Organ function and quality of life after transoral laser microsurgery and adjuvant radiotherapy for locally advanced laryngeal cancer

Current indications for adjuvant treatment following transoral laser microsurgery of early and intermediate laryngeal cancer

PURPOSE OF REVIEW

This review summarizes the information in the literature on the indications for adjuvant therapy after transoral laser microsurgery (TLM) for early/intermediate stage laryngeal cancer.

RECENT FINDINGS

A high rate of 'nonevaluable' margins after TLM significantly complicates decision-making concerning adjuvant therapy. However, consensus grows that second-look TLM in patients with multiple superficial and deep positive margins is more sensible than sending these patients systematically for adjuvant radiotherapy (RT).

SUMMARY

The classical adagium: 'Failure to achieve negative margins indicates need for adjuvant RT' does not translate automatically to patients with glottic cancer treated by TLM. Rather, specifically patients with multiple superficial positive margins and positive deep margins after TLM need careful judging what constitutes the best additional adjuvant treatment. Second-look resection is nowadays regarded as the preferred adjuvant treatment for many of these patients whereas RT is reserved for those in whom a second look TLM is judged unlikely to result in 'true negative margins.' Additionally, when the pathology of the re-resection reveals multiple foci of residual disease or suggests again a resection with positive margins, adjuvant postoperative RT is likely to result in a better local control. If this strict selection of patients for adjuvant RT is adhered to carefully, oncological and functional results will be optimal.

Intraoperative Surgical Complications in Transoral Laser CO2 Microsurgery of the Larynx: An Observational, Prospective, Single-Center Study

INTRODUCTION

Despite good outcomes of CO₂ laser of the larynx, a lack of prospective data related to intraoperative complications in the indexed literature is evident.

MATERIALS AND METHODS

An observational, prospective, nonrandomized study.

RESULTS

One hundred and twenty-eight patients met the inclusion criteria. The total rate of intraoperative complications was 14.8% (19/128). The rate of complications according to anatomical location was 7 (38.8%) of 18 for supraglottic tumors and 11 (10.3%) of 107 for glottic tumors, and 1 (33.3%) of 3 for subglottic tumors (P = .001). We do not found difference in complications according to severity (minor vs major complication).

CONCLUSION

Previous studies reported good oncologic outcomes and low complication rates with CO₂ transoral laser microsurgery (TOLMS) compared to traditional open surgery. However, it is important to consider the different intraoperative surgical, major and minor complications related to CO₂ TOLMS and discuss this with our patients during the preoperative assessment, especially in those patients who need a supraglottic tumor resection.

Treatment of early-stage laryngeal cancer: A comparison of treatment options

Over the course of the last several decades, the treatment options for early laryngeal cancers (T1 and T2) have evolved; however, simultaneously the mortality rate has increased. As larynx preservation approaches have become the standard of care, the selection of the proper treatment modality has become paramount. Radiation therapy or transoral laser microsurgery are the most common options for treatment of these early lesions. Oncologic and functional outcomes are considered equivalent between the two modalities for early glottic cancers; however, no direct comparisons exist for robust analysis. In terms of larynx preservation, there also is not compelling data favoring one treatment option or another. For early stage lesions, the goal for any larynx-sparing technique, either radiation or surgery, should be the intent to cure with single modality treatment and minimal short- and long-term toxicity. This article is designed to create a frame of reference for managing early stage disease with respect to lesions of the glottis and supraglottis while weighing treatment implications from an oncologic, functional, and cost perspective.

Retrospective analysis of factors influencing oncologic outcome in 590 patients with early-intermediate glottic cancer treated by transoral laser microsurgery

BACKGROUND

The purpose of this study was to identify the factors influencing oncologic outcomes for patients with early-intermediate glottic cancer treated by transoral laser microsurgery (TLM).

METHODS

This was a retrospective mono-institutional study. A total of 590 patients with cTis-cT3 glottic cancer underwent TLM with curative intent.

RESULTS

TLM alone was performed in 538 patients (91.2%) and TLM followed by adjuvant radiotherapy (RT) was done in 52 (8.8%). Five-year recurrence-free survival (RFS) and 10-year overall survival (OS) were 85.3% and 74.7%, respectively. The larynx-preservation ratio was 95.9%. In particular, from our data, we found that occult metastases were rare (1.2%); preventive tracheotomy was not necessary; the local recurrence rate of Tis was similar to that in the T2 and T3 group; and no major or lethal complications were observed.

CONCLUSION

Age (>60 vs ≤60), type of cordectomy (≥IV vs ≤III), status of margins, fixed arytenoid, and pathologic T classification, were the variables associated with RFS, OS, and organ-preservation rate. © 2016 Wiley Periodicals, Head Neck 39: 71-81, 2017.

Transoral CO2 Laser Microsurgery Outcomes for Early Glottic Carcinomas T1-T2

Introduction

 Transoral laser microsurgery (TLM) has won territory in larynx oncology, establishing itself as an effective option in treatment of glottic, supraglottic, and hypopharynx tumors. Its advantages include limited resections, a reduction in number of tracheostomies, and the use of nasogastric tubes. Moreover, its oncological benefits are similar to those from open surgery in patients with early or advanced stages, when correctly selected.

Objective

 The objective of this study is to review oncologic outcomes obtained with the treatment of a series of glottic tumors, treated by TLM.

Methods

 Retrospective analysis of patients previously untreated, diagnosed with squamous cell carcinoma of the glottis (T1a, T1b, T2) in a tertiary university hospital. Endpoints for analysis were local control, overall and disease-specific survival, and larynx preservation rate.

Results

 The study group included 58 patients that met the inclusion criteria: 57 (98.3%) men and 1 (1.7%) woman. Mean age was 65.5 ± 10.7 years (Min: 46/Max: 88). The tumor stages of the patients included were 30 T1a, 11 (19%) T1b, and 17 (29.3%) T2. Three-year overall survival rate was 89.7% (Fig. 1), and three-year disease-specific survival rate was 96.5%, three-year local control rate was 98.3%, and three-year organ preservation rate was 98.3%.

Conclusion

 TLM is a safe and effective option in the treatment of glottis carcinomas, associated with less morbidity and a high percentage of local control, overall survival, specific survival, and organ preservation.

Analysis of Postsurgical Health-Related Quality of Life and Quality of Voice of Patients With Laryngeal Carcinoma

This study aims to analyze the postsurgical health-related quality of life (HRQOL) and quality of voice (QOV) of patients with laryngeal carcinoma with an expectation of improving the treatment and HRQOL of these patients. Based on the collection of information of patients with laryngeal carcinoma regarding clinical characteristics (age, TNM stage, with or without laryngeal preservation and/or neck dissection, with or without postoperative irradiation and/or chemotherapy, etc.), QOV using Voice Handicap Index (VIH) scale and HRQOL using EORTC QLQ-C30 and EORTCQLQ-H&N35 scales, the differences of postsurgical HRQOL related to their clinical characteristics were analyzed using univariate nonparametric tests, the main factors impacting the postsurgical HRQOL were analyzed using regression analyses (generalized linear models) and the correlation between QOV and HRQOL analyzed using spearman correlation analysis. A total of 92 patients were enrolled in this study, on whom the use of EORTC QLQ-C30, EORTC QLQ-H&N35 and VHI scales revealed that: the differences of HRQOL were significant among patients with different ages, TNM stages, and treatment modalities; the main factors impacting the postsurgical HRQOL were pain, speech disorder, and dry mouth; and QOV was significantly correlated with HRQOL. For the patients with laryngeal carcinoma included in our study, the quality of life after open surgeries were impacted by many factors predominated by pain, speech disorder, and dry mouth. It is suggested that doctors in China do more efforts on the patients' postoperative pain and xerostomia management and speech rehabilitation with the hope of improving the patients' quality of life.

Complications in CO2 Laser Transoral Microsurgery for Larynx Carcinomas

Introduction Transoral laser microsurgery (TLM) has established itself as an effective option in the management of malignant tumors of the glottis, supraglottis, and hypopharynx. Nonetheless, TLM is not a harmless technique. Complications such as bleeding, dyspnea, or ignition of the air may appear in this type of surgery. Objective The aim of this study is to describe the complications that occurred in a group of patients treated for glottic and supraglottic carcinomas in all stages by TLM. Methods This study is a retrospective analysis of patients diagnosed with squamous cell carcinoma of the glottis and supraglottis for all stages (T1, T2, T3, T4), N -/ + , M -/+ treated with TLM between January 2009 and March 2012 in a tertiary hospital. Results Ninety-eight patients met the inclusion criteria, which had undergone a total of 131 interventions. Ninety-four (95.9%) patients were male and 4 (4.1%) were female. The mean age was 64.2 years (± 10.7 years = min 45; max 88). The presence of intraoperative complications was low, affecting only 2% of patients. Immediate postoperative complications occurred in 6.1%, whereas delayed complications affected 13.2% of patients, without any of them being fatal. Conclusion TLM has shown good oncologic results and low complication rate compared with traditional open surgery during intervention, in the immediate and delayed postoperative period and in the long-term with respect to radiotherapy.

Quality of Life After Conservation Surgery for Laryngeal Cancer

Quality of life preservation has become an essential goal of treatment in the management of laryngeal carcinoma. Although established treatments of reference such as total laryngectomy and chemoradiation protocols have focused on survival and anatomic preservation of the larynx, they still generate considerable functional morbidity with detrimental effects on quality of life. Transoral and transcervical partial laryngectomy techniques can offer significant advantages when used prudently after proper patient selection. The growing relevance of those techniques in the management of advanced and recurrent laryngeal carcinoma deserves particular attention, with potential for improved quality of life without compromising oncologic outcomes.

Clinical significance of granulation tissue after transoral laser microsurgery for glottic cancer

Background:

Granulation tissue after transoral laser microsurgery can make it difficult to distinguish between normal healing and tumour recurrence.

Materials and methods:

We carried out a retrospective analysis of 316 consecutive glottic carcinomas (Tis–T3). Presence of granulation tissue at one and six months was correlated with demographic and clinical data, tumour and surgical characteristics, and tumour relapse.

Results:

Granulation tissue appeared in 53.8 per cent of patients at month 1, resolving spontaneously in 41.8 per cent. Revision surgery was performed in 60.1 per cent and was effective in 41.1 per cent. At month 6, 14.9 per cent of patients presented with granulation tissue. In 74.5 per cent the tissue was surgically removed and was positive for malignancy in 62.9 per cent. Tumour relapse presented in 29.4 per cent with granulation tissue at month 1 and in 61.7 per cent at month 6 (p= 0.000). Granulation tissue at month 1 correlated with thyroid cartilage exposure and continued smoking. At month 6, granulation tissue correlated with thyroid cartilage exposure, the affected surgical margins and diabetes.

Conclusion:

Granulation tissue after transoral laser microsurgery is frequent. When it persists at six months, revision surgery is formally recommended.

A systematic review of current and emerging approaches in the field of larynx preservation

Treatment options targeting laryngeal preservation include conservative surgery, concurrent chemo-radiotherapy, induction chemotherapy (IC) followed by radiotherapy (RT), and alternating chemo-radiation. The goal of this paper was to perform a systematic review of randomized clinical trials (RCTs) on current and emerging approaches in the field of larynx preservation. The search identified 36 papers of which 27 did not fall within the inclusion criteria (i.e. non-RCTs). IC followed by RT has been shown to allow laryngeal preservation in about two-thirds of pts with locally advanced laryngeal or hypopharyngeal cancer without compromising survival. IC is regarded as the landmark treatment of non-surgical larynx preservation approaches. Concomitant and alternating chemoradiotherapy treatments are also acceptable in larynx preservation.

Second primary malignancies in head and neck cancer patients: high prevalence of curable-stage disease

BACKGROUND AND PURPOSE

Patients treated for squamous cell carcinoma of the head and neck (HNSCC) carry a high risk of second primary malignancies (SPM). Recently, computed tomography (CT) of the chest was shown to significantly decrease the risk of death due to bronchial carcinoma (BC) in a cohort of smokers whose risk of BC is increased but might be lower than that of patients previously treated for HNSCC. Thus, the present study evaluated the potential benefit of CT and other examinations in the detection of SPM in HNSCC patients.

PATIENTS AND METHODS

Between July 2008 and November 2011, 118 participants underwent a prospective, systematic examination for SPM (13 women, 105 men, median age 62 years). All patients had been previously treated for HNSCC and showed no recurrence or distant metastases at the time of the study start. CT scans, ear-nose-throat endoscopy, and endoscopy of the esophagus and stomach were performed.

RESULTS

Overall, 33 suspicious findings were clarified by additional investigations. In all, 26 SPM were confirmed in 21 of 118 patients (18%; 10 lung, 7 HNSCC, 3 gastrointestinal, 1 renal). Eighteen of these 21 patients (86%) underwent therapy with curative intent.

CONCLUSION

The examinations revealed a high prevalence of curable stage SPM in HNSCC patients. Adapting a surveillance scheme including a chest CT is recommended.

Cyclin D1, EGFR, and Akt/mTOR pathway. Potential prognostic markers in localized laryngeal squamous cell carcinoma

INTRODUCTION

EGFR (epidermal growth factor receptor), cyclin D1 and Akt/mTOR pathways are active in head and neck cancer. The aim of this study was to explore biomarker expression, their correlations with clinicopathological parameters and their prognostic utility in a cohort of patients with localized squamous laryngeal carcinoma.

PATIENTS AND METHODS

We assessed relative messenger RNA expression of EGFR, Akt1, 2, and 3, mTOR and CCND1, copy number variants of the EGFR and CCND1 genes and immunohistochemical protein expression of EGFR, p-Akt308, p-Akt473, pmTOR, PTEN, p53 and cyclin D1 in paraffin-embedded tissue samples of localized laryngeal carcinomas.

RESULTS

In 289 patients with T3-4 (77.8%), node-negative (84.1%) tumors of the larynx, high EGFR and CCND1 mRNA correlated with no or ex-smoking, (p = 0.003 and p = 0.029, respectively), while low Akt3 mRNA correlated with alcohol abuse, N0 stage, total laryngectomy, and absence of neck dissection. At a median follow-up of 74.5 months, high mTOR mRNA expression was marginally associated with shorter disease-free survival (hazard ratio [HR] = 1.54; p = 0.093) and high Akt3 mRNA with shorter overall survival (HR = 1.49; p = 0.0786), in univariate analysis. In multivariate analysis, node-positive status, subglottic-transglottic location, surgery other than total laryngectomy and mTOR/CCND1 mRNA interaction with a hazard ratio of 2.16 (p value for interaction:  0.0010) were independent predictors of relapse, while node-positive status and subglottic-transglottic location were associated with higher risk for death.

CONCLUSION

In localized laryngeal cancer, clinicopathological parameters and an interaction of high mTOR and CCND1 mRNA expression were found to be associated with poor patient outcome.

Preservation of organ function in head and neck cancer

Preservation of function is a crucial aspect for the evaluation of therapies applied in the field of head and neck cancer. However, preservation of anatomic structures cannot automatically be equated with preservation of function. Functional outcome becomes increasingly important particularly for the evaluation of alternative treatment options with equivalent oncological outcomes.AS A RESULT, PRESENT STUDIES TAKE INTO ACCOUNT THREE TOPIC AREAS WITH VARYING EMPHASIS: (1) the effects of cancer therapy on essential physiological functions, (2) additional therapy-induced side-effects and complications, and (3) health-related quality of life. The present article summarizes vital aspects of clinical research from recent years. Functional outcomes after surgical and non-surgical treatment approaches are presented according to tumor localization and staging criteria. Additional methodological aspects relating to data gathering and documentation as well as challenges in implementing the results in clinical practice are also discussed.

Performance of the EORTC questionnaire for the assessment of quality of life in head and neck cancer patients EORTC QLQ-H&N35: a methodological review

PURPOSE

The EORTC QLQ-H&N35 (H&N35) is widely used to measure quality of life in head and neck cancer patients. The aims of this study were to obtain insight into a) the languages in which the H&N35 has been used and the psychometric properties in those languages, b) the study designs, and c) its acceptance by patients and investigators.

METHODS

A systematic literature review was performed searching for all original papers that had used at least one item of the H&N35. Identified papers were read and the information about methodological issues abstracted statistically analysed.

RESULTS

A total of 136 papers were identified. The H&N35 was administered in 19 different languages in 27 countries. The study design was cross-sectional in the majority of studies (53 %), prospective cohort studies (31 %), phase-II-trials (7 %), phase-III-trials (6 %) and case-control studies (1 %). The scales with the highest percentages of missing values were Sexuality (11.5 %) and Speech (7 %). The median Cronbach's alpha of the multi-item scales ranged from 0.61 (Senses) to 0.93 (Sexuality). Construct validity was rarely investigated. On average, 12 scales (range 0-18) of the instrument were used by the investigators. The scale most often used was swallowing (in 85 % of studies) and least often used was Weight Gain (39 %).

CONCLUSION

The H&N35 is widely used throughout the world, mainly in observational studies, and has demonstrated robust psychometric features in different languages. However, some methodological problems reported imply that the instrument can be improved in some areas.

Predictors of radiotherapy outcome in patients with T2 supraglottic carcinoma

The decision regarding treatment of early supraglottic carcinoma remains controversial. Single institution clinical data of patients with T2 supraglottic carcinoma treated exclusively with radiotherapy in terms of prognostic factors and treatment results were analyzed. Patient-related factors that would potentially by useful for optimal therapeutic decision to be undertaken were especially investigated. Between 1994 and 2004, 78 patients with T2 supraglottic carcinoma underwent radiotherapy (RT) in Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Gliwice Branch, Poland. There were 54 (69%) males and 24 (31%) females in the median age of 61 years. There were 17 (22%) patients with N+. Median body mass of patients before (BM0) and after RT (BM1) was 74 kg (range 45.2-130 kg) and 72.9 kg (range 49.9-122.5 kg), respectively. Median hemoglobin concentrations before (Hb0) and after (Hb1) RT were 14.3 and 13.4 g/dl, respectively. Median change of Hb concentration during RT (dHb) was -0.8 g/dl. All were treated up to total doses (TD) ranged from 62.5 to 72 Gy. The overall treatment time (OTT) ranged from 30 to 70 days. Estimates of local control (LC), ultimate local control (uLC), and overall survival (OS) were calculated using the Kaplan-Meier method. Log rank statistics, Cox proportional hazard model and step-wise Cox regression hazard model were employed to identify prognostic factors for LC, uLC, and OS in univariate and multivariate analyses. The 5-year LC, RC, uLC and OS rates were 85, 92, 88, and 56%, respectively. In multivariate analysis N+ (p = 0.01) and prolonged OTT (p = 0.03) significantly decreased LC. Females (p = 0.02), higher BM0 (p = 0.03), and HB0 (p = 0.006) significantly prolonged OS. Patient-related factors like gender, hemoglobin concentration, and body mass may predict treatment outcome. Radiotherapy is effective for T2 supraglottic carcinoma of the larynx unless higher dose intensity is provided. Involved regional lymph nodes significantly deteriorate locoregional cure.

Feasibility, toxicity, and efficacy of short induction chemotherapy of docetaxel plus cisplatin or carboplatin (TP) followed by concurrent chemoradio-therapy for organ preservation in advanced cancer of the hypopharynx, larynx, and base of tongue. Early results

PURPOSE

Concurrent chemoradiotherapy (CRT) is standard treatment for advanced head and neck cancer. Whether short induction chemotherapy (ICT) provides additional benefit or, in particular, predictive benefit for the response to chemoradiotherapy is an open question. The present study aimed to assess the feasibility, toxicity, and efficacy of induction with docetaxel and platinum salt (TP) and subsequent CRT.

PATIENTS AND METHODS

A total of 25 patients with functionally inoperable cancer of the base of the tongue, hypopharynx, or larynx received 1 cycle of docetaxel (75 mg/m², day 1) combined with either cisplatin (30 mg/m², days 1-3; n = 23) or carboplatin (AUC 1.5 days 1-3; n = 2). Responders (n = 22, >30% tumor reduction, graded by endoscopy) and 1 non-responder received CRT (target dose: 69-72 Gy) with cisplatin/paclitaxel, carboplatin/paclitaxel, or cisplatin/docetaxel.

RESULTS

All patients completed ICT with acceptable toxicity (leukocytopenia grade 4: 8%). The remission rate of the primary tumor was 88% (22/25 patients). There was no need to delay CRT due to toxicity in any case. Each patient received the full radiation dose. Of the patients, 56% received >80% of the chemotherapy. The acute toxicity of CRT was moderate, no grade 4 toxicities occurred, while grade 3 toxicities included the following: infection (39%), dermatitis (13%), leukocytopenia (30%), and thrombocytopenia (4%). The local control rate was 84.6% ± 8.5% and the survival rate was 89.6% ± 7.2% at 12 months. Organ preservation was possible in 22/23 (95%) cases.

CONCLUSION

Short induction with a TP regimen and subsequent CRT with a taxan is feasible and associated with an encouraging local control rate.

Multidisciplinary approach in the treatment of T1 glottic cancer. The role of patient preference in a homogenous patient population

BACKGROUND AND PURPOSE

To compare oncological outcome and voice quality among a uniform and well-defined subset of patients with T1 glottic carcinoma.

PATIENTS AND METHODS

Patients, affected by laryngeal glottic carcinoma, treated by laser CO2 surgery or radiotherapy, have been analyzed. Overall survival and disease-free survival were calculated. In order to verify differences in functional outcomes and voice quality, all patients were interviewed during their last follow-up visit during 2009 using the VHI (Voice Handicap Index) questionnaire. The data were analyzed using the MedCalc software.

RESULTS

A total of 143 patients were analyzed: 73 underwent surgery and 70 underwent radiotherapy. No statistically significant differences were found between the two groups in terms of overall survival and disease-free survival; dividing patients into stages T1a and T1b also made no difference. In order to evaluate the differences in outcomes for surgery and radiotherapy, patients were interviewed using the VHI questionnaire. Better scores for each category in the VHI were found for patients receiving radiotherapy compared to surgery (physical: p = 0.0023; functional: p < 0.0001; environmental: p < 0.001). The median VHI score for radiotherapy patients was 4, while for surgical patients it was 18 (p < 0.0001).

CONCLUSION

This study confirms the well-known knowledge that results from radiotherapy and surgery in early glottic cancer treatment are equivalent. Furthermore, the role of patient preference in the treatment modality choice and the value of a multidisciplinary approach for a detailed and multi-oriented discussion with the patient are outlined.

Osteonecrosis of the jaws: clinicopathologic and radiologic characteristics, preventive and therapeutic strategies

BACKGROUND

Bisphosphonate (BP) use has increased dramatically in recent years, becoming an integral part of the overall antineoplastic management of patients with metastatic bone disease. Even though their application has shown to be effective in reducing pain and minimizing the risk of skeletal-related events, their administration may bring also adverse events such osteonecrosis of the jaws (ONJ).

METHODS

After a thorough review of the literature, important aspects of the pathophysiology, diagnosis, prevention, and treatment of ONJ are presented.

RESULTS

ONJ is evident in up to 10% of patients receiving intravenous BP treatment. Despite the fact that its exact pathophysiology is unknown, it is characterized by bone necrosis that can occur either spontaneously or after dental surgery or tooth extraction. Panoramic radiographs are useful for the diagnosis and routine assessment of patients and computed tomography can differentiate between ONJ and metastatic disease. Additionally, magnetic resonance imaging depicts local disease extension readily, and scintigraphy is the most sensitive imaging modality for detecting early involvement. Preventive measures and routine dental evaluations are essential components of the overall patient management. In the event of ONJ, stage I or II should be managed conservatively, whereas more advanced stages (III and IV) should be treated surgically.

CONCLUSION

ONJ is a well-defined clinical entity that all medical and dental doctors should be aware of, since if it is not dealt with readily and effectively, it may deteriorate the clinical status and quality of life of affected patients.

Surgery for Laryngopharyngeal SCC in the Era of Organ Preservation

Over the past decades, randomized clinical trials have assessed and validated the concept of larynx preservation. This new concept has obviously modified the treatment algorithm for laryngopharyngeal squamous cell carcinoma. However surgery for larynx and hypopharynx cancer remains indicated in many cases. Initial partial surgery is indicated for early diseases. This surgery may be performed endoscopically or openly. The results are excellent in terms of local control and function. Transoral robotic surgery is under evaluation. Initial radical surgery is indicated for advanced diseases in case of very infiltrative tumor, in case of cartilage destruction or when tolerance and/or compliance to chemotherapy-based approached is questionable. Larynx preservation is to be discussed between these two situations. In randomized trials evaluating the different larynx preservation strategies, a substantial number of larynxes could be preserved without compromising disease control or survival. The best approach in terms of quality of function preservation, overall acute and late toxicity, disease control and survival is still a matter of clinical research. It must be stressed that salvage surgery is a definite part of these larynx preservation protocols in order to maintain the ultimate disease control. This discussion underscored the need of a multidisciplinary decision making and the need of a coordinated clinical research.