USA
| | - Laura B. Machado
- Department of Radiology, Division of Body Imaging, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia PA 19104, USA
| | - Patricia LoRusso
- Yale University, 333 Cedar Street, WWW217, New Haven, CT, 06510, USA
| | - Alice Chen
- Early Clinical Trials Development Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, 31 Center Blvd, 3A44, Bethesda, MD, 20892, USA
| | - Les R. Folio
- Acting Associate Chief Medical Informatics Officer, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Senior Member, Department of Machine Learning, Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Professor, Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL 33602, USA
| | - Priscila H. Goncalves
- HIV and AIDS Malignancy Branch, National Institutes of Health, Bethesda, MD, 20892, USA
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2
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Ware JM, Folio LR, Pittaluga S, Klion A, Khoury P. Resolution of hypereosinophilic syndrome following resection of a schwannoma. J Allergy Clin Immunol Pract 2023; 11:1320-1322. [PMID: 36621605 PMCID: PMC10085834 DOI: 10.1016/j.jaip.2022.12.028] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/08/2022] [Accepted: 12/21/2022] [Indexed: 01/07/2023]
Affiliation(s)
- JeanAnne M Ware
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Les R Folio
- Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center, Tampa, Fla; Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Fla
| | - Stephania Pittaluga
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Md
| | - Amy Klion
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Paneez Khoury
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
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3
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Yang F, Lu PX, Deng M, Wáng YXJ, Rajaraman S, Xue Z, Folio LR, Antani SK, Jaeger S. Annotations of Lung Abnormalities in the Shenzhen Chest X-ray Dataset for Computer-Aided Screening of Pulmonary Diseases. Data 2022; 7. [PMID: 36381384 PMCID: PMC9645800 DOI: 10.3390/data7070095] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
Developments in deep learning techniques have led to significant advances in automated abnormality detection in radiological images and paved the way for their potential use in computer-aided diagnosis (CAD) systems. However, the development of CAD systems for pulmonary tuberculosis (TB) diagnosis is hampered by the lack of training data that is of good visual and diagnostic quality, of sufficient size, variety, and, where relevant, containing fine region annotations. This study presents a collection of annotations/segmentations of pulmonary radiological manifestations that are consistent with TB in the publicly available and widely used Shenzhen chest X-ray (CXR) dataset made available by the U.S. National Library of Medicine and obtained via a research collaboration with No. 3. People’s Hospital Shenzhen, China. The goal of releasing these annotations is to advance the state-of-the-art for image segmentation methods toward improving the performance of fine-grained segmentation of TB-consistent findings in digital Chest X-ray images. The annotation collection comprises the following: 1) annotation files in JSON (JavaScript Object Notation) format that indicate locations and shapes of 19 lung pattern abnormalities for 336 TB patients; 2) mask files saved in PNG format for each abnormality per TB patient; 3) a CSV (comma-separated values) file that summarizes lung abnormality types and numbers per TB patient. To the best of our knowledge, this is the first collection of pixel-level annotations of TB-consistent findings in CXRs. Dataset:https://data.lhncbc.nlm.nih.gov/public/Tuberculosis-Chest-X-ray-Datasets/Shenzhen-Hospital-CXR-Set/Annotations/index.html.
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Affiliation(s)
- Feng Yang
- National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA
- Correspondence: (F.Y.); (S.A.); (S.J)
| | - Pu-Xuan Lu
- Department of Radiology, Shenzhen Center for Chronic Disease Control, Shenzhen, China
| | - Min Deng
- Department of Imaging and Interventional Radiology, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, N.T., Hong Kong
| | - Yì Xiáng J. Wáng
- Department of Imaging and Interventional Radiology, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, N.T., Hong Kong
| | | | - Zhiyun Xue
- National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Les R. Folio
- Diagnostic Imaging & Interventional Radiology, Moffitt Cancer Center, Tampa, Florida, United States
| | - Sameer K. Antani
- National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA
- Correspondence: (F.Y.); (S.A.); (S.J)
| | - Stefan Jaeger
- National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA
- Correspondence: (F.Y.); (S.A.); (S.J)
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4
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Yao Y, Du Jiang P, Chao BN, Cagdas D, Kubo S, Balasubramaniyam A, Zhang Y, Shadur B, NaserEddin A, Folio LR, Schwarz B, Bohrnsen E, Zheng L, Lynberg M, Gottlieb S, Leney-Greene MA, Park AY, Tezcan I, Akdogan A, Gocmen R, Onder S, Rosenberg A, Soilleux EJ, Johnson E, Jackson PK, Demeter J, Chauvin SD, Paul F, Selbach M, Bulut H, Clatworthy MR, Tuong ZK, Zhang H, Stewart BJ, Bosio CM, Stepensky P, Clare S, Ganesan S, Pascall JC, Daumke O, Butcher GW, McMichael AJ, Simon AK, Lenardo MJ. GIMAP6 regulates autophagy, immune competence, and inflammation in mice and humans. J Exp Med 2022; 219:213217. [PMID: 35551368 PMCID: PMC9111091 DOI: 10.1084/jem.20201405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 01/18/2022] [Accepted: 03/16/2022] [Indexed: 11/26/2022] Open
Abstract
Inborn errors of immunity (IEIs) unveil regulatory pathways of human immunity. We describe a new IEI caused by mutations in the GTPase of the immune-associated protein 6 (GIMAP6) gene in patients with infections, lymphoproliferation, autoimmunity, and multiorgan vasculitis. Patients and Gimap6−/− mice show defects in autophagy, redox regulation, and polyunsaturated fatty acid (PUFA)–containing lipids. We find that GIMAP6 complexes with GABARAPL2 and GIMAP7 to regulate GTPase activity. Also, GIMAP6 is induced by IFN-γ and plays a critical role in antibacterial immunity. Finally, we observed that Gimap6−/− mice died prematurely from microangiopathic glomerulosclerosis most likely due to GIMAP6 deficiency in kidney endothelial cells.
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Affiliation(s)
- Yikun Yao
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.,National Institute of Allergy and Infectious Diseases Clinical Genomics Program, Rockville, MD
| | - Ping Du Jiang
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.,National Institute of Allergy and Infectious Diseases Clinical Genomics Program, Rockville, MD
| | - Brittany N Chao
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.,National Institute of Allergy and Infectious Diseases Clinical Genomics Program, Rockville, MD.,Nuffield Department of Medicine Research Building, Roosevelt Drive, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Kennedy Institute of Rheumatology, University of Oxford, Roosevelt Drive, Oxford, UK
| | - Deniz Cagdas
- Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey.,Department of Pediatric Immunology, Institute of Child Health, Hacettepe University, Ankara, Turkey.,Ihsan Dogramaci Childrens Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Satoshi Kubo
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.,National Institute of Allergy and Infectious Diseases Clinical Genomics Program, Rockville, MD
| | - Arasu Balasubramaniyam
- Crystallography, Max-Delbrück-Centrum for Molecular Medicine in the Helmholtz Association, Berlin, Germany.,Institute for Chemistry and Biochemistry, Freie Universität Berlin, Takustrasse 6, Berlin, Germany
| | - Yu Zhang
- Human Immunological Diseases Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Rockville, MD
| | - Bella Shadur
- Hadassah University Medical Center, Department of Bone Marrow Transplantation and Cancer Immunotherapy, Jerusalem, Israel.,The Garvan Institute of Medical Research, Immunology Division, Darlinghurst, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Darlinghurst, Sydney, Australia
| | - Adeeb NaserEddin
- Hadassah University Medical Center, Department of Bone Marrow Transplantation and Cancer Immunotherapy, Jerusalem, Israel
| | - Les R Folio
- Clinical Center, National Institutes of Health, Bethesda, MD
| | - Benjamin Schwarz
- Laboratory of Bacteriology, National Institute of Allergy and Infectious Diseases, Rockville, MD
| | - Eric Bohrnsen
- Laboratory of Bacteriology, National Institute of Allergy and Infectious Diseases, Rockville, MD
| | - Lixin Zheng
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.,National Institute of Allergy and Infectious Diseases Clinical Genomics Program, Rockville, MD
| | - Matthew Lynberg
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.,National Institute of Allergy and Infectious Diseases Clinical Genomics Program, Rockville, MD
| | - Simone Gottlieb
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.,National Institute of Allergy and Infectious Diseases Clinical Genomics Program, Rockville, MD
| | - Michael A Leney-Greene
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.,Human Immunological Diseases Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Rockville, MD
| | - Ann Y Park
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.,National Institute of Allergy and Infectious Diseases Clinical Genomics Program, Rockville, MD
| | - Ilhan Tezcan
- Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey.,Department of Pediatric Immunology, Institute of Child Health, Hacettepe University, Ankara, Turkey.,Ihsan Dogramaci Childrens Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ali Akdogan
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Rahsan Gocmen
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Sevgen Onder
- Department of Pathology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Avi Rosenberg
- Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD.,Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Errin Johnson
- The Dunn School of Pathology, South Parks Road, Oxford, UK
| | - Peter K Jackson
- Baxter Laboratory, Departments of Microbiology & Immunology and Pathology Stanford University School of Medicine, Stanford, CA
| | - Janos Demeter
- Baxter Laboratory, Departments of Microbiology & Immunology and Pathology Stanford University School of Medicine, Stanford, CA
| | - Samuel D Chauvin
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.,National Institute of Allergy and Infectious Diseases Clinical Genomics Program, Rockville, MD
| | - Florian Paul
- Crystallography, Max-Delbrück-Centrum for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Matthias Selbach
- Crystallography, Max-Delbrück-Centrum for Molecular Medicine in the Helmholtz Association, Berlin, Germany.,Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Haydar Bulut
- Crystallography, Max-Delbrück-Centrum for Molecular Medicine in the Helmholtz Association, Berlin, Germany.,Institute for Chemistry and Biochemistry, Freie Universität Berlin, Takustrasse 6, Berlin, Germany
| | - Menna R Clatworthy
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Medical Research Council Laboratory of Molecular Biology, Cambridge, UK.,Cellular Genetics, Wellcome Sanger Institute, Hinxton, UK
| | - Zewen K Tuong
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Medical Research Council Laboratory of Molecular Biology, Cambridge, UK.,Cellular Genetics, Wellcome Sanger Institute, Hinxton, UK
| | - Hanlin Zhang
- Kennedy Institute of Rheumatology, University of Oxford, Roosevelt Drive, Oxford, UK
| | - Benjamin J Stewart
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Medical Research Council Laboratory of Molecular Biology, Cambridge, UK.,Cellular Genetics, Wellcome Sanger Institute, Hinxton, UK
| | - Catharine M Bosio
- Laboratory of Bacteriology, National Institute of Allergy and Infectious Diseases, Rockville, MD
| | - Polina Stepensky
- Hadassah University Medical Center, Department of Bone Marrow Transplantation and Cancer Immunotherapy, Jerusalem, Israel
| | - Simon Clare
- Host-Microbiota Interactions Laboratory, Wellcome Sanger Institute, Hinxton, UK
| | - Sundar Ganesan
- Biological Imaging Section, Research Technologies Branch, National Institute of Allergy and Infectious Diseases, Rockville, MD
| | - John C Pascall
- Laboratory of Lymphocyte Signalling and Development, Babraham Institute, Babraham Research Campus, Cambridge, UK
| | - Oliver Daumke
- Crystallography, Max-Delbrück-Centrum for Molecular Medicine in the Helmholtz Association, Berlin, Germany.,Institute for Chemistry and Biochemistry, Freie Universität Berlin, Takustrasse 6, Berlin, Germany
| | - Geoffrey W Butcher
- Laboratory of Lymphocyte Signalling and Development, Babraham Institute, Babraham Research Campus, Cambridge, UK
| | - Andrew J McMichael
- Nuffield Department of Medicine Research Building, Roosevelt Drive, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Anna Katharina Simon
- Kennedy Institute of Rheumatology, University of Oxford, Roosevelt Drive, Oxford, UK
| | - Michael J Lenardo
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.,National Institute of Allergy and Infectious Diseases Clinical Genomics Program, Rockville, MD
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5
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Staziaki PV, Santinha JAA, Coelho MO, Angulo D, Hussain M, Folio LR. Gamification in Radiology Training Module Developed During the Society for Imaging Informatics in Medicine Annual Meeting Hackathon. J Digit Imaging 2022; 35:714-722. [PMID: 35166970 PMCID: PMC9156580 DOI: 10.1007/s10278-022-00603-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 08/18/2021] [Revised: 01/31/2022] [Accepted: 02/02/2022] [Indexed: 12/15/2022] Open
Abstract
The purpose of this manuscript is to report our experience in the 2021 SIIM Virtual Hackathon, where we developed a proof-of-concept of a radiology training module with elements of gamification. In the 50 h allotted in the hackathon, we proposed an idea, connected with colleagues from five different countries, and completed an operational proof-of-concept, which was demonstrated live at the hackathon showcase, competing with eight other teams. Our prototype involved participants annotating publicly available chest radiographs of patients with tuberculosis. We showed how we could give experience points to trainees based on annotation precision compared to ground truth radiologists' annotation, ranked in a live leaderboard. We believe that gamification elements could provide an engaging solution for radiology education. Our project was awarded first place out of eight participating hackathon teams.
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Affiliation(s)
- Pedro V Staziaki
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, 480 Harrison Ave, FGH Building, 4th floor, MA, 02118, Boston, USA.
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA.
| | - João A A Santinha
- IST University of Lisbon, Av. Rovisco Pais 1, 1049-001, Lisbon, Portugal
- Clinical Computational Imaging Group, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal
| | - Marcelo O Coelho
- Department of Imaging Diagnosis, Federal University of São Paulo (UNIFESP), Rua Napoleão de Barros, 800, Vila Clementino, São Paulo, SP, CEP 04024-002, Brazil
| | - Diego Angulo
- Prodigious, CLL 93B N 13 44 PISO 3, Bogotá, Colombia
| | - Mohannad Hussain
- Techie Maestro Inc., 928 Creekside Drive, Waterloo, ON, N2V2W6, Canada
| | - Les R Folio
- NIH Clinical Center, 10 Center Drive, Bethesda, MD, 20892, USA
- Adjunct Clinical Professor of Radiology, George Washington University Hospital, Washington, DC, USA
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Rajaraman S, Zamzmi G, Folio LR, Antani S. Detecting Tuberculosis-Consistent Findings in Lateral Chest X-Rays Using an Ensemble of CNNs and Vision Transformers. Front Genet 2022; 13:864724. [PMID: 35281798 PMCID: PMC8907925 DOI: 10.3389/fgene.2022.864724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 02/10/2022] [Indexed: 11/25/2022] Open
Abstract
Research on detecting Tuberculosis (TB) findings on chest radiographs (or Chest X-rays: CXR) using convolutional neural networks (CNNs) has demonstrated superior performance due to the emergence of publicly available, large-scale datasets with expert annotations and availability of scalable computational resources. However, these studies use only the frontal CXR projections, i.e., the posterior-anterior (PA), and the anterior-posterior (AP) views for analysis and decision-making. Lateral CXRs which are heretofore not studied help detect clinically suspected pulmonary TB, particularly in children. Further, Vision Transformers (ViTs) with built-in self-attention mechanisms have recently emerged as a viable alternative to the traditional CNNs. Although ViTs demonstrated notable performance in several medical image analysis tasks, potential limitations exist in terms of performance and computational efficiency, between the CNN and ViT models, necessitating a comprehensive analysis to select appropriate models for the problem under study. This study aims to detect TB-consistent findings in lateral CXRs by constructing an ensemble of the CNN and ViT models. Several models are trained on lateral CXR data extracted from two large public collections to transfer modality-specific knowledge and fine-tune them for detecting findings consistent with TB. We observed that the weighted averaging ensemble of the predictions of CNN and ViT models using the optimal weights computed with the Sequential Least-Squares Quadratic Programming method delivered significantly superior performance (MCC: 0.8136, 95% confidence intervals (CI): 0.7394, 0.8878, p < 0.05) compared to the individual models and other ensembles. We also interpreted the decisions of CNN and ViT models using class-selective relevance maps and attention maps, respectively, and combined them to highlight the discriminative image regions contributing to the final output. We observed that (i) the model accuracy is not related to disease region of interest (ROI) localization and (ii) the bitwise-AND of the heatmaps of the top-2-performing models delivered significantly superior ROI localization performance in terms of mean average precision [mAP@(0.1 0.6) = 0.1820, 95% CI: 0.0771,0.2869, p < 0.05], compared to other individual models and ensembles. The code is available at https://github.com/sivaramakrishnan-rajaraman/Ensemble-of-CNN-and-ViT-for-TB-detection-in-lateral-CXR.
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Affiliation(s)
- Sivaramakrishnan Rajaraman
- Computational Health Research Branch, National Library of Medicine, National Institutes of Health, Bethesda, MD, United States
- *Correspondence: Sivaramakrishnan Rajaraman,
| | - Ghada Zamzmi
- Computational Health Research Branch, National Library of Medicine, National Institutes of Health, Bethesda, MD, United States
| | | | - Sameer Antani
- Computational Health Research Branch, National Library of Medicine, National Institutes of Health, Bethesda, MD, United States
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Candemir S, Nguyen XV, Folio LR, Prevedello LM. Training Strategies for Radiology Deep Learning Models in Data-limited Scenarios. Radiol Artif Intell 2021; 3:e210014. [PMID: 34870217 PMCID: PMC8637222 DOI: 10.1148/ryai.2021210014] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [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: 01/13/2021] [Revised: 09/08/2021] [Accepted: 09/16/2021] [Indexed: 12/22/2022]
Abstract
Data-driven approaches have great potential to shape future practices in radiology. The most straightforward strategy to obtain clinically accurate models is to use large, well-curated and annotated datasets. However, patient privacy constraints, tedious annotation processes, and the limited availability of radiologists pose challenges to building such datasets. This review details model training strategies in scenarios with limited data, insufficiently labeled data, and/or limited expert resources. This review discusses strategies to enlarge the data sample, decrease the time burden of manual supervised labeling, adjust the neural network architecture to improve model performance, apply semisupervised approaches, and leverage efficiencies from pretrained models. Keywords: Computer-aided Detection/Diagnosis, Transfer Learning, Limited Annotated Data, Augmentation, Synthetic Data, Semisupervised Learning, Federated Learning, Few-Shot Learning, Class Imbalance.
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Affiliation(s)
- Sema Candemir
- From the Department of Radiology, The Ohio State University College
of Medicine, 395 W 12th Ave, Columbus, OH 43212 (S.C., X.V.N., L.M.P.); and
Department of Radiology and Imaging Sciences, Clinical Center, National
Institutes of Health, Bethesda, Md (L.R.F.)
| | - Xuan V. Nguyen
- From the Department of Radiology, The Ohio State University College
of Medicine, 395 W 12th Ave, Columbus, OH 43212 (S.C., X.V.N., L.M.P.); and
Department of Radiology and Imaging Sciences, Clinical Center, National
Institutes of Health, Bethesda, Md (L.R.F.)
| | - Les R. Folio
- From the Department of Radiology, The Ohio State University College
of Medicine, 395 W 12th Ave, Columbus, OH 43212 (S.C., X.V.N., L.M.P.); and
Department of Radiology and Imaging Sciences, Clinical Center, National
Institutes of Health, Bethesda, Md (L.R.F.)
| | - Luciano M. Prevedello
- From the Department of Radiology, The Ohio State University College
of Medicine, 395 W 12th Ave, Columbus, OH 43212 (S.C., X.V.N., L.M.P.); and
Department of Radiology and Imaging Sciences, Clinical Center, National
Institutes of Health, Bethesda, Md (L.R.F.)
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8
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Catanzano T, Robbins JB, Schwartz FR, Rajiah P, Wang SS, Nandwana S, Soloff EV, Folio LR. Collaborative Writing Projects: Set Yourself up for Success. J Comput Assist Tomogr 2021; 45:495-499. [PMID: 34270477 DOI: 10.1097/rct.0000000000001187] [Citation(s) in RCA: 1] [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: 11/25/2022]
Abstract
ABSTRACT This article will review critical components for the successful completion of a multi-institution, multiauthor collaborative paper. Best practices for the creation and publication of a collaborative paper will be addressed.
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Affiliation(s)
- Tara Catanzano
- From the University of Massachusetts Medical School-Baystate, Springfield, MA Faculty Development and Enrichment, University of Wisconsin School of Medicine and Public Health, Madison, WI Duke Department of Radiology, Durham, NC Mayo Clinic, Rochester, MN Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA Department of Radiology, University of Washington, Seattle, WA Radiology and Imaging and Sciences, Clinical Center, National Institutes of Health, Radiology, Bethesda, MD George Washington University Hospital, Washington, DC
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Roth CJ, Clunie DA, Vining DJ, Berkowitz SJ, Berlin A, Bissonnette JP, Clark SD, Cornish TC, Eid M, Gaskin CM, Goel AK, Jacobs GC, Kwan D, Luviano DM, McBee MP, Miller K, Hafiz AM, Obcemea C, Parwani AV, Rotemberg V, Silver EL, Storm ES, Tcheng JE, Thullner KS, Folio LR. Multispecialty Enterprise Imaging Workgroup Consensus on Interactive Multimedia Reporting Current State and Road to the Future: HIMSS-SIIM Collaborative White Paper. J Digit Imaging 2021; 34:495-522. [PMID: 34131793 PMCID: PMC8329131 DOI: 10.1007/s10278-021-00450-5] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/05/2021] [Accepted: 03/19/2021] [Indexed: 12/20/2022] Open
Abstract
Diagnostic and evidential static image, video clip, and sound multimedia are captured during routine clinical care in cardiology, dermatology, ophthalmology, pathology, physiatry, radiation oncology, radiology, endoscopic procedural specialties, and other medical disciplines. Providers typically describe the multimedia findings in contemporaneous electronic health record clinical notes or associate a textual interpretative report. Visual communication aids commonly used to connect, synthesize, and supplement multimedia and descriptive text outside medicine remain technically challenging to integrate into patient care. Such beneficial interactive elements may include hyperlinks between text, multimedia elements, alphanumeric and geometric annotations, tables, graphs, timelines, diagrams, anatomic maps, and hyperlinks to external educational references that patients or provider consumers may find valuable. This HIMSS-SIIM Enterprise Imaging Community workgroup white paper outlines the current and desired clinical future state of interactive multimedia reporting (IMR). The workgroup adopted a consensus definition of IMR as “interactive medical documentation that combines clinical images, videos, sound, imaging metadata, and/or image annotations with text, typographic emphases, tables, graphs, event timelines, anatomic maps, hyperlinks, and/or educational resources to optimize communication between medical professionals, and between medical professionals and their patients.” This white paper also serves as a precursor for future efforts toward solving technical issues impeding routine interactive multimedia report creation and ingestion into electronic health records.
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Affiliation(s)
| | | | - David J Vining
- Department of Abdominal Imaging, MD Anderson Cancer Center, Houston, TX, USA
| | - Seth J Berkowitz
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Alejandro Berlin
- Radiation Medicine Program, Princess Margaret Cancer Centre - University Health Network, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Jean-Pierre Bissonnette
- Departments of Radiation Oncology and Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Shawn D Clark
- University of Miami Hospitals and Clinics, Miami, FL, USA
| | - Toby C Cornish
- Department of Pathology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Monief Eid
- eHealth & Digital Transformation Agency, Ministry of Health, Riyadh, Saudi Arabia
| | - Cree M Gaskin
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | | | | | - David Kwan
- Health Technology and Information Management, Ontario Health (Cancer Care Ontario), Toronto, ON, Canada
| | - Damien M Luviano
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Morgan P McBee
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | | | - Abdul Moiz Hafiz
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Ceferino Obcemea
- Radiation Research Program, National Cancer Institute, Bethesda, MD, USA
| | - Anil V Parwani
- Department of Pathology, The Ohio State University, Columbus, OH, USA
| | - Veronica Rotemberg
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Erik S Storm
- Department of Radiology and Medical Education, Salem VA Medical Center, Salem, VA, USA
| | - James E Tcheng
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC, USA
| | | | - Les R Folio
- Lead CT Radiologist, NIH Clinical Center, Bethesda, MD, USA
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10
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Marciano BE, Olivier KN, Folio LR, Zerbe CS, Hsu AP, Freeman AF, Filie AC, Spinner MA, Sanchez LA, Lovell JP, Parta M, Cuellar-Rodriguez JM, Hickstein DD, Holland SM. Pulmonary Manifestations of GATA2 Deficiency. Chest 2021; 160:1350-1359. [PMID: 34089740 DOI: 10.1016/j.chest.2021.05.046] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 05/10/2021] [Accepted: 05/15/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND GATA2 deficiency is a genetic disorder of hematopoiesis, lymphatics, and immunity caused by autosomal dominant or sporadic mutations in GATA2. The disease has a broad phenotype encompassing immunodeficiency, myelodysplasia, leukemia, and vascular or lymphatic dysfunction as well as prominent pulmonary manifestations. RESEARCH QUESTION What are the pulmonary manifestations of GATA2 deficiency? STUDY DESIGN AND METHODS A retrospective review was conducted of clinical medical records, diagnostic imaging, pulmonary pathologic specimens, and tests of pulmonary function. RESULTS Of 124 patients (95 probands and 29 ascertained), the lung was affected in 56%. In addition to chronic infections, pulmonary alveolar proteinosis (11 probands) and pulmonary arterial hypertension (nine probands) were present. Thoracic CT imaging found small nodules in 54% (54 probands and 12 relatives), reticular infiltrates in 40% (45 probands and four relatives), paraseptal emphysema in 25% (30 probands and one relative), ground-glass opacities in 35% (41 probands and two relatives), consolidation in 21% (23 probands and two relatives), and a typical crazy-paving pattern in 7% (eight probands and no relatives). Nontuberculous mycobacteria were the most frequent organisms associated with chronic infection. Allogeneic hematopoietic stem cell transplantation successfully reversed myelodysplasia and immune deficiency and also improved pulmonary hypertension and pulmonary alveolar proteinosis in most patients. INTERPRETATION GATA2 deficiency has prominent pulmonary manifestations. These clinical observations confirm the essential role of hematopoietic cells in many aspects of pulmonary function, including infections, alveolar proteinosis, and pulmonary hypertension, many of which precede the formal diagnosis, and many of which respond to stem cell transplantation.
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Affiliation(s)
- Beatriz E Marciano
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Kenneth N Olivier
- Pulmonary Branch, National Heart, Lung and Blood Institute, National Cancer Institute, National Institutes of Health, Bethesda, MD.
| | - Les R Folio
- Department of Radiology and Imaging Sciences, Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Christa S Zerbe
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Amy P Hsu
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Alexandra F Freeman
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Armando C Filie
- Cytology Services Laboratory Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Michael A Spinner
- Division of Oncology, Department of Medicine, Stanford University, Stanford
| | - Lauren A Sanchez
- Division of Allergy, Immunology, and Bone Marrow Transplantation, Department of Pediatrics, University of California, San Francisco, CA
| | - Jana P Lovell
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Mark Parta
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Jennifer M Cuellar-Rodriguez
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Dennis D Hickstein
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Steven M Holland
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Cancer Institute, National Institutes of Health, Bethesda, MD
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11
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Shafiei A, Bagheri M, Farhadi F, Apolo AB, Biassou NM, Folio LR, Jones EC, Summers RM. CT Evaluation of Lymph Nodes That Merge or Split during the Course of a Clinical Trial: Limitations of RECIST 1.1. Radiol Imaging Cancer 2021; 3:e200090. [PMID: 33874734 PMCID: PMC8189184 DOI: 10.1148/rycan.2021200090] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 02/11/2021] [Accepted: 02/16/2021] [Indexed: 06/12/2023]
Abstract
Purpose To compare Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 with volumetric measurement in the setting of target lymph nodes that split into two or more nodes or merge into one conglomerate node. Materials and Methods In this retrospective study, target lymph nodes were evaluated on CT scans from 166 patients with different types of cancer; 158 of the scans came from The Cancer Imaging Archive. Each target node was measured using RECIST 1.1 criteria before and after merging or splitting, followed by volumetric segmentation. To compare RECIST 1.1 with volume, a single-dimension hypothetical diameter (HD) was determined from the nodal volume. The nodes were divided into three groups: (a) one-target merged (one target node merged with other nodes); (b) two-target merged (two neighboring target nodes merged); and (c) split node (a conglomerate node cleaved into smaller fragments). Bland-Altman analysis and t test were applied to compare RECIST 1.1 with HD. On the basis of the RECIST 1.1 concept, we compared response category changes between RECIST 1.1 and HD. Results The data set consisted of 30 merged nodes (19 one-target merged and 11 two-target merged) and 20 split nodes (mean age for all 50 included patients, 50 years ± 7 [standard deviation]; 38 men). RECIST 1.1, volumetric, and HD measurements indicated an increase in size in all one-target merged nodes. While volume and HD indicated an increase in size for nodes in the two-target merged group, RECIST 1.1 showed a decrease in size in all two-target merged nodes. Although volume and HD demonstrated a decrease in size of all split nodes, RECIST 1.1 indicated an increase in size in 60% (12 of 20) of the nodes. Discrepancy of the response categories between RECIST 1.1 and HD was observed in 5% (one of 19) in one-target merged, 82% (nine of 11) in two-target merged, and 55% (11 of 20) in split nodes. Conclusion RECIST 1.1 does not optimally reflect size changes when lymph nodes merge or split. Keywords: CT, Lymphatic, Tumor Response Supplemental material is available for this article. © RSNA, 2021.
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12
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Rajaraman S, Folio LR, Dimperio J, Alderson PO, Antani SK. Improved Semantic Segmentation of Tuberculosis-Consistent Findings in Chest X-rays Using Augmented Training of Modality-Specific U-Net Models with Weak Localizations. Diagnostics (Basel) 2021; 11:diagnostics11040616. [PMID: 33808240 PMCID: PMC8065621 DOI: 10.3390/diagnostics11040616] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 03/12/2021] [Revised: 03/25/2021] [Accepted: 03/28/2021] [Indexed: 11/16/2022] Open
Abstract
Deep learning (DL) has drawn tremendous attention for object localization and recognition in both natural and medical images. U-Net segmentation models have demonstrated superior performance compared to conventional hand-crafted feature-based methods. Medical image modality-specific DL models are better at transferring domain knowledge to a relevant target task than those pretrained on stock photography images. This character helps improve model adaptation, generalization, and class-specific region of interest (ROI) localization. In this study, we train chest X-ray (CXR) modality-specific U-Nets and other state-of-the-art U-Net models for semantic segmentation of tuberculosis (TB)-consistent findings. Automated segmentation of such manifestations could help radiologists reduce errors and supplement decision-making while improving patient care and productivity. Our approach uses the publicly available TBX11K CXR dataset with weak TB annotations, typically provided as bounding boxes, to train a set of U-Net models. Next, we improve the results by augmenting the training data with weak localization, postprocessed into an ROI mask, from a DL classifier trained to classify CXRs as showing normal lungs or suspected TB manifestations. Test data are individually derived from the TBX11K CXR training distribution and other cross-institutional collections, including the Shenzhen TB and Montgomery TB CXR datasets. We observe that our augmented training strategy helped the CXR modality-specific U-Net models achieve superior performance with test data derived from the TBX11K CXR training distribution and cross-institutional collections (p < 0.05). We believe that this is the first study to i) use CXR modality-specific U-Nets for semantic segmentation of TB-consistent ROIs and ii) evaluate the segmentation performance while augmenting the training data with weak TB-consistent localizations.
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Affiliation(s)
- Sivaramakrishnan Rajaraman
- National Library of Medicine, National Institutes of Health, Bethesda, MD 20894, USA;
- Correspondence: ; Tel.: +1-301-827-2383
| | - Les R. Folio
- Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD 20894, USA; (L.R.F.); (J.D.)
| | - Jane Dimperio
- Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD 20894, USA; (L.R.F.); (J.D.)
| | | | - Sameer K. Antani
- National Library of Medicine, National Institutes of Health, Bethesda, MD 20894, USA;
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13
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Rajaraman S, Sornapudi S, Alderson PO, Folio LR, Antani SK. Analyzing inter-reader variability affecting deep ensemble learning for COVID-19 detection in chest radiographs. PLoS One 2020; 15:e0242301. [PMID: 33180877 PMCID: PMC7660555 DOI: 10.1371/journal.pone.0242301] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/01/2020] [Indexed: 01/17/2023] Open
Abstract
Data-driven deep learning (DL) methods using convolutional neural networks (CNNs) demonstrate promising performance in natural image computer vision tasks. However, their use in medical computer vision tasks faces several limitations, viz., (i) adapting to visual characteristics that are unlike natural images; (ii) modeling random noise during training due to stochastic optimization and backpropagation-based learning strategy; (iii) challenges in explaining DL black-box behavior to support clinical decision-making; and (iv) inter-reader variability in the ground truth (GT) annotations affecting learning and evaluation. This study proposes a systematic approach to address these limitations through application to the pandemic-caused need for Coronavirus disease 2019 (COVID-19) detection using chest X-rays (CXRs). Specifically, our contribution highlights significant benefits obtained through (i) pretraining specific to CXRs in transferring and fine-tuning the learned knowledge toward improving COVID-19 detection performance; (ii) using ensembles of the fine-tuned models to further improve performance over individual constituent models; (iii) performing statistical analyses at various learning stages for validating results; (iv) interpreting learned individual and ensemble model behavior through class-selective relevance mapping (CRM)-based region of interest (ROI) localization; and, (v) analyzing inter-reader variability and ensemble localization performance using Simultaneous Truth and Performance Level Estimation (STAPLE) methods. We find that ensemble approaches markedly improved classification and localization performance, and that inter-reader variability and performance level assessment helps guide algorithm design and parameter optimization. To the best of our knowledge, this is the first study to construct ensembles, perform ensemble-based disease ROI localization, and analyze inter-reader variability and algorithm performance for COVID-19 detection in CXRs.
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Affiliation(s)
- Sivaramakrishnan Rajaraman
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, Bethesda, Maryland, United States of America
| | - Sudhir Sornapudi
- Department of Electrical and Computer Engineering, Missouri University of Science and Technology, Rolla, Missouri, United States of America
| | - Philip O. Alderson
- School of Medicine, Saint Louis University, St. Louis, Missouri, United States of America
| | - Les R. Folio
- Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Sameer K. Antani
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, Bethesda, Maryland, United States of America
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14
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Apolo AB, Nadal R, Tomita Y, Davarpanah NN, Cordes LM, Steinberg SM, Cao L, Parnes HL, Costello R, Merino MJ, Folio LR, Lindenberg L, Raffeld M, Lin J, Lee MJ, Lee S, Alarcon SV, Yuno A, Dawson NA, Allette K, Roy A, De Silva D, Lee MM, Sissung TM, Figg WD, Agarwal PK, Wright JJ, Ning YM, Gulley JL, Dahut WL, Bottaro DP, Trepel JB. Cabozantinib in patients with platinum-refractory metastatic urothelial carcinoma: an open-label, single-centre, phase 2 trial. Lancet Oncol 2020; 21:1099-1109. [PMID: 32645282 PMCID: PMC8236112 DOI: 10.1016/s1470-2045(20)30202-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [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: 01/03/2020] [Revised: 03/12/2020] [Accepted: 03/19/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cabozantinib is a multikinase inhibitor of MET, VEGFR, AXL, and RET, which also has an effect on the tumour immune microenvironment by decreasing regulatory T cells and myeloid-derived suppressor cells. In this study, we examined the activity of cabozantinib in patients with metastatic platinum-refractory urothelial carcinoma. METHODS This study was an open-label, single-arm, three-cohort phase 2 trial done at the National Cancer Institute (Bethesda, MD, USA). Eligible patients were 18 years or older, had histologically confirmed urothelial carcinoma or rare genitourinary tract histologies, Karnofsky performance scale index of 60% or higher, and documented disease progression after at least one previous line of platinum-based chemotherapy (platinum-refractory). Cohort one included patients with metastatic urothelial carcinoma with measurable disease as defined by Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1. Two additional cohorts that enrolled in parallel (patients with bone-only urothelial carcinoma metastases and patients with rare histologies of the genitourinary tract) were exploratory. Patients received cabozantinib 60 mg orally once daily in 28-day cycles until disease progression or unacceptable toxicity. The primary endpoint was investigator-assessed objective response rate by RECIST in cohort one. Response was assessed in all patients who met the eligibility criteria and who received at least 8 weeks of therapy. All patients who received at least one dose of cabozantinib were included in the safety analysis. This completed study is registered with ClinicalTrials.gov, NCT01688999. FINDINGS Between Sept 28, 2012, and Oct, 20, 2015, 68 patients were enrolled on the study (49 in cohort one, six in cohort two, and 13 in cohort three). All patients received at least one dose of cabozantinib. The median follow-up was 61·2 months (IQR 53·8-70·0) for the 57 patients evaluable for response. In the 42 evaluable patients in cohort one, there was one complete response and seven partial responses (objective response rate 19%, 95% CI 9-34). The most common grade 3-4 adverse events were fatigue (six [9%] patients), hypertension (five [7%]), proteinuria (four [6%]), and hypophosphataemia (four [6%]). There were no treatment-related deaths. INTERPRETATION Cabozantinib has single-agent clinical activity in patients with heavily pretreated, platinum-refractory metastatic urothelial carcinoma with measurable disease and bone metastases and is generally well tolerated. Cabozantinib has innate and adaptive immunomodulatory properties providing a rationale for combining cabozantinib with immunotherapeutic strategies. FUNDING National Cancer Institute Intramural Program and the Cancer Therapy Evaluation Program.
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Affiliation(s)
- Andrea B Apolo
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA.
| | - Rosa Nadal
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Yusuke Tomita
- Developmental Therapeutics Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Nicole N Davarpanah
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Lisa M Cordes
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Seth M Steinberg
- Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Liang Cao
- Genetics Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Howard L Parnes
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Rene Costello
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Maria J Merino
- Laboratory of Pathology, Magnuson Clinical Center, Bethesda, MD, USA
| | - Les R Folio
- Radiology and Imaging Sciences, Magnuson Clinical Center, Bethesda, MD, USA
| | - Liza Lindenberg
- Molecular Imaging Program, Magnuson Clinical Center, Bethesda, MD, USA
| | - Mark Raffeld
- Laboratory of Pathology, Magnuson Clinical Center, Bethesda, MD, USA
| | - Jeffrey Lin
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Min-Jung Lee
- Developmental Therapeutics Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Sunmin Lee
- Developmental Therapeutics Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Sylvia V Alarcon
- Developmental Therapeutics Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Akira Yuno
- Developmental Therapeutics Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Nancy A Dawson
- Lombardi Comprehensive Cancer Center, Medstar Georgetown University Hospital, Washington DC, USA
| | - Kimaada Allette
- Genitourinary Malignancies Branch, Center for Cancer Research, Magnuson Clinical Center, Bethesda, MD, USA
| | - Arpita Roy
- Urologic Oncology Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Dinuka De Silva
- Urologic Oncology Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Molly M Lee
- Urologic Oncology Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Tristan M Sissung
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - William D Figg
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Piyush K Agarwal
- Urologic Oncology Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - John J Wright
- Genitourinary Malignancies Branch, Center for Cancer Research, Magnuson Clinical Center, Bethesda, MD, USA
| | - Yangmin M Ning
- Genitourinary Malignancies Branch, Center for Cancer Research, Magnuson Clinical Center, Bethesda, MD, USA
| | - James L Gulley
- Developmental Therapeutics Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - William L Dahut
- Developmental Therapeutics Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Donald P Bottaro
- Urologic Oncology Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Jane B Trepel
- Developmental Therapeutics Branch, Magnuson Clinical Center, Bethesda, MD, USA
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15
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Ravell JC, Matsuda-Lennikov M, Chauvin SD, Zou J, Biancalana M, Deeb SJ, Price S, Su HC, Notarangelo G, Jiang P, Morawski A, Kanellopoulou C, Binder K, Mukherjee R, Anibal JT, Sellers B, Zheng L, He T, George AB, Pittaluga S, Powers A, Kleiner DE, Kapuria D, Ghany M, Hunsberger S, Cohen JI, Uzel G, Bergerson J, Wolfe L, Toro C, Gahl W, Folio LR, Matthews H, Angelus P, Chinn IK, Orange JS, Trujillo-Vargas CM, Franco JL, Orrego-Arango J, Gutiérrez-Hincapié S, Patel NC, Raymond K, Patiroglu T, Unal E, Karakukcu M, Day AG, Mehta P, Masutani E, De Ravin SS, Malech HL, Altan-Bonnet G, Rao VK, Mann M, Lenardo MJ. Defective glycosylation and multisystem abnormalities characterize the primary immunodeficiency XMEN disease. J Clin Invest 2020; 130:507-522. [PMID: 31714901 DOI: 10.1172/jci131116] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/18/2019] [Indexed: 01/01/2023] Open
Abstract
X-linked immunodeficiency with magnesium defect, EBV infection, and neoplasia (XMEN) disease are caused by deficiency of the magnesium transporter 1 (MAGT1) gene. We studied 23 patients with XMEN, 8 of whom were EBV naive. We observed lymphadenopathy (LAD), cytopenias, liver disease, cavum septum pellucidum (CSP), and increased CD4-CD8-B220-TCRαβ+ T cells (αβDNTs), in addition to the previously described features of an inverted CD4/CD8 ratio, CD4+ T lymphocytopenia, increased B cells, dysgammaglobulinemia, and decreased expression of the natural killer group 2, member D (NKG2D) receptor. EBV-associated B cell malignancies occurred frequently in EBV-infected patients. We studied patients with XMEN and patients with autoimmune lymphoproliferative syndrome (ALPS) by deep immunophenotyping (32 immune markers) using time-of-flight mass cytometry (CyTOF). Our analysis revealed that the abundance of 2 populations of naive B cells (CD20+CD27-CD22+IgM+HLA-DR+CXCR5+CXCR4++CD10+CD38+ and CD20+CD27-CD22+IgM+HLA-DR+CXCR5+CXCR4+CD10-CD38-) could differentially classify XMEN, ALPS, and healthy individuals. We also performed glycoproteomics analysis on T lymphocytes and show that XMEN disease is a congenital disorder of glycosylation that affects a restricted subset of glycoproteins. Transfection of MAGT1 mRNA enabled us to rescue proteins with defective glycosylation. Together, these data provide new clinical and pathophysiological foundations with important ramifications for the diagnosis and treatment of XMEN disease.
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Affiliation(s)
- Juan C Ravell
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA
| | - Mami Matsuda-Lennikov
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA
| | - Samuel D Chauvin
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA
| | - Juan Zou
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA
| | - Matthew Biancalana
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA
| | - Sally J Deeb
- Proteomics and Signal Transduction Group and Computational Systems Biochemistry, Max Planck Institute of Biochemistry, Martinsried, Germany
| | - Susan Price
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, NIAID, Bethesda, Maryland, USA
| | - Helen C Su
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, NIAID, Bethesda, Maryland, USA
| | - Giulia Notarangelo
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA
| | - Ping Jiang
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA
| | - Aaron Morawski
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA
| | - Chrysi Kanellopoulou
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA
| | - Kyle Binder
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA.,Neuroimmunology Branch, National Institute of Neurological Disorders and Stroke (NINDS), Bethesda, Maryland, USA
| | - Ratnadeep Mukherjee
- Center for Cancer Research, National Cancer Institute (NCI), Bethesda, Maryland, USA
| | - James T Anibal
- Center for Cancer Research, National Cancer Institute (NCI), Bethesda, Maryland, USA
| | - Brian Sellers
- Trans-NIH Center for Human Immunology, Autoimmunity, and Inflammation, NIH, Bethesda, Maryland, USA
| | - Lixin Zheng
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA
| | - Tingyan He
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA.,Department of Rheumatology and Immunology, Shenzhen Children's Hospital, Shenzhen, China
| | - Alex B George
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA
| | - Stefania Pittaluga
- Hematopathology Section, Laboratory of Pathology, NCI, Bethesda, Maryland, USA
| | - Astin Powers
- Laboratory of Pathology, NCI, Bethesda, Maryland, USA
| | | | - Devika Kapuria
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, Maryland, USA
| | - Marc Ghany
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, Maryland, USA
| | | | - Jeffrey I Cohen
- Medical Virology Section, Laboratory of Infectious Diseases, NIAID
| | - Gulbu Uzel
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, NIAID, Bethesda, Maryland, USA
| | - Jenna Bergerson
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, NIAID, Bethesda, Maryland, USA
| | - Lynne Wolfe
- National Human Genome Research Institute, and
| | - Camilo Toro
- National Human Genome Research Institute, and
| | | | - Les R Folio
- Radiology and Imaging Sciences, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Helen Matthews
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA
| | - Pam Angelus
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, NIAID, Bethesda, Maryland, USA.,Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, NCI, NIH, Bethesda, Maryland, USA
| | - Ivan K Chinn
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Jordan S Orange
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Claudia M Trujillo-Vargas
- Grupo de Inmunodeficiencias Primarias, Facultad de Medicina, Universidad de Antioquia UdeA, Medellin, Colombia
| | - Jose Luis Franco
- Grupo de Inmunodeficiencias Primarias, Facultad de Medicina, Universidad de Antioquia UdeA, Medellin, Colombia
| | - Julio Orrego-Arango
- Grupo de Inmunodeficiencias Primarias, Facultad de Medicina, Universidad de Antioquia UdeA, Medellin, Colombia
| | | | - Niraj Chandrakant Patel
- Section of Infectious Disease and Immunology, Department of Pediatrics, Carolinas Medical Center, and.,Levine Children's Hospital Atrium Health, Charlotte, North Carolina, USA
| | - Kimiyo Raymond
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Turkan Patiroglu
- Department of Pediatrics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Ekrem Unal
- Department of Pediatrics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Musa Karakukcu
- Department of Pediatrics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Alexandre Gr Day
- Department of Physics, Boston University, Boston, Massachusetts, USA
| | - Pankaj Mehta
- Department of Physics, Boston University, Boston, Massachusetts, USA
| | - Evan Masutani
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA
| | - Suk S De Ravin
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, NIAID, Bethesda, Maryland, USA
| | - Harry L Malech
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, NIAID, Bethesda, Maryland, USA
| | - Grégoire Altan-Bonnet
- Center for Cancer Research, National Cancer Institute (NCI), Bethesda, Maryland, USA
| | - V Koneti Rao
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, NIAID, Bethesda, Maryland, USA
| | - Matthias Mann
- Proteomics and Signal Transduction Group and Computational Systems Biochemistry, Max Planck Institute of Biochemistry, Martinsried, Germany
| | - Michael J Lenardo
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA
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16
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Yeom YS, Villoing D, Greenstein N, Kitahara CM, Folio LR, Kim CH, Lee C. INVESTIGATION OF THE INFLUENCE OF THYROID LOCATION ON IODINE-131 S VALUES. Radiat Prot Dosimetry 2020; 189:163-171. [PMID: 32285115 PMCID: PMC7357322 DOI: 10.1093/rpd/ncaa027] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/19/2020] [Accepted: 02/11/2020] [Indexed: 06/11/2023]
Abstract
The use of iodine-131 S values based on reference computational phantoms with fixed thyroid model may lead to significant dosimetric errors in patients who may have different thyroid location from the reference phantoms. In the present study, we investigated individual thyroid location variation by examining the computed tomography image sets of 40 adult male and female patients. Subsequently, the thyroid location of the adult male and female mesh-type reference phantoms of the International Commission on Radiological Protection (ICRP) was adjusted to match each the highest, mean and the lowest locations of the thyroid observed in this dataset. The thyroid-adjusted phantoms were implemented into the Geant4 Monte Carlo code to calculate thyroid location-dependent iodine-131 S values (rT ← thyroid) for a total of 30 target regions. The maximum variation among the observed thyroid locations was 39 mm and 36 mm for male and female patients, respectively. The mean thyroid locations of both male and female patients showed a good agreement with the ICRP reference phantoms. The thyroid location-dependent Iodine-131 S values were significantly different from the reference phantoms for most target regions by up to a factor of 3. The use of thyroid location-dependent S values in dose reconstructions should help quantify the dosimetric uncertainty in epidemiologic investigations of patients receiving iodine-131 therapy for hyperthyroidism and thyroid cancer.
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Affiliation(s)
- Yeon Soo Yeom
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville MD 20850, USA
| | - Daphnée Villoing
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville MD 20850, USA
| | | | - Cari M Kitahara
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville MD 20850, USA
| | - Les R Folio
- Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD 20852, USA
| | - Chan Hyeong Kim
- Department of Nuclear Engineering, Hanyang University, Seoul, Korea
| | - Choonsik Lee
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville MD 20850, USA
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17
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Ferré EMN, Break TJ, Burbelo PD, Allgäuer M, Kleiner DE, Jin D, Xu Z, Folio LR, Mollura DJ, Swamydas M, Gu W, Hunsberger S, Lee CCR, Bondici A, Hoffman KW, Lim JK, Dobbs K, Niemela JE, Fleisher TA, Hsu AP, Snow LN, Darnell DN, Ojaimi S, Cooper MA, Bozzola M, Kleiner GI, Martinez JC, Deterding RR, Kuhns DB, Heller T, Winer KK, Rajan A, Holland SM, Notarangelo LD, Fennelly KP, Olivier KN, Lionakis MS. Lymphocyte-driven regional immunopathology in pneumonitis caused by impaired central immune tolerance. Sci Transl Med 2020; 11:11/495/eaav5597. [PMID: 31167928 DOI: 10.1126/scitranslmed.aav5597] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 04/05/2019] [Indexed: 12/19/2022]
Abstract
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), a monogenic disorder caused by AIRE mutations, presents with several autoimmune diseases. Among these, endocrine organ failure is widely recognized, but the prevalence, immunopathogenesis, and treatment of non-endocrine manifestations such as pneumonitis remain poorly characterized. We enrolled 50 patients with APECED in a prospective observational study and comprehensively examined their clinical and radiographic findings, performed pulmonary function tests, and analyzed immunological characteristics in blood, bronchoalveolar lavage fluid, and endobronchial and lung biopsies. Pneumonitis was found in >40% of our patients, presented early in life, was misdiagnosed despite chronic respiratory symptoms and accompanying radiographic and pulmonary function abnormalities, and caused hypoxemic respiratory failure and death. Autoantibodies against BPIFB1 and KCNRG and the homozygous c.967_979del13 AIRE mutation are associated with pneumonitis development. APECED pneumonitis features compartmentalized immunopathology, with accumulation of activated neutrophils in the airways and lymphocytic infiltration in intraepithelial, submucosal, peribronchiolar, and interstitial areas. Beyond APECED, we extend these observations to lung disease seen in other conditions with secondary AIRE deficiency (thymoma and RAG deficiency). Aire-deficient mice had similar compartmentalized cellular immune responses in the airways and lung tissue, which was ameliorated by deficiency of T and B lymphocytes. Accordingly, T and B lymphocyte-directed immunomodulation controlled symptoms and radiographic abnormalities and improved pulmonary function in patients with APECED pneumonitis. Collectively, our findings unveil lung autoimmunity as a common, early, and unrecognized manifestation of APECED and provide insights into the immunopathogenesis and treatment of pulmonary autoimmunity associated with impaired central immune tolerance.
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Affiliation(s)
- Elise M N Ferré
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Timothy J Break
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Peter D Burbelo
- Dental Clinical Research Core, National Institute of Dental and Craniofacial Research (NIDCR), NIH, Bethesda, MD 20892, USA
| | - Michael Allgäuer
- Laboratory of Pathology, Center for Cancer Research, NCI, NIH, Bethesda, MD 20892, USA.,Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - David E Kleiner
- Laboratory of Pathology, Center for Cancer Research, NCI, NIH, Bethesda, MD 20892, USA
| | - Dakai Jin
- Radiology and Imaging Sciences, NIH Clinical Center (CC), NIH, Bethesda, MD 20892, USA
| | - Ziyue Xu
- Radiology and Imaging Sciences, NIH Clinical Center (CC), NIH, Bethesda, MD 20892, USA
| | - Les R Folio
- Radiology and Imaging Sciences, NIH Clinical Center (CC), NIH, Bethesda, MD 20892, USA
| | - Daniel J Mollura
- Radiology and Imaging Sciences, NIH Clinical Center (CC), NIH, Bethesda, MD 20892, USA
| | - Muthulekha Swamydas
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Wenjuan Gu
- Biostatistics Research Branch, Division of Clinical Research (DCR), NIAID, NIH, Bethesda, MD 20892, USA
| | - Sally Hunsberger
- Biostatistics Research Branch, Division of Clinical Research (DCR), NIAID, NIH, Bethesda, MD 20892, USA
| | - Chyi-Chia R Lee
- Laboratory of Pathology, Center for Cancer Research, NCI, NIH, Bethesda, MD 20892, USA
| | - Anamaria Bondici
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Kevin W Hoffman
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jean K Lim
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Kerry Dobbs
- Immune Deficiency Genetics Section, LCIM, NIAID, NIH, Bethesda, MD 20892, USA
| | - Julie E Niemela
- Immunology Service, Department of Laboratory Medicine (DLM), NIH CC, NIH, Bethesda, MD 20892, USA
| | - Thomas A Fleisher
- Immunology Service, Department of Laboratory Medicine (DLM), NIH CC, NIH, Bethesda, MD 20892, USA
| | - Amy P Hsu
- Immunopathogenesis Section, LCIM, NIAID, NIH, Bethesda, MD 20892, USA
| | - Laquita N Snow
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Dirk N Darnell
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Samar Ojaimi
- Department of Infectious Diseases, Monash Health, Melbourne, VIC 3800, Australia.,Centre for Inflammatory Diseases, Monash University, Melbourne, VIC 3800, Australia
| | - Megan A Cooper
- Department of Pediatrics, Division of Rheumatology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Martin Bozzola
- Department of Pediatrics, British Hospital, Perdriel 74, CABA-Buenos Aires, Argentina
| | - Gary I Kleiner
- University of Miami Department of Pediatrics, Miami, FL 33136, USA
| | - Juan C Martinez
- Cystic Fibrosis, Pulmonary, and Sleep Division, Joe DiMaggio Children's Hospital, Hollywood, FL 33021, USA
| | - Robin R Deterding
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Douglas B Kuhns
- Neutrophil Monitoring Laboratory, Applied/Developmental Research Directorate, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research Inc., Frederick, MD 21701, USA
| | - Theo Heller
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 20892, USA
| | - Karen K Winer
- Pediatric Growth and Nutrition Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD 20892, USA
| | - Arun Rajan
- Thoracic and Gastrointestinal Malignancies Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD 20892, USA
| | - Steven M Holland
- Immunopathogenesis Section, LCIM, NIAID, NIH, Bethesda, MD 20892, USA
| | - Luigi D Notarangelo
- Immune Deficiency Genetics Section, LCIM, NIAID, NIH, Bethesda, MD 20892, USA
| | - Kevin P Fennelly
- Laboratory of Chronic Airway Infection, Pulmonary Branch, National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD 20892, USA
| | - Kenneth N Olivier
- Laboratory of Chronic Airway Infection, Pulmonary Branch, National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD 20892, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA.
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18
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Rajaraman S, Siegelman J, Alderson PO, Folio LS, Folio LR, Antani SK. Iteratively Pruned Deep Learning Ensembles for COVID-19 Detection in Chest X-rays. IEEE Access 2020; 8:115041-115050. [PMID: 32742893 PMCID: PMC7394290 DOI: 10.1109/access.2020.3003810] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/17/2020] [Indexed: 05/08/2023]
Abstract
We demonstrate use of iteratively pruned deep learning model ensembles for detecting pulmonary manifestation of COVID-19 with chest X-rays. This disease is caused by the novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus, also known as the novel Coronavirus (2019-nCoV). A custom convolutional neural network and a selection of ImageNet pretrained models are trained and evaluated at patient-level on publicly available CXR collections to learn modality-specific feature representations. The learned knowledge is transferred and fine-tuned to improve performance and generalization in the related task of classifying CXRs as normal, showing bacterial pneumonia, or COVID-19-viral abnormalities. The best performing models are iteratively pruned to reduce complexity and improve memory efficiency. The predictions of the best-performing pruned models are combined through different ensemble strategies to improve classification performance. Empirical evaluations demonstrate that the weighted average of the best-performing pruned models significantly improves performance resulting in an accuracy of 99.01% and area under the curve of 0.9972 in detecting COVID-19 findings on CXRs. The combined use of modality-specific knowledge transfer, iterative model pruning, and ensemble learning resulted in improved predictions. We expect that this model can be quickly adopted for COVID-19 screening using chest radiographs.
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Affiliation(s)
| | | | | | - Lucas S. Folio
- Functional and Applied Biomechanics Section, Clinical CenterNational Institutes of HealthBethesdaMD20892USA
- Walt Whitman High SchoolBethesdaMD20817USA
| | - Les R. Folio
- Radiological and Imaging Sciences, Clinical CenterNational Institutes of HealthBethesdaMD20894USA
| | - Sameer K. Antani
- Lister Hill National Center for Biomedical CommunicationsNational Library of MedicineBethesdaMD20894USA
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19
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Lee C, Kuzmin GA, Bae J, Yao J, Mosher E, Folio LR. Automatic Mapping of CT Scan Locations on Computational Human Phantoms for Organ Dose Estimation. J Digit Imaging 2020; 32:175-182. [PMID: 30187315 DOI: 10.1007/s10278-018-0119-2] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
To develop an algorithm to automatically map CT scan locations of patients onto computational human phantoms to provide with patient-specific organ doses. We developed an algorithm that compares a two-dimensional skeletal mask generated from patient CTs with that of a whole body computational human phantom. The algorithm selected the scan locations showing the highest Dice Similarity Coefficient (DSC) calculated between the skeletal masks of a patient and a phantom. To test the performance of the algorithm, we randomly selected five sets of neck, chest, and abdominal CT images from the National Institutes of Health Clinical Center. We first automatically mapped scan locations of the CT images on a computational human phantom using our algorithm. We had several radiologists to manually map the same CT images on the phantom and compared the results with the automated mapping. Finally, organ doses for automated and manual mapping locations were calculated by an in-house CT dose calculator and compared to each other. The visual comparison showed excellent agreement between manual and automatic mapping locations for neck, chest, and abdomen-pelvis CTs. The difference in mapping locations averaged over the start and end in the five patients was less than 1 cm for all neck, chest, and AP scans: 0.9, 0.7, and 0.9 cm for neck, chest, and AP scans, respectively. Five cases out of ten in the neck scans show zero difference between the average manual and automatic mappings. Average of absolute dose differences between manual and automatic mappings was 2.3, 2.7, and 4.0% for neck, chest, and AP scans, respectively. The automatic mapping algorithm provided accurate scan locations and organ doses compared to manual mapping. The algorithm will be useful in cases requiring patient-specific organ dose for a large number of patients such as patient dose monitoring, clinical trials, and epidemiologic studies.
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Affiliation(s)
- Choonsik Lee
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA. .,Radiation Epidemiology Branch/DCEG/NCI/NIH, 9609 Medical Center Drive, Rockville, MD, 20850, USA.
| | - Gleb A Kuzmin
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jinyong Bae
- Kansas City University of Medicine and Bioscience, Kansas City, KS, USA
| | - Jianhua Yao
- Radiology and Imaging Sciences Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Elizabeth Mosher
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Les R Folio
- Radiology and Imaging Sciences Clinical Center, National Institutes of Health, Bethesda, MD, USA
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20
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Willemink MJ, Koszek WA, Hardell C, Wu J, Fleischmann D, Harvey H, Folio LR, Summers RM, Rubin DL, Lungren MP. Preparing Medical Imaging Data for Machine Learning. Radiology 2020; 295:4-15. [PMID: 32068507 PMCID: PMC7104701 DOI: 10.1148/radiol.2020192224] [Citation(s) in RCA: 311] [Impact Index Per Article: 77.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/03/2019] [Accepted: 12/30/2019] [Indexed: 12/19/2022]
Abstract
Artificial intelligence (AI) continues to garner substantial interest in medical imaging. The potential applications are vast and include the entirety of the medical imaging life cycle from image creation to diagnosis to outcome prediction. The chief obstacles to development and clinical implementation of AI algorithms include availability of sufficiently large, curated, and representative training data that includes expert labeling (eg, annotations). Current supervised AI methods require a curation process for data to optimally train, validate, and test algorithms. Currently, most research groups and industry have limited data access based on small sample sizes from small geographic areas. In addition, the preparation of data is a costly and time-intensive process, the results of which are algorithms with limited utility and poor generalization. In this article, the authors describe fundamental steps for preparing medical imaging data in AI algorithm development, explain current limitations to data curation, and explore new approaches to address the problem of data availability.
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Affiliation(s)
- Martin J. Willemink
- From the Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, S-072, Stanford, CA 94305-5105 (M.J.W., D.F., D.L.R., M.P.L.); Segmed, Menlo Park, Calif (M.J.W., W.A.K., C.H., J.W.); School of Engineering, Stanford University, Stanford, Calif (J.W.); Institute of Cognitive Neuroscience, University College London, London, England (H.H.); Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (L.R.F.); Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, National Institutes of Health, Clinical Center, Bethesda, Md (R.M.S.); Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Stanford Center for Artificial Intelligence in Medicine and Imaging (AIMI), Stanford, Calif (M.P.L.)
| | - Wojciech A. Koszek
- From the Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, S-072, Stanford, CA 94305-5105 (M.J.W., D.F., D.L.R., M.P.L.); Segmed, Menlo Park, Calif (M.J.W., W.A.K., C.H., J.W.); School of Engineering, Stanford University, Stanford, Calif (J.W.); Institute of Cognitive Neuroscience, University College London, London, England (H.H.); Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (L.R.F.); Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, National Institutes of Health, Clinical Center, Bethesda, Md (R.M.S.); Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Stanford Center for Artificial Intelligence in Medicine and Imaging (AIMI), Stanford, Calif (M.P.L.)
| | - Cailin Hardell
- From the Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, S-072, Stanford, CA 94305-5105 (M.J.W., D.F., D.L.R., M.P.L.); Segmed, Menlo Park, Calif (M.J.W., W.A.K., C.H., J.W.); School of Engineering, Stanford University, Stanford, Calif (J.W.); Institute of Cognitive Neuroscience, University College London, London, England (H.H.); Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (L.R.F.); Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, National Institutes of Health, Clinical Center, Bethesda, Md (R.M.S.); Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Stanford Center for Artificial Intelligence in Medicine and Imaging (AIMI), Stanford, Calif (M.P.L.)
| | - Jie Wu
- From the Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, S-072, Stanford, CA 94305-5105 (M.J.W., D.F., D.L.R., M.P.L.); Segmed, Menlo Park, Calif (M.J.W., W.A.K., C.H., J.W.); School of Engineering, Stanford University, Stanford, Calif (J.W.); Institute of Cognitive Neuroscience, University College London, London, England (H.H.); Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (L.R.F.); Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, National Institutes of Health, Clinical Center, Bethesda, Md (R.M.S.); Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Stanford Center for Artificial Intelligence in Medicine and Imaging (AIMI), Stanford, Calif (M.P.L.)
| | - Dominik Fleischmann
- From the Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, S-072, Stanford, CA 94305-5105 (M.J.W., D.F., D.L.R., M.P.L.); Segmed, Menlo Park, Calif (M.J.W., W.A.K., C.H., J.W.); School of Engineering, Stanford University, Stanford, Calif (J.W.); Institute of Cognitive Neuroscience, University College London, London, England (H.H.); Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (L.R.F.); Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, National Institutes of Health, Clinical Center, Bethesda, Md (R.M.S.); Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Stanford Center for Artificial Intelligence in Medicine and Imaging (AIMI), Stanford, Calif (M.P.L.)
| | - Hugh Harvey
- From the Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, S-072, Stanford, CA 94305-5105 (M.J.W., D.F., D.L.R., M.P.L.); Segmed, Menlo Park, Calif (M.J.W., W.A.K., C.H., J.W.); School of Engineering, Stanford University, Stanford, Calif (J.W.); Institute of Cognitive Neuroscience, University College London, London, England (H.H.); Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (L.R.F.); Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, National Institutes of Health, Clinical Center, Bethesda, Md (R.M.S.); Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Stanford Center for Artificial Intelligence in Medicine and Imaging (AIMI), Stanford, Calif (M.P.L.)
| | - Les R. Folio
- From the Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, S-072, Stanford, CA 94305-5105 (M.J.W., D.F., D.L.R., M.P.L.); Segmed, Menlo Park, Calif (M.J.W., W.A.K., C.H., J.W.); School of Engineering, Stanford University, Stanford, Calif (J.W.); Institute of Cognitive Neuroscience, University College London, London, England (H.H.); Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (L.R.F.); Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, National Institutes of Health, Clinical Center, Bethesda, Md (R.M.S.); Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Stanford Center for Artificial Intelligence in Medicine and Imaging (AIMI), Stanford, Calif (M.P.L.)
| | - Ronald M. Summers
- From the Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, S-072, Stanford, CA 94305-5105 (M.J.W., D.F., D.L.R., M.P.L.); Segmed, Menlo Park, Calif (M.J.W., W.A.K., C.H., J.W.); School of Engineering, Stanford University, Stanford, Calif (J.W.); Institute of Cognitive Neuroscience, University College London, London, England (H.H.); Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (L.R.F.); Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, National Institutes of Health, Clinical Center, Bethesda, Md (R.M.S.); Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Stanford Center for Artificial Intelligence in Medicine and Imaging (AIMI), Stanford, Calif (M.P.L.)
| | - Daniel L. Rubin
- From the Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, S-072, Stanford, CA 94305-5105 (M.J.W., D.F., D.L.R., M.P.L.); Segmed, Menlo Park, Calif (M.J.W., W.A.K., C.H., J.W.); School of Engineering, Stanford University, Stanford, Calif (J.W.); Institute of Cognitive Neuroscience, University College London, London, England (H.H.); Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (L.R.F.); Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, National Institutes of Health, Clinical Center, Bethesda, Md (R.M.S.); Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Stanford Center for Artificial Intelligence in Medicine and Imaging (AIMI), Stanford, Calif (M.P.L.)
| | - Matthew P. Lungren
- From the Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, S-072, Stanford, CA 94305-5105 (M.J.W., D.F., D.L.R., M.P.L.); Segmed, Menlo Park, Calif (M.J.W., W.A.K., C.H., J.W.); School of Engineering, Stanford University, Stanford, Calif (J.W.); Institute of Cognitive Neuroscience, University College London, London, England (H.H.); Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (L.R.F.); Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, National Institutes of Health, Clinical Center, Bethesda, Md (R.M.S.); Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Stanford Center for Artificial Intelligence in Medicine and Imaging (AIMI), Stanford, Calif (M.P.L.)
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Do HM, Spear LG, Nikpanah M, Mirmomen SM, Machado LB, Toscano AP, Turkbey B, Bagheri MH, Gulley JL, Folio LR. Augmented Radiologist Workflow Improves Report Value and Saves Time: A Potential Model for Implementation of Artificial Intelligence. Acad Radiol 2020; 27:96-105. [PMID: 31818390 DOI: 10.1016/j.acra.2019.09.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/12/2019] [Accepted: 09/17/2019] [Indexed: 12/12/2022]
Abstract
RATIONALE AND OBJECTIVES Our primary aim was to improve radiology reports by increasing concordance of target lesion measurements with oncology records using radiology preprocessors (RP). Faster notification of incidental actionable findings to referring clinicians and clinical radiologist exam interpretation time savings with RPs quantifying tumor burden were also assessed. MATERIALS AND METHODS In this prospective quality improvement initiative, RPs annotated lesions before radiologist interpretation of CT exams. Clinical radiologists then hyperlinked approved measurements into interactive reports during interpretations. RPs evaluated concordance with our tumor measurement radiologist, the determinant of tumor burden. Actionable finding detection and notification times were also deduced. Clinical radiologist interpretation times were calculated from established average CT chest, abdomen, and pelvis interpretation times. RESULTS RPs assessed 1287 body CT exams with 812 follow-up CT chest, abdomen, and pelvis studies; 95 (11.7%) of which had 241 verified target lesions. There was improved concordance (67.8% vs. 22.5%) of target lesion measurements. RPs detected 93.1% incidental actionable findings with faster clinician notification by a median time of 1 hour (range: 15 minutes-16 hours). Radiologist exam interpretation times decreased by 37%. CONCLUSIONS This workflow resulted in three-fold improved target lesion measurement concordance with oncology records, earlier detection and faster notification of incidental actionable findings to referring clinicians, and decreased exam interpretation times for clinical radiologists. These findings demonstrate potential roles for automation (such as AI) to improve report value, worklist prioritization, and patient care.
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Tirosh A, Journy N, Folio LR, Lee C, Leite C, Yao J, Kovacs W, Linehan WM, Malayeri A, Kebebew E, Berrington de González A. Cumulative Radiation Exposures from CT Screening and Surveillance Strategies for von Hippel-Lindau-associated Solid Pancreatic Tumors. Radiology 2018; 290:116-124. [PMID: 30299237 DOI: 10.1148/radiol.2018180687] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Purpose To assess the potential ionizing radiation exposure from CT scans for both screening and surveillance of patients with von Hippel-Lindau (VHL) syndrome. Materials and Methods For this retrospective study, abdomen-pelvic (AP) and chest-abdomen-pelvic (CAP) CT scans were performed with either a three-phase (n = 1242) or a dual-energy virtual noncontrast protocol (VNC; n = 149) in 747 patients with VHL syndrome in the National Institutes of Health Clinical Center between 2009 and 2015 (mean age, 47.6 years ± 14.6 [standard deviation]; age range, 12-83 years; 320 women [42.8%]). CT scanning parameters for patients with pancreatic neuroendocrine tumors (PNETs; 124 patients and 381 scans) were compared between a tumor diameter-based surveillance protocol and a VHL genotype and tumor diameter-based algorithm (a tailored algorithm) developed by three VHL clinicians. Organ and lifetime radiation doses were estimated by two radiologists and five radiation scientists. Cumulative radiation doses were compared between the PNET surveillance algorithms by analyses of variance, and a two-tailed P value less than .05 indicated statistical significance. Results Median cumulative colon doses for annual CAP and AP CT scans from age 15 to 40 years ranged from 0.34 Gy (5th-95th percentiles, 0.18-0.75; dual-energy VNC CT) to 0.89 Gy (5th-95th percentiles, 0.42-1.0; three-phase CT). For the current PNET surveillance protocol, the cumulative effective radiation dose from age 40 to 65 years was 682 mSv (tumors < 1.2 cm) and 2125 mSv (tumors > 3 cm). The tailored algorithm could halve these doses for patients with initial tumor diameter less than 1.2 cm (P < .001). Conclusion CT screening of patients with von Hippel-Lindau syndrome can lead to substantial radiation exposures, even with dual-energy virtual noncontrast CT. A genome and tumor diameter-based algorithm for pancreatic neuroendocrine tumor surveillance may potentially reduce lifetime radiation exposure. © RSNA, 2018 Online supplemental material is available for this article.
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Affiliation(s)
- Amit Tirosh
- From the Neuroendocrine Tumors Service, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel 52621 (A.T.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (A.T.); Division of Cancer Epidemiology and Genetics (N.J., C. Lee, A.B.d.G.), Department of Radiology and Imaging Sciences (L.R.F., J.Y., W.K., A.M.), and Urologic Oncology Branch (C. Leite, W.M.L.), National Cancer Institute, National Institutes of Health, Bethesda, Md; Centre for Research in Epidemiology and Population Health (CESP), INSERM U1018, Villejuif, France (N.J.); and Department of Surgery and Stanford Cancer Institute, Stanford University, Stanford, Calif (E.K.)
| | - Neige Journy
- From the Neuroendocrine Tumors Service, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel 52621 (A.T.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (A.T.); Division of Cancer Epidemiology and Genetics (N.J., C. Lee, A.B.d.G.), Department of Radiology and Imaging Sciences (L.R.F., J.Y., W.K., A.M.), and Urologic Oncology Branch (C. Leite, W.M.L.), National Cancer Institute, National Institutes of Health, Bethesda, Md; Centre for Research in Epidemiology and Population Health (CESP), INSERM U1018, Villejuif, France (N.J.); and Department of Surgery and Stanford Cancer Institute, Stanford University, Stanford, Calif (E.K.)
| | - Les R Folio
- From the Neuroendocrine Tumors Service, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel 52621 (A.T.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (A.T.); Division of Cancer Epidemiology and Genetics (N.J., C. Lee, A.B.d.G.), Department of Radiology and Imaging Sciences (L.R.F., J.Y., W.K., A.M.), and Urologic Oncology Branch (C. Leite, W.M.L.), National Cancer Institute, National Institutes of Health, Bethesda, Md; Centre for Research in Epidemiology and Population Health (CESP), INSERM U1018, Villejuif, France (N.J.); and Department of Surgery and Stanford Cancer Institute, Stanford University, Stanford, Calif (E.K.)
| | - Choonsik Lee
- From the Neuroendocrine Tumors Service, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel 52621 (A.T.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (A.T.); Division of Cancer Epidemiology and Genetics (N.J., C. Lee, A.B.d.G.), Department of Radiology and Imaging Sciences (L.R.F., J.Y., W.K., A.M.), and Urologic Oncology Branch (C. Leite, W.M.L.), National Cancer Institute, National Institutes of Health, Bethesda, Md; Centre for Research in Epidemiology and Population Health (CESP), INSERM U1018, Villejuif, France (N.J.); and Department of Surgery and Stanford Cancer Institute, Stanford University, Stanford, Calif (E.K.)
| | - Christiane Leite
- From the Neuroendocrine Tumors Service, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel 52621 (A.T.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (A.T.); Division of Cancer Epidemiology and Genetics (N.J., C. Lee, A.B.d.G.), Department of Radiology and Imaging Sciences (L.R.F., J.Y., W.K., A.M.), and Urologic Oncology Branch (C. Leite, W.M.L.), National Cancer Institute, National Institutes of Health, Bethesda, Md; Centre for Research in Epidemiology and Population Health (CESP), INSERM U1018, Villejuif, France (N.J.); and Department of Surgery and Stanford Cancer Institute, Stanford University, Stanford, Calif (E.K.)
| | - Jianhua Yao
- From the Neuroendocrine Tumors Service, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel 52621 (A.T.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (A.T.); Division of Cancer Epidemiology and Genetics (N.J., C. Lee, A.B.d.G.), Department of Radiology and Imaging Sciences (L.R.F., J.Y., W.K., A.M.), and Urologic Oncology Branch (C. Leite, W.M.L.), National Cancer Institute, National Institutes of Health, Bethesda, Md; Centre for Research in Epidemiology and Population Health (CESP), INSERM U1018, Villejuif, France (N.J.); and Department of Surgery and Stanford Cancer Institute, Stanford University, Stanford, Calif (E.K.)
| | - William Kovacs
- From the Neuroendocrine Tumors Service, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel 52621 (A.T.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (A.T.); Division of Cancer Epidemiology and Genetics (N.J., C. Lee, A.B.d.G.), Department of Radiology and Imaging Sciences (L.R.F., J.Y., W.K., A.M.), and Urologic Oncology Branch (C. Leite, W.M.L.), National Cancer Institute, National Institutes of Health, Bethesda, Md; Centre for Research in Epidemiology and Population Health (CESP), INSERM U1018, Villejuif, France (N.J.); and Department of Surgery and Stanford Cancer Institute, Stanford University, Stanford, Calif (E.K.)
| | - W Marston Linehan
- From the Neuroendocrine Tumors Service, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel 52621 (A.T.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (A.T.); Division of Cancer Epidemiology and Genetics (N.J., C. Lee, A.B.d.G.), Department of Radiology and Imaging Sciences (L.R.F., J.Y., W.K., A.M.), and Urologic Oncology Branch (C. Leite, W.M.L.), National Cancer Institute, National Institutes of Health, Bethesda, Md; Centre for Research in Epidemiology and Population Health (CESP), INSERM U1018, Villejuif, France (N.J.); and Department of Surgery and Stanford Cancer Institute, Stanford University, Stanford, Calif (E.K.)
| | - Ashkan Malayeri
- From the Neuroendocrine Tumors Service, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel 52621 (A.T.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (A.T.); Division of Cancer Epidemiology and Genetics (N.J., C. Lee, A.B.d.G.), Department of Radiology and Imaging Sciences (L.R.F., J.Y., W.K., A.M.), and Urologic Oncology Branch (C. Leite, W.M.L.), National Cancer Institute, National Institutes of Health, Bethesda, Md; Centre for Research in Epidemiology and Population Health (CESP), INSERM U1018, Villejuif, France (N.J.); and Department of Surgery and Stanford Cancer Institute, Stanford University, Stanford, Calif (E.K.)
| | - Electron Kebebew
- From the Neuroendocrine Tumors Service, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel 52621 (A.T.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (A.T.); Division of Cancer Epidemiology and Genetics (N.J., C. Lee, A.B.d.G.), Department of Radiology and Imaging Sciences (L.R.F., J.Y., W.K., A.M.), and Urologic Oncology Branch (C. Leite, W.M.L.), National Cancer Institute, National Institutes of Health, Bethesda, Md; Centre for Research in Epidemiology and Population Health (CESP), INSERM U1018, Villejuif, France (N.J.); and Department of Surgery and Stanford Cancer Institute, Stanford University, Stanford, Calif (E.K.)
| | - Amy Berrington de González
- From the Neuroendocrine Tumors Service, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel 52621 (A.T.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (A.T.); Division of Cancer Epidemiology and Genetics (N.J., C. Lee, A.B.d.G.), Department of Radiology and Imaging Sciences (L.R.F., J.Y., W.K., A.M.), and Urologic Oncology Branch (C. Leite, W.M.L.), National Cancer Institute, National Institutes of Health, Bethesda, Md; Centre for Research in Epidemiology and Population Health (CESP), INSERM U1018, Villejuif, France (N.J.); and Department of Surgery and Stanford Cancer Institute, Stanford University, Stanford, Calif (E.K.)
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Jaeger S, Juarez-Espinosa OH, Candemir S, Poostchi M, Yang F, Kim L, Ding M, Folio LR, Antani S, Gabrielian A, Hurt D, Rosenthal A, Thoma G. Detecting drug-resistant tuberculosis in chest radiographs. Int J Comput Assist Radiol Surg 2018; 13:1915-1925. [PMID: 30284153 PMCID: PMC6223762 DOI: 10.1007/s11548-018-1857-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [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: 09/15/2017] [Accepted: 09/05/2018] [Indexed: 11/21/2022]
Abstract
Purpose Tuberculosis is a major global health threat claiming millions of lives each year. While the total number of tuberculosis cases has been decreasing over the last years, the rise of drug-resistant tuberculosis has reduced the chance of controlling the disease. The purpose is to implement a timely diagnosis of drug-resistant tuberculosis, which is essential to administering adequate treatment regimens and stopping the further transmission of drug-resistant tuberculosis. Methods A main tool for diagnosing tuberculosis is the conventional chest X-ray. We are investigating the possibility of discriminating automatically between drug-resistant and drug-sensitive tuberculosis in chest X-rays by means of image analysis and machine learning methods. Results For discriminating between drug-sensitive and drug-resistant tuberculosis, we achieve an area under the receiver operating characteristic curve (AUC) of up to 66%, using an artificial neural network in combination with a set of shape and texture features. We did not observe any significant difference in the results when including follow-up X-rays for each patient. Conclusion Our results suggest that a chest X-ray contains information about the likelihood of a drug-resistant tuberculosis infection, which can be exploited computationally. We therefore suggest to repeat the experiments of our pilot study on a larger set of chest X-rays.
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Affiliation(s)
- Stefan Jaeger
- Lister Hill National Center for Biomedical Communications, U.S. National Library of Medicine, Bethesda, MD, 20894, USA.
| | - Octavio H Juarez-Espinosa
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases, Rockville, MD, 20852, USA
| | - Sema Candemir
- Lister Hill National Center for Biomedical Communications, U.S. National Library of Medicine, Bethesda, MD, 20894, USA
| | - Mahdieh Poostchi
- Lister Hill National Center for Biomedical Communications, U.S. National Library of Medicine, Bethesda, MD, 20894, USA
| | - Feng Yang
- Lister Hill National Center for Biomedical Communications, U.S. National Library of Medicine, Bethesda, MD, 20894, USA.,School of Computer and Information Technology, Beijing Jiaotong University, Beijing, 100044, China
| | - Lewis Kim
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases, Rockville, MD, 20852, USA
| | - Meng Ding
- Bayer HealthCare, 1 Bayer Dr, Indianola, PA, 15051, USA
| | - Les R Folio
- Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Sameer Antani
- Lister Hill National Center for Biomedical Communications, U.S. National Library of Medicine, Bethesda, MD, 20894, USA
| | - Andrei Gabrielian
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases, Rockville, MD, 20852, USA
| | - Darrell Hurt
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases, Rockville, MD, 20852, USA
| | - Alex Rosenthal
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases, Rockville, MD, 20852, USA
| | - George Thoma
- Lister Hill National Center for Biomedical Communications, U.S. National Library of Medicine, Bethesda, MD, 20894, USA
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Mandell JC, Wortman JR, Rocha TC, Folio LR, Andriole KP, Khurana B. Computed Tomography Window Blending: Feasibility in Thoracic Trauma. Acad Radiol 2018; 25:1190-1200. [PMID: 29428212 DOI: 10.1016/j.acra.2017.12.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 12/17/2017] [Accepted: 12/28/2017] [Indexed: 11/25/2022]
Abstract
RATIONALE AND OBJECTIVES This study aims to demonstrate the feasibility of processing computed tomography (CT) images with a custom window blending algorithm that combines soft-tissue, bone, and lung window settings into a single image; to compare the time for interpretation of chest CT for thoracic trauma with window blending and conventional window settings; and to assess diagnostic performance of both techniques. MATERIALS AND METHODS Adobe Photoshop was scripted to process axial DICOM images from retrospective contrast-enhanced chest CTs performed for trauma with a window-blending algorithm. Two emergency radiologists independently interpreted the axial images from 103 chest CTs with both blended and conventional windows. Interpretation time and diagnostic performance were compared with Wilcoxon signed-rank test and McNemar test, respectively. Agreement with Nexus CT Chest injury severity was assessed with the weighted kappa statistic. RESULTS A total of 13,295 images were processed without error. Interpretation was faster with window blending, resulting in a 20.3% time saving (P < .001), with no difference in diagnostic performance, within the power of the study to detect a difference in sensitivity of 5% as determined by post hoc power analysis. The sensitivity of the window-blended cases was 82.7%, compared to 81.6% for conventional windows. The specificity of the window-blended cases was 93.1%, compared to 90.5% for conventional windows. All injuries of major clinical significance (per Nexus CT Chest criteria) were correctly identified in all reading sessions, and all negative cases were correctly classified. All readers demonstrated near-perfect agreement with injury severity classification with both window settings. CONCLUSIONS In this pilot study utilizing retrospective data, window blending allows faster preliminary interpretation of axial chest CT performed for trauma, with no significant difference in diagnostic performance compared to conventional window settings. Future studies would be required to assess the utility of window blending in clinical practice.
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Abstract
Multimedia-enhanced radiology report (MERR) development is defined and described from an informatics perspective, in which the MERR is seen as a superior information-communicating entity. Recent technical advances, such as the hyperlinking of report text directly to annotated images, improve MERR information content and accessibility compared with text-only reports. The MERR is analyzed by its components, which include hypertext, tables, graphs, embedded images, and their interconnections. The authors highlight the advantages of each component for improving the radiologist's communication of report content information and the user's ability to extract information. Requirements for MERR implementation (eg, integration of picture archiving and communication systems, radiology information systems, and electronic medical record systems) and the authors' initial experiences and challenges in MERR implementation at the National Institutes of Health are reviewed. The transition to MERRs has provided advantages over use of traditional text-only radiology reports because of the capacity to include hyperlinked report text that directs clinicians to image annotations, images, tables, and graphs. A framework is provided for thinking about the MERR from the user's perspective. Additional applications of emerging technologies (eg, artificial intelligence and machine learning) are described in the crafting of what the authors believe is the radiology report of the future. ©RSNA, 2018.
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Affiliation(s)
- Les R Folio
- From Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 9000 Rockville Pike, Building 10, Bethesda, MD 20892
| | - Laura B Machado
- From Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 9000 Rockville Pike, Building 10, Bethesda, MD 20892
| | - Andrew J Dwyer
- From Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 9000 Rockville Pike, Building 10, Bethesda, MD 20892
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Sanchez GAM, Reinhardt A, Ramsey S, Wittkowski H, Hashkes PJ, Berkun Y, Schalm S, Murias S, Dare JA, Brown D, Stone DL, Gao L, Klausmeier T, Foell D, de Jesus AA, Chapelle DC, Kim H, Dill S, Colbert RA, Failla L, Kost B, O'Brien M, Reynolds JC, Folio LR, Calvo KR, Paul SM, Weir N, Brofferio A, Soldatos A, Biancotto A, Cowen EW, Digiovanna JJ, Gadina M, Lipton AJ, Hadigan C, Holland SM, Fontana J, Alawad AS, Brown RJ, Rother KI, Heller T, Brooks KM, Kumar P, Brooks SR, Waldman M, Singh HK, Nickeleit V, Silk M, Prakash A, Janes JM, Ozen S, Wakim PG, Brogan PA, Macias WL, Goldbach-Mansky R. JAK1/2 inhibition with baricitinib in the treatment of autoinflammatory interferonopathies. J Clin Invest 2018. [PMID: 29649002 DOI: 10.1172/jci98814)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Monogenic IFN-mediated autoinflammatory diseases present in infancy with systemic inflammation, an IFN response gene signature, inflammatory organ damage, and high mortality. We used the JAK inhibitor baricitinib, with IFN-blocking activity in vitro, to ameliorate disease. METHODS Between October 2011 and February 2017, 10 patients with CANDLE (chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperatures), 4 patients with SAVI (stimulator of IFN genes-associated [STING-associated] vasculopathy with onset in infancy), and 4 patients with other interferonopathies were enrolled in an expanded access program. The patients underwent dose escalation, and the benefit was assessed by reductions in daily disease symptoms and corticosteroid requirement. Quality of life, organ inflammation, changes in IFN-induced biomarkers, and safety were longitudinally assessed. RESULTS Eighteen patients were treated for a mean duration of 3.0 years (1.5-4.9 years). The median daily symptom score decreased from 1.3 (interquartile range [IQR], 0.93-1.78) to 0.25 (IQR, 0.1-0.63) (P < 0.0001). In 14 patients receiving corticosteroids at baseline, daily prednisone doses decreased from 0.44 mg/kg/day (IQR, 0.31-1.09) to 0.11 mg/kg/day (IQR, 0.02-0.24) (P < 0.01), and 5 of 10 patients with CANDLE achieved lasting clinical remission. The patients' quality of life and height and bone mineral density Z-scores significantly improved, and their IFN biomarkers decreased. Three patients, two of whom had genetically undefined conditions, discontinued treatment because of lack of efficacy, and one CANDLE patient discontinued treatment because of BK viremia and azotemia. The most common adverse events were upper respiratory infections, gastroenteritis, and BK viruria and viremia. CONCLUSION Upon baricitinib treatment, clinical manifestations and inflammatory and IFN biomarkers improved in patients with the monogenic interferonopathies CANDLE, SAVI, and other interferonopathies. Monitoring safety and efficacy is important in benefit-risk assessment. TRIAL REGISTRATION ClinicalTrials.gov NCT01724580 and NCT02974595. FUNDING This research was supported by the Intramural Research Program of the NIH, NIAID, and NIAMS. Baricitinib was provided by Eli Lilly and Company, which is the sponsor of the expanded access program for this drug.
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Affiliation(s)
- Gina A Montealegre Sanchez
- Translational Autoinflammatory Disease Section, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Adam Reinhardt
- Faculty of Physicians of the University of Nebraska Medical Center, College of Medicine, Omaha, Nebraska, USA
| | | | - Helmut Wittkowski
- Department of Pediatric Rheumatology and Immunology, University Children's Hospital, Muenster, Germany
| | | | - Yackov Berkun
- Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | | | - Jason A Dare
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Diane Brown
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Deborah L Stone
- National Human Genome Research Institute, NIH, Bethesda, Maryland, USA
| | - Ling Gao
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | | | - Dirk Foell
- Department of Pediatric Rheumatology and Immunology, University Children's Hospital, Muenster, Germany
| | - Adriana A de Jesus
- Translational Autoinflammatory Disease Section, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Dawn C Chapelle
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | - Hanna Kim
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | - Samantha Dill
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | - Robert A Colbert
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | - Laura Failla
- Translational Autoinflammatory Disease Section, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Bahar Kost
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | - Michelle O'Brien
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | | | - Les R Folio
- Clinical Center, NIH, Bethesda, Maryland, USA
| | | | | | - Nargues Weir
- National Heart, Lung, and Blood Institute (NHLBI), NIH, Bethesda, Maryland, USA
| | | | - Ariane Soldatos
- National Institute of Neurological Disorders and Stroke (NINDS), NIH, Bethesda, Maryland, USA
| | - Angelique Biancotto
- National Heart, Lung, and Blood Institute (NHLBI), NIH, Bethesda, Maryland, USA
| | - Edward W Cowen
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | | | - Massimo Gadina
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | - Andrew J Lipton
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | | | - Joseph Fontana
- National Heart, Lung, and Blood Institute (NHLBI), NIH, Bethesda, Maryland, USA
| | - Ahmad S Alawad
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, Maryland, USA
| | - Rebecca J Brown
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, Maryland, USA
| | - Kristina I Rother
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, Maryland, USA
| | - Theo Heller
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, Maryland, USA
| | | | - Parag Kumar
- Clinical Center, NIH, Bethesda, Maryland, USA
| | - Stephen R Brooks
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | - Meryl Waldman
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, Maryland, USA
| | - Harsharan K Singh
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Volker Nickeleit
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Maria Silk
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | | | | | - Seza Ozen
- Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Paul G Wakim
- Biostatistics and Clinical Epidemiology Service, NIH Clinical Center, Bethesda, Maryland, USA
| | - Paul A Brogan
- University College London (UCL) Great Ormond Street Institute of Child Health and Great Ormond Street Hospital NHS Foundation, London, United Kingdom
| | | | - Raphaela Goldbach-Mansky
- Translational Autoinflammatory Disease Section, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
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Sanchez GAM, Reinhardt A, Ramsey S, Wittkowski H, Hashkes PJ, Berkun Y, Schalm S, Murias S, Dare JA, Brown D, Stone DL, Gao L, Klausmeier T, Foell D, de Jesus AA, Chapelle DC, Kim H, Dill S, Colbert RA, Failla L, Kost B, O'Brien M, Reynolds JC, Folio LR, Calvo KR, Paul SM, Weir N, Brofferio A, Soldatos A, Biancotto A, Cowen EW, Digiovanna JJ, Gadina M, Lipton AJ, Hadigan C, Holland SM, Fontana J, Alawad AS, Brown RJ, Rother KI, Heller T, Brooks KM, Kumar P, Brooks SR, Waldman M, Singh HK, Nickeleit V, Silk M, Prakash A, Janes JM, Ozen S, Wakim PG, Brogan PA, Macias WL, Goldbach-Mansky R. JAK1/2 inhibition with baricitinib in the treatment of autoinflammatory interferonopathies. J Clin Invest 2018; 128:3041-3052. [PMID: 29649002 PMCID: PMC6026004 DOI: 10.1172/jci98814] [Citation(s) in RCA: 328] [Impact Index Per Article: 54.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 04/04/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND. Monogenic IFN–mediated autoinflammatory diseases present in infancy with systemic inflammation, an IFN response gene signature, inflammatory organ damage, and high mortality. We used the JAK inhibitor baricitinib, with IFN-blocking activity in vitro, to ameliorate disease. METHODS. Between October 2011 and February 2017, 10 patients with CANDLE (chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperatures), 4 patients with SAVI (stimulator of IFN genes–associated [STING-associated] vasculopathy with onset in infancy), and 4 patients with other interferonopathies were enrolled in an expanded access program. The patients underwent dose escalation, and the benefit was assessed by reductions in daily disease symptoms and corticosteroid requirement. Quality of life, organ inflammation, changes in IFN-induced biomarkers, and safety were longitudinally assessed. RESULTS. Eighteen patients were treated for a mean duration of 3.0 years (1.5–4.9 years). The median daily symptom score decreased from 1.3 (interquartile range [IQR], 0.93–1.78) to 0.25 (IQR, 0.1–0.63) (P < 0.0001). In 14 patients receiving corticosteroids at baseline, daily prednisone doses decreased from 0.44 mg/kg/day (IQR, 0.31–1.09) to 0.11 mg/kg/day (IQR, 0.02–0.24) (P < 0.01), and 5 of 10 patients with CANDLE achieved lasting clinical remission. The patients’ quality of life and height and bone mineral density Z-scores significantly improved, and their IFN biomarkers decreased. Three patients, two of whom had genetically undefined conditions, discontinued treatment because of lack of efficacy, and one CANDLE patient discontinued treatment because of BK viremia and azotemia. The most common adverse events were upper respiratory infections, gastroenteritis, and BK viruria and viremia. CONCLUSION. Upon baricitinib treatment, clinical manifestations and inflammatory and IFN biomarkers improved in patients with the monogenic interferonopathies CANDLE, SAVI, and other interferonopathies. Monitoring safety and efficacy is important in benefit-risk assessment. TRIAL REGISTRATION. ClinicalTrials.gov NCT01724580 and NCT02974595. FUNDING. This research was supported by the Intramural Research Program of the NIH, NIAID, and NIAMS. Baricitinib was provided by Eli Lilly and Company, which is the sponsor of the expanded access program for this drug.
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Affiliation(s)
- Gina A Montealegre Sanchez
- Translational Autoinflammatory Disease Section, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Adam Reinhardt
- Faculty of Physicians of the University of Nebraska Medical Center, College of Medicine, Omaha, Nebraska, USA
| | | | - Helmut Wittkowski
- Department of Pediatric Rheumatology and Immunology, University Children's Hospital, Muenster, Germany
| | | | - Yackov Berkun
- Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | | | - Jason A Dare
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Diane Brown
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Deborah L Stone
- National Human Genome Research Institute, NIH, Bethesda, Maryland, USA
| | - Ling Gao
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | | | - Dirk Foell
- Department of Pediatric Rheumatology and Immunology, University Children's Hospital, Muenster, Germany
| | - Adriana A de Jesus
- Translational Autoinflammatory Disease Section, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Dawn C Chapelle
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | - Hanna Kim
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | - Samantha Dill
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | - Robert A Colbert
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | - Laura Failla
- Translational Autoinflammatory Disease Section, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Bahar Kost
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | - Michelle O'Brien
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | | | - Les R Folio
- Clinical Center, NIH, Bethesda, Maryland, USA
| | | | | | - Nargues Weir
- National Heart, Lung, and Blood Institute (NHLBI), NIH, Bethesda, Maryland, USA
| | | | - Ariane Soldatos
- National Institute of Neurological Disorders and Stroke (NINDS), NIH, Bethesda, Maryland, USA
| | - Angelique Biancotto
- National Heart, Lung, and Blood Institute (NHLBI), NIH, Bethesda, Maryland, USA
| | - Edward W Cowen
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | | | - Massimo Gadina
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | - Andrew J Lipton
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | | | - Joseph Fontana
- National Heart, Lung, and Blood Institute (NHLBI), NIH, Bethesda, Maryland, USA
| | - Ahmad S Alawad
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, Maryland, USA
| | - Rebecca J Brown
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, Maryland, USA
| | - Kristina I Rother
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, Maryland, USA
| | - Theo Heller
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, Maryland, USA
| | | | - Parag Kumar
- Clinical Center, NIH, Bethesda, Maryland, USA
| | - Stephen R Brooks
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, Maryland, USA
| | - Meryl Waldman
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, Maryland, USA
| | - Harsharan K Singh
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Volker Nickeleit
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Maria Silk
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | | | | | - Seza Ozen
- Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Paul G Wakim
- Biostatistics and Clinical Epidemiology Service, NIH Clinical Center, Bethesda, Maryland, USA
| | - Paul A Brogan
- University College London (UCL) Great Ormond Street Institute of Child Health and Great Ormond Street Hospital NHS Foundation, London, United Kingdom
| | | | - Raphaela Goldbach-Mansky
- Translational Autoinflammatory Disease Section, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
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Shafiei A, Bagheri M, Farhadi F, Lay N, Yao J, Folio LR, Jones EC, Summers RM. Optimizing measurement when lymph nodes merge on serial CT in clinical trials. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e18590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Mohammadhadi Bagheri
- Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD
| | | | - Nathan Lay
- National Institutes of Health (NIH), Bethesda, MD
| | - Jianhua Yao
- National Institutes of Health (NIH), Bethesda, MD
| | - Les R. Folio
- National Institutes of Health (NIH), Bethesda, MD
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Shafiei A, Bagheri M, Farhadi F, Lay N, Yao J, Folio LR, Jones EC, Summers RM. A proposed measurement scheme when lymph nodes split on serial CT in clinical trials. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e18591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Mohammadhadi Bagheri
- Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD
| | | | - Nathan Lay
- National Institutes of Health (NIH), Bethesda, MD
| | - Jianhua Yao
- National Institutes of Health (NIH), Bethesda, MD
| | - Les R. Folio
- National Institutes of Health (NIH), Bethesda, MD
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Rayn KN, Ritchie C, Folio LR, Stamatakis L, Verghese MM, Agarwal PK. Bilateral Ureteroenteric Strictures: A Case of the "Reverse 7". Urology 2018; 118:e3-e4. [PMID: 29729367 DOI: 10.1016/j.urology.2018.04.022] [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] [Received: 04/17/2018] [Revised: 04/17/2018] [Accepted: 04/24/2018] [Indexed: 10/17/2022]
Abstract
Anastomotic stricture is a well-known complication of the urinary diversion that accompanies radical cystectomy. Management options range from endoscopic procedures to open surgeries, with a subset of the latter employing bowel as the interposing segment. In this report, we describe a rare patient, who successfully underwent a "Reverse 7" procedure, bypassing strictures at both anastomotic junctions between ureters and neobladder.
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Affiliation(s)
- Kareem N Rayn
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Cayde Ritchie
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Les R Folio
- Radiology and Imaging Sciences, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Lambros Stamatakis
- Department of Urology, Medstar Washington Hospital Center, Washington, DC
| | - Mohan M Verghese
- Department of Urology, Medstar Washington Hospital Center, Washington, DC
| | - Piyush K Agarwal
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD.
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Abstract
OBJECTIVE Radiation exposure of the lens during neck CT may increase a patient's risk of developing cataracts. Radiologists at the National Institutes of Health worked with technicians to modify the neck CT scanning procedure to include a reduction in the scanning range, a reduction in the tube potential (kilovoltage), and a change in neck positioning using a head tilt. We objectively quantified the organ dose changes after this procedure modification using a computer simulation. MATERIALS AND METHODS We retrospectively analyzed CT images of 40 patients (20 men and 20 women) scanned before and after the procedure change. Radiation dose to the lens delivered before and after the procedure change was calculated using an in-house CT dose calculator combined with computational human phantoms deformed to match head tilt angles. We also calculated the doses to other radiosensitive organs including the brain, pituitary gland, eye globes, and salivary glands before and after the procedure change. RESULTS Our dose calculations showed that modifying the neck position, shortening the scanning range, and reducing the tube potential reduced the dose to the lens by 89% (p < 0.0001). The median brain, pituitary gland, globes, and salivary gland doses also decreased by 59%, 52%, 66%, and 29%, respectively. We found that overranging significantly affects the lens dose. CONCLUSION Combining head tilt and scanning range reduction is an easy and effective method that significantly reduces radiation dose to the lens and other radiosensitive head and neck organs.
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Affiliation(s)
- Elizabeth Mosher
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - John A. Butman
- Radiology and Imaging Sciences Clinical Center, National Institutes of Health, Bethesda, MD
| | - Les R. Folio
- Radiology and Imaging Sciences Clinical Center, National Institutes of Health, Bethesda, MD
| | - Nadia M. Biassou
- Radiology and Imaging Sciences Clinical Center, National Institutes of Health, Bethesda, MD
| | - Choonsik Lee
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
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Goyal N, Apolo AB, Berman ED, Bagheri MH, Levine JE, Glod JW, Kaplan RN, Machado LB, Folio LR. ENABLE (Exportable Notation and Bookmark List Engine): an Interface to Manage Tumor Measurement Data from PACS to Cancer Databases. J Digit Imaging 2018; 30:275-286. [PMID: 28074302 DOI: 10.1007/s10278-016-9938-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Oncologists evaluate therapeutic response in cancer trials based on tumor quantification following selected "target" lesions over time. At our cancer center, a majority of oncologists use Response Evaluation Criteria in Solid Tumors (RECIST) v1.1 quantifying tumor progression based on lesion measurements on imaging. Currently, our oncologists handwrite tumor measurements, followed by multiple manual data transfers; however, our Picture Archiving Communication System (PACS) (Carestream Health, Rochester, NY) has the ability to export tumor measurements, making it possible to manage tumor metadata digitally. We developed an interface, "Exportable Notation and Bookmark List Engine" (ENABLE), which produces prepopulated RECIST v1.1 worksheets and compiles cohort data and data models from PACS measurement data, thus eliminating handwriting and manual data transcription. We compared RECIST v1.1 data from eight patients (16 computed tomography exams) enrolled in an IRB-approved therapeutic trial with ENABLE outputs: 10 data fields with a total of 194 data points. All data in ENABLE's output matched with the existing data. Seven staff were taught how to use the interface with a 5-min explanatory instructional video. All were able to use ENABLE successfully without additional guidance. We additionally assessed 42 metastatic genitourinary cancer patients with available RECIST data within PACS to produce a best response waterfall plot. ENABLE manages tumor measurements and associated metadata exported from PACS, producing forms and data models compatible with cancer databases, obviating handwriting and the manual re-entry of data. Automation should reduce transcription errors and improve efficiency and the auditing process.
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Affiliation(s)
- Nikhil Goyal
- Radiology and Imaging Sciences, CC, NIH, Building 10, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Andrea B Apolo
- Genitourinary Malignancies Branch, NCI, NIH, Building 10, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Eliana D Berman
- Genitourinary Malignancies Branch, NCI, NIH, Building 10, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Mohammad Hadi Bagheri
- Radiology and Imaging Sciences, CC, NIH, Building 10, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Jason E Levine
- Center for Cancer Research, NCI, NIH, Building 10, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - John W Glod
- Pediatric Oncology Branch, CCR, NCI, NIH, Building 10, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Rosandra N Kaplan
- Pediatric Oncology Branch, CCR, NCI, NIH, Building 10, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Laura B Machado
- Radiology and Imaging Sciences, CC, NIH, Building 10, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Les R Folio
- Radiology and Imaging Sciences, CC, NIH, Building 10, 9000 Rockville Pike, Bethesda, MD, 20892, USA.
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Fenerty KE, Patronas NJ, Heery CR, Gulley JL, Folio LR. Resources Required for Semi-Automatic Volumetric Measurements in Metastatic Chordoma: Is Potentially Improved Tumor Burden Assessment Worth the Time Burden? J Digit Imaging 2018; 29:357-64. [PMID: 26596767 DOI: 10.1007/s10278-015-9846-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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] [Indexed: 01/16/2023] Open
Abstract
The Response Evaluation Criteria in Solid Tumors (RECIST) is the current standard for assessing therapy response in patients with malignant solid tumors; however, volumetric assessments are thought to be more representative of actual tumor size and hence superior in predicting patient outcomes. We segmented all primary and metastatic lesions in 21 chordoma patients for comparison to RECIST. Primary tumors were segmented on MR and validated by a neuroradiologist. Metastatic lesions were segmented on CT and validated by a general radiologist. We estimated times for a research assistant to segment all primary and metastatic chordoma lesions using semi-automated volumetric segmentation tools available within our PACS (v12.0, Carestream, Rochester, NY), as well as time required for radiologists to validate the segmentations. We also report success rates of semi-automatic segmentation in metastatic lesions on CT and time required to export data. Furthermore, we discuss the feasibility of volumetric segmentation workflow in research and clinical settings. The research assistant spent approximately 65 h segmenting 435 lesions in 21 patients. This resulted in 1349 total segmentations (average 2.89 min per lesion) and over 13,000 data points. Combined time for the neuroradiologist and general radiologist to validate segmentations was 45.7 min per patient. Exportation time for all patients totaled only 6 h, providing time-saving opportunities for data managers and oncologists. Perhaps cost-neutral resource reallocation can help acquire volumes paralleling our example workflow. Our results will provide researchers with benchmark resources required for volumetric assessments within PACS and help prepare institutions for future volumetric assessment criteria.
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Affiliation(s)
- Kathleen E Fenerty
- Laboratory of Tumor Immunology and Biology, CCR, NCI, NIH, Bethesda, MD, USA.
| | - Nicholas J Patronas
- Department of Radiology and Imaging Sciences, Clinical Center, NIH, Bethesda, MD, USA
| | - Christopher R Heery
- Laboratory of Tumor Immunology and Biology, CCR, NCI, NIH, Bethesda, MD, USA
| | - James L Gulley
- Genitourinary Malignancies Branch, CCR, NCI, NIH, Bethesda, MD, USA
| | - Les R Folio
- Department of Radiology and Imaging Sciences, Clinical Center, NIH, Bethesda, MD, USA
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Kovacs WC, Yao J, Bluemke DA, Folio LR. Opportunities to Reduce CT Radiation Exposure, Experience Over 5 Years at the NIH Clinical Center. Radiat Prot Dosimetry 2017; 175:482-492. [PMID: 28096313 PMCID: PMC5927337 DOI: 10.1093/rpd/ncw377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 12/05/2016] [Accepted: 12/10/2016] [Indexed: 06/06/2023]
Abstract
Our current study was undertaken in order to compare CT exposures during various dose-reduction initiatives at the National Institutes of Health Clinical center, to show trends in exposure reduction over a 5-y period, and to provide benchmarks that other facilities may use. Using an in-house extraction tool (Radiation Exposure Extraction Engine), we derived CT exposure data from Digital Imaging and Communications in Medicine (DICOM) headers over 5 y. We present parameters used and compare most common exams between 2010 and 2015. During a period of exposure-reduction initiatives, data of 79 396 exams from nine CT scanners on 87 scan protocols were analyzed. Adult chest exposures were reduced 53% and chest, abdomen and pelvis exams were reduced 43% (p < 0.001). Only extremity exams did not show significantly reduced exposure. Collecting data over several years allowed us to confirm and compare several initiatives. We demonstrated significant exposure reductions during continued reduction efforts on common exams. Our results may provide benchmarks for similar centers.
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Affiliation(s)
- William C. Kovacs
- Diagnostic Radiology Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Jianhua Yao
- Diagnostic Radiology Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - David A. Bluemke
- Diagnostic Radiology Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Les R. Folio
- Diagnostic Radiology Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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Symons R, Pourmorteza A, Sandfort V, Ahlman MA, Cropper T, Mallek M, Kappler S, Ulzheimer S, Mahesh M, Jones EC, Malayeri AA, Folio LR, Bluemke DA. Feasibility of Dose-reduced Chest CT with Photon-counting Detectors: Initial Results in Humans. Radiology 2017; 285:980-989. [PMID: 28753389 DOI: 10.1148/radiol.2017162587] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Purpose To investigate whether photon-counting detector (PCD) technology can improve dose-reduced chest computed tomography (CT) image quality compared with that attained with conventional energy-integrating detector (EID) technology in vivo. Materials and Methods This was a HIPAA-compliant institutional review board-approved study, with informed consent from patients. Dose-reduced spiral unenhanced lung EID and PCD CT examinations were performed in 30 asymptomatic volunteers in accordance with manufacturer-recommended guidelines for CT lung cancer screening (120-kVp tube voltage, 20-mAs reference tube current-time product for both detectors). Quantitative analysis of images included measurement of mean attenuation, noise power spectrum (NPS), and lung nodule contrast-to-noise ratio (CNR). Images were qualitatively analyzed by three radiologists blinded to detector type. Reproducibility was assessed with the intraclass correlation coefficient (ICC). McNemar, paired t, and Wilcoxon signed-rank tests were used to compare image quality. Results Thirty study subjects were evaluated (mean age, 55.0 years ± 8.7 [standard deviation]; 14 men). Of these patients, 10 had a normal body mass index (BMI) (BMI range, 18.5-24.9 kg/m2; group 1), 10 were overweight (BMI range, 25.0-29.9 kg/m2; group 2), and 10 were obese (BMI ≥30.0 kg/m2, group 3). PCD diagnostic quality was higher than EID diagnostic quality (P = .016, P = .016, and P = .013 for readers 1, 2, and 3, respectively), with significantly better NPS and image quality scores for lung, soft tissue, and bone and with fewer beam-hardening artifacts (all P < .001). Image noise was significantly lower for PCD images in all BMI groups (P < .001 for groups 1 and 3, P < .01 for group 2), with higher CNR for lung nodule detection (12.1 ± 1.7 vs 10.0 ± 1.8, P < .001). Inter- and intrareader reproducibility were good (all ICC > 0.800). Conclusion Initial human experience with dose-reduced PCD chest CT demonstrated lower image noise compared with conventional EID CT, with better diagnostic quality and lung nodule CNR. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Rolf Symons
- From the Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bethesda, MD 20892 (R.S., A.P., V.S., M.A.A., T.C., M. Mallek, E.C.J., A.A.M., L.R.F., D.A.B.); Siemens Healthcare, Forchheim, Germany (S.K., S.U.); and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (M. Mahesh)
| | - Amir Pourmorteza
- From the Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bethesda, MD 20892 (R.S., A.P., V.S., M.A.A., T.C., M. Mallek, E.C.J., A.A.M., L.R.F., D.A.B.); Siemens Healthcare, Forchheim, Germany (S.K., S.U.); and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (M. Mahesh)
| | - Veit Sandfort
- From the Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bethesda, MD 20892 (R.S., A.P., V.S., M.A.A., T.C., M. Mallek, E.C.J., A.A.M., L.R.F., D.A.B.); Siemens Healthcare, Forchheim, Germany (S.K., S.U.); and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (M. Mahesh)
| | - Mark A Ahlman
- From the Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bethesda, MD 20892 (R.S., A.P., V.S., M.A.A., T.C., M. Mallek, E.C.J., A.A.M., L.R.F., D.A.B.); Siemens Healthcare, Forchheim, Germany (S.K., S.U.); and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (M. Mahesh)
| | - Tracy Cropper
- From the Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bethesda, MD 20892 (R.S., A.P., V.S., M.A.A., T.C., M. Mallek, E.C.J., A.A.M., L.R.F., D.A.B.); Siemens Healthcare, Forchheim, Germany (S.K., S.U.); and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (M. Mahesh)
| | - Marissa Mallek
- From the Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bethesda, MD 20892 (R.S., A.P., V.S., M.A.A., T.C., M. Mallek, E.C.J., A.A.M., L.R.F., D.A.B.); Siemens Healthcare, Forchheim, Germany (S.K., S.U.); and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (M. Mahesh)
| | - Steffen Kappler
- From the Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bethesda, MD 20892 (R.S., A.P., V.S., M.A.A., T.C., M. Mallek, E.C.J., A.A.M., L.R.F., D.A.B.); Siemens Healthcare, Forchheim, Germany (S.K., S.U.); and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (M. Mahesh)
| | - Stefan Ulzheimer
- From the Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bethesda, MD 20892 (R.S., A.P., V.S., M.A.A., T.C., M. Mallek, E.C.J., A.A.M., L.R.F., D.A.B.); Siemens Healthcare, Forchheim, Germany (S.K., S.U.); and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (M. Mahesh)
| | - Mahadevappa Mahesh
- From the Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bethesda, MD 20892 (R.S., A.P., V.S., M.A.A., T.C., M. Mallek, E.C.J., A.A.M., L.R.F., D.A.B.); Siemens Healthcare, Forchheim, Germany (S.K., S.U.); and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (M. Mahesh)
| | - Elizabeth C Jones
- From the Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bethesda, MD 20892 (R.S., A.P., V.S., M.A.A., T.C., M. Mallek, E.C.J., A.A.M., L.R.F., D.A.B.); Siemens Healthcare, Forchheim, Germany (S.K., S.U.); and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (M. Mahesh)
| | - Ashkan A Malayeri
- From the Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bethesda, MD 20892 (R.S., A.P., V.S., M.A.A., T.C., M. Mallek, E.C.J., A.A.M., L.R.F., D.A.B.); Siemens Healthcare, Forchheim, Germany (S.K., S.U.); and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (M. Mahesh)
| | - Les R Folio
- From the Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bethesda, MD 20892 (R.S., A.P., V.S., M.A.A., T.C., M. Mallek, E.C.J., A.A.M., L.R.F., D.A.B.); Siemens Healthcare, Forchheim, Germany (S.K., S.U.); and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (M. Mahesh)
| | - David A Bluemke
- From the Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bethesda, MD 20892 (R.S., A.P., V.S., M.A.A., T.C., M. Mallek, E.C.J., A.A.M., L.R.F., D.A.B.); Siemens Healthcare, Forchheim, Germany (S.K., S.U.); and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (M. Mahesh)
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Ozen A, Comrie WA, Ardy RC, Domínguez Conde C, Dalgic B, Beser ÖF, Morawski AR, Karakoc-Aydiner E, Tutar E, Baris S, Ozcay F, Serwas NK, Zhang Y, Matthews HF, Pittaluga S, Folio LR, Unlusoy Aksu A, McElwee JJ, Krolo A, Kiykim A, Baris Z, Gulsan M, Ogulur I, Snapper SB, Houwen RHJ, Leavis HL, Ertem D, Kain R, Sari S, Erkan T, Su HC, Boztug K, Lenardo MJ. CD55 Deficiency, Early-Onset Protein-Losing Enteropathy, and Thrombosis. N Engl J Med 2017; 377:52-61. [PMID: 28657829 PMCID: PMC6690356 DOI: 10.1056/nejmoa1615887] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Studies of monogenic gastrointestinal diseases have revealed molecular pathways critical to gut homeostasis and enabled the development of targeted therapies. METHODS We studied 11 patients with abdominal pain and diarrhea caused by early-onset protein-losing enteropathy with primary intestinal lymphangiectasia, edema due to hypoproteinemia, malabsorption, and less frequently, bowel inflammation, recurrent infections, and angiopathic thromboembolic disease; the disorder followed an autosomal recessive pattern of inheritance. Whole-exome sequencing was performed to identify gene variants. We evaluated the function of CD55 in patients' cells, which we confirmed by means of exogenous induction of expression of CD55. RESULTS We identified homozygous loss-of-function mutations in the gene encoding CD55 (decay-accelerating factor), which lead to loss of protein expression. Patients' T lymphocytes showed increased complement activation causing surface deposition of complement and the generation of soluble C5a. Costimulatory function and cytokine modulation by CD55 were defective. Genetic reconstitution of CD55 or treatment with a complement-inhibitory therapeutic antibody reversed abnormal complement activation. CONCLUSIONS CD55 deficiency with hyperactivation of complement, angiopathic thrombosis, and protein-losing enteropathy (the CHAPLE syndrome) is caused by abnormal complement activation due to biallelic loss-of-function mutations in CD55. (Funded by the National Institute of Allergy and Infectious Diseases and others.).
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Affiliation(s)
- Ahmet Ozen
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - William A Comrie
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Rico C Ardy
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Cecilia Domínguez Conde
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Buket Dalgic
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Ömer F Beser
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Aaron R Morawski
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Elif Karakoc-Aydiner
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Engin Tutar
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Safa Baris
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Figen Ozcay
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Nina K Serwas
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Yu Zhang
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Helen F Matthews
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Stefania Pittaluga
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Les R Folio
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Aysel Unlusoy Aksu
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Joshua J McElwee
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Ana Krolo
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Ayca Kiykim
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Zeren Baris
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Meltem Gulsan
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Ismail Ogulur
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Scott B Snapper
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Roderick H J Houwen
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Helen L Leavis
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Deniz Ertem
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Renate Kain
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Sinan Sari
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Tülay Erkan
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Helen C Su
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Kaan Boztug
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
| | - Michael J Lenardo
- From the Section of Molecular Development of the Immune System, Laboratory of Immunology (A.O., W.A.C., A.R.M., H.F.M., M.J.L.), the Clinical Genomics Program (A.O., W.A.C., A.R.M., Y.Z., H.F.M., H.C.S., M.J.L.), and the Human Immunological Diseases Section, Laboratory of Host Defenses (Y.Z., H.C.S.), National Institute of Allergy and Infectious Diseases, the Laboratory of Pathology, National Cancer Institute (S.P.), and Radiology and Imaging Sciences, Clinical Center (L.R.F.), National Institutes of Health, Bethesda, MD; the Department of Pediatrics, Division of Allergy and Immunology (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition (E.T., D.E.), Marmara University, Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases (A.O., E.K.-A., S.B., A. Kiykim, I.O.), and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, İstanbul University Cerrahpaşa Faculty of Medicine (Ö.F.B., T.E.), Istanbul, and the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Gazi University (B.D., S.S.), the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Başkent University (F.O., Z.B., M.G.), and the Pediatric Gastroenterology Clinic, Dr. Sami Ulus Children's Hospital (A.U.A.), Ankara - all in Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences (R.C.A., C.D.C., N.K.S., A. Krolo, K.B.), Clinical Institute of Pathology (R.K.), the Department of Pediatrics and Adolescent Medicine (K.B.), and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics (K.B.), Medical University of Vienna, Vienna; Merck Research Laboratories (J.J.M.), and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School (S.B.S.), Boston; and the Department of Pediatric Gastroenterology, University Medical Center-Wilhelmina Children's Hospital (R.H.J.H.), and the Department of Rheumatology and Clinical Immunology, University Medical Center (H.L.L.), Utrecht, the Netherlands
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Bagheri MH, Ahlman MA, Lindenberg L, Turkbey B, Lin J, Cahid Civelek A, Malayeri AA, Agarwal PK, Choyke PL, Folio LR, Apolo AB. Advances in medical imaging for the diagnosis and management of common genitourinary cancers. Urol Oncol 2017; 35:473-491. [PMID: 28506596 PMCID: PMC5931389 DOI: 10.1016/j.urolonc.2017.04.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [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: 01/10/2017] [Revised: 04/05/2017] [Accepted: 04/15/2017] [Indexed: 01/01/2023]
Abstract
Medical imaging of the 3 most common genitourinary (GU) cancers-prostate adenocarcinoma, renal cell carcinoma, and urothelial carcinoma of the bladder-has evolved significantly during the last decades. The most commonly used imaging modalities for the diagnosis, staging, and follow-up of GU cancers are computed tomography, magnetic resonance imaging (MRI), and positron emission tomography (PET). Multiplanar multidetector computed tomography and multiparametric MRI with diffusion-weighted imaging are the main imaging modalities for renal cell carcinoma and urothelial carcinoma, and although multiparametric MRI is rapidly becoming the main imaging tool in the evaluation of prostate adenocarcinoma, biopsy is still required for diagnosis. Functional and molecular imaging using 18-fluorodeoxyglucose-PET and sodium fluoride-PET are essential for the diagnosis, and especially follow-up, of metastatic GU tumors. This review provides an overview of the latest advances in the imaging of these 3 major GU cancers.
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Affiliation(s)
- Mohammad H Bagheri
- Clinical Image Processing Service, Radiology and Imaging Sciences Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Mark A Ahlman
- Nuclear Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD; Radiology and Imaging Sciences Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Liza Lindenberg
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Baris Turkbey
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Jeffrey Lin
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Ali Cahid Civelek
- Radiology and Imaging Sciences Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Ashkan A Malayeri
- Radiology and Imaging Sciences Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Piyush K Agarwal
- Urologic Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Peter L Choyke
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Les R Folio
- Radiology and Imaging Sciences Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Andrea B Apolo
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD.
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38
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Buty M, Xu Z, Wu A, Gao M, Nelson C, Papadakis GZ, Teomete U, Celik H, Turkbey B, Choyke P, Mollura DJ, Bagci U, Folio LR. Quantitative Image Quality Comparison of Reduced- and Standard-Dose Dual-Energy Multiphase Chest, Abdomen, and Pelvis CT. ACTA ACUST UNITED AC 2017; 3:114-122. [PMID: 28856247 PMCID: PMC5573232 DOI: 10.18383/j.tom.2017.00002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 12/12/2022]
Abstract
We present a new image quality assessment method for determining whether reducing radiation dose impairs the image quality of computed tomography (CT) in qualitative and quantitative clinical analyses tasks. In this Institutional Review Board-exempt study, we conducted a review of 50 patients (male, 22; female, 28) who underwent reduced-dose CT scanning on the first follow-up after standard-dose multiphase CT scanning. Scans were for surveillance of von Hippel–Lindau disease (N = 26) and renal cell carcinoma (N = 10). We investigated density, morphometric, and structural differences between scans both at tissue (fat, bone) and organ levels (liver, heart, spleen, lung). To quantify structural variations caused by image quality differences, we propose using the following metrics: dice similarity coefficient, structural similarity index, Hausdorff distance, gradient magnitude similarity deviation, and weighted spectral distance. Pearson correlation coefficient and Welch 2-sample t test were used for quantitative comparisons of organ morphometry and to compare density distribution of tissue, respectively. For qualitative evaluation, 2-sided Kendall Tau test was used to assess agreement among readers. Both qualitative and quantitative evaluations were designed to examine significance of image differences for clinical tasks. Qualitative judgment served as an overall assessment, whereas detailed quantifications on structural consistency, intensity homogeneity, and texture similarity revealed more accurate and global difference estimations. Qualitative and quantitative results indicated no significant image quality degradation. Our study concludes that low(er)-dose CT scans can be routinely used because of no significant loss in quantitative image information compared with standard-dose CT scans.
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Affiliation(s)
- Mario Buty
- National Institutes of Health, Radiology and Imaging Sciences Bethesda, Maryland
| | - Ziyue Xu
- National Institutes of Health, Radiology and Imaging Sciences Bethesda, Maryland
| | - Aaron Wu
- National Institutes of Health, Radiology and Imaging Sciences Bethesda, Maryland
| | - Mingchen Gao
- National Institutes of Health, Radiology and Imaging Sciences Bethesda, Maryland
| | - Chelyse Nelson
- National Institutes of Health, Radiology and Imaging Sciences Bethesda, Maryland
| | - Georgios Z Papadakis
- National Institutes of Health, Radiology and Imaging Sciences Bethesda, Maryland
| | - Uygar Teomete
- Bluefield Regional Medical Center, Bluefield, West Virginia
| | - Haydar Celik
- National Institutes of Health, Radiology and Imaging Sciences Bethesda, Maryland
| | - Baris Turkbey
- National Institutes of Health, Radiology and Imaging Sciences Bethesda, Maryland
| | - Peter Choyke
- National Institutes of Health, Radiology and Imaging Sciences Bethesda, Maryland
| | - Daniel J Mollura
- National Institutes of Health, Radiology and Imaging Sciences Bethesda, Maryland
| | - Ulas Bagci
- Center for Research in Computer Vision, University of Central Florida, Orlando, Florida
| | - Les R Folio
- National Institutes of Health, Radiology and Imaging Sciences Bethesda, Maryland
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Mandell JC, Khurana B, Folio LR, Hyun H, Smith SE, Dunne RM, Andriole KP. Clinical Applications of a CT Window Blending Algorithm: RADIO (Relative Attenuation-Dependent Image Overlay). J Digit Imaging 2017; 30:358-368. [PMID: 28097498 DOI: 10.1007/s10278-017-9941-1] [Citation(s) in RCA: 9] [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: 11/29/2022] Open
Abstract
A methodology is described using Adobe Photoshop and Adobe Extendscript to process DICOM images with a Relative Attenuation-Dependent Image Overlay (RADIO) algorithm to visualize the full dynamic range of CT in one view, without requiring a change in window and level settings. The potential clinical uses for such an algorithm are described in a pictorial overview, including applications in emergency radiology, oncologic imaging, and nuclear medicine and molecular imaging.
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Affiliation(s)
- Jacob C Mandell
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
| | - Bharti Khurana
- Division of Emergency Radiology, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Les R Folio
- Radiology and Imaging Sciences, NIH Clinical Center, Bethesda, USA
| | - Hyewon Hyun
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stacy E Smith
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.,Center for Evidence Based Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ruth M Dunne
- Divisions of Thoracic Imaging and Abdominal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Katherine P Andriole
- Center for Evidence Based Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Symons R, Cork TE, Sahbaee P, Fuld MK, Kappler S, Folio LR, Bluemke DA, Pourmorteza A. Low-dose lung cancer screening with photon-counting CT: a feasibility study. Phys Med Biol 2016; 62:202-213. [PMID: 27991453 DOI: 10.1088/1361-6560/62/1/202] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
To evaluate the feasibility of using a whole-body photon-counting detector (PCD) CT scanner for low-dose lung cancer screening compared to a conventional energy integrating detector (EID) system. Radiation dose-matched EID and PCD scans of the COPDGene 2 phantom were acquired at different radiation dose levels (CTDIvol: 3.0, 1.5, and 0.75 mGy) and different tube voltages (120, 100, and 80 kVp). EID and PCD images were compared for quantitative Hounsfield unit (HU) accuracy, noise levels, and contrast-to-noise ratios (CNR) for detection of ground-glass nodules (GGN) and emphysema. The PCD HU accuracy was better than EID for water at all scan parameters. PCD HU stability for lung, GGN and emphysema regions were superior to EID and PCD attenuation values were more reproducible than EID for all scan parameters (all P < 0.01), while HUs for lung, GGN and emphysema ROIs changed significantly for EID with decreasing dose (all P < 0.001). PCD showed lower noise levels at the lowest dose setting at 120, 100 and 80 kVp (15.2 ± 0.3 HU versus 15.8 ± 0.2 HU, P = 0.03; 16.1 ± 0.3 HU versus 18.0 ± 0.4 HU, P = 0.003; and 16.1 ± 0.3 HU versus 17.9 ± 0.3 HU, P = 0.001, respectively), resulting in superior CNR for evaluation of GGNs and emphysema at 100 and 80 kVp. PCD provided better HU stability for lung, ground-glass, and emphysema-equivalent foams at lower radiation dose settings with better reproducibility than EID. Additionally, PCD showed up to 10% less noise, and 11% higher CNR at 0.75 mGy for both 100 and 80 kVp. PCD technology may help reduce radiation exposure in lung cancer screening while maintaining diagnostic quality.
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Affiliation(s)
- Rolf Symons
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
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Fenerty KE, Folio LR, Patronas NJ, Marté JL, Gulley JL, Heery CR. Predicting clinical outcomes in chordoma patients receiving immunotherapy: a comparison between volumetric segmentation and RECIST. BMC Cancer 2016; 16:672. [PMID: 27553491 PMCID: PMC4995658 DOI: 10.1186/s12885-016-2699-x] [Citation(s) in RCA: 10] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 08/09/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The Response Evaluation Criteria in Solid Tumors (RECIST) are the current standard for evaluating disease progression or therapy response in patients with solid tumors. RECIST 1.1 calls for axial, longest-diameter (or perpendicular short axis of lymph nodes) measurements of a maximum of five tumors, which limits clinicians' ability to adequately measure disease burden, especially in patients with irregularly shaped tumors. This is especially problematic in chordoma, a disease for which RECIST does not always adequately capture disease burden because chordoma tumors are typically irregularly shaped and slow-growing. Furthermore, primary chordoma tumors tend to be adjacent to vital structures in the skull or sacrum that, when compressed, lead to significant clinical consequences. METHODS Volumetric segmentation is a newer technology that allows tumor burden to be measured in three dimensions on either MR or CT. Here, we compared the ability of RECIST measurements and tumor volumes to predict clinical outcomes in a cohort of 21 chordoma patients receiving immunotherapy. RESULTS There was a significant difference in radiologic time to progression Kaplan-Meier curves between clinical outcome groups using volumetric segmentation (P = 0.012) but not RECIST (P = 0.38). In several cases, changes in volume were earlier and more sensitive reflections of clinical status. CONCLUSION RECIST is a useful evaluation method when obvious changes are occurring in patients with chordoma. However, in many cases, RECIST does not detect small changes, and volumetric assessment was capable of detecting changes and predicting clinical outcome earlier than RECIST. Although this study was small and retrospective, we believe our results warrant further research in this area.
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Affiliation(s)
- Kathleen E Fenerty
- Laboratory of Tumor Immunology and Biology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, 10 Center Drive, Room 13N208, Bethesda, MD, 20892, USA
| | - Les R Folio
- Cancer Imaging Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Nicholas J Patronas
- Cancer Imaging Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jennifer L Marté
- Genitourinary Malignancies Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - James L Gulley
- Genitourinary Malignancies Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Christopher R Heery
- Laboratory of Tumor Immunology and Biology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, 10 Center Drive, Room 13N208, Bethesda, MD, 20892, USA.
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Sandfort V, Ahlman MA, Jones EC, Selwaness M, Y Chen M, R Folio L, Bluemke DA. High pitch third generation dual-source CT: Coronary and cardiac visualization on routine chest CT. J Cardiovasc Comput Tomogr 2016; 10:282-8. [PMID: 27133589 PMCID: PMC4958576 DOI: 10.1016/j.jcct.2016.03.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 03/21/2016] [Accepted: 03/25/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chest CT scans are frequently performed in radiology departments but have not previously contained detailed depiction of cardiac structures. OBJECTIVES To evaluate myocardial and coronary visualization on high-pitch non-gated CT of the chest using 3rd generation dual-source computed tomography (CT). METHODS Cardiac anatomy of patients who had 3rd generation, non-gated high pitch contrast enhanced chest CT and who also had prior conventional (low pitch) chest CT as part of a chest abdomen pelvis exam was evaluated. Cardiac image features were scored by reviewers blinded to diagnosis and pitch. Paired analysis was performed. RESULTS 3862 coronary segments and 2220 cardiac structures were evaluated by two readers in 222 CT scans. Most patients (97.2%) had chest CT for oncologic evaluation. The median pitch was 2.34 (IQR 2.05, 2.65) in high pitch and 0.8 (IQR 0.8, 0.8) in low pitch scans (p < 0.001). High pitch CT showed higher image visualization scores for all cardiovascular structures compared with conventional pitch scans (p < 0.0001). Coronary arteries were visualized in 9 coronary segments per exam in high pitch scans versus 2 segments for conventional pitch (p < 0.0001). Radiation exposure was lower in the high pitch group compared with the conventional pitch group (median CTDIvol 10.83 vs. 12.36 mGy and DLP 790 vs. 827 mGycm respectively, p < 0.01 for both) with comparable image noise (p = 0.43). CONCLUSION Myocardial structure and coronary arteries are frequently visualized on non-gated 3rd generation chest CT. These results raise the question of whether the heart and coronary arteries should be routinely interpreted on routine chest CT that is otherwise obtained for non-cardiac indications.
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Affiliation(s)
- Veit Sandfort
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Mark A Ahlman
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Elizabeth C Jones
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Mariana Selwaness
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Marcus Y Chen
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Les R Folio
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - David A Bluemke
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA.
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Mansoor A, Bagci U, Foster B, Xu Z, Papadakis GZ, Folio LR, Udupa JK, Mollura DJ. Segmentation and Image Analysis of Abnormal Lungs at CT: Current Approaches, Challenges, and Future Trends. Radiographics 2016; 35:1056-76. [PMID: 26172351 DOI: 10.1148/rg.2015140232] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The computer-based process of identifying the boundaries of lung from surrounding thoracic tissue on computed tomographic (CT) images, which is called segmentation, is a vital first step in radiologic pulmonary image analysis. Many algorithms and software platforms provide image segmentation routines for quantification of lung abnormalities; however, nearly all of the current image segmentation approaches apply well only if the lungs exhibit minimal or no pathologic conditions. When moderate to high amounts of disease or abnormalities with a challenging shape or appearance exist in the lungs, computer-aided detection systems may be highly likely to fail to depict those abnormal regions because of inaccurate segmentation methods. In particular, abnormalities such as pleural effusions, consolidations, and masses often cause inaccurate lung segmentation, which greatly limits the use of image processing methods in clinical and research contexts. In this review, a critical summary of the current methods for lung segmentation on CT images is provided, with special emphasis on the accuracy and performance of the methods in cases with abnormalities and cases with exemplary pathologic findings. The currently available segmentation methods can be divided into five major classes: (a) thresholding-based, (b) region-based, (c) shape-based, (d) neighboring anatomy-guided, and (e) machine learning-based methods. The feasibility of each class and its shortcomings are explained and illustrated with the most common lung abnormalities observed on CT images. In an overview, practical applications and evolving technologies combining the presented approaches for the practicing radiologist are detailed.
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Affiliation(s)
- Awais Mansoor
- From the Center for Infectious Disease Imaging, Department of Radiology and Imaging Sciences, National Institutes of Health, Bethesda, Md
| | - Ulas Bagci
- From the Center for Infectious Disease Imaging, Department of Radiology and Imaging Sciences, National Institutes of Health, Bethesda, Md
| | - Brent Foster
- From the Center for Infectious Disease Imaging, Department of Radiology and Imaging Sciences, National Institutes of Health, Bethesda, Md
| | - Ziyue Xu
- From the Center for Infectious Disease Imaging, Department of Radiology and Imaging Sciences, National Institutes of Health, Bethesda, Md
| | - Georgios Z Papadakis
- From the Center for Infectious Disease Imaging, Department of Radiology and Imaging Sciences, National Institutes of Health, Bethesda, Md
| | - Les R Folio
- From the Center for Infectious Disease Imaging, Department of Radiology and Imaging Sciences, National Institutes of Health, Bethesda, Md
| | - Jayaram K Udupa
- From the Center for Infectious Disease Imaging, Department of Radiology and Imaging Sciences, National Institutes of Health, Bethesda, Md
| | - Daniel J Mollura
- From the Center for Infectious Disease Imaging, Department of Radiology and Imaging Sciences, National Institutes of Health, Bethesda, Md
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Pourmorteza A, Symons R, Sandfort V, Mallek M, Fuld MK, Henderson G, Jones EC, Malayeri AA, Folio LR, Bluemke DA. Abdominal Imaging with Contrast-enhanced Photon-counting CT: First Human Experience. Radiology 2016; 279:239-45. [PMID: 26840654 PMCID: PMC4820083 DOI: 10.1148/radiol.2016152601] [Citation(s) in RCA: 139] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE To evaluate the performance of a prototype photon-counting detector (PCD) computed tomography (CT) system for abdominal CT in humans and to compare the results with a conventional energy-integrating detector (EID). MATERIALS AND METHODS The study was HIPAA-compliant and institutional review board-approved with informed consent. Fifteen asymptomatic volunteers (seven men; mean age, 58.2 years ± 9.8 [standard deviation]) were prospectively enrolled between September 2 and November 13, 2015. Radiation dose-matched delayed contrast agent-enhanced spiral and axial abdominal EID and PCD scans were acquired. Spiral images were scored for image quality (Wilcoxon signed-rank test) in five regions of interest by three radiologists blinded to the detector system, and the axial scans were used to assess Hounsfield unit accuracy in seven regions of interest (paired t test). Intraclass correlation coefficient (ICC) was used to assess reproducibility. PCD images were also used to calculate iodine concentration maps. Spatial resolution, noise-power spectrum, and Hounsfield unit accuracy of the systems were estimated by using a CT phantom. RESULTS In both systems, scores were similar for image quality (median score, 4; P = .19), noise (median score, 3; P = .30), and artifact (median score, 1; P = .17), with good interrater agreement (image quality, noise, and artifact ICC: 0.84, 0.88, and 0.74, respectively). Hounsfield unit values, spatial resolution, and noise-power spectrum were also similar with the exception of mean Hounsfield unit value in the spinal canal, which was lower in the PCD than the EID images because of beam hardening (20 HU vs 36.5 HU; P < .001). Contrast-to-noise ratio of enhanced kidney tissue was improved with PCD iodine mapping compared with EID (5.2 ± 1.3 vs 4.0 ± 1.3; P < .001). CONCLUSION The performance of PCD showed no statistically significant difference compared with EID when the abdomen was evaluated in a conventional scan mode. PCD provides spectral information, which may be used for material decomposition.
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Affiliation(s)
- Amir Pourmorteza
- From Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bldg 10, Bethesda, MD 20892 (A.P., R.S., V.S., M.M., G.H., E.C.J., A.A.M., L.R.F., D.A.B.); and Siemens Medical Solutions, Malvern, Pa (M.K.F.)
| | - Rolf Symons
- From Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bldg 10, Bethesda, MD 20892 (A.P., R.S., V.S., M.M., G.H., E.C.J., A.A.M., L.R.F., D.A.B.); and Siemens Medical Solutions, Malvern, Pa (M.K.F.)
| | - Veit Sandfort
- From Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bldg 10, Bethesda, MD 20892 (A.P., R.S., V.S., M.M., G.H., E.C.J., A.A.M., L.R.F., D.A.B.); and Siemens Medical Solutions, Malvern, Pa (M.K.F.)
| | - Marissa Mallek
- From Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bldg 10, Bethesda, MD 20892 (A.P., R.S., V.S., M.M., G.H., E.C.J., A.A.M., L.R.F., D.A.B.); and Siemens Medical Solutions, Malvern, Pa (M.K.F.)
| | - Matthew K. Fuld
- From Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bldg 10, Bethesda, MD 20892 (A.P., R.S., V.S., M.M., G.H., E.C.J., A.A.M., L.R.F., D.A.B.); and Siemens Medical Solutions, Malvern, Pa (M.K.F.)
| | - Gregory Henderson
- From Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bldg 10, Bethesda, MD 20892 (A.P., R.S., V.S., M.M., G.H., E.C.J., A.A.M., L.R.F., D.A.B.); and Siemens Medical Solutions, Malvern, Pa (M.K.F.)
| | - Elizabeth C. Jones
- From Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bldg 10, Bethesda, MD 20892 (A.P., R.S., V.S., M.M., G.H., E.C.J., A.A.M., L.R.F., D.A.B.); and Siemens Medical Solutions, Malvern, Pa (M.K.F.)
| | - Ashkan A. Malayeri
- From Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bldg 10, Bethesda, MD 20892 (A.P., R.S., V.S., M.M., G.H., E.C.J., A.A.M., L.R.F., D.A.B.); and Siemens Medical Solutions, Malvern, Pa (M.K.F.)
| | - Les R. Folio
- From Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bldg 10, Bethesda, MD 20892 (A.P., R.S., V.S., M.M., G.H., E.C.J., A.A.M., L.R.F., D.A.B.); and Siemens Medical Solutions, Malvern, Pa (M.K.F.)
| | - David A. Bluemke
- From Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Bldg 10, Bethesda, MD 20892 (A.P., R.S., V.S., M.M., G.H., E.C.J., A.A.M., L.R.F., D.A.B.); and Siemens Medical Solutions, Malvern, Pa (M.K.F.)
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Heery CR, Ibrahim NK, Arlen PM, Mohebtash M, Murray JL, Koenig K, Madan RA, McMahon S, Marté JL, Steinberg SM, Donahue RN, Grenga I, Jochems C, Farsaci B, Folio LR, Schlom J, Gulley JL. Docetaxel Alone or in Combination With a Therapeutic Cancer Vaccine (PANVAC) in Patients With Metastatic Breast Cancer: A Randomized Clinical Trial. JAMA Oncol 2016; 1:1087-95. [PMID: 26291768 DOI: 10.1001/jamaoncol.2015.2736] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Previous phase 1 and 2 trials of PANVAC, a poxviral-based cancer vaccine, have suggested clinical efficacy in some patients with breast, ovarian, and colorectal cancer and have shown evidence of immunologic activity. Preclinical data have shown that docetaxel can modify tumor phenotype, making tumor cells more amenable to T cell-mediated killing. OBJECTIVE The goal of this study was to determine if the treatment combination of docetaxel and PANVAC improves clinical outcomes in patients with metastatic breast cancer compared with docetaxel treatment alone. DESIGN, SETTING, AND PARTICIPANTS Between May 2006 and February 2012, this open-label, phase 2 randomized clinical trial enrolled 48 patients with metastatic breast cancer of all subtypes, without limitation on other lines of previous therapy, to receive treatment with either docetaxel with PANVAC (arm A) or docetaxel alone (arm B). Final clinical data were collected on September 16, 2013. All patients were treated at either the National Cancer Institute or the Department of Breast Medical Oncology, MD Anderson Cancer Center. MAIN OUTCOMES AND MEASURES The primary end point was progression-free survival (PFS), using a phase 2.5 statistical design, with the intent of identifying a trend toward benefit (defined as 1-sided P≤.10) to guide a larger trial design. Secondary end points included safety and immunologic correlative studies. RESULTS Forty-eight participants were enrolled: 25 were randomized to the combination treatment arm A, and 23 to arm B. No patient remained in the study at the time of the final analysis. Patient and tumor characteristics were well matched. Analysis of adverse events in both treatment arms demonstrated very little difference between the 2 groups. In the combination treatment arm (arm A), statistically significant increases were noted in the frequency of grades 1 and 2 edema (P=.02, likely related to greater median number of docetaxel cycles) and injection-site reactions (P<.001). In the final data analysis, median PFS was 7.9 months in arm A vs 3.9 months in arm B (hazard ratio, 0.65 [95% CI, 0.34-1.14]; P=.09). CONCLUSIONS AND RELEVANCE The results suggest that the combination of PANVAC with docetaxel in metastatic breast cancer may provide a clinical benefit. This study was hypothesis generating and provides both rationale and statistical assumptions for a larger definitive randomized study. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00179309.
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Affiliation(s)
- Christopher R Heery
- Laboratory of Tumor Immunology and Biology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Nuhad K Ibrahim
- Division of Cancer Medicine, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Philip M Arlen
- Laboratory of Tumor Immunology and Biology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Mahsa Mohebtash
- Laboratory of Tumor Immunology and Biology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - James L Murray
- Division of Cancer Medicine, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Kimberly Koenig
- Division of Cancer Medicine, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Ravi A Madan
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Sheri McMahon
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jennifer L Marté
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Seth M Steinberg
- Biostatistics and Data Management Section, Office of the Clinical Director, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Renee N Donahue
- Laboratory of Tumor Immunology and Biology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Italia Grenga
- Laboratory of Tumor Immunology and Biology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Caroline Jochems
- Laboratory of Tumor Immunology and Biology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Benedetto Farsaci
- Laboratory of Tumor Immunology and Biology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Les R Folio
- Radiology and Imaging Services, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jeffrey Schlom
- Laboratory of Tumor Immunology and Biology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - James L Gulley
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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46
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Mollura DJ, Palmore TN, Folio LR, Bluemke DA. Radiology preparedness in ebola virus disease: guidelines and challenges for disinfection of medical imaging equipment for the protection of staff and patients. Radiology 2015; 275:538-44. [PMID: 25654616 DOI: 10.1148/radiol.15142670] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The overlap of early Ebola virus disease (EVD) symptoms (eg, fever, headache, abdominal pain, diarrhea, emesis, and fatigue) with symptoms of other more common travel-related diseases (eg, malaria, typhoid fever, pneumonia, and meningococcemia) may result in delayed diagnosis of EVD before isolation of infected patients. Radiology departments should consider policies for and approaches to decontamination of expensive and potentially easily damaged radiology equipment. In addition, the protection of radiology personnel must be considered during the work-up phase of undiagnosed EVD patients presenting to emergency departments. The purpose of this article is to consider the effect of EVD on radiology departments and imaging equipment, with particular consideration of guidelines currently available from the Centers for Disease Control and Prevention that may be applicable to radiology.
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Affiliation(s)
- Daniel J Mollura
- From the Center for Infectious Disease Imaging (D.J.M., D.A.B.), Department of Radiology and Imaging Sciences, Clinical Center (D.J.M., L.R.F., D.A.B.), and Clinical Center Hospital Epidemiology Service (T.N.P.), National Institutes of Health, 10 Center Dr, Building 10, Room 1C349, Mailstop 1182, Bethesda, MD 20892
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47
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Kuehn HS, Ouyang W, Lo B, Deenick EK, Niemela JE, Avery DT, Schickel JN, Tran DQ, Stoddard J, Zhang Y, Frucht DM, Dumitriu B, Scheinberg P, Folio LR, Frein CA, Price S, Koh C, Heller T, Seroogy CM, Huttenlocher A, Rao VK, Su HC, Kleiner D, Notarangelo LD, Rampertaap Y, Olivier KN, McElwee J, Hughes J, Pittaluga S, Oliveira JB, Meffre E, Fleisher TA, Holland SM, Lenardo MJ, Tangye SG, Uzel G. Immune dysregulation in human subjects with heterozygous germline mutations in CTLA4. Science 2014; 345:1623-1627. [PMID: 25213377 DOI: 10.1126/science.1255904] [Citation(s) in RCA: 622] [Impact Index Per Article: 62.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Cytotoxic T lymphocyte antigen-4 (CTLA-4) is an inhibitory receptor found on immune cells. The consequences of mutations in CTLA4 in humans are unknown. We identified germline heterozygous mutations in CTLA4 in subjects with severe immune dysregulation from four unrelated families. Whereas Ctla4 heterozygous mice have no obvious phenotype, human CTLA4 haploinsufficiency caused dysregulation of FoxP3(+) regulatory T (Treg) cells, hyperactivation of effector T cells, and lymphocytic infiltration of target organs. Patients also exhibited progressive loss of circulating B cells, associated with an increase of predominantly autoreactive CD21(lo) B cells and accumulation of B cells in nonlymphoid organs. Inherited human CTLA4 haploinsufficiency demonstrates a critical quantitative role for CTLA-4 in governing T and B lymphocyte homeostasis.
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Affiliation(s)
- Hye Sun Kuehn
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Weiming Ouyang
- Laboratory of Cell Biology, Division of Monoclonal Antibodies, Office of Biotechnology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Bethesda, MD 20892, USA
| | - Bernice Lo
- Molecular Development of the Immune System Section, Laboratory of Immunology, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA.,NIAID Clinical Genomics Program, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA
| | - Elissa K Deenick
- Immunology and Immunodeficiency Group, Immunology Division, Garvan Institute of Medical Research, Sydney, NSW 2010, Australia.,St. Vincent's Clinical School Faculty of Medicine, University of New South Wales, Sydney, NSW 2010, Australia
| | - Julie E Niemela
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Danielle T Avery
- Immunology and Immunodeficiency Group, Immunology Division, Garvan Institute of Medical Research, Sydney, NSW 2010, Australia
| | - Jean-Nicolas Schickel
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06511, USA
| | - Dat Q Tran
- Department of Pediatrics, University of Texas Medical School, Houston, TX 77030, USA
| | - Jennifer Stoddard
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Yu Zhang
- NIAID Clinical Genomics Program, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA.,Immunological Diseases Unit, Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA
| | - David M Frucht
- Laboratory of Cell Biology, Division of Monoclonal Antibodies, Office of Biotechnology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Bethesda, MD 20892, USA
| | - Bogdan Dumitriu
- Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD 20892, USA
| | - Phillip Scheinberg
- Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD 20892, USA
| | - Les R Folio
- Radiology and Imaging and Sciences, Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Cathleen A Frein
- Clinical Research Directorate, Clinical Monitoring Research Program, Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA
| | - Susan Price
- Molecular Development of the Immune System Section, Laboratory of Immunology, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA.,NIAID Clinical Genomics Program, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA
| | - Christopher Koh
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 20892, USA
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 20892, USA
| | | | - Anna Huttenlocher
- Department of Pediatrics, University of Wisconsin, Madison, WI 53706, USA.,Department of Medical Microbiology and Immunology, University of Wisconsin, Madison, WI 53706, USA
| | - V Koneti Rao
- Molecular Development of the Immune System Section, Laboratory of Immunology, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA.,NIAID Clinical Genomics Program, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA
| | - Helen C Su
- NIAID Clinical Genomics Program, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA.,Immunological Diseases Unit, Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA
| | - David Kleiner
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD 20892, USA
| | - Luigi D Notarangelo
- Division of Immunology and Manton Center for Orphan Disease Research, Children's Hospital, Harvard Medical School, Boston, MA 10217, USA
| | - Yajesh Rampertaap
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA
| | - Kenneth N Olivier
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA
| | - Joshua McElwee
- Merck Research Laboratories, Merck & Co., Boston, MA 02130, USA
| | - Jason Hughes
- Merck Research Laboratories, Merck & Co., Boston, MA 02130, USA
| | - Stefania Pittaluga
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD 20892, USA
| | - Joao B Oliveira
- Instituto de Medicina Integral Prof. Fernando Figueira-IMIP, 50070 Recife-PE, Brazil
| | - Eric Meffre
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06511, USA
| | - Thomas A Fleisher
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Steven M Holland
- NIAID Clinical Genomics Program, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA.,Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA
| | - Michael J Lenardo
- Molecular Development of the Immune System Section, Laboratory of Immunology, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA.,NIAID Clinical Genomics Program, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA
| | - Stuart G Tangye
- Immunology and Immunodeficiency Group, Immunology Division, Garvan Institute of Medical Research, Sydney, NSW 2010, Australia.,St. Vincent's Clinical School Faculty of Medicine, University of New South Wales, Sydney, NSW 2010, Australia
| | - Gulbu Uzel
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA
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48
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Lucas CL, Kuehn HS, Zhao F, Niemela JE, Deenick EK, Palendira U, Avery DT, Moens L, Cannons JL, Biancalana M, Stoddard J, Ouyang W, Frucht DM, Rao VK, Atkinson TP, Agharahimi A, Hussey AA, Folio LR, Olivier KN, Fleisher TA, Pittaluga S, Holland SM, Cohen JI, Oliveira JB, Tangye SG, Schwartzberg PL, Lenardo MJ, Uzel G. Dominant-activating germline mutations in the gene encoding the PI(3)K catalytic subunit p110δ result in T cell senescence and human immunodeficiency. Nat Immunol 2014; 15:88-97. [PMID: 24165795 PMCID: PMC4209962 DOI: 10.1038/ni.2771] [Citation(s) in RCA: 464] [Impact Index Per Article: 46.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 10/21/2013] [Indexed: 12/15/2022]
Abstract
The p110δ subunit of phosphatidylinositol-3-OH kinase (PI(3)K) is selectively expressed in leukocytes and is critical for lymphocyte biology. Here we report fourteen patients from seven families who were heterozygous for three different germline, gain-of-function mutations in PIK3CD (which encodes p110δ). These patients presented with sinopulmonary infections, lymphadenopathy, nodular lymphoid hyperplasia and viremia due to cytomegalovirus (CMV) and/or Epstein-Barr virus (EBV). Strikingly, they had a substantial deficiency in naive T cells but an over-representation of senescent effector T cells. In vitro, T cells from patients exhibited increased phosphorylation of the kinase Akt and hyperactivation of the metabolic checkpoint kinase mTOR, enhanced glucose uptake and terminal effector differentiation. Notably, treatment with rapamycin to inhibit mTOR activity in vivo partially restored the abundance of naive T cells, largely 'rescued' the in vitro T cell defects and improved the clinical course.
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Affiliation(s)
- Carrie L Lucas
- 1] Molecular Development of the Immune System Section, Laboratory of Immunology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA. [2]
| | - Hye Sun Kuehn
- 1] Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA. [2]
| | - Fang Zhao
- 1] Cell Signaling Section, Genetic Disease Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA. [2] Pritzker School of Medicine, The University of Chicago, Chicago, Illinois, USA. [3]
| | - Julie E Niemela
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Elissa K Deenick
- 1] Immunology and Immunodeficiency Group, Immunology Program, Garvan Institute of Medical Research, Sydney, Australia. [2] St. Vincent's Clinical School Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Umaimainthan Palendira
- 1] Immunology and Immunodeficiency Group, Immunology Program, Garvan Institute of Medical Research, Sydney, Australia. [2] St. Vincent's Clinical School Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Danielle T Avery
- Immunology and Immunodeficiency Group, Immunology Program, Garvan Institute of Medical Research, Sydney, Australia
| | - Leen Moens
- Immunology and Immunodeficiency Group, Immunology Program, Garvan Institute of Medical Research, Sydney, Australia
| | - Jennifer L Cannons
- Cell Signaling Section, Genetic Disease Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Matthew Biancalana
- Molecular Development of the Immune System Section, Laboratory of Immunology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer Stoddard
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Weiming Ouyang
- Laboratory of Cell Biology, Division of Monoclonal Antibodies, Office of Biotechnology Products, Center for Drug Evaluation and Research, United States Food and Drug Administration, Bethesda, Maryland, USA
| | - David M Frucht
- Laboratory of Cell Biology, Division of Monoclonal Antibodies, Office of Biotechnology Products, Center for Drug Evaluation and Research, United States Food and Drug Administration, Bethesda, Maryland, USA
| | - V Koneti Rao
- Molecular Development of the Immune System Section, Laboratory of Immunology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - T Prescott Atkinson
- Division of Allergy and Immunology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Anahita Agharahimi
- 1] Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA. [2] Laboratory of Clinical Infectious Diseases, Clinical Research Directorate-Clinical Monitoring Research Program, Science Applications International Corporation-Frederick, Frederick National Laboratory for Clinical Research, Frederick, Maryland, USA
| | - Ashleigh A Hussey
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Les R Folio
- Radiology and Imaging and Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Kenneth N Olivier
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Thomas A Fleisher
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Stefania Pittaluga
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Steven M Holland
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Jeffrey I Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Joao B Oliveira
- Instituto de Medicina Integral Prof. Fernando Figueira, Recife-Pernambuco, Brazil
| | - Stuart G Tangye
- 1] Immunology and Immunodeficiency Group, Immunology Program, Garvan Institute of Medical Research, Sydney, Australia. [2] St. Vincent's Clinical School Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Pamela L Schwartzberg
- Cell Signaling Section, Genetic Disease Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Michael J Lenardo
- Molecular Development of the Immune System Section, Laboratory of Immunology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Gulbu Uzel
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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49
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Huang J, Bluemke DA, Zhang X, Summers RM, Folio LR, Yao J. A cross-platform and distributive database system for cumulative tumor measurement. Annu Int Conf IEEE Eng Med Biol Soc 2013; 2012:1266-9. [PMID: 23366129 DOI: 10.1109/embc.2012.6346168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This paper discusses the development of a cross-platform, web accessible, vendor-independent database system capable of storing and comparing longitudinal tumor measurements for multiple tumors. This innovative system can create a comprehensive cumulative report that summarizes clinical findings and links to the original image studies, which will clinically enhance the workflow of oncologists. A case study on a pancreatic tumor data set with 524 tumor measurements and 134 patients is demonstrated.
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Affiliation(s)
- Jiaxin Huang
- National Institutes of Health Clinical Center, Bethesda, MD, USA.
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50
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Folio LR, Choi MM, Solomon JM, Schaub NP. Automated registration, segmentation, and measurement of metastatic melanoma tumors in serial CT scans. Acad Radiol 2013; 20:604-13. [PMID: 23477826 DOI: 10.1016/j.acra.2012.12.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 12/18/2012] [Accepted: 12/19/2012] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Our goal was to evaluate a new software capability that integrates registration, segmentation and tumor measurement across serial exams within a picture archiving communication system (PACS) to expedite tumor measurement. MATERIALS AND METHODS Patients treated under institutional review board-approved protocols for metastatic melanoma were retrospectively reviewed. Of the 19 included patients, five were male, the median age was 43.2, and all received treatment using an adoptive cell therapy. Seventy-one lung, liver, and subcutaneous tumors were manually measured using RECIST (Response Evaluation Criteria In Solid Tumors) criteria before therapy (baseline computed tomography [CT]) and within 3 months after therapy (follow-up CT). We performed semiautomated registration, segmentation, and RECIST measurements at both time points within PACS (Carestream Health, Rochester, NY). We compared manual and software-generated RECIST measurements using Bland-Altman plots. RESULTS The median manually measured RECIST diameter for all baseline tumors was 2.1 (1.0-6.2) cm. The refined registration function identified 70/71 (98.6%) tumors on the follow-up CT. On the baseline CT, all 21 liver, 27/32 (84%) lung, and 10/18 (55%) subcutaneous tumors completed segmentation. On the follow-up CT, 19/21 (90%) liver, 21/27 (78%) lung, and 8/10 (80%) subcutaneous tumors completed segmentation. The Bland-Altman plot demonstrated a 95% confidence interval of ±0.7 cm when comparing the software-generated and manual RECIST measurements. CONCLUSIONS The PACS software performed semiautomated baseline tumor measurements and fully automated follow-up tumor measurements in a majority of lung, liver, and subcutaneous tumors. In our patients, semiautomated metastatic tumor measurement did not obviate the need for physician oversight due to disease and treatment-related factors.
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Affiliation(s)
- Les R Folio
- Radiology and Imaging Sciences, National Institutes of Health, 10 Center Drive, Building 10, Room 1C340, Bethesda, MD 20892, USA.
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