1
|
Liu H, Li Z, Xue Y, Zhao T, Wu Y. A multicenter retrospective analysis of clinical outcomes of intracranial chondrosarcoma in 26 patients. Sci Rep 2023; 13:14647. [PMID: 37669996 PMCID: PMC10480207 DOI: 10.1038/s41598-023-41378-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/25/2023] [Indexed: 09/07/2023] Open
Abstract
Intracranial chondrosarcoma is a rare tumor with limited reports. We reviewed the clinical outcomes, imaging findings, and pathological characteristics at three centers to improve the diagnosis and treatment of intracranial chondrosarcoma. We retrospectively analyzed 26 patients with intracranial chondrosarcoma who had undergone surgical treatment at Tangdu Hospital of Air Force Military Medical University, Mianyang Central Hospital, and Nanchong Central Hospital from January 2010 to July 2022. Clinical manifestations, imaging features, surgical treatment, prognosis, and overall survival (OS) were analyzed. All 26 chondrosarcomas were located at the skull base. Gross total resection (GTR), subtotal resection (STR), and partial resection (PR) were performed in 14, 10, and 2 cases, respectively. Four cases underwent endoscopic transnasal surgery, while the remaining cases underwent craniotomy. The clinical symptoms were evaluated 1 week after surgery, and 15 cases were relieved to varying degrees. Postoperative complications included pulmonary infection, subcutaneous hydrops, dysphagia and choking, facial numbness, abducens paralysis, and intracranial infection (ICI). Fifteen cases received postoperative adjuvant radiotherapy. Seven cases showed recurrence: two with PR, four with STR, and one with GTR. Six cases received reoperation or radiotherapy after tumor progression, and one untreated patient died 5 months after tumor recurrence. The extent of tumor resection (HR 21.74, 95% CI 1.25-376.6, P = 0.03) and pathological grading (HR 131.99, 95% CI 4.05-4300.5, P = 0.006) were associated with improved OS. We presented our experience in the treatment of intracranial chondrosarcoma at three centers in the past 12 years. Intracranial chondrosarcoma lacked typical imaging features and are difficult to differentiate from other skull base lesions. Maximum extent of tumor resection with minimal injury to neurological function remains the most important treatment strategy. The extent of surgical resection and pathological grading were found to be predictors for OS.
Collapse
Affiliation(s)
- Hongyuan Liu
- Department of Neurosurgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, People's Republic of China
| | - Zongping Li
- Department of Neurosurgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, People's Republic of China
| | - Yafei Xue
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Tianzhi Zhao
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi, People's Republic of China.
| | - Yingxi Wu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi, People's Republic of China.
| |
Collapse
|
2
|
Zhao Z, Guan JZ, Wu M, Lai GH, Zhu ZL. Downregulation of microRNA-23b protects against ischemia-reperfusion injury via p53 signaling pathway by upregulating MDM4 in rats. J Cell Biochem 2019; 120:4599-4612. [PMID: 30537038 DOI: 10.1002/jcb.27748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/31/2018] [Indexed: 11/08/2022]
Abstract
Total knee arthroplasty is a commonly performed safe procedure and typically executed in severe knee arthritis, but it also triggers ischemia-reperfusion injury (IRI). More recently, microRNAs (miRs) have been reported to play a contributory role in IRI through the key signaling pathway. Hence, the current study aimed to investigate the effect and specific mechanism of microRNA-23b (miR-23b), murine double minute 4 (MDM4), and the p53 signaling pathway in IRI rat models. First, the IRI model was established, and the expression pattern of miR-23b, MDM4, and the p53 signaling pathway-related genes was characterized in cartilaginous tissues. Then, miR-23b mimics or inhibitors were applied for the elevation or the depletion of the miR-23b expression and siRNA-MDM4 for the depletion of the MDM4 expression in the articular chondrocytes. By means of immunohistochemistry, quantitative real-time polymerase chain reaction, and Western blot analysis, IRI rats exhibited increased miR-23b expression, activated p53 signaling pathway, and decreased MDM4 expression. MDM4 was verified as a target gene of miR-23b through. Downregulated miR-23b increased the expression of MDM4, AKT, and Bcl-2, but decreased the expression of p53, p21, and Bax. In addition, a series of cell experiments demonstrated that downregulated miR-23b promoted articular chondrocyte proliferation and cell cycle entry, but inhibited articular chondrocyte apoptosis. The absence of the effects of miR-23b was observed after MDM4 knocked down. Our results indicate that silencing miR-23b could act to attenuate IRI and reduce the apoptosis of articular chondrocytes through inactivation of the p53 signaling pathway by upregulating MDM4, which provide basic therapeutic considerations for a novel target against IRI.
Collapse
Affiliation(s)
- Zhi Zhao
- Department of Orthopedics, The First Affiliated Hospital of Bengbu Medical College, Anhui Key Laboratory of Tissue Transplantation, Bengbu, China
| | - Jian-Zhong Guan
- Department of Orthopedics, The First Affiliated Hospital of Bengbu Medical College, Anhui Key Laboratory of Tissue Transplantation, Bengbu, China
| | - Min Wu
- Department of Orthopedics, The First Affiliated Hospital of Bengbu Medical College, Anhui Key Laboratory of Tissue Transplantation, Bengbu, China
| | - Gui-Hua Lai
- Department of Anatomy, Bengbu Medical College, Bengbu, China
| | - Zhong-Lian Zhu
- Department of Orthopedics, The First Affiliated Hospital of Bengbu Medical College, Anhui Key Laboratory of Tissue Transplantation, Bengbu, China
| |
Collapse
|
3
|
Wang YB, Shi Q, Li G, Zheng JH, Lin J, Qiu W. MicroRNA-488 inhibits progression of colorectal cancer via inhibition of the mitogen-activated protein kinase pathway by targeting claudin-2. Am J Physiol Cell Physiol 2018; 316:C33-C47. [PMID: 30207785 DOI: 10.1152/ajpcell.00047.2018] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Colorectal cancer (CRC) affects people globally, and lymph node metastasis (LNM) is an important indicator of poor clinical outcome in CRC. The current study aims to evaluate the role of microRNA-448 (miR-488) and claudin-2 (CLDN2) in epithelial-mesenchymal transition (EMT) and LNM of CRC through the MAPK signaling pathway. First, microarray analysis indicated that miR-488 was poorly expressed in CRC, whereas CLDN2 was highly expressed. Additionally, the bioinformatics website MicroRNA.org and the dual luciferase reporter gene assay found that CLDN2 was a target gene of miR-488. Next, the results for the correlations between expression of miR-488 and clinicopathological characteristics of CRC indicated that the expression of miR-488 was closely associated with differentiation degree, LNM, and Dukes stages in CRC patients. Moreover, overexpression of miR-488 inhibited the activation of the MAPK signal transduction pathway. Notably, loss- and gain-of-function experiments demonstrated that upregulation of miR-488 suppressed SW480 cell viability, invasion, and migration and promoted apoptosis in SW480 cells. Finally, overexpression of miR-488 inhibited LNM, microlymphatic vessel density, and tumor growth in nude mice. We conclude that overexpression of miR-488 could suppress the cell proliferation, EMT, and LNM of CRC cells via inhibition of the CLDN2-mediated MAPK signaling pathway, which could be a new molecular therapy target for CRC.
Collapse
Affiliation(s)
- Yong-Bing Wang
- Department of General Surgery, Shanghai University of Medicine and Health Sciences Affiliated Pudong New District People's Hospital , Shanghai , People's Republic of China
| | - Quan Shi
- Department of General Surgery, Shanghai University of Medicine and Health Sciences Affiliated Pudong New District People's Hospital , Shanghai , People's Republic of China
| | - Gang Li
- Department of General Surgery, Shanghai University of Medicine and Health Sciences Affiliated Pudong New District People's Hospital , Shanghai , People's Republic of China
| | - Jun-Hua Zheng
- Department of General Surgery, Shanghai University of Medicine and Health Sciences Affiliated Pudong New District People's Hospital , Shanghai , People's Republic of China
| | - Jie Lin
- Department of General Surgery, Shanghai University of Medicine and Health Sciences Affiliated Pudong New District People's Hospital , Shanghai , People's Republic of China
| | - Wei Qiu
- Department of General Surgery, Shanghai University of Medicine and Health Sciences Affiliated Pudong New District People's Hospital , Shanghai , People's Republic of China
| |
Collapse
|
4
|
Effects of microRNA-292-5p on myocardial ischemia-reperfusion injury through the peroxisome proliferator-activated receptor-α/-γ signaling pathway. Gene Ther 2018; 25:234-248. [PMID: 29670247 DOI: 10.1038/s41434-018-0014-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 02/10/2018] [Accepted: 02/26/2018] [Indexed: 12/30/2022]
Abstract
Ischemia-reperfusion injury (IRI) is a major cause of cardiac damage following various pathological processes, such as free radical damage and cell apoptosis. This study aims to investigate whether microRNA-292-5p (miR-292-5p) protects against myocardial ischemia-reperfusion injury (IRI) via the peroxisome proliferator-activated receptor (PPAR)-α/-γ signaling pathway in myocardial IRI mice models. Mouse models of myocardial IRI were established. Adult male C57BL/6 mice were divided into different groups. The hemodynamic indexes, levels of related inflammatory factors and serum myocardial enzymes, and malondialdehyde (MDA) content and the activity of superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) were detected. The 2,3,5-triphenyltetrazolium chloride (TTC) staining was applied to determine infarct size. TUNEL staining was used to detect cardiomyocyte apoptosis. RT-qPCR and western blotting were performed to measure the related gene expressions. Compared with the model group and the T0070907 + miR-292-5p inhibitor, the miR-292-5p inhibitor group exhibited decreased incidence and duration time of ventricular tachycardia and ventricular fibrillation, serum myocardial enzymes, TNF-α, IL-6, IL-1β, MDA, cardiomyocyte apoptosis, expressions of Bax and p53 in addition to increased SOD and GSH-Px activity, and increased expressions of Bcl-2, PPARα, PPARγ, PLIN5, AQP7, and PCK1. The T0070907 group exhibited opposite results compared to the miR-292-5p inhibitor group. The results indicate that miR-292-5p downregulation protects against myocardial IRI through activation of the PPAR-α/PPAR-γ signaling pathway.
Collapse
|
5
|
Proposed Treatment Paradigm for Intracranial Chondrosarcomas Based on Multidisciplinary Coordination. World Neurosurg 2017; 109:e517-e530. [PMID: 29033377 DOI: 10.1016/j.wneu.2017.10.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 10/02/2017] [Accepted: 10/04/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVES There was no consensus regarding the treatment of intracranial chondrosarcoma (CSA). The study aimed to evaluate the adverse factors for progression-free survival (PFS) and overall survival (OS) and to propose a treatment strategy for CSA. METHODS The clinical chart and radiographic data of 106 consecutive cases (mesenchymal and conventional CSA in 18 and 88 patients, respectively) of surgically treated CSAs were retrospectively reviewed. RESULTS Gross total resection was achieved in 43 patients (40.6%), and adjuvant radiotherapy was administered in 45 patients. After a mean follow-up duration of 47.8 months, 38 patients (37.3%) experienced recurrence. PFS and disease-specific OS at 5 years was 57.7% and 74.4%. Independent adverse factors for PFS were previous surgery (hazard ratio [HR] 2.261; P = 0.028), increased lesion size (HR, 1.298; P = 0.026), extent of surgical resection (HR, 3.226; P < 0.001), malignant pathology (HR, 2.018; P = 0.003), and postoperative radiotherapy (HR, 3.246; P = 0.001). The stereotactic radiosurgery subgroup presented best 5-year PFS of 88.9%, and a linear accelerator prolonged the mean PFS time (57.0 months) compared with no radiation (38.1 months). In the incomplete resection subgroup (n = 63), radiotherapy significantly benefited tumor control (HR, 2.101; P = 0.016). Extent of surgical resection (HR, 1.797; P = 0.026) and malignant disease (HR, 1.717; P = 0.030) were associated with OS. CONCLUSIONS Intracranial CSAs were not completely amendable by surgery alone. Gross total resection as far as possible plus radiation were necessary for mesenchymal CSA and conventional CSA with active growth or residual tumor. Stereotactic radiosurgery was an alternative if proton therapy was unavailable. A future study with a large cohort is required to verify our findings.
Collapse
|
6
|
Tatman PD, Osbun J, Yakkioui Y, Kaur S, Parada C, Busald T, Born D, Ahmad O, Zhang J, Ferreira M. Kinase Activity in Recurring Primary Skull Base Chordomas and Chondrosarcomas: Identification of Novel Pathways of Oncogenesis and Potential Drug Targets. World Neurosurg 2017. [PMID: 28647652 DOI: 10.1016/j.wneu.2017.06.106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Chordomas and chondrosarcomas can occur in the skull base. Currently, 45% of chordomas and 56% of chondrosarcomas recur within 5 years of surgery. The role of adjuvant therapy is highly debated. No pharmacotherapies have been approved by the U.S. Food and Drug Administration for chordomas or chondrosarcomas. High propensity for recurrence and lack of definitive adjuvant therapy necessitate additional basic science research to identify molecular anomalies associated with recurrent disease. METHODS We pooled tumor lysates from patients based on clinical criteria into 4 groups: primary chordomas, primary chordomas that recurred, primary chondrosarcomas, and primary chondrosarcomas that recurred. We used a peptide labeling method, isobaric tags for relative and absolute quantitation, to uniquely identify each tumor group. Phosphorylated peptides were identified and quantified via mass spectroscopy to determine and predict active kinases. RESULTS Six groups of phosphorylated peptides were associated with primary tumors that later recurred. Specific kinases associated with primary chordomas that recurred were FES and FER. Specific kinases associated with primary chondrosarcomas that recurred were FES, FER, SRC family kinases, PKC, ROCK, and mitogen-activated protein kinase signaling (JNK, ERK1, p38). CONCLUSIONS These data provide clinicians with a means to screen skull base chordomas and chondrosarcomas to help identify tumors with a propensity to recur. Many of these kinases can be efficaciously inhibited by Food and Drug Administration-approved drugs that have not yet been used in clinical trials for treatment of skull base chordomas or chondrosarcomas. Validation of kinases identified in this study may advance treatment options for patients with these tumors.
Collapse
Affiliation(s)
- Philip D Tatman
- Medical Scientist Training Program, University of Colorado, Aurora, Colorado, USA; Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Joshua Osbun
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA; Department of Neurological Surgery, Emory, Atlanta, Georgia, USA
| | - Youssef Yakkioui
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA; Department of Neurological Surgery, Maastricht University, Maastricht, The Netherlands
| | - Sumanpret Kaur
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Carolina Parada
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Tina Busald
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Donald Born
- Department of Neuropathology, Stanford, California, USA
| | - Owais Ahmad
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Jing Zhang
- Department of Neuropathology, University of Washington, Seattle, Washington, USA
| | - Manuel Ferreira
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.
| |
Collapse
|
7
|
Colia V, Provenzano S, Hindi N, Casali PG, Stacchiotti S. Systemic therapy for selected skull base sarcomas: Chondrosarcoma, chordoma, giant cell tumour and solitary fibrous tumour/hemangiopericytoma. Rep Pract Oncol Radiother 2016; 21:361-9. [PMID: 27330421 DOI: 10.1016/j.rpor.2015.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 07/10/2015] [Accepted: 12/18/2015] [Indexed: 12/14/2022] Open
Abstract
This review highlights the data currently available on the activity of systemic therapy in chondrosarcoma, chordoma, giant cell tumour of the bone (GCTB) and solitary fibrous tumour, i.e., four rare sarcomas amongst mesenchymal malignancy arising from the skull base.
Collapse
Affiliation(s)
- Vittoria Colia
- Adult Mesenchymal Tumour & Rare Cancer Medical Oncology Unit, Cancer Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Salvatore Provenzano
- Adult Mesenchymal Tumour & Rare Cancer Medical Oncology Unit, Cancer Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Nadia Hindi
- Adult Mesenchymal Tumour & Rare Cancer Medical Oncology Unit, Cancer Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Paolo G Casali
- Adult Mesenchymal Tumour & Rare Cancer Medical Oncology Unit, Cancer Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Silvia Stacchiotti
- Adult Mesenchymal Tumour & Rare Cancer Medical Oncology Unit, Cancer Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| |
Collapse
|
8
|
Iyer A, Kano H, Kondziolka D, Liu X, Flickinger JC, Lunsford LD. Postsurgical management strategies in patients with skull base chondrosarcomas. CNS Oncol 2015; 2:203-8. [PMID: 25057979 DOI: 10.2217/cns.13.3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Chondrosarcomas of the skull base are rare, slow-growing tumors that are often lethal and remain a management quandary. A systematic review was performed to understand postsurgical management options for patients with these tumors. The current standard of care includes surgical resection followed by either adjuvant radiation therapy and/or early radiosurgery. The role of chemotherapy has been limited, but remains under investigation. Overall survival and progression-free survival range between 70 and 100% at 5 years when multimodality approaches are used. Overall survival may be greater for patients who have a shorter interval (<6 months) between diagnosis and radiosurgery, an older age, and either a single or no prior resection. Progression-free survival may be increased for patients older than 40 years of age, who have not had prior radiation therapy, and for those with smaller tumors that do not compress the brainstem.
Collapse
Affiliation(s)
- Aditya Iyer
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | | | | | | |
Collapse
|
9
|
Safaee M, Clark AJ, Tihan T, Parsa AT, Bloch O. Falcine and parasagittal chondrosarcomas. J Clin Neurosci 2013; 20:1232-6. [PMID: 23759737 DOI: 10.1016/j.jocn.2013.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 01/10/2013] [Indexed: 10/26/2022]
Abstract
Intracranial chondrosarcomas are primary cartilaginous neoplasms that represent 6% of all skull base tumors. Intracranial extraskeletal chondrosarcomas are more rare, often arising from the meninges at the falx, tentorium, or cerebral convexity. They are generally characterized as classical or mesenchymal, with the latter associated with worse outcomes. We present our institutional series of falcine and parasagittal chondrosarcomas along with a review of the literature. Although skull base chondrosarcomas pose significant challenges due to their invasive biology and proximity to vital brainstem structures and cranial nerves, intracranial extraskeletal chondrosarcomas are generally associated with a good prognosis. Our review of the literature identified 29 patients with falcine and parasagittal chondrosarcomas. There were six recurrences, five among patients with the mesenchymal subtype and one in a patient with the classical subtype. All deaths occurred in patients with the mesenchymal subtype. Management of skull base chondrosarcomas is controversial but extraskeletal intracranial tumors can generally be managed by surgical resection alone. Treatment should be tailored to the biology of the tumor, with radiation therapy reserved for patients with the mesenchymal subtype.
Collapse
Affiliation(s)
- Michael Safaee
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Ave., Room 779M, San Francisco, CA 94143-0112, USA
| | | | | | | | | |
Collapse
|
10
|
Abstract
Chondrosarcomas are indolent but invasive chondroid malignancies that can form in the skull base. Standard management of chondrosarcoma involves surgical resection and adjuvant radiation therapy. This review evaluates evidence from the literature to assess the importance of the surgical approach and extent of resection on outcomes for patients with skull base chondrosarcoma. Also evaluated is the ability of the multiple modalities of radiation therapy, such as conventional fractionated radiotherapy, proton beam, and stereotactic radiosurgery, to control tumor growth. Finally, emerging therapies for the treatment of skull-base chondrosarcoma are discussed.
Collapse
Affiliation(s)
- Orin Bloch
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94143-0112, USA
| | | |
Collapse
|
11
|
|
12
|
Primary orbital mesenchymal chondrosarcoma: case report and review of the literature. Case Rep Med 2012; 2012:292147. [PMID: 22761622 PMCID: PMC3385622 DOI: 10.1155/2012/292147] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 04/19/2012] [Indexed: 11/24/2022] Open
Abstract
Orbital mesenchymal chondrosarcoma is a very uncommon lesion of the bone and extraskeletal tissue. To our knowledge, approximately 30 cases have been described. We present the case of a 52-year-old male who presented with a history of progressive proptosis and chemosis of the right eye caused by an orbital tumor. He underwent exenteration of the right orbit, and the histological examination revealed a mesenchymal orbital chondrosarcoma. This paper attempts to describe a rare entity that should be considered in the differential diagnosis of calcified orbital lesions, especially in young adults. Complete removal of the tumor is the mainstay of treatment, but adjuvant radiation therapy and chemotherapy should be considered.
Collapse
|