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Zuo P, Li T, Sun T, Wu W, Wang Y, Zhang M, Wu Z, Zhang J, Zhang L. Clinical features and surgical outcomes of high grade pleomorphic xanthoastrocytomas: a single-center experience with a systematic review. Front Oncol 2023; 13:1193611. [PMID: 37448517 PMCID: PMC10338055 DOI: 10.3389/fonc.2023.1193611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 06/16/2023] [Indexed: 07/15/2023] Open
Abstract
Purpose High grade pleomorphic xanthoastrocytomas (HGPXAs) are very rare and their management and prognostic outcomes remain unclear. To better understand the disease, we aimed to evaluate the risk factors for progression-free survival (PFS) and overall survival (OS), and propose a treatment protocol based on cases from our institute and cases from the literature. Methods The authors reviewed the clinical data of 26 patients with HGPXAs who underwent surgical treatment in Department of Neurosurgery of Beijing Tiantan Hospital between August 2014 and September 2021. We also searched the PubMed database using the keywords "anaplastic" combined with "pleomorphic xanthoastrocytoma(s)" between January 1997 and October 2022. Risk factors for PFS and OS were evaluated in the pooled cases. Results The authors' cohort included 11 males and 15 females with a mean age of 36.7 ± 20.3 years (range: 5.5-71 years). Gross-total resection (GTR) and non-GTR were achieved in 17 (65.4%) and 9 (34.6%) patients, respectively. Radiotherapy and chemotherapy were administered to 22 and 20 patients, respectively. After a mean follow-up of 20.5 ± 21.2 months (range: 0.5-78.1 months), 7 patients suffered tumor recurrence and 6 patients died with a mean OS time of 19.4 ± 10.8 months (range: 8-36 months). In the literature between January 1997 and October 2022, 56 cases of HGPXAs were identified in 29 males and 27 females with a mean age of 29.6 ± 19.6 years (range; 4-74 years). Among them, 24 (44.4%) patients achieved GTR. Radiotherapy and chemotherapy was administered to 31 (62%) patients and 23 (46%) patients, respectively. After a median follow-up of 31.4 ± 35.3 months (range: 0.75-144 months), the mortality and recurrence rates were 32.5% (13/40) and 70% (28/40), respectively. Multivariate Cox regression model demonstrated that non-GTR (HR 0.380, 95% CI 0.174-0.831, p=0.015), age≥30 (HR 2.620, 95% CI 1.183-5.804, p=0.018), no RT (HR 0.334,95% CI 0.150-0.744, p=0.007) and no CT (HR 0.422, 95% CI 0.184-0.967, p=0.042) were negative prognostic factors for PFS. Non-GTR (HR 0.126, 95% CI 0.037-0.422, p=0.001), secondary HGPXAs (HR 7.567, 95% CI 2.221-25.781, p=0.001), age≥30 (HR 3.568, 95% CI 1.190-10.694, p=0.023) and no RT (HR 0.223,95% CI 0.073-0.681, p=0.008) were risk factors for OS. Conclusion High grade pleomorphic xanthoastrocytomas are very rare brain tumors. Children and younger adults have better clinical outcome than elderly patients. Secondary HGPXAs had worse OS than primary HGPXAs. Complete surgical excision plus RT and CT is recommended for this entity. The frequency of BRAF mutations in HGPXAs is 47.5% (19/40) in this study, however, we do not find the connections between BRAF mutations and clinical outcomes. Future studies with larger cohorts are necessary to verify our findings.
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Affiliation(s)
- Pengcheng Zuo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tian Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tao Sun
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenhao Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yujin Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mingxin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Junting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liwei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
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Lin Z, Yang R, Zheng H, Li Z, Yi G, Wu Q, Yang C, Huang G. Pleomorphic xanthoastrocytoma, anaplastic pleomorphic xanthoastrocytoma, and epithelioid glioblastoma: case series with clinical characteristics, molecular features and progression relationship. Clin Neurol Neurosurg 2022; 221:107379. [DOI: 10.1016/j.clineuro.2022.107379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 06/16/2022] [Accepted: 07/18/2022] [Indexed: 11/03/2022]
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Marakovic J, Chudy D, Muller D, Tomac D, Marcinkovic P, Oreskovic D, Kastelancic A, Raguz M. Malignant transformation of pleomorphic xanthoastrocytoma in pregnant patient: Clinical case and ethical dilemma. Surg Neurol Int 2021; 12:469. [PMID: 34621584 PMCID: PMC8492419 DOI: 10.25259/sni_120_2021] [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: 02/07/2021] [Accepted: 08/21/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Pleomorphic xanthoastrocytoma (PXA) is a rare astrocytic tumor, accounting for <1% of astrocytic tumors. Due to its rarity, etiology, natural history, and biologic behavior is not completely explained. We present a case of malignant transformation of a PXA to glioblastoma in pregnant patient 6 month after tumor biopsy. Case Description: A 28-year-old female patient was presented with a newly onset of headache, nausea, and right-sided hemiparesis at 21st week of pregnancy. Magnetic resonance imaging (MRI) revealed cystic mass in the left frontal region. Patient underwent biopsy to confirm pathohistological analysis; the tumor tissue corresponded to an anaplastic PXA. Two weeks after initial biopsy, open surgery along with gross total tumor removal was performed confirming pathohistological analysis. Six months later, after childbirth, and control MRI revealed a recurrent tumor mass: the patient underwent surgical resection and the tumor tissue corresponded to a glioblastoma. The patients were further treated with radiation and chemotherapy according to oncologist. Conclusion: Distinguishing between PXA patients who have a good prognosis and those at risk for early progression is very important for the PXA clinical management. Despite cellular pleomorphism, mitotic index and the extent of resection are shown to be the main predictors for recurrence-free survival and overall survival rates. The standard therapy management is not yet established. Our patient treatment was associated with a significant ethical dilemma. Respecting patient’s wishes to deliver a baby, nor radio or chemo treatments were done. Further studies are necessary to provide factors responsible for malignant transformation of PXA. In addition, in ethically sensitive situation, such as tumor in pregnant patient, good communication, respecting patient’s wishes, and a multidisciplinary teamwork is the key for better outcome.
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Affiliation(s)
- Jurica Marakovic
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia.,School of Medicine University of Zagreb, Zagreb, Croatia
| | - Darko Chudy
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia.,Department of Surgery, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Danko Muller
- School of Medicine University of Zagreb, Zagreb, Croatia.,Department of Pathology and Cytology, Dubrava University Hospital, Zagreb, Croatia
| | - Damir Tomac
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia
| | - Petar Marcinkovic
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia
| | - Darko Oreskovic
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia
| | | | - Marina Raguz
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia
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Matsumoto Y, Kobayashi M, Shingu K, Tateishi A, Ohya M, Sano K, Negishi T, Shigeto S, Kobayashi T, Hara Y, Kakizawa Y, Kanno H. An anaplastic pleomorphic xanthoastrocytoma with periventricular extension: An autopsy case report and review of the literature. Neuropathology 2020; 40:507-514. [PMID: 32578272 DOI: 10.1111/neup.12666] [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: 11/14/2019] [Revised: 04/09/2020] [Accepted: 04/11/2020] [Indexed: 11/28/2022]
Abstract
Pleomorphic xanthoastrocytomas (PXAs) are rare low-grade astrocytic tumors that typically present as superficial nodular cystic tumors of the cerebrum attached to the leptomeninx. Histologically, they are pleomorphic, hypercellular glial neoplasms. Despite the presence of microscopic pleomorphism, patients' postoperative prognosis is generally good. Anaplastic PXAs (APXAs) have a high mitotic index and patients with APXAs have a worse prognosis than patients with PXAs. Here, we report an autopsy case of APXA initially diagnosed as PXA. After gross total resection, the tumor recurred and was diagnosed as an APXA; thereafter, the patient died. An autopsy revealed that the tumor had relapsed at the primary site and had spread to the leptomeningeal space while concurrently invading the cerebrum including the periventricular area forming multifocal lesions. The histological findings of the autopsy were similar to those for epithelioid glioblastoma (EGBM) and small cell glioblastoma (SCGBM). In particular, the periventricular area with multifocal lesions was composed of SCGBM-like cells. It has been shown that multifocal lesions are frequently identified in patients with SCGBM. This is the first histopathologically confirmed case of APXA-related tumor presenting with periventricular extension and multifocal lesion formation. The periventricular extension might be a feature of PXAs and APXAs. However, suspected periventricular spread on imaging in past cases of PXAs and APXAs might instead represent the malignant transformation of these tumors to glioblastoma-like high-grade tumors, which often show SCGBM-like histological patterns.
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Affiliation(s)
- Yuki Matsumoto
- Department of Pathology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Mikiko Kobayashi
- Department of Pathology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kunihiko Shingu
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Ayako Tateishi
- Department of Pathology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Maki Ohya
- Department of Pathology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kenji Sano
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan.,Department of Pathology, Iida Municipal Hospital, Iida, Japan
| | - Tatsuya Negishi
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Shohei Shigeto
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Tatsuya Kobayashi
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan.,Department of Neurosurgery, Ichinose Neurosurgical Hospital, Matsumoto, Japan
| | - Yosuke Hara
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan.,Department of Neurosurgery, Asama Nanroku Komoro Medical Center, Komoro, Japan
| | - Yukinari Kakizawa
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan.,Department of Neurosurgery, Suwa Red Cross Hospital, Suwa, Japan
| | - Hiroyuki Kanno
- Department of Pathology, Shinshu University School of Medicine, Matsumoto, Japan
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Watanabe N, Ishikawa E, Kohzuki H, Sakamoto N, Zaboronok A, Matsuda M, Shibuya M, Matsumura A. Malignant transformation of pleomorphic xanthoastrocytoma and differential diagnosis: case report. BMC Neurol 2020; 20:21. [PMID: 31941461 PMCID: PMC6961389 DOI: 10.1186/s12883-020-1601-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 01/06/2020] [Indexed: 11/19/2022] Open
Abstract
Background Pleomorphic xanthoastrocytoma (PXA) is a rare astrocytic glioma, characterized by large pleomorphic and frequently multinucleated cells, spindle and lipidized cells, a dense pericellular reticulin network, and numerous eosinophilic granular bodies according to the grade II glial tumor standards of the World Health Organization’s (WHO) 2016 guidelines. PXA rarely transforms into anaplastic PXA or glioblastoma (GBM) and anaplastic PXA, classified as WHO grade III, has a more aggressive clinical behavior with poorer prognosis than PXA. Case presentation Here we describe an unusual case of PXA in a 19-year-old woman, first admitted with headache and a mass in the left temporal lobe in 2005 that was removed. Twelve years later, she returned with left temporal headache, diplopia and tinnitus. A local tumor recurrence was found, and a second resection was performed. The specimen showed highly malignant findings, such as necrosis, microvascular proliferation, and multiple mitoses. The integrated diagnosis was made as high grade glioma, probably derived from PXA. Immunohistochemical (IHC) stains were positive for oligo2, and approximately 21% positive for Ki-67, while negative for CD34, IDH1 R132H. INI1 and ATRX were retained. As the histological classification was glioblastoma, the patient received GBM-appropriate chemotherapy and radiation therapy and outpatient follow-ups have demonstrated no obvious symptoms for 1 year after surgery. Additional molecular analyses found BRAF V600E mutations in both resections, supporting the idea that the recurrent tumor had derived from PXA. Conclusions This case highlights the complexities of differential diagnosis based on the World Health Organization’s 2016 guidelines. More integrated criteria to differentiate anaplastic PXA from GBM and epithelioid GBM, combined with genetic screening results, might be needed.
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Affiliation(s)
- Noriyuki Watanabe
- Departments of Neurosurgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Eiichi Ishikawa
- Departments of Neurosurgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan.
| | - Hidehiro Kohzuki
- Departments of Neurosurgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Noriaki Sakamoto
- Departments of Diagnostic Pathology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Alexander Zaboronok
- Departments of Neurosurgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Masahide Matsuda
- Departments of Neurosurgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Makoto Shibuya
- Central Laboratory, Hachioji Medical Center, Tokyo Medical University, Tokyo, Japan
| | - Akira Matsumura
- Departments of Neurosurgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
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Mallick S, Giridhar P, Benson R, Melgandi W, Rath GK. Demography, Pattern of Care, and Survival in Patients with Xanthoastrocytoma: A Systematic Review and Individual Patient Data Analysis of 325 Cases. J Neurosci Rural Pract 2019; 10:430-437. [PMID: 31595115 PMCID: PMC6779544 DOI: 10.1055/s-0039-1697873] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objectives Xanthoastrocytoma (XA) is a low-grade glial tumor seen in young adults and there is lack of robust data on treatment of this rare tumor. In this systematic review and individual patient's data analysis, we aimed to look into the demography, pattern of care, survival outcomes, and prognostic factors in patients with both Grade II and III XA. Methods A comprehensive search was conducted with the Medical Subject Heading terms: "Xanthoastrocytoma; Pleomorphic Xanthoastrocytoma; Anaplastic Xanthoastrocytoma; Xanthoastrocytoma AND treatment; and Anaplastic Xanthoastrocytoma AND survival" to find all possible publications. Results A total of 325 individual patients from a total of 138 publications pertaining to XA were retrieved. Median age of the entire cohort was 19 years. About 56.1% of the patients underwent a gross total resection (GTR) and 31.4% underwent a subtotal resection. Nearly, 76.6% of the patients had a Grade II tumor and adjuvant radiation was delivered in 27.4% of the patients. Estimated 2- and 5-year progression-free survival (PFS) were 68.5 and 51.2%, respectively. Age, grade, and extent of surgery were significant factors affecting PFS. Estimated 2- and 5-year overall survival (OS) was 88.8 and 78%, respectively. The median OS for Grade II and Grade III tumors were 209 and 49 months, respectively. Age and extent of surgery were significant factors affecting OS. Conclusion XA is a disease of young adults with favorable prognosis. Younger patients (<20 years), patients who undergo a GTR, and patients with a lower grade tumor have a better treatment outcome.
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Affiliation(s)
- Supriya Mallick
- Department of Radiation Oncology, B.R.A. Institute-Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Prashanth Giridhar
- Department of Radiation Oncology, B.R.A. Institute-Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Rony Benson
- Department of Radiation Oncology, B.R.A. Institute-Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Wineeta Melgandi
- Department of Radiation Oncology, B.R.A. Institute-Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Goura Kishor Rath
- Department of Radiation Oncology, B.R.A. Institute-Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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Murakami C, Yoshida Y, Yamazaki T, Yamazaki A, Nakata S, Hokama Y, Ishiuchi S, Akimoto J, Shishido-Hara Y, Yoshimoto Y, Matsumura N, Nobusawa S, Ikota H, Yokoo H. Clinicopathological characteristics of circumscribed high-grade astrocytomas with an unusual combination of BRAF V600E, ATRX, and CDKN2A/B alternations. Brain Tumor Pathol 2019; 36:103-111. [DOI: 10.1007/s10014-019-00344-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 03/27/2019] [Indexed: 12/12/2022]
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Kang M, Chung DH, Kim NR, Cho HY, Ha SY, Lee S, An J, Seok JY, Yie GT, Yoo CJ, Lee SG, Kim EY, Kim WK, Son S, Sym SJ, Shin DB, Hwang HY, Kim EY, Lee KC. Intraoperative Frozen Cytology of Central Nervous System Neoplasms: An Ancillary Tool for Frozen Diagnosis. J Pathol Transl Med 2019; 53:104-111. [PMID: 30636391 PMCID: PMC6435984 DOI: 10.4132/jptm.2018.11.10] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/10/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Pathologic diagnosis of central nervous system (CNS) neoplasms is made by comparing light microscopic, immunohistochemical, and molecular cytogenetic findings with clinicoradiologic observations. Intraoperative frozen cytology smears can improve the diagnostic accuracy for CNS neoplasms. Here, we evaluate the diagnostic value of cytology in frozen diagnoses of CNS neoplasms. METHODS Cases were selected from patients undergoing both frozen cytology and frozen sections. Diagnostic accuracy was evaluated. RESULTS Four hundred and fifty-four cases were included in this retrospective single-center review study covering a span of 10 years. Five discrepant cases (1.1%) were found after excluding 53 deferred cases (31 cases of tentative diagnosis, 22 cases of inadequate frozen sampling). A total of 346 cases of complete concordance and 50 cases of partial concordance were classified as not discordant cases in the present study. Diagnostic accuracy of intraoperative frozen diagnosis was 87.2%, and the accuracy was 98.8% after excluding deferred cases. Discrepancies between frozen and permanent diagnoses (n = 5, 1.1%) were found in cases of nonrepresentative sampling (n = 2) and misinterpretation (n = 3). High concordance was observed more frequently in meningeal tumors (97/98, 99%), metastatic brain tumors (51/52, 98.1%), pituitary adenomas (86/89, 96.6%), schwannomas (45/47, 95.8%), high-grade astrocytic tumors (47/58, 81%), low grade astrocytic tumors (10/13, 76.9%), non-neoplastic lesions (23/36, 63.9%), in decreasing frequency. CONCLUSIONS Using intraoperative cytology and frozen sections of CNS tumors is a highly accurate diagnostic ancillary method, providing subtyping of CNS neoplasms, especially in frequently encountered entities.
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Affiliation(s)
- Myunghee Kang
- Department of Pathology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Dong Hae Chung
- Department of Pathology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Na Rae Kim
- Department of Pathology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Hyun Yee Cho
- Department of Pathology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Seung Yeon Ha
- Department of Pathology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Sangho Lee
- Department of Pathology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jungsuk An
- Department of Pathology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jae Yeon Seok
- Department of Pathology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Gie-Taek Yie
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Chan Jong Yoo
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Sang Gu Lee
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Eun Young Kim
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Woo Kyung Kim
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Seong Son
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Sun Jin Sym
- Division of Medical Oncology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Dong Bok Shin
- Division of Medical Oncology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Hee Young Hwang
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Eung Yeop Kim
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Kyu Chan Lee
- Department of Radiation Oncology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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