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Bone Metastases in Patients with Metastatic Breast Cancer: Morphologic and Metabolic Monitoring of Response to Systemic Therapy with Integrated PET/CT¹

¹ From the Department of Nuclear Medicine (U.T., C.G., H.W.D.Y., H.A.M.) and Division of Breast Medical Oncology (S.D., M.C.), University of Texas M.D. Anderson Cancer Center, Unit 1263, 1515 Holcombe Blvd, Houston, TX 77030. Received March 27, 2007; revision requested May 25; revision received May 31; accepted June 14; final version accepted September 17. Supported in part by grants from Scientific Research Expenses for Health and Welfare Programs and the Grant-in-Aid for Cancer Research from the Ministry of Health, Labor, and Welfare. Address correspondence to U.T. (e-mail: utateish{at}ncc.go.jp).

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCE IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

 
Purpose: To retrospectively compare morphologic and metabolic changes in bone metastases in response to systemic therapy in patients with metastatic breast cancer (MBC) with integrated positron emission tomography (PET)/computed tomography (CT).

Materials and Methods: The institutional review board waived the requirement for informed consent and approved this HIPAA-compliant study. A retrospective analysis was performed with 102 women (mean age, 55 years) with MBC who received systemic treatment. All patients underwent integrated PET/CT before and after treatment. Two reviewers analyzed the images in consensus. Morphologic changes, including morphologic patterns, and lesion attenuation were evaluated. Standardized uptake value (SUV) and total lesion glycolysis (TLG) were analyzed to evaluate metabolic changes. Uni- and multivariate analyses were performed to identify factors that enabled response duration (RD) to be predicted.

Results: At baseline, the morphologic patterns of the target lesions were lytic (n = 33), sclerotic (n = 22), mixed (n = 42), and unclassified (n = 5). Progression of sclerotic change after treatment was identified in 49 patients (48%). After treatment, the mean attenuation of the lesion increased, whereas the mean SUV and TLG decreased. Increases in attenuation correlated significantly with decreases in SUV (r = –0.510, P < .001) and TLG (r = –0.491, P < . 001). Univariate analysis revealed that the increase in attenuation and the decrease in SUV were potential predictors of RD. Multivariate analysis revealed that an increase in the change in SUV was a significant predictor of RD (relative risk, 2.4; P = .003).

Conclusion: A decrease in SUV after treatment was an independent predictor of RD in patients with MBC who had bone metastases.

© RSNA, 2008

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCE IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

 
Bone is the most common site of distant metastasis, and metastases to bone are diagnosed in 30%–85% of patients with advanced breast cancer (1). Bone metastasis causes much of the morbidity and disability in patients with breast cancer because of its potentially prolonged clinical course. Proper assessment of treatment response is essential for making correct treatment decisions and improving outcome.

Fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) has been shown to be substantially more accurate than conventional imaging in the assessment of functional tumor response to chemotherapy or hormone therapy in patients with primary breast cancer (2–5) and those with metastatic breast cancer (MBC) (6–9). Furthermore, the degree of the increase in glycolysis has been found to enable physicians to predict the outcome of breast cancer (10). Although PET has been proved to be an effective tool in the care of patients with breast cancer, it provides limited information on the morphologic abnormalities in bone. Three types of bone metastases (ie, lytic, sclerotic, and mixed) often complicate assessment of treatment outcome (10–13).

Accurately co-registered functional and morphologic data sets are generated with integrated PET/computed tomographic (CT) imaging systems, and the initial results for diagnosis of skeletal metastasis with this combined functional and morphologic system have been promising (14). However, despite the increasing use of integrated PET/CT in the management of breast cancer, to our knowledge, the clinical utility of combined assessment of FDG avidity and morphologic changes in breast cancer metastases to bone has not been fully elucidated. Thus, the aim of our study was to retrospectively compare morphologic and metabolic changes in bone metastases in response to systemic therapy in patients with MBC with integrated PET/CT.

	MATERIALS AND METHODS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCE IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

 
Patients
Our institutional review board waived the requirement for informed consent and approved our Health Insurance Portability and Accountability Act–compliant study. A retrospective search of our institutional PET/CT database revealed 162 women who were referred for staging of MBC and assessment of the response of MBC to treatment between June 2003 and August 2006. Sixty (37%) of the 162 patients originally identified as being eligible for this study were later excluded because they had a history of radiation therapy (n = 20), treatment with a granulocyte colony–stimulating factor or erythropoietin (n = 17), concomitant malignancy (n = 17), or diabetes (n = 2); because of a severe metal artifact (n = 1); or because PET/CT revealed no discernable lesions in patients in whom bone metastases had been identified with bone scintigraphy only or magnetic resonance (MR) imaging only (n = 3). Thus, a total of 102 patients (mean age, 55 years; age range, 25–89 years) with bone metastases from breast cancer were ultimately included.

Chemotherapy and hormone therapy were the preferred first-line treatments for MBC in this study. Hormone therapy consisted of administration of an estrogen receptor antagonist (tamoxifen) or an aromatase inhibitor. Chemotherapy alone was used to treat widespread or life-threatening disease, and patients with negative estrogen receptor findings underwent only chemotherapy. Combined chemotherapy and hormone therapy was preformed in 76 patients, whereas 26 patients underwent only chemotherapy.

Imaging
PET/CT was performed prior to systemic therapy as a baseline study (mean, 11 days; range, 0–18 days) and after treatment (mean, 28 days; range, 21–38 days) in all patients. PET/CT images were acquired with an integrated PET/CT device (Discovery ST-8; GE Medical Systems, Milwaukee, Wis), and the whole-body mode was implemented as the standard software. Before PET/CT, the patients fasted for at least 6 hours. All patients were tested to confirm that their glucose level was within the normal range (80–120 mg/dL [4.4–6.6 mmol/L]) before FDG administration. Before PET, unenhanced CT was performed from the base of the skull to the upper thigh according to a standardized protocol performed with the following settings: transverse 3.75-mm section thickness, 140 kVp, 120 mA, and 13.5-mm table speed.

Emission scans were obtained 60 minutes after intravenous administration of FDG (mean dose, 555 MBq; range, 444–740 MBq). The acquisition time was 3 minutes per bed position in the two-dimensional mode. Images were reconstructed with attenuation-weighted ordered-subset expectation maximization with and without attenuation correction.

Image Interpretation and Morphologic Analyses
PET and CT images obtained in all standard planes were reviewed on an Advance workstation (GE Medical Systems). Two reviewers (U.T., C.G.; each with 2 years of experience) visually and quantitatively analyzed the images and recorded their findings after they reached a consensus. For visual analysis, abnormal FDG uptake was defined as substantially greater activity in tissue than in the aortic blood on attenuation-corrected images. Only the lesion that exhibited the most substantial uptake was selected as the target lesion for response to therapy. A region of interest (ROI) was outlined within areas of increased FDG uptake and measured on each section. When the lesion was extensively heterogeneous, the ROI was set to cover all lesion components.

When abnormal FDG uptake was present in bone, the exact anatomic location of the abnormal uptake was identified on CT images. Patients were classified as having lytic, sclerotic, mixed, or unclassified metastatic bone disease at the time of diagnosis of bone metastasis on the basis of the findings of the CT portion of the PET/CT examination. Unclassified disease included the lesions that had minimal sclerotic or lytic change when compared with the adjacent bone. The morphologic changes observed on CT scans were classified as lytic-progressive change, sclerotic-progressive change, or structural change. The change in CT attenuation (Att) (measured in Hounsfield units) in the ROI of the entire lesion before and after treatment was calculated with the following equation: Att = [(Att_pre – Att_post)/Att_pre] · 100, where Att_pre and Att_post denote pre- and posttreatment attenuation, respectively.

Standardized Uptake Value
The maximum standardized uptake value (SUV) was calculated with the following equation: SUV = A/(ID/BW), where A is the decay-corrected mean activity in tissue (measured in millicuries per milliliter), ID is the injected dose of FDG (measured in millicuries), and BW is the patient's body weight (measured in grams). Changes in SUV (SUV) after treatment were calculated with the following equation: SUV = [(SUV_pre – SUV_post)/SUV_pre] · 100, where SUV_pre and SUV_post denote pre- and posttreatment SUV, respectively.

Total Lesion Glycolysis
The change in total lesion glycolysis (TLG), also called the Larson-Ginsberg index, was calculated as the response score (15) based on the volume (V) obtained with PET and the average SUV with use of the following equation: TLG = {[(SUV_pre · V_pre) – (SUV_post · V_post)]/(SUV_pre · V_pre)} · 100, where the subscripts "pre" and "post" refer to the pre- and posttreatment values, respectively.

Responders and Nonresponders
Two radiologists (U.T., C.G.) retrospectively reviewed the medical records for follow-up findings detected at visual analysis of PET/CT images, bone scintigrams, and MR images. In patients who were designated as responders, the target lesion showed decreased uptake when compared with the same lesion depicted on baseline images. In nonresponders, a follow-up examination revealed FDG uptake in the target lesion was substantially increased or similar to that seen previously. When the target lesion showed increased FDG uptake compared to the baseline value, bone scintigraphy and MR imaging were also performed. Increased FDG uptake in the target lesion, which was also substantially enlarged at MR imaging or had positive bone scintigraphy findings, was considered indicative of relapsed or progressive disease.

Statistical Analysis
Comparison of mean values between groups was performed with the Student t test. Response duration (RD), which was the period from the time at which the patients met the criteria to be considered responders to the time at which the event occurred as the first evidence of relapse or progression, was chosen as the end point for assessment of the prognostic value. The time of the initial diagnosis of bone metastasis was the starting time for the assessment of RD. Univariate regression analyses were performed to assess the cumulative hazard of disease progression by comparing Kaplan-Meier survival curves and performing log-rank tests. Multivariate Cox proportional hazards regression analyses were applied to test the independence of established prognostic factors in the prediction of disease progression. P < .05 was considered to indicate a significant difference. Statistical analysis was performed with SPSS software (version 12; SPSS, Chicago, Ill).

	RESULTS

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Patients and Lesions
The median number of lesions per patient was four (range, 1–16 lesions per patient). At the time of initial diagnosis, target bone lesions were located in the spine (n = 74), ilium (n = 15), sternum (n = 7), pubis (n = 2), clavicle (n = 1), humerus (n = 1), and femur (n = 1), as well as in a rib (n = 1). Fifty-seven patients (56%) had a distant metastasis in tissue other than bone at baseline (Table 1). Diagnoses consisted of invasive ductal carcinoma in 90 patients (88%) and lobar carcinoma in 12 (12%). Pathologic studies revealed that 82 patients (80%) had estrogen receptor–positive disease, 57 (56%) had progesterone receptor–positive disease, and 19 (19%) showed signs of HER2 gene expression. After a median follow-up period of 15 months (range, 1–36 months), 77 patients (75%) were still alive, whereas 25 patients (25%) had died from their disease.

View larger version (80K): [in this window] [in a new window] [Download PPT slide]   Figure 1a: FDG PET, CT, and FDG PET/CT images obtained before and after systemic therapy. Baseline transaxial (a) FDG PET, (b) correlative CT, and (c) PET/CT images in a 49-year-old woman show bone metastasis in the thoracic spine at the level of the T11 vertebra (arrow). Mean values of attenuation, SUV, and TLG of the lesion are 268.4 HU, 7.9 g/mL, and 439.8, respectively. Abnormal FDG uptake in the liver corresponds to hepatic metastasis. Transaxial (d) FDG PET, (e) correlative CT, and (f) PET/CT images obtained 18 months after the start of hormone therapy and chemotherapy show progression of sclerotic change and metabolic reduction (arrow). Different abnormal FDG uptake in the liver corresponds to a new lesion of hepatic metastasis. Mean values of attenuation, SUV, and TLG of the lesion are 309.0 HU, 2.8 g/mL, and 338.1, respectively. Thus, the increase in attenuation was 15.1%, whereas the decreases in SUV and TLG were 64.6% and 23.1%, respectively.

View larger version (73K): [in this window] [in a new window] [Download PPT slide]   Figure 1b: FDG PET, CT, and FDG PET/CT images obtained before and after systemic therapy. Baseline transaxial (a) FDG PET, (b) correlative CT, and (c) PET/CT images in a 49-year-old woman show bone metastasis in the thoracic spine at the level of the T11 vertebra (arrow). Mean values of attenuation, SUV, and TLG of the lesion are 268.4 HU, 7.9 g/mL, and 439.8, respectively. Abnormal FDG uptake in the liver corresponds to hepatic metastasis. Transaxial (d) FDG PET, (e) correlative CT, and (f) PET/CT images obtained 18 months after the start of hormone therapy and chemotherapy show progression of sclerotic change and metabolic reduction (arrow). Different abnormal FDG uptake in the liver corresponds to a new lesion of hepatic metastasis. Mean values of attenuation, SUV, and TLG of the lesion are 309.0 HU, 2.8 g/mL, and 338.1, respectively. Thus, the increase in attenuation was 15.1%, whereas the decreases in SUV and TLG were 64.6% and 23.1%, respectively.

View larger version (85K): [in this window] [in a new window] [Download PPT slide]   Figure 1c: FDG PET, CT, and FDG PET/CT images obtained before and after systemic therapy. Baseline transaxial (a) FDG PET, (b) correlative CT, and (c) PET/CT images in a 49-year-old woman show bone metastasis in the thoracic spine at the level of the T11 vertebra (arrow). Mean values of attenuation, SUV, and TLG of the lesion are 268.4 HU, 7.9 g/mL, and 439.8, respectively. Abnormal FDG uptake in the liver corresponds to hepatic metastasis. Transaxial (d) FDG PET, (e) correlative CT, and (f) PET/CT images obtained 18 months after the start of hormone therapy and chemotherapy show progression of sclerotic change and metabolic reduction (arrow). Different abnormal FDG uptake in the liver corresponds to a new lesion of hepatic metastasis. Mean values of attenuation, SUV, and TLG of the lesion are 309.0 HU, 2.8 g/mL, and 338.1, respectively. Thus, the increase in attenuation was 15.1%, whereas the decreases in SUV and TLG were 64.6% and 23.1%, respectively.

View larger version (98K): [in this window] [in a new window] [Download PPT slide]   Figure 1d: FDG PET, CT, and FDG PET/CT images obtained before and after systemic therapy. Baseline transaxial (a) FDG PET, (b) correlative CT, and (c) PET/CT images in a 49-year-old woman show bone metastasis in the thoracic spine at the level of the T11 vertebra (arrow). Mean values of attenuation, SUV, and TLG of the lesion are 268.4 HU, 7.9 g/mL, and 439.8, respectively. Abnormal FDG uptake in the liver corresponds to hepatic metastasis. Transaxial (d) FDG PET, (e) correlative CT, and (f) PET/CT images obtained 18 months after the start of hormone therapy and chemotherapy show progression of sclerotic change and metabolic reduction (arrow). Different abnormal FDG uptake in the liver corresponds to a new lesion of hepatic metastasis. Mean values of attenuation, SUV, and TLG of the lesion are 309.0 HU, 2.8 g/mL, and 338.1, respectively. Thus, the increase in attenuation was 15.1%, whereas the decreases in SUV and TLG were 64.6% and 23.1%, respectively.

View larger version (75K): [in this window] [in a new window] [Download PPT slide]   Figure 1e: FDG PET, CT, and FDG PET/CT images obtained before and after systemic therapy. Baseline transaxial (a) FDG PET, (b) correlative CT, and (c) PET/CT images in a 49-year-old woman show bone metastasis in the thoracic spine at the level of the T11 vertebra (arrow). Mean values of attenuation, SUV, and TLG of the lesion are 268.4 HU, 7.9 g/mL, and 439.8, respectively. Abnormal FDG uptake in the liver corresponds to hepatic metastasis. Transaxial (d) FDG PET, (e) correlative CT, and (f) PET/CT images obtained 18 months after the start of hormone therapy and chemotherapy show progression of sclerotic change and metabolic reduction (arrow). Different abnormal FDG uptake in the liver corresponds to a new lesion of hepatic metastasis. Mean values of attenuation, SUV, and TLG of the lesion are 309.0 HU, 2.8 g/mL, and 338.1, respectively. Thus, the increase in attenuation was 15.1%, whereas the decreases in SUV and TLG were 64.6% and 23.1%, respectively.

View larger version (92K): [in this window] [in a new window] [Download PPT slide]   Figure 1f: FDG PET, CT, and FDG PET/CT images obtained before and after systemic therapy. Baseline transaxial (a) FDG PET, (b) correlative CT, and (c) PET/CT images in a 49-year-old woman show bone metastasis in the thoracic spine at the level of the T11 vertebra (arrow). Mean values of attenuation, SUV, and TLG of the lesion are 268.4 HU, 7.9 g/mL, and 439.8, respectively. Abnormal FDG uptake in the liver corresponds to hepatic metastasis. Transaxial (d) FDG PET, (e) correlative CT, and (f) PET/CT images obtained 18 months after the start of hormone therapy and chemotherapy show progression of sclerotic change and metabolic reduction (arrow). Different abnormal FDG uptake in the liver corresponds to a new lesion of hepatic metastasis. Mean values of attenuation, SUV, and TLG of the lesion are 309.0 HU, 2.8 g/mL, and 338.1, respectively. Thus, the increase in attenuation was 15.1%, whereas the decreases in SUV and TLG were 64.6% and 23.1%, respectively.

View larger version (10K): [in this window] [in a new window] [Download PPT slide]   Figure 2: Scatterplot shows the relationship between SUV and TLG. The change in SUV was positively correlated with the change in TLG (r = 0.614, P < .001).

View larger version (10K): [in this window] [in a new window] [Download PPT slide]   Figure 3: Scatterplot shows the relationship between attenuation and SUV. The increase in attenuation was negatively correlated with the decrease in SUV (r = –0.510, P < .001).

View larger version (11K): [in this window] [in a new window] [Download PPT slide]   Figure 4: Scatterplot shows the relationship between attenuation and TLG. The increase in attenuation was negatively correlated with the decrease in TLG (r = –0.491, P < .001).

View larger version (8K): [in this window] [in a new window] [Download PPT slide]   Figure 5a: (a) Graph shows cumulative probability of progression of bone metastases in patients with an attenuation increase of 8.6% or more (solid line) and those with an attenuation increase of less than 8.6% (dashed line). A significant difference in cumulative hazard of progression was found between the groups at log-rank testing (P < .05). (b) Graph shows cumulative probability of progression of bone metastases in patients with an SUV decrease of 8.5% or more (solid line) and those with an SUV decrease of less than 8.5% (dashed line). A significant difference in cumulative hazard of progression was found between the groups at log-rank testing (P < .01).

View larger version (8K): [in this window] [in a new window] [Download PPT slide]   Figure 5b: (a) Graph shows cumulative probability of progression of bone metastases in patients with an attenuation increase of 8.6% or more (solid line) and those with an attenuation increase of less than 8.6% (dashed line). A significant difference in cumulative hazard of progression was found between the groups at log-rank testing (P < .05). (b) Graph shows cumulative probability of progression of bone metastases in patients with an SUV decrease of 8.5% or more (solid line) and those with an SUV decrease of less than 8.5% (dashed line). A significant difference in cumulative hazard of progression was found between the groups at log-rank testing (P < .01).

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCE IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

PET contributes to the detection of lytic bone metastasis, which is associated with a poorer prognosis than is sclerotic metastasis (10). The FDG avidity of bone metastases in patients with MBC depends on the metastasis type. We found that an increase in the attenuation of bone metastases correlates with a decrease in SUV or TLG. This finding appears to corroborate the results of a previous study (15). Morphologic and metabolic assessment of bone metastasis with PET/CT can assist in monitoring the response to systemic therapy for bone metastases in patients with MBC.

Change in TLG (TLG) is the ratio of the metabolic rate of the tumor at baseline to the metabolic rate of the tumor after treatment. TLG corresponds to the change in the cell mass of the target lesion and reflects the global response of the entire tumor to treatment (15). In a study of 15 patients with rectal cancer, TLG was shown to be a strong predictor of disease-specific and recurrence-free survival (16). It is important to note that other investigators found that TLG reflected treatment response in patients with several types of locally advanced cancers and revealed information complementary to that obtained with SUV analysis. In contrast, our data showed that TLG did not enable us to predict RD in patients who had bone metastases. The discrepancy between these findings may be related to the minimal changes in the volume of target bone lesions.

Metabolic reduction after treatment has been suggested to be of value in the assessment of treatment efficacy in a variety of solid tumors (17–22). A change in tumor size after treatment is frequently used to evaluate therapeutic response in patients with breast cancer (23). However, patients with bone metastasis have often been excluded from clinical trials because bone metastases are considered immeasurable. On the other hand, PET/CT enables semiquantitative assessment of uptake, which makes it convenient to use when evaluating tumor viability during treatment. Our findings showed that patients who had bone metastasis and metabolic reduction with an SUV decrease of 8.5% or more after treatment had a 2.4-fold higher relative risk of a long RD during follow-up.

In regard to the generation of data to aid in the prediction of outcome, the inclusion of patients who developed distant metastases to tissue other than bone during the course of the disease was a limitation of our study because the presence of distant metastases in other tissues can have a considerable effect on patient outcome. In a study of patients with advanced breast cancer, researchers found a wide variation in survival rates and showed that 20% of the patients with bone metastases survived for more than 5 years (24). Therefore, we used RD as the primary end point to evaluate the value of PET/CT findings as a predictor of therapeutic efficacy.

Our study had other potential limitations. It may not have been sufficiently powered for the demonstration of significant differences among some of the covariates because we assessed only one target lesion per patient. However, the strength of our primary outcome, as well as the historic precedence of a significant predictor in the multivariate analysis, lends credence to our conclusions. Since data collection was performed retrospectively, selection bias may have affected our results. There may have been another aspect of bias in our study. The enrolled patients underwent one of two treatments for bone metastasis: (a) hormone therapy and chemotherapy and (b) chemotherapy alone. Further prospective studies are needed to assess the treatment effect of one standard regimen for bone metastasis with use of PET/CT. In our study, it was unclear whether PET/CT proved to be more cost-effective than conventional strategies. However, to our knowledge, the costs and health outcomes associated with PET/CT in addition to those of conventional studies for MBC in clinical practice have not been assessed in the clinical or economic context. Clinical trials are needed to determine the cost-effectiveness of PET/CT in the care of patients with MBC.

In conclusion, our study results provide evidence that the change in SUV of bone metastasis after treatment is highly predictive of RD in patients with MBC. The predictive power of this parameter for long RD needs to be validated in a prospective study, and we plan to conduct such a study at our institution.

	ADVANCE IN KNOWLEDGE

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCE IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

 

• A decrease in attenuation and an increase in standardized uptake value (SUV) of bone metastases after systemic therapy are associated with a markedly increased risk of disease progression in patients with metastatic breast cancer (MBC).
  

	IMPLICATION FOR PATIENT CARE

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCE IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

 

• A decrease in SUV of the lesion after systemic therapy was an independent predictor of response duration in patients with MBC who had bone metastasis.
  

	FOOTNOTES

 

Abbreviations: FDG = fluorine 18 fluorodeoxyglucose • MBC = metastatic breast cancer • RD = response duration • SUV = standardized uptake value • TLG = total lesion glycolysis

Author contributions: Guarantors of integrity of entire study, all authors; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; manuscript final version approval, all authors; literature research, U.T., M.C., H.A.M.; clinical studies, all authors; statistical analysis, U.T.; and manuscript editing, U.T., H.W.D.Y., M.C., H.A.M.

Authors stated no financial relationship to disclose.

	References

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCE IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

 

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