scholarly journals Evaluation of image quality at the detector’s edge of dedicated breast positron emission tomography

2020 ◽  
Author(s):  
Yoko Satoh ◽  
Utaroh Motosugi ◽  
Masamichi Imai ◽  
Yoshie Omiya ◽  
Hiroshi Onishi
Keyword(s):  
Positron Emission Tomography ◽  
Image Quality ◽  
Chest Wall ◽  
Clinical Studies ◽  
Phantom Study ◽  
Emission Tomography ◽  
Clinical Images ◽  
Positron Emission ◽  
Pet Ct ◽  
Significant Difference

Abstract Background: We assessed image quality of dedicated breast positron emission tomography (dbPET) at the detector's edge by phantom and clinical studies.Methods: A breast phantom with four spheres (16, 10, 7.5, and 5 mm diameter) was filled with 18F-fluorodeoxyglucose solution (sphere-to-background ratio, 8:1). The spheres occupied five different positions from the top edge to the centre of the detector and were scanned for 5 min in each position. Reconstructed images were visually evaluated, and % background variability (%N5mm), % contrast (%QH,5mm), and contrast-to-noise ratio (QH,5mm/N5mm) for the 5 mm sphere; and coefficient of variation of the background (CVbackground) were calculated. Subsequently, clinical cases were analysed. Tumour-to-background ratios (TBRs) between breast cancer near the chest wall (close to the detector’s edge; peripheral group) and at other locations (non-peripheral group) were compared. The TBR of each lesion was compared between dbPET and PET/computed tomography (CT).Results: Closer to the detector’s edge, the %N5mm and CVbackground increased and %QH,5mm and QH,5mm/N5mm decreased in the phantom study. The disadvantages of this placement were visually confirmed. Regarding clinical images, TBR of dbPET was significantly higher than that of PET/CT in both the peripheral (12.1±6.2 vs. 6.5±3.4, p=0.0001) and non-peripheral (13.1±7.1 vs. 7.7±7.4, p=0.0004) groups. There was no significant difference in TBR of dbPET between the peripheral and non-peripheral groups (12.1±6.2 vs. 13.1±7.1, p=0.6367).Conclusion: The phantom study revealed poorer image quality closer to the detector edge at a depth of 1/8 of the axial field of view (FOV) than at other more central parts. In clinical studies, however, lesion detectability of dbPET was the same regardless of the lesion position, and it was higher than that in PET/CT. dbPET has a great potential for detecting breast lesions near the chest wall if they are within the FOV, even in young women with small breasts.

scholarly journals Evaluation of image quality at the detector’s edge of dedicated breast positron emission tomography

2020 ◽  
Author(s):  
Yoko Satoh ◽  
Utaroh Motosugi ◽  
Masamichi Imai ◽  
Yoshie Omiya ◽  
Hiroshi Onishi
Keyword(s):  
Positron Emission Tomography ◽  
Image Quality ◽  
Chest Wall ◽  
Clinical Studies ◽  
Phantom Study ◽  
Emission Tomography ◽  
Breast Lesions ◽  
Clinical Images ◽  
Positron Emission ◽  
Pet Ct

Abstract Background: The dedicated breast positron emission tomography (dbPET) scanner (Elmamo, Shimadzu, Kyoto, Japan) has received approval from the Japanese Pharmaceutical Affairs Law and is commercially available in Japan. We assessed image quality of dbPET at the detector's edge, where the mammary glands near the chest wall are located in phantom and clinical studies.Methods: A breast phantom with four spheres (16, 10, 7.5, and 5 mm diameter) was filled with 18F-fluorodeoxyglucose solution (sphere-to-background ratio, 8:1). The spheres occupied five different positions from the top edge to the centre of the detector and were scanned for 5 min in each position. Reconstructed images were visually evaluated, and the contrast-to-noise ratio (CNR), contrast recovery coefficient (CRC) for the 5-mm sphere, and coefficient of variation of the background (CVB) were calculated. Subsequently, clinical images obtained with standard spine PET/CT and prone dbPET were retrospectively analysed. Tumour-to-background ratios (TBRs) between breast cancer near the chest wall (close to the detector’s edge; peripheral group) and at other locations (non-peripheral group) were compared. The TBR of each lesion was compared between dbPET and PET/computed tomography (CT).Results: Closer to the detector’s edge, the CNR and CRC decreased while the CVB increased in the phantom study. The disadvantages of this placement were visually confirmed. Regarding clinical images, TBR of dbPET was significantly higher than that of PET/CT in both the peripheral (12.38±6.41 vs 6.73±3.5, p=0.0006) and non-peripheral (12.44±5.94 vs 7.71±7.1, p=0.0183) groups. There was no significant difference in TBR of dbPET between the peripheral and non-peripheral groups (12.4±6.4 vs 12.4±5.9, p=0.8261).Conclusion: The phantom study revealed poorer image quality closer to the detector edge at a depth of <2 cm from the detector's edge than at other more central parts. In clinical studies, however, the visibility of breast lesions with dbPET was the same regardless of the lesion position, and it was higher than that in PET/CT. dbPET has a great potential for detecting breast lesions near the chest wall if they are at least 2 cm from the edge of the FOV, even in young women with small breasts.

scholarly journals Evaluation of image quality at the detector’s edge of dedicated breast positron emission tomography: Can small breast cancer near the chest wall be detected ?

2020 ◽  
Author(s):  
Yoko Satoh ◽  
Utaroh Motosugi ◽  
Masamichi Imai ◽  
Yoshie Omiya ◽  
Hiroshi Onishi
Keyword(s):  
Breast Cancer ◽  
Positron Emission Tomography ◽  
Image Quality ◽  
Chest Wall ◽  
Phantom Study ◽  
Emission Tomography ◽  
Clinical Images ◽  
Positron Emission ◽  
Pet Ct ◽  
Significant Difference

Abstract Purpose : We assessed image quality of dedicated breast positron emission tomography (dbPET) at the detector's edge by phantom and clinical studies.Methods: A breast phantom with four spheres (16, 10, 7.5, and 5 mm in diameter) was filled with 18 F-fluorodeoxyglucose solution of sphere-to-background ratio was 8:1. It was positioned such that the spheres were five different positions from the top edge to the centre of the detector and scanned for 5 min in each position. Reconstructed images were visually evaluated, and % background variability ( %N 5mm ), % contrast ( %Q H ,5mm ), contrast-to-noise ratio ( Q H ,5mm / N 5mm ), and coefficient of variation of the background ( CV background ) were calculated. Next, tumour-to-background ratios (TBRs) between breast cancer near the chest wall (close to the detector’s edge; peripheral group) and at other locations (non-peripheral group) were compared. The TBR of each lesion was also compared between dbPET and PET/computed tomography (CT).Results: As closer to the detector’s edge, the %N 5mm and CV background increased and %Q H ,5mm and Q H ,5mm / N 5mm decreased in the phantom study. The disadvantages of this placement were visually confirmed. With regard to clinical images, TBR of dbPET was significantly higher than that of PET/CT in both the peripheral (12.1±6.2 vs. 6.5±3.4, p =0.0001) and non-peripheral (13.1±7.1 vs. 7.7±7.4, p =0.0004) groups. There was no significant difference in TBR of dbPET between the peripheral and non-peripheral groups (12.1±6.2 vs. 13.1±7.1, p= 0.6367).Conclusion : In the phantom study, the image quality decreased closer to the detector’s edge than at a depth of 1/8. In clinical studies, however, the lesion detectability of dbPET was the same even if the lesion was close to the detector’s edge or not, and it was higher than that in PET/CT. dbPET has a great potential for detecting breast lesions near the chest wall even in young women with small breasts.

scholarly journals Evaluation of image quality at the detector’s edge of dedicated breast positron emission tomography

2021 ◽  
Vol 8 (1) ◽  
Author(s):  
Yoko Satoh ◽  
Utaroh Motosugi ◽  
Masamichi Imai ◽  
Yoshie Omiya ◽  
Hiroshi Onishi
Keyword(s):  
Image Quality ◽  
Chest Wall ◽  
Clinical Studies ◽  
Breast Imaging ◽  
Phantom Study ◽  
Breast Lesions ◽  
Clinical Images ◽  
Dedicated Breast Pet ◽  
Pet Ct ◽  
Significant Difference

Abstract Background Using phantoms and clinical studies in prone hanging breast imaging, we assessed the image quality of a commercially available dedicated breast PET (dbPET) at the detector’s edge, where mammary glands near the chest wall are located. These are compared to supine PET/CT breast images of the same clinical subjects. Methods A breast phantom with four spheres (16-, 10-, 7.5-, and 5-mm diameter) was filled with 18F-fluorodeoxyglucose solution (sphere-to-background activity concentration ratio, 8:1). The spheres occupied five different positions from the top edge to the centre of the detector and were scanned for 5 min in each position. Reconstructed images were visually evaluated, and the contrast-to-noise ratio (CNR), contrast recovery coefficient (CRC) for all spheres, and coefficient of variation of the background (CVB) were calculated. Subsequently, clinical images obtained with standard supine PET/CT and prone dbPET were retrospectively analysed. Tumour-to-background ratios (TBRs) between breast cancer near the chest wall (close to the detector’s edge; peripheral group) and at other locations (non-peripheral group) were compared. The TBR of each lesion was compared between dbPET and PET/CT. Results Closer to the detector’s edge, the CNR and CRC of all spheres decreased while the CVB increased in the phantom study. The disadvantages of this placement were visually confirmed. Regarding clinical images, TBR of dbPET was significantly higher than that of PET/CT in both the peripheral (12.38 ± 6.41 vs 6.73 ± 3.5, p = 0.0006) and non-peripheral (12.44 ± 5.94 vs 7.71 ± 7.1, p = 0.0183) groups. There was no significant difference in TBR of dbPET between the peripheral and non-peripheral groups. Conclusion The phantom study revealed poorer image quality at < 2-cm distance from the detector’s edge than at other more central parts. In clinical studies, however, the visibility of breast lesions with dbPET was the same regardless of the lesion position, and it was higher than that in PET/CT. dbPET has a great potential for detecting breast lesions near the chest wall if they are at least 2 cm from the edge of the FOV, even in young women with small breasts.

scholarly journals Evaluation of image quality at the detector’s edge of dedicated breast positron emission tomography

2020 ◽  
Author(s):  
Yoko Satoh ◽  
Utaroh Motosugi ◽  
Masamichi Imai ◽  
Yoshie Omiya ◽  
Hiroshi Onishi
Keyword(s):  
Image Quality ◽  
Chest Wall ◽  
Clinical Studies ◽  
Breast Imaging ◽  
Phantom Study ◽  
Breast Lesions ◽  
Clinical Images ◽  
Dedicated Breast Pet ◽  
Pet Ct ◽  
Significant Difference

Abstract Background: Using phantoms and clinical studies in prone hanging breast imaging, we assessed the image quality of a commercially available dedicated breast PET (dbPET) at the detector's edge, where mammary glands near the chest wall are located. These are compared to supine PET/CT breast images of the same clinical subjects.Methods: A breast phantom with four spheres (16, 10, 7.5, and 5 mm diameter) was filled with 18F-fluorodeoxyglucose solution (sphere-to-background activity concentration ratio, 8:1). The spheres occupied five different positions from the top edge to the centre of the detector and were scanned for 5 min in each position. Reconstructed images were visually evaluated, and the contrast-to-noise ratio (CNR), contrast recovery coefficient (CRC) for the 5-mm sphere, and coefficient of variation of the background (CVB) were calculated. Subsequently, clinical images obtained with standard supine PET/CT and prone dbPET were retrospectively analysed. Tumour-to-background ratios (TBRs) between breast cancer near the chest wall (close to the detector’s edge; peripheral group) and at other locations (non-peripheral group) were compared. The TBR of each lesion was compared between dbPET and PET/CT.Results: Closer to the detector’s edge, the CNR and CRC decreased while the CVB increased in the phantom study for all sphere sizes. The disadvantages of this placement were visually confirmed. Regarding clinical images, TBR of dbPET was significantly higher than that of PET/CT in both the peripheral (12.38±6.41 vs 6.73±3.5, p=0.0006) and non-peripheral (12.44±5.94 vs 7.71±7.1, p=0.0183) groups. There was no significant difference in TBR of dbPET between the peripheral and non-peripheral groups.Conclusion: The phantom study revealed poorer image quality at <2 cm distance from the detector's edge than at other more central parts. In clinical studies, however, the visibility of breast lesions with dbPET was the same regardless of the lesion position, and it was higher than that in PET/CT. dbPET has a great potential for detecting breast lesions near the chest wall if they are at least 2 cm from the edge of the FOV, even in young women with small breasts.

scholarly journals Comparison between The Diagnostic Performance of Positron Emission Tomography and Diffusion-Weighted MRI in Detecting Recurrence of Head and Neck Squamous Cell Carcinoma during Post Treatment Follow-up

QJM ◽  
2020 ◽  
Vol 113 (Supplement_1) ◽  
Author(s):  
M A Talaat ◽  
E K Hakim ◽  
M S Taha ◽  
T M Rabie ◽  
A M Askoura ◽  
...  
Keyword(s):  
Positron Emission Tomography ◽  
Squamous Cell Carcinoma ◽  
Meta Analysis ◽  
Emission Tomography ◽  
Diffusion Weighted Mri ◽  
Positron Emission ◽  
Pet Ct ◽  
Significant Difference ◽  
Pet Ct Scan

Abstract Background Head and neck squamous cell carcinoma (HNSCC) is the sixth most common malignancy worldwide. (16) Despite aggressive combined-modality treatment regimens, there remains a high percentage (15-50%) of locoregional recurrences.(7) This problem make the clinician to rely on the functional imaging modalities such as Diffusion weighted MRI and Positron Emission Tomography to detect recurrence. Objective To perform a meta-analytical study on the comparison between the diagnostic role of DW/MRI and PET/CT scan in detecting recurrence of HNSCC during post-treatment follow-up. Methods This meta-analysis was conducted from 1/1/ 1998 to 31/3/2018 . Literature search on PubMed and Google scholar was done to identify randomised controlled trials and comparative studies either prospective or retrospective. MedCalc ver. 18.2 (MedCalc, Ostend, Belgium) was used for data analysis. Results Of the eight articles included, The meta-analysis was based on a total of 199 patients. All of them used DW/MRI and 186 of them used PET/CT. Comparative study between the two groups regarding sensitivity, specificity and accuracy revealed; highly significant difference in sensitivity in favor of PET/CT (p &lt; 0.009), significant increase in specificity in favor of DW/MRI (p = 0.048) and no significant difference in accuracy between the two group. Conclusion PET/CT scan was found to be more sensitive than DW/MRI while DW/MRI was found to be more specific than PET/CT. Yet both have the same degree of accuracy.

Brain Positron Emission Tomography-Computed Tomography Gender Differences in Tinnitus Patients

2016 ◽  
Vol 27 (09) ◽  
pp. 714-719 ◽  
Author(s):  
Nathan Shlamkovich ◽  
Haim Gavriel ◽  
Ephraim Eviatar ◽  
Mordechay Lorberboym ◽  
Eliad Aviram
Keyword(s):  
Computed Tomography ◽  
Positron Emission Tomography ◽  
Fdg Pet ◽  
Emission Tomography ◽  
Positron Emission ◽  
Pet Ct ◽  
Significant Difference ◽  
Therapeutic Protocols ◽  
And Gender ◽  
Fdg Pet Ct

Background: Increased metabolism in the left auditory cortex has been reported in tinnitus patients. However, gender difference has not been addressed. Purpose: To assess the differences in Positron emission tomography–computed tomography (PET-CT) results between the genders in tinnitus patients. Research Design: Retrospective cohort. Study Sample: Included were patients referred to our clinic between January 2011 and August 2013 who complained of tinnitus and underwent fluorodeoxyglucose (FDG)-PET to assess brain metabolism. Data Analysis: Univariate and multivariate nominal logistic regressions were used to evaluate the association between upper temporal gyrus (UTG; right and left) and gender. Results: Included were 140 patients (87 males) with an average age of 52.5 yr (median = 53.1). Bilateral tinnitus was found in 85 patients (60.7%), left sided in 30 (21.4%), and right sided in 21(15%). Increased uptake in the UTG was found in 60% of the patients on either side. Males had a statistically significant increased uptake in the UTG in those with unilateral tinnitus and in the entire population. Conclusions: We present the largest study reported so far on tinnitus patients who have undergone FDG-PET-CT. We found a statistically significant difference between the genders in FDG uptake by the UTG. Further investigations should be undertaken to reveal the etiologies for these differences and to assess different therapeutic protocols according to gender.

scholarly journals Total-body 18F-FDG PET Scan in Oncological Patients: How Fast could it be?

2021 ◽  
Author(s):  
Pengcheng Hu ◽  
Yiqiu Zhang ◽  
Haojun Yu ◽  
Shuguang Chen ◽  
Hui Tan ◽  
...  
Keyword(s):  
Image Quality ◽  
Phantom Study ◽  
Pet Scan ◽  
Clinical Settings ◽  
Recovery Coefficient ◽  
Clinical Images ◽  
Oncological Patients ◽  
Pet Ct ◽  
Significant Difference ◽  
Total Body

Abstract Purpose: The aim of the study was to explore a fast PET scan protocol of the total-body uEXPLORER scanner by assessing the image quality consistent to that of a conventional digital PET/CT scanner both from the phantom and clinical perspectives.Methods: The phantom study using a NEMA/IEC NU-2 body phantom was performed both on a total-body PET/CT (uEXPLORER) and a digital routine PET/CT (uMI 780), with hot sphere to background activity concentration ratio of 4:1. The contrast recovery coefficient (CRC), background variability (BV), recovery coefficient RCmax and RCmean were assessed and compared between that in uEXPLORER with the different scanning duration and reconstruction protocols and that in uMI 780 with clinical settings. The coefficient of variation (COV) of the uMI 780 with clinical settings were calculated and used as a threshold to determine the optimized scanning duration and reconstruction protocols were, which can provide a consistent image quality for the two scanners. And subsequently, the proposed protocol was validated by 30 oncological patients. Images acquired in uMI 780 with a 2-3 minute for each bed position were referred as G780. All PET raw data were reconstructed using data-cutting technique to simulate a 30s, 45s or 60s acquisition duration on uEXPLORER. The iterations were 2 and 3 for uEXPLORER, referred as G30s_3i, G45s_2i, G45s_3i, G60s_2i, and G60s_3i. A 5-point Likert scale was used in the qualitative analysis to assess the image quality. The image quality was also compared with the liver COV, the lesion target-to-background ratio (TBR), and the lesion signal-to-noise ratio (SNR).Results: In the phantom study, CRC, BV, RCmax and RCmean in uEXPLORER with different scanning duration and reconstruction iterations were compared with that in uMI 780 with clinical settings and a minor fluctuation was found among different scanning durations. COV of the uMI 780 with clinical settings was 11.6% and determined protocol with a 30-45s scanning duration and 2 or 3 iterations to provide a similar image quality.In the quantitative analysis on the clinical images, there was no significant difference between G780 and G45s_3i. All the other groups in uEXPLORER with a 45s- and above acquisition showed a significantly improved image quality than that in uMI 780 with clinical settings. Comparing the liver COV, there was no significantly difference between G780 and G30s_3i. And no significant difference in lesion TBR was identified between G780 and G45s_2i, while uEXPLORER had a better performance in lesion SNR compared to that in uMI 780 with clinical settings. Conclusions: This study demonstrated a fast PET protocol with a 30-45s acquisition in uEXPLORER with consistent image quality to that in uMI 780 with clinical settings.

scholarly journals 2019 Roger A. Mann Award Winner: Imaging of Bone Perfusion and Metabolism in Subjects Undergoing Total Ankle Arthroplasty Using 18F-Positron Emission Tomography

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0002
Author(s):  
Jonathan H. Garfinkel ◽  
Jonathan P. Dyke ◽  
Lauren Volpert ◽  
Austin Sanders ◽  
Meghan Newcomer ◽  
...  
Keyword(s):  
Positron Emission Tomography ◽  
Blood Flow ◽  
The Body ◽  
Emission Tomography ◽  
Bone Blood Flow ◽  
Positron Emission ◽  
Ankle Replacement ◽  
Pet Ct ◽  
Significant Difference ◽  
18F Fluoride

Category: Ankle Arthritis Introduction/Purpose: Total ankle replacement (TAR) continues to exhibit a relatively high incidence of complications and need for revision surgery, particularly when compared to knee and hip arthroplasty. One common mode of failure in TAR is talar component subsidence. This may be caused by disruption in the talar blood supply related to the surgical technique. Positron emission tomography (PET) imaging with [18F]-Fluoride has demonstrated utility in evaluating bone perfusion, and PET-CT in particular is useful in the setting of total joint replacement. In this study we aim to quantify changes in talar perfusion before and after TAR with the INBONE II system (Wright Medical Technology, Inc., Memphis, TN) using [18F]-Fluoride PET-CT. It is our hypothesis that perfusion to the talus would decrease after TAR. Methods: Eight subjects (5M/3F) aged 70.4 ± 7.5 years [Range 61-83] were enrolled for 18F-PET/CT imaging prior to and 3 months following TAR. 5–10 mCi of 18F-Fluoride was administered and dynamic acquisition in list mode for 45 minutes was performed on the operative and non-operative ankles simultaneously on a Siemens mCT Biograph scanner. Static acquisition of the whole body was also performed one hour after injection. Regions of interest (ROI’s) were placed on the postoperative CT images in the body of the talus beneath the INBONE II talar component. These regions were manually delineated on the preoperative CT scans, and were drawn to replicate the ROIs placed on the postoperative studies. ROI’s were overlaid on the fused static 18F-PET images and standard uptake values (SUVs) calculated for these regions as well as the whole foot. Changes in SUVs were analyzed using a paired t-tests with a significance level of 0.05. Results: We found no significant difference in bone perfusion in the talus after TAR in our cohort of patients. 18F uptake in the ROI underneath the talar component compared to that measured at baseline prior to surgery was 3.36 +/- 1.44 SUV postoperatively vs. 2.65 ± 1.24 SUV preoperatively, (p=0.33). Similar results were seen in the whole foot: 2.99 +/- 1.22 SUV postoperatively vs. 2.47 ± 0.75 SUV preoperatively (p=0.16). Figure 1 displays preoperative and postoperative uptake in the bone in the area corresponding to the base of the talar component. Although we did not find a significant difference in our initial study, the observed increase in perfusion to the talus after TAR may reach significance with a larger cohort of patients. Conclusion: 18F-PET demonstrates the ability to quantify changes in bone perfusion and metabolism following TAR. Our results suggest that the vascular blood supply to the talus is not disrupted after TAR. Additional pharmacokinetic analysis of the dynamic activity curves will also allow for estimates of bone blood flow and osteoblastic turnover via compartmental modeling. These results may be used to confirm the presence of adequate bone blood flow and vascularity in the body of the talus following total ankle replacement.

scholarly journals Asymptomatic Mesenchymal Hamartoma of the Chest Wall in Child With Fluorodeoxyglucose Uptake on PET/CT—Report of a Case

2015 ◽  
Vol 100 (5) ◽  
pp. 915-919 ◽  
Author(s):  
Kentaro Okamoto ◽  
Yukiko Tani ◽  
Takeshi Yamaguchi ◽  
Kei Ogino ◽  
Takashi Tsuchioka ◽  
...  
Keyword(s):  
Positron Emission Tomography ◽  
Chest Wall ◽  
Emission Tomography ◽  
Mesenchymal Hamartoma ◽  
X Ray ◽  
First Case ◽  
Positron Emission ◽  
Pet Ct ◽  
Chest X Ray ◽  
Fdg Accumulation

We had experience with a case of mesenchymal hamartoma of the chest wall (MHCW) with fluorodeoxyglucose (FDG) uptake on positron emission tomography/computed tomography (PET/CT). We reported the first case of asymptomatic MHCW in a child with preoperative PET/CT. Mesenchymal hamartoma of the chest wall is a rare benign tumor that usually presents as a visible chest wall mass or respiratory problems secondary to compression of the lung in early infancy. It is often reported that malignant transformation is extraordinarily rare. Positron emission tomography/CT is useful for diagnosis of malignancy. There is no report of MHCW in a child with preoperative PET/CT before. We examined an asymptomatic 1-year-old girl with an incidental finding on a chest x-ray. Scans of CT and PET/CT were performed before surgical resection. After surgery, the resected tumor was examined histologically. Chest x-ray and CT scan of the chest confirmed a 25- × 20-mm round shaped intrapleural mass containing calcification and destructing the rib, arising from the third rib. Scan of PET/CT demonstrated the mass with light FDG accumulation. Histologically, the mass was homogenous, with thick funicular of hyaline cartilage interdigitating with scattered fiber. There were no malignant cells. No malignant MHCW was demonstrated in the mass, with light FDG accumulation by PET/CT. PET/CT might be a useful tool to distinguish malignant MHCW in children.

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