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Simunovic M, Grubac V, Zbuk K, Wong R, Coates A. Role of the status of the mesorectal fascia in the selection of patients with rectal cancer for preoperative radiation therapy: a retrospective cohort study. Can J Surg 2019; 61:332-338. [PMID: 30247008 DOI: 10.1503/cjs.009417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background Patients with rectal cancer in whom the mesorectal fascia is threatened by tumour are more likely than all patients with stage II/III disease to benefit from preoperative radiotherapy (RT). The objective of this study was to assess whether the
status of the mesorectal fascia versus a stage II/III designation can best inform the use of preoperative RT in patients undergoing major rectal cancer resection. Methods We reviewed the charts of consecutive patients with primary rectal cancer treated by a single surgeon at McMaster University, Hamilton, Ontario, between March 2006 and December 2012. The status of the mesorectal fascia was assessed by digital rectal examination, pelvic computed tomography and, when needed, pelvic magnetic resonance imaging (MRI). Patients whose mesorectal fascia was threatened or involved by tumour received preoperative RT. The study outcomes were rates of positive circumferential radial margin (CRM) and local tumour recurrence. Results A total of 153 patients were included, of whom 76 (49.7%) received preoperative RT because of concerns of a compromised mesorectal fascia. The median length of follow-up was 4.5 years. The number of CRM-positive cases in the RT and no-RT groups was 16 (22%) and 1 (1%), respectively (p < 0.01), and the number of cases of local tumour recurrence was 5 (7%) and 2 (3%), respectively (p = 0.2). Rates were similar when only patients with stage II/III tumours were included. Overall, 26 patients (17.0%) received MRI. Conclusion The status of the mesorectal fascia, not tumour stage, may best identify patients for preoperative RT.
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Affiliation(s)
- Marko Simunovic
- From the Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Grubac, Coates); the Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic); the Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Zbuk, Wong); and the Escarpment Cancer Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ont. (Simunovic)
| | - Vanja Grubac
- From the Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Grubac, Coates); the Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic); the Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Zbuk, Wong); and the Escarpment Cancer Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ont. (Simunovic)
| | - Kevin Zbuk
- From the Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Grubac, Coates); the Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic); the Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Zbuk, Wong); and the Escarpment Cancer Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ont. (Simunovic)
| | - Raimond Wong
- From the Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Grubac, Coates); the Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic); the Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Zbuk, Wong); and the Escarpment Cancer Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ont. (Simunovic)
| | - Angela Coates
- From the Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Grubac, Coates); the Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic); the Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Zbuk, Wong); and the Escarpment Cancer Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ont. (Simunovic)
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Shin DW, Shin JY, Oh SJ, Park JK, Yu H, Ahn MS, Bae KB, Hong KH, Ji YI. The Prognostic Value of Circumferential Resection Margin Involvement in Patients with Extraperitoneal Rectal Cancer. Am Surg 2016. [DOI: 10.1177/000313481608200421] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The prognostic influence of circumferential resection margin (CRM) status in extraperitoneal rectal cancer probably differs from that of intraperitoneal rectal cancer because of its different anatomical and biological behaviors. However, previous reports have not provided the data focused on extraperitoneal rectal cancer. Therefore, the aim of this study was to examine the prognostic significance of the CRM status in patients with extraperitoneal rectal cancer. From January 2005 to December 2008, 248 patients were treated for extraperitoneal rectal cancer and enrolled in a pro-spectively collected database. Extraperitoneal rectal cancer was defined based on tumors located below the anterior peritoneal reflection, as determined intraoperatively by a surgeon. Cox model was used for multivariate analysis to examine risk factors of recurrence and mortality in the 248 patients, and multivariate logistic regression analysis was performed to identify predictors of recurrence and mortality in 135 patients with T3 rectal cancer. CRM involvement for extraperitoneal rectal cancer was present in 29 (11.7%) of the 248 patients, and was the identified predictor of local recurrence, overall recurrence, and death by multivariate Cox analysis. In the 135 patients with T3 cancer, CRM involvement was found to be associated with higher probability of local recurrence and mortality. In extraperitoneal rectal cancer, CRM involvement is an independent risk factor of recurrence and survival. Based on the results of the present study, it seems that CRM involvement in extraperitoneal rectal cancer is considered an indicator for (neo)adjuvant therapy rather than conventional TN status.
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Affiliation(s)
- Dong Woo Shin
- Department of Surgery, Haeundae Paik Hospital, College of Medicine, Inje University, Haeundae-ro, Haeundae-gu, Pusan, Korea
| | - Jin Yong Shin
- Department of Surgery, Haeundae Paik Hospital, College of Medicine, Inje University, Haeundae-ro, Haeundae-gu, Pusan, Korea
| | - Sung Jin Oh
- Department of Surgery, Haeundae Paik Hospital, College of Medicine, Inje University, Haeundae-ro, Haeundae-gu, Pusan, Korea
| | - Jong Kwon Park
- Department of Surgery, Haeundae Paik Hospital, College of Medicine, Inje University, Haeundae-ro, Haeundae-gu, Pusan, Korea
| | - Hyeon Yu
- Department of Surgery, Haeundae Paik Hospital, College of Medicine, Inje University, Haeundae-ro, Haeundae-gu, Pusan, Korea
| | - Min Sung Ahn
- Department of Surgery, Pusan Paik Hospital, College of Medicine, Inje University, Pusan, Korea
| | - Ki Beom Bae
- Department of Surgery, Pusan Paik Hospital, College of Medicine, Inje University, Pusan, Korea
| | - Kwan Hee Hong
- Department of Surgery, Pusan Paik Hospital, College of Medicine, Inje University, Pusan, Korea
| | - Yong Il Ji
- Department of Gynecology and Obstetrics, Haeundae Paik Hospital, College of Medicine, Inje University, Haeundae-ro, Haeundae-gu, Pusan, Korea
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Glimelius B. Is the benefit of oxaliplatin in rectal cancer clinically relevant? Lancet Oncol 2015; 16:883-5. [PMID: 26189066 DOI: 10.1016/s1470-2045(15)00018-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 05/27/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.
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Does radiotherapy of the primary rectal cancer affect prognosis after pelvic exenteration for recurrent rectal cancer? Dis Colon Rectum 2015; 58:65-73. [PMID: 25489696 DOI: 10.1097/dcr.0000000000000213] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Radiotherapy reduces local recurrence rates but is also capable of short- and long-term toxicity. It may also render treatment of local recurrence more challenging if it develops despite previous radiotherapy. OBJECTIVE This study examined the impact of radiotherapy for the primary rectal cancer on outcomes after pelvic exenteration for local recurrence. DESIGN We conducted a retrospective review of exenteration databases. SETTING The study took place at a quaternary referral center that specializes in pelvic exenteration. PATIENTS Patients referred for pelvic exenteration from October 1994 to November 2012 were reviewed. Patients who did and did not receive radiotherapy as part of their primary rectal cancer treatment were compared. MAIN OUTCOME MEASURES The main outcomes of interest were resection margins, overall survival, disease-free survival, and surgical morbidities. RESULTS There were 108 patients, of which 87 were eligible for analysis. Patients who received radiotherapy for their primary rectal cancer (n = 41) required more radical exenterations (68% vs 44%; p = 0.020), had lower rates of clear resection margins (63% vs 87%; p = 0.010), had increased rates of surgical complications per patient (p = 0.014), and had a lower disease-free survival (p = 0.022). Overall survival and disease-free survival in patients with clear margins were also lower in the primary irradiated patients (p = 0.049 and p < 0.0001). This difference in survival persisted in multivariate analysis that corrected for T and N stages of the primary tumor. LIMITATIONS This study is limited by its retrospective nature and heterogeneous radiotherapy regimes among radiotherapy patients. CONCLUSIONS Patients who previously received radiotherapy for primary rectal cancer treatment have worse oncologic outcomes than those who had not received radiotherapy after pelvic exenteration for locally recurrent rectal cancer.
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Vignali A, Nardi PD. Multidisciplinary treatment of rectal cancer in 2014: where are we going? World J Gastroenterol 2014; 20:11249-11261. [PMID: 25170209 PMCID: PMC4145763 DOI: 10.3748/wjg.v20.i32.11249] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 05/08/2014] [Accepted: 05/25/2014] [Indexed: 02/06/2023] Open
Abstract
In the present review we discuss the recent developments and future directions in the multimodal treatment of locally advanced rectal cancer, with respect to staging and re-staging modalities, to the current role of neoadjuvant chemo-radiation and to the conservative and more limited surgical approaches based on tumour response after neoadjuvant combined therapy. When initial tumor staging is considered a high accuracy has been reported for T pre-treatment staging, while preoperative lymph node mapping is still suboptimal. With respect to tumour re-staging, all the current available modalities still present a limited accuracy, in particular in defining a complete response. The role of short vs long-course radiotherapy regimens as well as the optimal time of surgery are still unclear and under investigation by means of ongoing randomized trials. Observational management or local excision following tumour complete response are promising alternatives to total mesorectal excision, but need further evaluation, and their use outside of a clinical trial is not recommended. The preoperative selection of patients who will benefit from neoadjuvant radiotherapy or not, as well as the proper identification of a clinical complete tumour response after combined treatment modalities,will influence the future directions in the treatment of locally advanced rectal cancer.
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Williamson JS, Jones HG, Davies M, Evans MD, Hatcher O, Beynon J, Harris DA. Outcomes in locally advanced rectal cancer with highly selective preoperative chemoradiotherapy. Br J Surg 2014; 101:1290-8. [PMID: 24924947 DOI: 10.1002/bjs.9570] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/20/2014] [Accepted: 04/17/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND This study compared outcomes after surgery alone for stage II/ III rectal cancer in a tertiary cancer unit versus highly selective use of preoperative chemoradiotherapy (CRT). METHODS This was a single-centre retrospective cohort study of consecutive patients receiving potentially curative surgery for stage II and III primary rectal cancer. CRT was given only for magnetic resonance imaging-predicted circumferential resection margin (CRM) involvement and nodal disease (at least N2). Primary endpoints were CRM involvement and local recurrence rates. Secondary endpoints were systemic recurrence and overall survival. Data were analysed by log rank test, and univariable and multivariable analysis. RESULTS Between 2002 and 2012, 363 patients were treated for rectal cancer. After applying exclusion criteria, 266 patients with stage II/III mid or low rectal cancer were analysed. Of these, 103 received neoadjuvant CRT and 163 proceeded directly to surgery, seven of whom required postoperative radiotherapy; the latter patients were included in the neoadjuvant CRT group for analysis. There was a significant difference in local recurrence between the CRT and surgery-alone groups (6·5 versus 0 per cent at 5 years; P = 0·040), but not in CRM involvement (7·2 versus 5·1 per cent; P = 0·470), 5-year systemic recurrence (37·2 versus 43·0 per cent; P = 0·560) and overall survival (64·2 versus 64·6 per cent; P = 0·628) rates. Metastatic disease developed more frequently in low rectal cancers (odds ratio 0·14; P < 0·001), regardless of whether neoadjuvant treatment was delivered. CONCLUSION Locally advanced rectal cancer does not necessarily require neoadjuvant CRT.
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Affiliation(s)
- J S Williamson
- Department of Colorectal Surgery, Singleton Hospital, Swansea, UK
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Francescutti V, Coates A, Thabane L, Goldsmith CH, Levine MN, Simunovic M. Patterns of use and outcomes for radiation therapy in the Quality Initiative in Rectal Cancer (QIRC) trial. Can J Surg 2014; 56:E148-53. [PMID: 24284154 DOI: 10.1503/cjs.019012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The Quality Initiative in Rectal Cancer (QIRC) trial targeted surgeon intraoperative technique and not radiation therapy (RT) use. We performed a post hoc analysis of RT use among patients in the QIRC trial, not by arm of trial but rather for the entire group. We wished to identify associations between local recurrence risk and use of preoperative, postoperative or no RT. METHODS We compared demographic, tumour and process of care measures among patients receiving preoperative, postoperative or no RT. A multivariable Cox regression model assessed local recurrence risk. RESULTS The QIRC trial enrolled 1015 patients at 16 hospitals between 2002 and 2004. Radiation therapy use did not differ between trial arms, and median follow-up was 3.6 years. For the preoperative, postoperative and no RT groups, respectively, the percentage of patients was 12.8%, 19.3% and 67.9%; the percentage of stage II/III tumours was 57.0%, 88.7% and 48.1%; and the local recurrence rate was 5.3%, 10.2% and 5.5% (p = 0.05). After controlling for patient and tumour characteristics, including tumour stage, the hazard ratio (HR) for local recurrence was increased in the postoperative RT versus the no RT group (HR 1.64, 95% confidence interval 1.04-2.58, p = 0.027). CONCLUSION Use of preoperative RT was low; most patients with stage II/III disease did not receive RT and, as expected, the postoperative RT group had the highest risk of local recurrence. Our results suggest opportunities to improve rectal cancer RT use in Ontario.
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Burke JP, Coffey JC, Boyle E, Keane F, McNamara DA. Early Outcomes for Rectal Cancer Surgery in the Republic of Ireland Following a National Centralization Program. Ann Surg Oncol 2013; 20:3414-21. [DOI: 10.1245/s10434-013-3131-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Indexed: 01/09/2023]
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Reply to the letter of Junginger et al. Strahlenther Onkol 2013 DOI 10.1007/s00066-013-0353-y. Strahlenther Onkol 2013; 189:700-1. [DOI: 10.1007/s00066-013-0406-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Comment on the editorial of Sautter-Bihl et al. in Strahlentherapie und Onkologie 2013 189:105-110. Strahlenther Onkol 2013; 189:697-9. [PMID: 23700208 DOI: 10.1007/s00066-013-0353-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Accepted: 03/18/2013] [Indexed: 12/13/2022]
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Allaix ME, Fichera A. Modern rectal cancer multidisciplinary treatment: the role of radiation and surgery. Ann Surg Oncol 2013; 20:2921-8. [PMID: 23604783 DOI: 10.1245/s10434-013-2966-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Treatment of rectal cancer has evolved during the last few decades due to more in-depth knowledge of rectal cancer biology and major advances in the field of preoperative staging, medical management and surgical techniques. Consequently, treatment strategies are shifting moving towards a more personalized approach based on the response to treatment. Currently topics of controversy are centered around the indication for neoadjuvant radiation therapy in locally advanced rectal cancer and the role of surgery in patients with complete clinical response after neoadjuvant combined modality therapy. This manuscript aims to critically evaluate the evolution of treatment of rectal cancer during the last three decades and future directions. METHODS A review of the literature has been performed in PubMed/Medline electronic databases. RESULTS Treatment modalities are moving towards a tailored approach to rectal cancer patients based on the response to chemoradiation. A "wait-and-see" approach and local excision by Transanal Endoscopic Microsurgery (TEM) are strategies recently proposed in case of complete clinical response. CONCLUSIONS The standard of care still requires that locally advanced rectal cancer should be treated by neoadjuvant chemoradiation therapy followed by total mesorectal excision, including patients with a clinical complete response. Further evidence is needed to endorse a "wait-and-see" strategy and to define the role of TEM.
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Affiliation(s)
- Marco E Allaix
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
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Abstract
PURPOSE OF REVIEW The field of colorectal surgery continues to move forward as technical innovations emerge and as surgeons ask critical questions. The results of subsequent investigations often lead to changes in practice. This review examines recent publications that describe these practice changes. RECENT FINDINGS We identified and reviewed recent publications in the areas of rectal cancer controversies, genetic risk profiling, practice improvements, diverticulitis, enhanced recovery protocols, fecal incontinence, and single incision laparoscopic surgery. SUMMARY New technologies and practice innovations will continue to enhance patient outcomes. Multiinstitutional studies, randomized when able, are necessary to further define the safety and efficacy of new surgical techniques and to further define best practices in colorectal surgery.
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Koch M, Schölch S, Ulrich A, Weitz J, Büchler MW. Pelvic exenteration for advanced rectal cancer. COLORECTAL CANCER 2012. [DOI: 10.2217/crc.12.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY Advanced rectal cancer is defined by local tumor invasion into adjacent structures and organs in the pelvis. A curative multimodal therapy approach for patients with advanced rectal cancer includes neoadjuvant treatment with subsequent pelvic exenteration. Pelvic exenteration is associated with high perioperative morbidity as this surgical procedure includes an extensive resection of pelvic anatomical planes with en bloc removal of the tumor and surrounding organs and structures. Safe reconstruction of the large pelvic floor defect is very important. Quality of life and oncological outcome after pelvic exenteration for advanced rectal cancer are good. In this article, we highlight important clinical and surgical aspects of pelvic exenteration for advanced rectal cancer and review the recent literature.
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Affiliation(s)
- Moritz Koch
- Department of Surgery, University Hospital Heidelberg, INF 110, 69120 Heidelberg, Germany
| | - Sebastian Schölch
- Department of Surgery, University Hospital Heidelberg, INF 110, 69120 Heidelberg, Germany
| | - Alexis Ulrich
- Department of Surgery, University Hospital Heidelberg, INF 110, 69120 Heidelberg, Germany
| | - Jürgen Weitz
- Department of Surgery, University Hospital Heidelberg, INF 110, 69120 Heidelberg, Germany
| | - Markus W Büchler
- Department of Surgery, University Hospital Heidelberg, INF 110, 69120 Heidelberg, Germany
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Abstract
The ongoing diversification of treatment strategies for rectal cancer justifies the demand for highly specialized radiological imaging. Currently, numerous studies have underlined the ability of magnetic resonance imaging (MRI) to determine those parameters that are critical for therapeutic decision-making and prognosis in rectal cancer. Computed tomography (CT) does not meet the criteria of a first line diagnostic procedure with regard to local staging but will remain the workhorse in the search for distant metastases. The increasing acceptance of extended MRI-based concepts will, however, improve cost-effectiveness and simplify patient management. Response evaluation and detection of recurrent disease are the major indications for positron emission tomography (PET)/CT, which is currently not routinely recommended.
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