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Barrett JR, Rendell V, Pokrzywa C, Lopez-Aguiar AG, Cannon J, Poultsides GA, Rocha F, Crown A, Beal E, Pawlik TM, Fields R, Panni RZ, Smith P, Idrees K, Cho C, Beems M, Maithel S, Weber S, Abbott DE. Adjuvant therapy following resection of gastroenteropancreatic neuroendocrine tumors provides no recurrence or survival benefit. J Surg Oncol 2020; 121:1067-1073. [PMID: 32153032 PMCID: PMC7279693 DOI: 10.1002/jso.25896] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 02/16/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Lack of high-level evidence supporting adjuvant therapy for patients with resected gastroenteropancreatic neuroendocrine tumors (GEP NETs) warrants an evaluation of its non-standard of care use. METHODS Patients with primary GEP NETs who underwent curative-intent resection at eight institutions between 2000 and 2016 were identified; 91 patients received adjuvant therapy. Recurrence-free survival (RFS) and overall survival (OS) were compared between adjuvant cytotoxic chemotherapy and somatostatin analog cohorts. RESULTS In resected patients, 33 received cytotoxic chemotherapy, and 58 received somatostatin analogs. Five-year RFS/OS was 49% and 83%, respectively. Cytotoxic chemotherapy RFS/OS was 36% and 61%, respectively, lower than the no therapy cohort (P < .01). RFS with somatostatin analog therapy (compared to none) was lower (P < .01), as was OS (P = .01). On multivariable analysis, adjuvant cytotoxic therapy was negatively associated with RFS but not OS controlling for patient/tumor-specific characteristics (RFS P < .01). CONCLUSIONS Our data, reflecting the largest reported experience to date, demonstrate that adjuvant therapy for resected GEP NETs is negatively associated with RFS and confers no OS benefit. Selection bias enriching our treatment cohort for individuals with unmeasured high-risk characteristics likely explains some of these results; future studies should focus on patient subsets who may benefit from adjuvant therapy.
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Affiliation(s)
- James R Barrett
- University of Wisconsin-Madison, Department of Surgery, Madison, WI
| | - Victoria Rendell
- University of Wisconsin-Madison, Department of Surgery, Madison, WI
| | | | | | - John Cannon
- Stanford University, Department of Surgery, Stanford, CA
| | | | - Flavio Rocha
- Virginia Mason Medical Center, Department of Surgery, Seattle, WA
| | - Angelena Crown
- Virginia Mason Medical Center, Department of Surgery, Seattle, WA
| | - Eliza Beal
- The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH
| | | | - Ryan Fields
- Washington University in St. Louis, Department of Surgery, St Louis, MO
| | - Roheena Z Panni
- Washington University in St. Louis, Department of Surgery, St Louis, MO
| | - Paula Smith
- Vanderbilt University Medical Center, Department of Surgery, Nashville, TN
| | - Kamran Idrees
- Vanderbilt University Medical Center, Department of Surgery, Nashville, TN
| | - Clifford Cho
- University of Michigan, Department of Surgery, Ann Arbor, MI
| | - Megan Beems
- University of Michigan, Department of Surgery, Ann Arbor, MI
| | - Shishir Maithel
- Emory University, Department of Surgery, Winship Cancer Institute, Atlanta, GA
| | - Sharon Weber
- University of Wisconsin-Madison, Department of Surgery, Madison, WI
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Naraev BG, Halland M, Halperin DM, Purvis AJ, O'Dorisio TM, Halfdanarson TR. Management of Diarrhea in Patients With Carcinoid Syndrome. Pancreas 2019; 48:961-972. [PMID: 31425482 PMCID: PMC6867674 DOI: 10.1097/mpa.0000000000001384] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 07/10/2019] [Indexed: 02/06/2023]
Abstract
Neuroendocrine tumors (NETs) arise from enterochromaffin cells found in neuroendocrine tissues, with most occurring in the gastrointestinal tract. The global incidence of NETs has increased in the past 15 years, likely due to better diagnostic methods. Small-bowel NETs are frequently associated with carcinoid syndrome (CS). Carcinoid syndrome diarrhea occurs in 80% of CS patients and poses a substantial symptomatic and economic burden. Patients with CS diarrhea frequently suffer from diarrhea and flushing and report corresponding impairment in quality of life, requiring substantial changes in daily activities and lifestyle. Treatment paradigms range from surgical debulking to liver-directed therapies to treatment with somatostatin analogs, nonspecific anti-diarrheal agents, and a tryptophan hydroxylase inhibitor. Other causes of diarrhea, including steatorrhea, short bowel syndrome, and bile acid malabsorption, should be considered in NET patients with refractory diarrhea. More therapeutic options are needed for symptomatic management of patients with NETs, and better understanding of the pathophysiology can empower clinicians with improved patient care.
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Affiliation(s)
| | - Magnus Halland
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Daniel M. Halperin
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amy J. Purvis
- University of Arizona Cancer Center (UACC), Phoenix, AZ
| | - Thomas M. O'Dorisio
- Neuroendocrine Cancer Program, University of Iowa Health Care, Iowa City, IA
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Sham JG, Ejaz A, Gage MM, Bagante F, Reames BN, Maithel S, Poultsides GA, Bauer TW, Fields RC, Weiss MJ, Marques HP, Aldrighetti L, Pawlik TM, He J. The Impact of Extent of Liver Resection Among Patients with Neuroendocrine Liver Metastasis: an International Multi-institutional Study. J Gastrointest Surg 2019; 23:484-491. [PMID: 29980977 DOI: 10.1007/s11605-018-3862-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 06/22/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Liver resection in patients with neuroendocrine liver metastasis (NELM) provides a survival benefit, yet the optimal extent of resection remains unknown. We sought to examine outcomes of patients undergoing non-anatomic (NAR) versus anatomic liver resection (AR) for NELM using a large international cohort of patients. METHODS Two hundred and fifty-eight patients who underwent curative intent liver resection from January 1990 to December 2016 were identified from eight institutions. Patients were excluded if they underwent concurrent ablation, had extrahepatic disease, underwent a debulking operation, or had mixed anatomic and non-anatomic resections. Overall (OS) and recurrence-free (RFS) survival were compared among patients based on the extent of liver resection (AR vs. NAR). RESULTS Most primary tumors were located in the pancreas (n = 117, 45.4%) or the small intestine (n = 65, 25.2%). Liver resection consisted of NAR (n = 126, 48.8%) or AR (n = 132, 51.2%) resection. The overwhelming majority of patients who underwent NAR had an estimated liver involvement of < 50% (NAR 109, 97.3% vs. AR n = 82, 65.6%; P < 0.001). Patients who underwent NAR also had higher rates of primary tumor lymph node metastasis (NAR n = 79, 71.2% vs. AR n = 37, 33.6%; P < 0.001) and microscopically positive margins (R1) (NAR n = 29, 25.7% vs. AR n = 16, 12.5%; P = 0.009). After a median follow-up of 47.7 months, 48 (18.6%) patients died and 37.0% (n = 95) had evidence of disease recurrence. Patients who underwent AR had both longer median OS (not reached) and RFS (not reached) versus patients who underwent NAR (median OS 138.3 months; median RFS 31.3 months) (both P < 0.01). After controlling for patient and disease-related factors, extent of liver resection was independently associated with an increased risk of recurrence (HR 2.39, 95% CI 1.04-5.48; P = 0.04) but not death (HR 1.92, 95% CI 0.40-9.28; P = 0.42). CONCLUSION NAR was independently associated with a higher incidence of recurrence versus patients who undergo a formal anatomic hepatectomy among patients with NELM.
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Affiliation(s)
- Jonathan G Sham
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 614, Baltimore, MD, 21287, USA
| | - Aslam Ejaz
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 614, Baltimore, MD, 21287, USA
| | - Michele M Gage
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 614, Baltimore, MD, 21287, USA
| | - Fabio Bagante
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Bradley N Reames
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 614, Baltimore, MD, 21287, USA
| | | | - George A Poultsides
- Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - Todd W Bauer
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Ryan C Fields
- Department of Surgery, School of Medicine, Washington University, St. Louis, MO, USA
| | - Matthew J Weiss
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 614, Baltimore, MD, 21287, USA
| | | | - Luca Aldrighetti
- Department of Surgery, Liver Unit, Scientific Institute San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Jin He
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 614, Baltimore, MD, 21287, USA.
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Kinney MAO, Nagorney DM, Clark DF, O'Brien TD, Turner JD, Marienau ME, Schroeder DR, Martin DP. Partial hepatic resections for metastatic neuroendocrine tumors: perioperative outcomes. J Clin Anesth 2018; 51:93-96. [PMID: 30098573 DOI: 10.1016/j.jclinane.2018.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/23/2018] [Accepted: 08/03/2018] [Indexed: 10/28/2022]
Abstract
STUDY OBJECTIVE Partial hepatic resection reduces tumor burden in patients with metastatic neuroendocrine tumors, thereby improving quality and length of life. These procedures can be challenging as well as life-threatening. Our aim was to evaluate our patients' perioperative outcomes and propose a definition for an intraoperative carcinoid crisis relevant to this surgery, given its unique surgical considerations. DESIGN Retrospective study. SETTING Mayo Clinic, Rochester, Minnesota. PATIENTS One hundred sixty-nine patients undergoing partial hepatic resection for metastatic neuroendocrine tumors between 1997 and 2015 were identified retrospectively from a surgical database at Mayo Clinic Rochester. INTERVENTIONS None. MEASUREMENTS Intraoperative carcinoid crisis for patients undergoing hepatic resection of neuroendocrine tumors was defined. Patients' medical records were reviewed and data were abstracted describing patient and procedural characteristics and perioperative outcomes. MAIN RESULTS There were no documented cases of carcinoid crisis (0.0%, 95% C.I. 0.0% to 2.2%). One patient developed clinical findings of an emerging carcinoid crisis, but was successfully treated with doses of octreotide and findings resolved in <10 min. Prophylactically 500 μg octreotide was given subcutaneously in 77% (130/169) of patients preoperatively. CONCLUSIONS There were no documented cases of carcinoid crisis (0.0%, 95% C.I. 0.0% to 2.2%). Adverse events were infrequent.
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Gibson WE, Gonzalez RS, Cates JMM, Liu E, Shi C. Hepatic micrometastases are associated with poor prognosis in patients with liver metastases from neuroendocrine tumors of the digestive tract. Hum Pathol 2018; 79:109-115. [PMID: 29763717 DOI: 10.1016/j.humpath.2018.05.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 04/25/2018] [Accepted: 05/04/2018] [Indexed: 01/29/2023]
Abstract
Pathologic examination of hepatic metastasectomies from patients with metastatic small intestinal or pancreatic neuroendocrine tumor frequently reveals micrometastases undetectable by radiologic or macroscopic gross examination. This finding raises the possibility that undetectable micrometastases remain in these patients after metastasectomy. Here we examined liver resections for micrometastases and assessed their impact on prognosis. Hepatic metastasectomies from 65 patients with neuroendocrine tumor of the small intestine (N = 43) or pancreas (N = 22) were reviewed for the presence of micrometastases, which were defined as microscopic tumor foci ≤1 mm in greatest dimension. Medical records were also reviewed for patient demographics, clinical history, and follow-up data. Micrometastasis was identified in 36 (55%) of 65 hepatic resection specimens. More hepatic micrometastases were seen in small intestinal cases than in pancreatic cases (29/43, 67%, versus 7/22, 32%; P < .01). They were typically present within portal tracts, sometimes with extension into the periportal region or sinusoidal spaces away from the portal tracts. Patients without hepatic micrometastases had fewer macrometastases or more R0 hepatic resections than those with micrometastases. The presence of hepatic micrometastases was associated with poor overall survival both before (hazard ratio [HR] 3.43; 95% CI 1.14-10.30; P = .03) and after accounting for confounding variables in stratified Cox regression (HR 4.82; 95% CI 1.0621.79; P = .04). In conclusion, hepatic micrometastases are common in patients with metastatic small intestinal or pancreatic neuroendocrine tumor and are independently associated with poor prognosis. These data suggest that surgical resection of hepatic metastases is likely not curative in these patients.
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Affiliation(s)
- William E Gibson
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN 37027
| | - Raul S Gonzalez
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY 14642
| | - Justin M M Cates
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN 37027
| | - Eric Liu
- Department of Surgery, Rocky Mountain Cancer Centers, Denver, CO 80218
| | - Chanjuan Shi
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN 37027.
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Prognostic Factors Affecting Long-Term Survival after Resection for Noncolorectal, Nonneuroendocrine, and Nonsarcoma Liver Metastases. Gastroenterol Res Pract 2017; 2017:5184146. [PMID: 28811821 PMCID: PMC5546055 DOI: 10.1155/2017/5184146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 06/20/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To evaluate feasibility and long-term outcome after hepatic resection for noncolorectal, nonneuroendocrine, and nonsarcoma (NCNNNS) liver metastases in a single center. METHODS We retrospectively reviewed our experience on patients who underwent surgery for NCNNNS liver metastases from 1995 to 2015. Patient baseline characteristics, tumor features, treatment options, and postoperative outcome were retrieved. RESULTS We included 47 patients. The overall 5-year survival (OS) rate after hepatectomy was 27.6%, with a median survival of 21 months. Overall survival was significantly longer for patients operated for nongastrointestinal liver metastases when compared with gastrointestinal (41 versus 10 months; p = 0.027). OS was significantly worse in patients with synchronous metastases than in those with metachronous disease (10 versus 22 months; p = 0.021). The occurrence of major postoperative complication negatively affected long-term prognosis (OS 23.5 versus 9.0 months; p = 0.028). Preoperative tumor characteristics (number and size of the lesions), intraoperative features (extension of resection, need for transfusions, and Pringle's maneuver), and R0 at pathology were not associated with differences in overall survival. CONCLUSION Liver resection represents a possible curative option for patients with NCNNNS metastases. The origin of the primary tumor and the timing of metastases presentation may help clinicians to better select which patients could take advantages from surgical intervention.
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Hepatic Resection or Ablation for Isolated Breast Cancer Liver Metastasis: A Case-control Study With Comparison to Medically Treated Patients. Ann Surg 2017; 264:147-154. [PMID: 26445472 DOI: 10.1097/sla.0000000000001371] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate the efficacy of surgical treatment for patients with isolated breast cancer liver metastases (BCLM). BACKGROUND Single-arm retrospective studies have shown promising results associated with surgery for isolated BCLM; however, this treatment remains controversial and its role is not well-defined. METHODS A review of 2150 patients with BCLM who underwent treatment in a single institution was conducted, and 167 (8%) patients with isolated BCLM were identified. A case-control study was conducted to compare outcomes in patients with isolated BCLM who underwent surgery and/or ablation to patients who underwent conventional medical therapy. RESULTS A total of 167 patients were included (surgery/ablation: 69; medical: 98), with a median follow-up for survivors of 73 months. Patients in the surgical cohort more frequently had estrogen receptor-positive tumors and received adjuvant chemotherapy and radiotherapy for their primary breast tumor. The hepatic tumor burden was less and the interval from breast cancer diagnosis to BCLM was significantly longer (53 vs 30 months) in the surgical cohort. Patients undergoing surgical treatment had a median recurrence-free interval of 28.5 months (95% confidence interval (CI): 19-38) with 10 patients (15%) recurrence free after 5 years. There was no significant difference in overall survival (OS) between the surgical and medical cohorts (median OS: 50 vs 45 months; 5-year OS: 38% vs 39%). CONCLUSIONS Hepatic resection and/or ablation was not associated with a survival advantage. However, significant recurrence-free intervals can be accomplished with surgical treatment. Surgical intervention might be considered in highly selected patients with the goal of providing time off of systemic chemotherapy.
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Tapia Rico G, Townsend AR, Klevansky M, Price TJ. Liver metastases resection for gastric and esophageal tumors: is there enough evidence to go down this path? Expert Rev Anticancer Ther 2016; 16:1219-1225. [PMID: 27744727 DOI: 10.1080/14737140.2016.1249858] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Surgical resection of liver metastases from colorectal and neuroendocrine tumours has become a standard of care for resectable patients with isolated hepatic disease and good performance status, leading to extended survival in a carefully selected subgroup of these patients. However, the role of hepatic surgery in gastric and oesophageal liver metastases is controversial and not clearly defined. Areas covered:a systematic electronic literature search was performed to select the most representative evidence regarding hepatectomies in liver metastases from these two tumours. PubMed, Medline, Embase Ovid and Google Scholar databases were scanned for articles written in English and published in peer-reviewed journals between 1994 and May 2016. Expert commentary: Given the shortage of randomised studies and the limited number of patients in many of the studies discussed here, the evidence base for the use of hepatectomies in these settings is not strong. Thus, while the data for resections of gastric liver metastases may in particular seem encouraging, the results should be interpreted with caution.
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Affiliation(s)
- Gonzalo Tapia Rico
- a Department of Medical Oncology , The Queen Elizabeth Hospital , Adelaide , SA , Australia
| | - Amanda R Townsend
- a Department of Medical Oncology , The Queen Elizabeth Hospital , Adelaide , SA , Australia.,b University of Adelaide , Adelaide , SA , Australia
| | - Myron Klevansky
- a Department of Medical Oncology , The Queen Elizabeth Hospital , Adelaide , SA , Australia
| | - Timothy J Price
- a Department of Medical Oncology , The Queen Elizabeth Hospital , Adelaide , SA , Australia.,b University of Adelaide , Adelaide , SA , Australia
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Uggeri F, Ronchi PA, Goffredo P, Garancini M, Degrate L, Nespoli L, Gianotti L, Romano F. Metastatic liver disease from non-colorectal, non-neuroendocrine, non-sarcoma cancers: a systematic review. World J Surg Oncol 2015; 13:191. [PMID: 26022107 PMCID: PMC4455532 DOI: 10.1186/s12957-015-0606-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 05/20/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Hepatic resection of liver metastases of non-colorectal, non-neuroendocrine, and non-sarcoma (NCNNNS) primary malignancies seems to improve survival in selected patients. The aims of the current review were to describe long-term results of surgery and to evaluate prognostic factors for survival in patients who underwent resection of NCNNNS liver metastases. METHODS We identified 30 full texts (25 single-center and 5 multicenter studies) published after year 1995 and published in English with a total of 3849 patients. For NCNNNS liver metastases, 83.4 % of these subjects were resected. RESULTS No prior systematic reviews or meta-analyses on this topic were identified. All studies were case series without matching control groups. The most common primary sites were breast (23.8 %), genito-urinary (21.8 %), and gastrointestinal tract (19.8 %). The median 5- and 10-year overall survival were 32.3 % (range 19-42 %) and 24 % (indicated only in two studies, range 23-25 %), respectively, with 71 % of R0 resections. CONCLUSIONS There is evidence suggesting that surgery of NCNNNS metastases is safe, feasible, and effective if treatment is part of a multidisciplinary approach and if indication is based on the prognostic factors underlined in literature analysis.
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Affiliation(s)
- Fabio Uggeri
- Department of Surgery and Translational Medicine, University of Milano-Bicocca, San Gerardo Hospital, via Pergolesi 33, Monza, 20900, Italy.
| | | | | | - Mattia Garancini
- Department of Surgery, San Gerardo Hospital, via Pergolesi 33, Monza, 20900, Italy.
| | - Luca Degrate
- Department of Surgery, San Gerardo Hospital, via Pergolesi 33, Monza, 20900, Italy.
| | - Luca Nespoli
- Department of Surgery and Translational Medicine, University of Milano-Bicocca, San Gerardo Hospital, via Pergolesi 33, Monza, 20900, Italy.
| | - Luca Gianotti
- Department of Surgery and Translational Medicine, University of Milano-Bicocca, San Gerardo Hospital, via Pergolesi 33, Monza, 20900, Italy.
| | - Fabrizio Romano
- Department of Surgery and Translational Medicine, University of Milano-Bicocca, San Gerardo Hospital, via Pergolesi 33, Monza, 20900, Italy.
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