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Yano K, Yotsukura M, Watanabe H, Akamine T, Yoshida Y, Nakagawa K, Yatabe Y, Kusumoto M, Watanabe SI. Oncological feasibility of segmentectomy for inner-located lung cancer. JTCVS OPEN 2024; 18:261-275. [PMID: 38690420 PMCID: PMC11056493 DOI: 10.1016/j.xjon.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 01/27/2024] [Accepted: 02/11/2024] [Indexed: 05/02/2024]
Abstract
Objective Oncological feasibility of segmentectomy for internal non-small cell lung cancer (NSCLC) has not been assessed adequately. We assessed the oncological feasibility of segmentectomy for inner-located NSCLC by investigating surgical margins and patient prognosis after undergoing the procedure. Methods Of the 3555 patients who underwent resection for lung cancer between 2013 and 2019 at our institution, 659 patients who underwent segmentectomy for clinical stage 0 to stage1A NSCLC were included in this study. Patients were separated into 2 groups according to whether the tumor was in the inner or outer third of the lung area. Clinical characteristics and prognoses were retrospectively compared between the groups. Results Of the included 659 cases, 183 (27.8%) were inner-located, and 476 (72.2%) had outer-located NSCLC. The surgical margin was significantly shorter in the inner-located group than in the outer group (median, 16 vs 25 mm; P < .001). The 5-year recurrence-free survival and overall survival probabilities were 91.1%/91.8% (P = .530) and 94.1%/95.6% (P = .345) for inner/outer-located groups, respectively. Multivariate analysis showed that clinical stage IA2 or 3 (P = .043), lymphovascular invasion (P < .001), and surgical margins <20 mm (P = .017) were independent prognostic factors for recurrence-free survival. The location of the inner or outer tumors was not related to the prognosis. Conclusions For clinical stage 0 to stage1A NSCLC, tumor location in the inner two-thirds of the lung was not associated with prognosis after segmentectomy. Because one of the independent prognostic factors is margin distance, segmentectomy for inner-located NSCLC would be oncologically acceptable when an adequate surgical margin is secured.
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Affiliation(s)
- Kaito Yano
- Department of Thoracic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Masaya Yotsukura
- Department of Thoracic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Hirokazu Watanabe
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Takaki Akamine
- Department of Thoracic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yukihiro Yoshida
- Department of Thoracic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Kazuo Nakagawa
- Department of Thoracic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yasushi Yatabe
- Department of Diagnostic Pathology, National Cancer Center Hospital, Tokyo, Japan
| | - Masahiko Kusumoto
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Shun-ichi Watanabe
- Department of Thoracic Surgery, National Cancer Center Hospital, Tokyo, Japan
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Meacci E, Refai M, Nachira D, Salati M, Kuzmych K, Tabacco D, Zanfrini E, Calabrese G, Napolitano AG, Congedo MT, Chiappetta M, Petracca-Ciavarella L, Sassorossi C, Andolfi M, Xiumè F, Tiberi M, Guiducci GM, Vita ML, Roncon A, Nanto AC, Margaritora S. Uniportal Video-Assisted Thoracoscopic Surgery Completion Lobectomy Long after Wedge Resection or Segmentectomy in the Same Lobe: A Bicenter Study. Cancers (Basel) 2024; 16:1286. [PMID: 38610964 PMCID: PMC11011079 DOI: 10.3390/cancers16071286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Completion lobectomy (CL) following a prior resection in the same lobe may be complicated by severe pleural or hilar adhesions. The role of uniportal video-assisted thoracoscopic surgery (U-VATS) has never been evaluated in this setting. METHODS Data were collected from two Italian centers. Between 2015 and 2022, 122 patients (60 men and 62 women, median age 67.7 ± 8.913) underwent U-VATS CL at least 4 weeks after previous lung surgery. RESULTS Twenty-eight (22.9%) patients were affected by chronic obstructive pulmonary disease (COPD) and twenty-five (20.4%) were active smokers. Among the cohort, the initial surgery was performed using U-VATS in 103 (84.4%) patients, triportal-VATS in 8 (6.6%), and thoracotomy in 11 (9.0%). Anatomical segmentectomy was the initial surgery in 46 (37.7%) patients, while hilar lymphadenectomy was performed in 16 (13.1%) cases. CL was performed on 110 (90.2%) patients, segmentectomy on 10 (8.2%), and completion pneumonectomy on 2 (1.6%). Upon reoperation, moderate pleural adhesions were observed in 38 (31.1%) patients, with 2 (1.6%) exhibiting strong adhesions. Moderate hilar adhesions were found in 18 (14.8%) patients and strong adhesions in 11 (9.0%). The median operative time was 203.93 ± 74.4 min. In four (3.3%) patients, PA taping was performed. One patient experienced intraoperative bleeding that did not require conversion to thoracotomy. Conversion to thoracotomy was necessary in three (2.5%) patients. The median postoperative drainage stay and postoperative hospital stay were 5.67 ± 4.44 and 5.52 ± 2.66 days, respectively. Postoperative complications occurred in 34 (27.9%) patients. Thirty-day mortality was null. Histology was the only factor found to negatively influence intraoperative outcomes (p = 0.000). Factors identified as negatively impacting postoperative outcomes at univariate analyses were male sex (p = 0.003), age > 60 years (p = 0.003), COPD (p = 0.014), previous thoracotomy (p = 0.000), previous S2 segmentectomy (p = 0.001), previous S8 segmentectomy (p = 0.008), and interval between operations > 5 weeks (p= 0.005). In multivariate analysis, only COPD confirmed its role as an independent risk factor for postoperative complications (HR: 5.12, 95% CI (1.07-24.50), p = 0.04). CONCLUSIONS U-VATS CL seems feasible and safe after wedge resection and anatomical segmentectomy.
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Affiliation(s)
- Elisa Meacci
- Department of General Thoracic Surgery, Fondazione Policlinico Gemelli IRCCS, Catholic University of Sacred Heart of Rome, 00168 Rome, Italy; (K.K.); (D.T.); (G.C.); (A.G.N.); (M.T.C.); (M.C.); (L.P.-C.); (C.S.); (M.L.V.); (S.M.)
| | - Majed Refai
- Department of Thoracic Surgery, Ospedali Riuniti, 60126 Ancona, Italy; (M.R.); (M.S.); (M.A.); (F.X.); (M.T.); (G.M.G.); (A.R.); (A.C.N.)
| | - Dania Nachira
- Department of General Thoracic Surgery, Fondazione Policlinico Gemelli IRCCS, Catholic University of Sacred Heart of Rome, 00168 Rome, Italy; (K.K.); (D.T.); (G.C.); (A.G.N.); (M.T.C.); (M.C.); (L.P.-C.); (C.S.); (M.L.V.); (S.M.)
| | - Michele Salati
- Department of Thoracic Surgery, Ospedali Riuniti, 60126 Ancona, Italy; (M.R.); (M.S.); (M.A.); (F.X.); (M.T.); (G.M.G.); (A.R.); (A.C.N.)
| | - Khrystyna Kuzmych
- Department of General Thoracic Surgery, Fondazione Policlinico Gemelli IRCCS, Catholic University of Sacred Heart of Rome, 00168 Rome, Italy; (K.K.); (D.T.); (G.C.); (A.G.N.); (M.T.C.); (M.C.); (L.P.-C.); (C.S.); (M.L.V.); (S.M.)
| | - Diomira Tabacco
- Department of General Thoracic Surgery, Fondazione Policlinico Gemelli IRCCS, Catholic University of Sacred Heart of Rome, 00168 Rome, Italy; (K.K.); (D.T.); (G.C.); (A.G.N.); (M.T.C.); (M.C.); (L.P.-C.); (C.S.); (M.L.V.); (S.M.)
| | - Edoardo Zanfrini
- Service of Thoracic Surgery, University Hospital of Lausanne, 1005 Lausanne, Switzerland;
| | - Giuseppe Calabrese
- Department of General Thoracic Surgery, Fondazione Policlinico Gemelli IRCCS, Catholic University of Sacred Heart of Rome, 00168 Rome, Italy; (K.K.); (D.T.); (G.C.); (A.G.N.); (M.T.C.); (M.C.); (L.P.-C.); (C.S.); (M.L.V.); (S.M.)
| | - Antonio Giulio Napolitano
- Department of General Thoracic Surgery, Fondazione Policlinico Gemelli IRCCS, Catholic University of Sacred Heart of Rome, 00168 Rome, Italy; (K.K.); (D.T.); (G.C.); (A.G.N.); (M.T.C.); (M.C.); (L.P.-C.); (C.S.); (M.L.V.); (S.M.)
| | - Maria Teresa Congedo
- Department of General Thoracic Surgery, Fondazione Policlinico Gemelli IRCCS, Catholic University of Sacred Heart of Rome, 00168 Rome, Italy; (K.K.); (D.T.); (G.C.); (A.G.N.); (M.T.C.); (M.C.); (L.P.-C.); (C.S.); (M.L.V.); (S.M.)
| | - Marco Chiappetta
- Department of General Thoracic Surgery, Fondazione Policlinico Gemelli IRCCS, Catholic University of Sacred Heart of Rome, 00168 Rome, Italy; (K.K.); (D.T.); (G.C.); (A.G.N.); (M.T.C.); (M.C.); (L.P.-C.); (C.S.); (M.L.V.); (S.M.)
| | - Leonardo Petracca-Ciavarella
- Department of General Thoracic Surgery, Fondazione Policlinico Gemelli IRCCS, Catholic University of Sacred Heart of Rome, 00168 Rome, Italy; (K.K.); (D.T.); (G.C.); (A.G.N.); (M.T.C.); (M.C.); (L.P.-C.); (C.S.); (M.L.V.); (S.M.)
| | - Carolina Sassorossi
- Department of General Thoracic Surgery, Fondazione Policlinico Gemelli IRCCS, Catholic University of Sacred Heart of Rome, 00168 Rome, Italy; (K.K.); (D.T.); (G.C.); (A.G.N.); (M.T.C.); (M.C.); (L.P.-C.); (C.S.); (M.L.V.); (S.M.)
| | - Marco Andolfi
- Department of Thoracic Surgery, Ospedali Riuniti, 60126 Ancona, Italy; (M.R.); (M.S.); (M.A.); (F.X.); (M.T.); (G.M.G.); (A.R.); (A.C.N.)
| | - Francesco Xiumè
- Department of Thoracic Surgery, Ospedali Riuniti, 60126 Ancona, Italy; (M.R.); (M.S.); (M.A.); (F.X.); (M.T.); (G.M.G.); (A.R.); (A.C.N.)
| | - Michela Tiberi
- Department of Thoracic Surgery, Ospedali Riuniti, 60126 Ancona, Italy; (M.R.); (M.S.); (M.A.); (F.X.); (M.T.); (G.M.G.); (A.R.); (A.C.N.)
| | - Gian Marco Guiducci
- Department of Thoracic Surgery, Ospedali Riuniti, 60126 Ancona, Italy; (M.R.); (M.S.); (M.A.); (F.X.); (M.T.); (G.M.G.); (A.R.); (A.C.N.)
| | - Maria Letizia Vita
- Department of General Thoracic Surgery, Fondazione Policlinico Gemelli IRCCS, Catholic University of Sacred Heart of Rome, 00168 Rome, Italy; (K.K.); (D.T.); (G.C.); (A.G.N.); (M.T.C.); (M.C.); (L.P.-C.); (C.S.); (M.L.V.); (S.M.)
| | - Alberto Roncon
- Department of Thoracic Surgery, Ospedali Riuniti, 60126 Ancona, Italy; (M.R.); (M.S.); (M.A.); (F.X.); (M.T.); (G.M.G.); (A.R.); (A.C.N.)
| | - Anna Chiara Nanto
- Department of Thoracic Surgery, Ospedali Riuniti, 60126 Ancona, Italy; (M.R.); (M.S.); (M.A.); (F.X.); (M.T.); (G.M.G.); (A.R.); (A.C.N.)
| | - Stefano Margaritora
- Department of General Thoracic Surgery, Fondazione Policlinico Gemelli IRCCS, Catholic University of Sacred Heart of Rome, 00168 Rome, Italy; (K.K.); (D.T.); (G.C.); (A.G.N.); (M.T.C.); (M.C.); (L.P.-C.); (C.S.); (M.L.V.); (S.M.)
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Lee CE, Yun J, Jeon YJ, Lee J, Park SY, Cho JH, Kim HK, Choi YS, Kim J, Shim YM. Outcomes of Completion Lobectomy for Locoregional Recurrence after Sublobar Resection in Patients with Non-small Cell Lung Cancer. J Chest Surg 2024; 57:128-135. [PMID: 38228499 DOI: 10.5090/jcs.23.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/02/2023] [Accepted: 11/21/2023] [Indexed: 01/18/2024] Open
Abstract
Background This retrospective study aimed to determine the treatment patterns and the surgical and oncologic outcomes after completion lobectomy (CL) in patients with locoregionally recurrent stage I non-small cell lung cancer (NSCLC) who previously underwent sublobar resection. Methods Data from 36 patients who initially underwent sublobar resection for clinical, pathological stage IA NSCLC and experienced locoregional recurrence between 2008 and 2016 were analyzed. Results Thirty-six (3.6%) of 1,003 patients who underwent sublobar resection for NSCLC experienced locoregional recurrence. The patients' median age was 66.5 (range, 44-77) years at the initial operation, and 28 (77.8%) patients were men. Six (16.7%) patients underwent segmentectomy and 30 (83.3%) underwent wedge resection as the initial operation. The median follow-up from the initial operation was 56 (range, 9-150) months. Ten (27.8%) patients underwent CL, 22 (61.1%) underwent non-surgical treatments (chemotherapy, radiation, concurrent chemoradiation therapy), and 4 (11.1%) did not receive treatment or were lost to follow-up after recurrence. Patients who underwent CL experienced no significant complications or deaths. The median follow-up time after CL was 64.5 (range, 19-93) months. The 5-year overall survival (OS) and post-recurrence survival (PRS) were higher in the surgical group than in the non-surgical (p<0.001) and no-treatment groups (p<0.001). Conclusion CL is a technically demanding but safe procedure for locoregionally recurrent stage I NSCLC after sublobar resection. Patients who underwent CL had better OS and PRS than patients who underwent non-surgical treatments or no treatments; however, a larger cohort study and long-term surveillance are necessary.
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Affiliation(s)
- Cho Eun Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeonghee Yun
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yeong Jeong Jeon
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Junghee Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Yong Park
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jhingook Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Piccoli J, Seitlinger J, Streit A, Wollbrett C, Siat J, Renaud S. Place of robotic surgery in completion lobectomy after anatomical segmentectomy. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad137. [PMID: 37572306 PMCID: PMC10663049 DOI: 10.1093/icvts/ivad137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/11/2023] [Accepted: 08/11/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVES Although segmentectomy is steadily increasing in early-stage non-small-cell lung cancer, recurrence in the ipsilateral lobe is also increasing. Completion lobectomy (CL) is a challenging procedure that has already been described in a few studies using video-assisted thoracic surgery or thoracotomy. In this study, we aimed to show the feasibility and safety of robot-assisted thoracic surgery in cases of CL. METHODS Among 2073 major resections performed between January 2018 and september 2022 in the Department of Thoracic Surgery at Nancy University Regional Hospital, we retrospectively included patients who underwent CL by robot-assisted thoracic surgery after previous segmentectomy for non-small-cell lung cancer. Data and perioperative results were described and analysed. RESULTS Seventeen patients underwent CL with a median recurrence time after previous segmentectomy of 18 months [interquartile range (IQR): 12]. Four patients (23.5%) had a pulmonary artery injury that was controlled, and no conversion to open thoracotomy was needed. The operative time was 150 min (IQR: 20), and blood loss was 300 ml (IQR: 150). The median postoperative chest tube duration was 2 days (IQR: 1), and the length of hospital stay was 3 days (IQR: 3), with no postoperative deaths. CONCLUSIONS Completion lobectomy is a challenging procedure due to severe adhesions surrounding vessels, which potentially could cause higher rate of PA bleeding than conventional surgeries. With experienced team and surgeons, CL with robotic surgery may be reported as a safe and feasible procedure.
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Affiliation(s)
- Juliette Piccoli
- Department of Cardiac Surgery, Nancy Regional University Hospital, Institut Lorrain du Cœur et des Vaisseaux. Rue du Morvan, Vandœuvre-lès-Nancy, France
| | - Joseph Seitlinger
- Department of Thoracic Surgery, Nancy Regional University Hospital, Institut Lorrain du Cœur et des Vaisseaux. Rue du Morvan, Vandœuvre-lès-Nancy, France
| | - Arthur Streit
- Department of Thoracic Surgery, Nancy Regional University Hospital, Institut Lorrain du Cœur et des Vaisseaux. Rue du Morvan, Vandœuvre-lès-Nancy, France
| | - Christophe Wollbrett
- Department of Thoracic Surgery, Nancy Regional University Hospital, Institut Lorrain du Cœur et des Vaisseaux. Rue du Morvan, Vandœuvre-lès-Nancy, France
| | - Joelle Siat
- Department of Thoracic Surgery, Nancy Regional University Hospital, Institut Lorrain du Cœur et des Vaisseaux. Rue du Morvan, Vandœuvre-lès-Nancy, France
| | - Stéphane Renaud
- Department of Thoracic Surgery, Nancy Regional University Hospital, Institut Lorrain du Cœur et des Vaisseaux. Rue du Morvan, Vandœuvre-lès-Nancy, France
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Liu YW, Kao CN, Chiang HH, Lee JY, Li HP, Chang PC, Chou SH. Pulmonary completion lobectomy after segmentectomy: An integrated analysis of perioperative outcomes. Thorac Cancer 2022; 13:2331-2339. [PMID: 35790895 PMCID: PMC9376176 DOI: 10.1111/1759-7714.14565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 11/27/2022] Open
Abstract
Background Completion lobectomy (CL) after anatomical segmentectomy is technically challenging and rarely performed. Here, we aimed to report perioperative outcomes of a single center real‐world CL data. Methods Seven patients who underwent CL after segmentectomy were retrospectively evaluated between 2015–2021. Additionally, 34 patients were included in the review based on relevant studies in the literature until March 2022. A total of 41 patients were finally analyzed and classified into groups, according to surgical approach (video‐assisted thoracic surgery [VATS] and thoracotomy; 12 and 29 patients, respectively) or interval‐to‐CL following initial segmentectomy (≤8 weeks [short] and >8 weeks [long]; 11 and 30 patients, respectively). Results There were no significant differences in estimated blood loss, postoperative hospital stay, or complications between the predefined groups. However, a longer operative time was observed in the long interval‐to‐CL group than in the short interval‐to‐CL group (267 vs. 226 min, p = 0.02). The rate of severe hilar adhesions was higher in the thoracotomy versus VATS groups (72 vs. 42%, p = 0.06) and in the long versus short interval‐to‐CL groups (70 vs. 45%, p = 0.15). On multivariable logistic regression analysis of a subgroup (n = 30), completion lobectomy of upper lobes may be associated with severe hilar adhesions (p = 0.02, odds ratio: 13.98; 95% confidence interval [CI]: 1.36–143.71). Conclusion Completion lobectomy after segmentectomy can be performed securely by either VATS or thoracotomy. Although the thoracotomy and long interval‐to‐CL groups retained a greater percentage of severe hilar adhesions, the perioperative outcomes were similar to those of VATS and short interval‐to‐CL groups, respectively.
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Affiliation(s)
- Yu-Wei Liu
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,PhD Program in Environmental and Occupational Medicine, College of Medicine, Kaohsiung Medical University, National Health Research Institutes, Kaohsiung, Taiwan
| | - Chieh-Ni Kao
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Hsing Chiang
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,PhD Program in Environmental and Occupational Medicine, College of Medicine, Kaohsiung Medical University, National Health Research Institutes, Kaohsiung, Taiwan
| | - Jui-Ying Lee
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsien-Pin Li
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Chih Chang
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shah-Hwa Chou
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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