Value of [18F]FDG PET/CT radiomic parameters in the context of response to chemotherapy in advanced cervical cancer.

The first-order statistical (FOS) and second-order texture analysis on basis of Gray-Level Co-occurence Matrix (GLCM) were obtained to assess metabolic, volumetric, statistical and radiomic parameters of cervical cancer in response to chemotherapy, recurrence and age of patients. The homogeneous group of 83 patients with histologically confirmed IIIC1-IVB stage cervical cancer were analyzed, retrospectively. Before and after chemotherapy, the advancement of the disease and the effectiveness of the therapy, respectively, were established using [18F] FDG PET/CT imaging. The statistically significant differences between pre- and post-therapy parameters were observed for SUVmax, SUVmean, TLG, MTV, asphericity (ASP, p = 0.000, Z > 0), entropy (E, p = 0.0000), correlation (COR, p = 0.0007), energy (En, p = 0.000) and homogeneity (H, p = 0.0018). Among the FOS parameters, moderate correlation was observed between pre-treatment coefficient of variation (COV) and patients' recurrence (R = 0.34, p = 0.001). Among the GLCM textural parameters, moderate positive correlation was observed for post-treatment contrast (C) with the age of patients (R = 0.3, p = 0.0038) and strong and moderate correlation was observed in the case of En and H with chemotherapy response (R = 0.54 and R = 0.46, respectively). All correlations were statistically significant. This study indicates the remarkable importance of pre- and post-treatment [18F] FDG PET statistical and textural GLCM parameters according to prediction of recurrence and chemotherapy response of cervical cancer patients.

Asphericity derived from [18F]FDG PET as a new prognostic parameter in cervical cancer patients.

The objective of this study was to assess the prognostic value of asphericity (ASP) and standardized uptake ratio (SUR) in cervical cancer patients. Retrospective analysis was performed on a group of 508 (aged 55 ± 12 years) previously untreated cervical cancer patients. All patients underwent a pretreatment [18F]FDG PET/CT study to assess the severity of the disease. The metabolic tumor volume (MTV) of the cervical cancer was delineated with an adaptive threshold method. For the resulting ROIs the maximum standardized uptake value (SUVmax) was measured. In addition, ASP and SUR were determined as previously described. Univariate Cox regression and Kaplan-Meier analysis with respect to event free survival (EFS), overall survival (OS), freedom from distant metastasis (FFDM) and locoregional control (LRC) was performed. Additionally, a multivariate Cox regression including clinically relevant parameters was performed. In the survival analysis, MTV and ASP were shown to be prognostic factors for all investigated endpoints. Tumor metabolism quantified with the SUVmax was not prognostic for any of the endpoints (p > 0.2). The SUR did not reach statistical significance either (p = 0.1, 0.25, 0.066, 0.053, respectively). In the multivariate analysis, the ASP remained a significant factor for EFS and LRC, while MTV was a significant factor for FFDM, indicating their independent prognostic value for the respective endpoints. The alternative parameter ASP has the potential to improve the prognostic value of [18F]FDG PET/CT for event-free survival and locoregional control in radically treated cervical cancer patients.

The potential of low-dose-rate brachytherapy with iodine-125 in the treatment of local recurrences of prostate cancer after primary high-dose-rate monotherapy.

Purpose: The incidence of local prostate cancer recurrences after monotherapy with high-dose-rate brachytherapy (HDR-BT) is low. However, a cumulated number of local recurrences during follow-up is naturally observed in highly specialized oncological centers. This retrospective study aimed to present the treatment of local recurrences after HDR-BT with low-dose-rate brachytherapy (LDR-BT). Material and methods: Nine patients with low- and intermediate-risk prostate cancer with a median age of 71 years (range, 59-82 years) were diagnosed with local recurrences after previous monotherapy HDR-BT, 3 × 10.5 Gy (from 2010 to 2013). Median time to biochemical recurrence was 59 months (range, 21-80 months). All patients received 145 Gy with salvage LDR-BT (iodine-125). Gastrointestinal and urological toxicities were evaluated based on patients' records following CTCAE v. 4.0 and IPSS scales. Results: The median follow-up after salvage treatment was 30 months (range, 17-63 months). Local recurrences (LR) were detected in two cases, and the actuarial 2-year local control was 88%. Biochemical failure was observed in four cases. Distant metastases (DM) were observed in 2 patients. In one patient, both LR and DM were diagnosed simultaneously. Four patients had no relapse of the disease, and a 2-year disease-free survival (DSF) was 58.3%. Before salvage treatment, median IPSS scores were 6.5 points (range, 1-23 points). At the first follow-up visit, after one month, the mean IPSS score was 20 points, and at the last follow-up visit, it was 8 points (range, 1-26 points). One patient had urinary retention after treatment. There was no significant change in IPSS scores before and after the treatment (p = 0.68). Two patients had grade 1 toxicity in the gastrointestinal tract. Conclusions: Salvage LDR-BT for patients with prostate cancer previously treated with HDR-BT monotherapy is characterized by acceptable toxicity, and may result in local disease control.

Diagnosis and treatment of lung cancer using nuclear medicine techniques - current state of the art.

Lung cancer is the leading cause of cancer-related death worldwide. Planar radiography and computed tomography are the most common imaging modalities used in diagnosis, staging, and therapy response assessment. However, the role of nuclear methods in assessing the severity of the disease and the effectiveness of treatment has increased in recent years. Introducing these diagnostic modalities into standard practice in lung cancer may contribute to the personalization of treatment. In this review, we summarize the current knowledge of nuclear medicine techniques in the diagnosis and treatment of lung cancer.

Tumour-Related Parameters as a Prognostic Factor in Patients with Advanced Cervical Cancer: 20-Year Follow-Up of Diagnostic and Treatment Changes during Chemioradiotherapy.

Concurrent radiochemotherapy (RCHT) has been the standard treatment for locally advanced cervical cancer since 1999. During this 20-year period, both diagnostic and radiotherapy techniques have developed, such as positron emission tomography (PET) or brachytherapy (BT) planning. The aim of the study was to assess the relationships between prognostic factors and the results of treatment in patients with advanced cervical cancer independent of these changes. The analysis included 266 patients with stage IIB or IIIB FIGO 2009 cervical cancer divided into two groups: one including 147 patients diagnosed with physical examination and ultrasonography (USG) and treated with RCHT with 2D BT from 2001 to 2005; another including 119 patients with metastatic pelvic lymph node diagnosed with PET and treated from 2010 to 2016 with RCHT and 3D BT. The mean five-year overall survival (OS) rate was 59.2% in the first vs. 65.5% in the second group (p = 0.048). However, in both groups, stage IIB patients had a significantly higher 5-year OS rate, despite the presence of nodal metastases in group 2. In the first group it was 75.1% in IIB vs. 54.8% in IIIB (p = 0.040) 5-year OS and 77.5% vs. 55.8% (p = 0.034) in the second group. Important was also a significant association between the dose of BT and survival in group 2: 45.7% vs. 69.2% for dose <28 Gy and 28 Gy (p = 0.018). Evolution in the diagnosis and treatment of patients with cervical cancer had led to improvement in the survival of patients and precise treatment with an appropriate stage assessment. However local advance of the tumour is still the most important prognostic factor.

The quality-adjusted life-years in the oncological patients' health-related quality of life.

The oncological treatment can significantly affect patients' health-related quality of life (HRQoL), which should be monitored to ensure our patients' well-being. The often-used HRQoL measurer is the quality-adjusted life-year (QALY) indicator of the disease burden, describing both quality and quantity of life lived. The main aim of the study was to discuss the methodology and usefulness of evaluating QALYs using the HRQoL questionnaires: EuroQoL (EQ)-5 dimensions-3 levels (EQ-5D-3L) and EQ visual analogue scale (EQ-VAS) in 32 cervical cancer patients. We obtained the questionnaire and calculated QALYs based on the Gross Domestic Product (GDP) method. In our study, the total scoring of the EQ-Index, EQ-VAS evaluation was 2620 and 2409 points, respectively, which corresponds with the QALYs value of 26.2 and 24.9, respectively. We expressed the QALYs outcome into the economic equivalent of nearly 900,000 US dollars (USD) as the total health profit for both the patients and the healthcare system. Obtaining the QALY factor can help establish the medical management's influence on the patients' HRQoL and improve the healthcare services to ensure the best health outcomes.

Prognostic Value of Pretherapeutic Primary Tumor MTV from [18F]FDG PET in Radically Treated Cervical Cancer Patients.

The aim of this study was to assess the usefulness of pretherapeutic primary tumor metabolic tumor volume (MTV) in the prognosis of radically treated cervical cancer patients. Retrospective, single-centre analysis was performed on a group of 508 cervical cancer patients. All patients underwent a pretreatment [18F]FDG PET/CT study for the assessment of the disease stage. Several PET-derived parameters-namely, maximum standardized uptake value (SUVmax), mean standardized uptake value (SUVmean), total lesion glycolysis (TLG) and MTV, as well as the clinical parameters, were analysed in terms of the overall survival (OS), event-free survival (EFS), locoregional control (LRC) and freedom from distant metastases (FFDM). Hyperthermia and brachytherapy were prognostic for EFS, OS, and LRC.FIGO stage > II showed a significant effect on EFS, OS, and FFDM. Moreover, hysterectomy was prognostic for OS and histology was prognostic for FFDM. From the PET-derived parameters only MTV of the primary tumor had a significant influence on OS (cutoff point: >12.7 mL, HR: 2.8, 1.75-4.48 95% CI, p < 0.001), LRC (cutoff point: >13.7 mL, HR 2.82, 1.42-5.61 95% CI, p = 0.003), EFS (cutoff point: >10.4 mL, HR: 2.57, 1.67-3.97 95% CI, p < 0.001) and FFDM (cutoff point: >10.4 mL, HR: 5.04, 1.82-13.99 95% CI, p = 0.002). Pretreatment MTV from the primary tumor is the only independent prognostic parameter in OS, LRC, EFS, and FFDM in radically treated cervical cancer patients and should be used in clinical practice in assessing prognosis in these patients.

Pretreatment [18F]FDG PET/CT Prognostic Factors in Patients with Squamous Cell Cervical Carcinoma FIGO IIIC1.

PURPOSE: This study aims to determine whether semiquantitative parameters obtained from both the primary tumor and metastatic pelvic lymph nodes (PLN) diagnosed in fluoro-18-deoxy-glucose positron emission tomography (FDG-PET-CT) are associated with disease-free survival (DFS), local control (LC), distant metastasis-free survival (DMFS) and overall survival (OS) in patients with locally advanced squamous cervical cancer (LACC) and metastatic pelvic lymph nodes. MATERIALS: Retrospective analysis was performed on 93 female patients with FIGO IIIC1. The median age was 53 years (27-75). The PET parameters both in the primary tumor and metastatic pelvic lymph nodes, including SUVmax, SUVmean, TLG, MTV, heterogeneity, along with clinical variables, before radical cisplatin-based radiochemotherapy (RCT) were analyzed. The p-values < 0.05 were considered statistically significant. RESULTS: Median follow-up was 38 months (4.5-92.6). Three years and five years OS were 75% and 70% respectively. Patients with SUVmax above 12.6, SUVmean above 7.6 and with TLG in tumors >245.7 lived longer (p < 0.05). The higher SUVmax or SUVmean reduced increased DMFS (HR 0.3 95%CI 0.56-0.96 and 0.59 95%CI 0.37-0.93). The clinical factors and other FDG PET CT parameters were not found to be statistically relevant in terms of OS, DFS, DM and LC. CONCLUSIONS: This study is the first report showing that in LACC patient population with PLN involvement treated with definitive RCT, high SUVmean, SUVmax and TLG of the primary tumor in FDG-PET-CT were linked with longer OS. Lower SUVmean and SUVmax were linked with shorter DMFS. None of the clinical factors and the nodal FDG-PET-CT parameters influenced the outcome.

Differences between [18F]FLT and [18F]FDG Uptake in PET/CT Imaging in CC Depend on Vaginal Bacteriology.

This study aims to investigate if vaginal bacteriology obtained prior to treatment influences the 3'-deoxy-3 18F-fluorothymidine (FLT) [18F]FLT and 2-deoxy-2-[18F]fluoro-d-glucose (2-[18F]FDG) [18F]FDG parameters in positron emission tomography (PET/CT) in cervical cancer (CC) patients. METHODS: Retrospective analysis was performed on 39 women with locally advanced histologically confirmed cervical cancer who underwent dual tracer PET/CT examinations. The [18F]FLT and [18F]FDG PET parameters in the primary tumor, including SUVmax, SUVmean, MTV, heterogeneity, before radiotherapy (RT) were analyzed, depending on the bacteriology. The p-values < 0.05 were considered statistically significant. RESULTS: In the vaginal and/or cervical smears, there were 27 (79.4%) positive results. In seven (20.6%) cases, no opportunistic pathogen growth was observed (No Bacteria Group). In positive bacteriology, eleven (32%) Gram-negative bacilli (Bacteria group 2) and fifteen (44%) Gram-positive bacteria (Bacteria group 1) were detected. Five patients with unknown results were excluded from the analysis. Data analysis shows a statistically significant difference between the SUVmax, and SUVmin values for three independent groups for the [18F]FLT. CONCLUSIONS: The lowest values of SUVmax and SUVmin for [18F]FLT are registered in Gram-negative bacteria, higher are in Gram-positive, and the absence of bacteria causes the highest [18F]FLT values.

Comparison of semiquantitative metabolic parameters of the primary tumor obtained in PET/CT with 18F-FDG and 18F-FLT in patients with cervical cancer.

AIM: The aim of the study was to compare semiquantitative metabolic parameters of primary tumor assessed in vivo in 18F-FDG- and 18F-FLT in cervical cancer patients. MATERIAL & METHODS: 39 patients with histologically confirmed cervical cancer underwent PET/CT scans acquired on separate days 60 min after i. v. injection of 364 ±â€Š75 MBq of 18F-FDG and 259 ±â€Š40 MBq of 18F-FLT. The reconstructed PET images were evaluated using a dedicated workstation for primary tumor semiquantitative parameters: SUVmax, MTV, TLG (for 18F-FLT-TLP) and heterogeneity (AUC-CSH). Wilcoxon-Mann-Whitney test and ROC curves were used for statistical analysis. Based on data from the local cancer registry and 3y- to -5y follow up patients were divided into 2 groups with regard to prognosis. Also differences between histopathological type and FIGO classification in two tracers were assessed. RESULTS: Depending on PET/CT results, patients were divided into 3 groups: group 1 with disease limited only to the cervix, group 2 with disease limited to the cervix and iliac lymph nodes, and group 3 with disseminated disease. Statistically significant differences were found between keratinizing and non-keratinizing SCC in SUVmax (p = 0.03) and AUC-CSH (p = 0.04) only in 18F-FLT-PET/CT. Following cut-off values for nodal involvement in SUVmax, MTV, TLG/TLP and AUC-CSH were calculated using ROC curves: 13.5, 39.22, 255.94, 0.59 respectively for 18F-FDG and 12.1, 37.59, 140.01, 0.46 respectively for 18F-FLT. Higher values in both tracers in MTV and TLG/TLP were found in a group with worse prognosis. CONCLUSION: This preliminary study suggests that higher values in MTV and TLG/TLP in both tracers might be associated with worse outcome in cervical cancer patients.

The effect of different segmentation methods on primary tumour metabolic volume assessed in 18F-FDG-PET/CT in patients with cervical cancer, for radiotherapy planning.

INTRODUCTION: Gynaecological cancers, including cervical cancer, often require a multidisciplinary approach that includes external beam radiotherapy, chemotherapy, and/or surgical treatment. Biological parameters of the tumour evaluated in 18F-FDG-PET/CT are used for target volume delineation in radiotherapy planning. The choice of segmentation method may affect the assessment of metabolic tumour volume (MTV) in 18F-FDG-PET/CT. AIM OF THE STUDY: To find the optimal segmentation method for the assessment of primary MTV in 18F-FDG-PET/CT in cervical cancer patients for radiotherapy planning. MATERIAL AND METHODS: Retrospective analysis was performed on a group of 30 patients with newly diagnosed, histologically confirmed cervical cancer. The primary MTVs were assessed by SUVmax and SUVmean values; three segmentation methods were used to assess the primary MTV: constant threshold of SUVmax of 2.5, threshold of SUVmax 35%, and threshold of SUV max 45%. The MTVs were compared with the tumour volumes obtained in magnetic resonance imaging (MRI), which was the "gold standard", to select the best optimal segmentation method reflecting the tumour size. Wilcoxon-Mann-Whitney and t-test were used for statistical analysis. RESULTS: Depending on the segmentation method chosen, significant differences in the MTVs were obtained (p < 0.001). The highest volumes were obtained using the method based on constant SUVmax of 2.5, while the smallest in case of threshold of SUVmax of 45%. Regarding the volume determined by MRI, a 35% SUVmax threshold was chosen as the most reliable method. CONCLUSIONS: The choice of appropriate segmentation method has a significant impact on the primary MTV assessment in 18F-FDG-PET/CT in patients with cervical cancer.

Influence of Biological Parameters Assessed in [18F]FDG PET/CT on Overall Survival in Cervical Cancer Patients.

AIM: The aim of this study was to estimate the influence of biological parameters assessed in [F]FDG PET/CT on overall survival (OS) in cervical cancer patients. METHODS: Retrospective analysis was performed on a group of 371 patients with newly diagnosed and histologically confirmed cervical cancer. PET biological parameters in primary tumor including SUVmax, SUVmean, total lesion glycolysis (TLG), metabolic tumor volume (MTV), heterogeneity, and parameters referring both to primary tumor and metastatic lesions: SUVtotal, TLGtotal, and MTVtotal, were analyzed. RESULTS: Based on PET/CT results, 3 subgroups were identified: cervical only-with disease limited only to the cervix (38%), +regional nodes-where increased glucose accumulation in addition to the cervical area was also observed in regional lymph nodes (36%), and +distal metastases-where PET scan showed a disseminated disease (26%). Depending on the stage of the disease, in the cervical-only group, 5-year survival rate was 86%; in the +regional nodes group, it was 80%; whereas in the +distal metastases group, 5-year survival rate was only 55%. However, based on Cox regression model, significant influence on OS was found only in heterogeneity of primary tumor; more inhomogeneous tumors suggest worse prognosis (0.25 ± 0.04 vs 0.16 ± 0.09, P < 0.001), SUVtotal (76.6 ± 130.1 vs 45.4 ± 73.4, P = 0.002), and MTVtotal (79.03 ± 88.27 vs 63.00 ± 83.80 cm, P = 0.03). For heterogeneity, cutoff point suggesting worse prognosis was 0.18; for SUVtotal, 52.3; and for MTVtotal, 66.55 cm. CONCLUSIONS: Stage of disease assessed in [F]FDG PET/CT significantly influences survival rate in patients with cervical cancer. SUVtotal, MTVtotal, and heterogeneity of primary tumor are independent prognostic factors on OS in cervical cancer patients.

Influence of 18F-FDG-PET/CT on staging of cervical cancer.

AIM: Cervical cancer is one of the most common cancers of the female reproductive system. The aim of the study was to assess the usefulness of the 18F-FDG-PET/CT study in staging of cervical cancer, with focus on the primary tumor parameters. MATERIAL & METHODS: 105 patients (mean age 56 ±â€…11y) with newly diagnosed cervical cancer underwent PET/CT examination which was performed 60 min after IV injection of 18F-FDG with a mean activity of 364 ±â€…75MBq. 68 patients were diagnosed with stage IIIA/IIIB, 19 patients with IIB, 10 patients with IB, 8 patients with stage IVA/IVB. Wilcoxon-Mann-Whitney test and ROC curves were used for statistical analysis. RESULTS: In 35 cases 18F-FDG-PET/CT did not show active proliferative process outside the cervix. In 38 cases metastases were found in iliac lymph nodes and in 32 patients scans showed metastases above the aortic bifurcation including lymph nodes and other organs. The largest volumes of primary tumor occurred in patients with distant metastases, while the lowest in patients with disease limited only to cervix. In 63 % of the patients PET/CT result was compatible with FIGO classification, in 20 % patients PET/CT result showed less advanced disease and in 17 % of the patients PET/CT results were higher than FIGO classification. CONCLUSION: PET/CT using 18F-FDG has an important impact on the assessment of the stage of cervical cancer. In over 30 % of patients, this study resulted in a radical change in the treatment plan.

Reducing dysphagia with palliative 2D high-dose-rate brachytherapy improves survival in esophageal cancer.

PURPOSE: The goal of this study was to assess the effectiveness of dysphagia relief and overall survival in patients with advanced esophageal cancer treated with palliative high-dose-rate (HDR) brachytherapy (BT) without computed tomography-based planning. MATERIAL AND METHODS: Palliative 2D HDR-BT was used to treat 93 patients with advanced or incurable esophageal cancer in a regional cancer center from October 2010 to December 2016. Before the treatment patients presented the following grades of dysphagia: 0 - 0%, I - 57%, II - 33.3%, III - 6.5%, IV - 3.2%. The planned dose was 22.5 Gy in 3 fractions. The median age of patients was 65 years (45-88). Squamous cell carcinoma was diagnosed in 59.4%, adenocarcinoma in 22.6%, and other histological types of tumors in 6.7% of cases. The histopathological report was unknown in 11.3% of patients. RESULTS: The mean follow-up was 5.0 months (range 1-43). The median tumor length was 72.5 mm. Due to BT dysphagia was significantly decreased: grade 0 - 38.7%, I - 31.2%, II - 20.4%, IV - 1.1% (p < 0.001). Dysphagia relief was achieved in 55% of patients and lasted for a mean time of 4.6 months; stabilization occurred in 31% and deterioration in 14%. The patients with partial or complete dysphagia relief lived longer (5.8 vs. 4.1 months, p = 0.02). The patients with a length of the tumor less than 72.5 mm, histopathologically confirmed adenocarcinoma or after dilatation with a metal stent subsequently to BT had improved overall survival as well (7.1 vs. 3.6; 8.0 vs. 4.1; 6.5 vs. 4.0 months, respectively; p < 0.05). The primary localization and primary grade of dysphagia were not factors that influenced the survival of patients. The logistic regression model did not reveal any predictors for treatment response. CONCLUSIONS: 2D HDR-BT reduces dysphagia and prolongs survival in patients who respond to the treatment. It meets the assumption of palliative treatment for advanced esophageal cancer because of its simplicity and effectiveness.

Hyperthermia in cervical cancer - current status.

BACKGROUND: This article reviews the salient features of recent results of clinical studies. It puts a special emphasis on technical aspects, mechanisms of action together with radiotherapy and chemotherapy and points out areas for additional investigation. AIM: To present the current state of knowledge on hyperthermia (HT) and to highlight its role in the treatment of cervical cancer. MATERIALS AND METHODS: The literature on the clinical use of combined hyperthermia for cervical cancer was analyzed. Clinical outcomes together with the technical aspects and the role of HT were also evaluated. RESULTS: Clinically randomized trials have demonstrated benefit including survival with the addition of hyperthermia to radiation or chemotherapy in the treatment of cervical cancer without significant acute or late morbidities. The technological advances have led to an effective and safer treatment delivery, thermal treatment planning, thermal dose monitoring and online adaptive temperature modulation. CONCLUSIONS: Due to rapid development over the last decade of hyperthermia systems and new studies at the basic science and clinical level, the perception of hyperthermia as a part of multimodality treatment in cervical cancer has been changed. However, there is still a need for multicentre randomized clinical trials.

Strategy and early results of treatment of advanced cervical cancer patients with synchronous cancers observed in PET-CT imaging.

OBJECTIVES: The aim of this study was to present strategy and early results of treatment of advanced cervical cancer patients with synchronous cancers observed in PET-CT imaging, treated at the Greater Poland Cancer Center. MATERIAL AND METHODS: The study included a group of 200 patients with diagnosed stage IIB-IIIB cervical cancer who received PET-CT for the purpose of radiotherapy treatment planning. RESULTS: Among our study group, four patients (2%) were found to have a synchronous cancer. Two of the cases were diagnosed as breast cancer. However, cancers diagnosed in the other two patients were head and neck malignancies - hypopharyngeal and laryngeal cancer. The choice of an optimal therapeutic approach requires taking into account characteristics of particular malignancies, their stage and histopathology. The whole therapy included radiotherapy of cervical cancer with various combinations of systemic treatment, radiotherapy or surgery of synchronous cancer. According to treatment results, patients diagnosed with breast cancer and hypopharyngeal cancer achieved complete remission of both primary and secondary tumour. Patient diagnosed with laryngeal malignancy, despite achieving complete remission of cervical cancer, finished radiotherapy of the synchronous cancer at a palliative dose. CONCLUSIONS: The growing availability of PET-CT and other imaging methods in cancer diagnosis will increase the number of diagnosed synchronous cancers. Second primary cancers are often detected at an early stage, where radical treatment can be performed for both primary and secondary tumour. However, treatment of such complicated clinical cases as synchronous cancers should be carried out by multidisciplinary teams.