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Keywani K, Eshuis WJ, Borgstein ABJ, van Det MJ, van Duijvendijk P, van Etten B, Grimminger PP, Heisterkamp J, Lagarde SM, Luyer MDP, Markar SR, Meijer SL, Pierie JPEN, Roviello F, Ruurda JP, van Sandick JW, Sosef M, Witteman BPL, de Steur WO, Lissenberg-Witte BI, van Berge Henegouwen MI, Gisbertz SS. Omentum preservation versus complete omentectomy in gastrectomy for gastric cancer (OMEGA trial): study protocol for a randomized controlled trial. Trials 2024; 25:588. [PMID: 39232781 PMCID: PMC11375919 DOI: 10.1186/s13063-024-08396-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 08/12/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Potentially curative therapy for locally advanced gastric cancer consists of gastrectomy, usually in combination with perioperative chemotherapy. An oncological resection includes a radical (R0) gastrectomy and modified D2 lymphadenectomy; generally, a total omentectomy is also performed, to ensure the removal of possible microscopic disease. However, the omentum functions as a regulator of regional immune responses to prevent infections and prevents adhesions which could lead to bowel obstructions. Evidence supporting a survival benefit of routine complete omentectomy during gastrectomy is lacking. METHODS OMEGA is a randomized controlled, open, parallel, non-inferiority, multicenter trial. Eligible patients are operable (ASA < 4) and have resectable (≦ cT4aN3bM0) primary gastric cancer. Patients will be 1:1 randomized between (sub)total gastrectomy with omentum preservation distal of the gastroepiploic vessels versus complete omentectomy. For a power of 80%, the target sample size is 654 patients. The primary objective is to investigate whether omentum preservation in gastrectomy for cancer is non-inferior to complete omentectomy in terms of 3-year overall survival. Secondary endpoints include intra- and postoperative outcomes, such as blood loss, operative time, hospital stay, readmission rate, quality of life, disease-free survival, and cost-effectiveness. DISCUSSION The OMEGA trial investigates if omentum preservation during gastrectomy for gastric cancer is non-inferior to complete omentectomy in terms of 3-year overall survival, with non-inferiority being determined based on results from both the intention-to-treat and the per-protocol analyses. The OMEGA trial will elucidate whether routine complete omentectomy could be omitted, potentially reducing overtreatment. TRIAL REGISTRATION ClinicalTrials.gov NCT05180864. Registered on 6th January 2022.
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Affiliation(s)
- K Keywani
- Amsterdam UMC Location, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - W J Eshuis
- Amsterdam UMC Location, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - A B J Borgstein
- Amsterdam UMC Location, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - M J van Det
- Ziekenhuis Groep Twente, Department of Surgery, Almelo, the Netherlands
| | | | - B van Etten
- Department of Surgery, Universitair Medisch Centrum Groningen, Groningen, the Netherlands
| | - P P Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - J Heisterkamp
- Department of Surgery, Elisabeth Tweesteden Ziekenhuis, Tilburg, the Netherlands
| | - S M Lagarde
- Department of Surgery, Erasmus Medisch Centrum, Rotterdam, the Netherlands
| | - M D P Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - S R Markar
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
| | - S L Meijer
- Amsterdam UMC location University of Amsterdam, Department of Pathology, Amsterdam, the Netherlands
| | - J P E N Pierie
- Department of Surgery, Medisch Centrum Leeuwarden, Leeuwarden, the Netherlands
| | - F Roviello
- Department of Surgery, Azienda Ospedaliera Universitaria, Siena, Italy
| | - J P Ruurda
- Universitair Medisch Centrum Utrecht, Department of Surgery, Utrecht, the Netherlands
| | - J W van Sandick
- The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Department of Surgery, Amsterdam, the Netherlands
| | - M Sosef
- Department of Surgery, Zuyderland ziekenhuis, Heerlen, the Netherlands
| | - B P L Witteman
- Department of Surgert, Rijnstate Ziekenhuis, Arnhem, the Netherlands
| | - W O de Steur
- Department of Surgery, Leids Universitair Medisch Centrum, Leiden, the Netherlands
| | - B I Lissenberg-Witte
- Department of Epidemiology and Data Science, VU University Amsterdam, Amsterdam, the Netherlands
| | - M I van Berge Henegouwen
- Amsterdam UMC Location, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - S S Gisbertz
- Amsterdam UMC Location, Department of Surgery, Amsterdam, the Netherlands.
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands.
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Eboreime O, Yorwin G, Ohenhen V. Post-myomectomy omental infarction: a case report. J Med Case Rep 2023; 17:279. [PMID: 37337268 DOI: 10.1186/s13256-023-03924-y] [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: 12/29/2020] [Accepted: 03/28/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Omental Infarction (OI) is uncommon and mimics common causes of acute abdomen. It is important to differentiate it from other abdominal conditions that require emergency management. It was first reported in literature in 1896 and about 400 cases have been reported till date. CASE PRESENTATION We reported on a 41 year-old Para 0+0 Ibo house wife who presented with 10 years history of supra-pubic mass and five months history of excessive menstrual flow. After physical examination, a diagnosis of symptomatic uterine fibroid was made. She had myomectomy and the raw surface created after the excision of the myomas was covered with omentum. Wound infection developed on the 8th post-operative day leading to a wound breakdown and later partial extrusion of infarcted omental tissue through the dehisced wound. During re-exploration, the infarcted omental tissue was extracted and the residual abdominal abscess was drained. Surgical site wound infection occurred on the 3rd day after re-operation and a sub-acute intestinal obstruction developed on the 4th day thereafter which responded to conservative management. CONCLUSION Careful surgical technique is imperative when utilizing the omentum for reconstructive abdominal surgery. Torsion of the omentum and creation of excess tension while using the omentum for reconstructive procedures should be avoided and increase awareness of this uncommon disease condition by the surgeon is also important. This case is to report a rare finding of omental infarction following myomectomy.
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Affiliation(s)
- Ofunre Eboreime
- Igbinedion University Teaching Hospital, Okada, Edo State, Nigeria.
| | - Godwin Yorwin
- Delta State University Teaching Hospital, Oghara, Nigeria
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Chung JH, Choi CW, Kim SJ, Hwang SH, Lee SH. Application of the Falciform Ligament Patch for the Prevention of Duodenal Stump Leakage After Gastrectomy: Technical Report on a Case Series. J Laparoendosc Adv Surg Tech A 2022; 33:447-451. [PMID: 36459622 DOI: 10.1089/lap.2022.0454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background: Duodenal stump leakage (DSL) is a serious complication after gastrectomy. In this study, we developed a novel prevention technique using a falciform ligament patch (FLP) to prevent DSL among high-risk patients after gastrectomy. Materials and Methods: From January 2019 to July 2021, 14 patients who were judged to be at high risk for DSL during preoperative examinations or surgery were included in this retrospective study, and the FLP was applied to the duodenal stump. The falciform ligament was separated from the liver after duodenal transection during gastrectomy; the end part was used to cover the duodenal stump and was fixed using nonabsorbable polypropylene sutures. Results: In total, 14 patients who underwent FLP had one or two risk factors that were identified: 5 patients, gastric cancer duodenal invasion; 4 patients, gastric outlet obstruction (GOO); 1 patient, cancer involving the distal resection margin; 1 patient, duodenal gastrointestinal stromal tumor involving the distal resection margin; 1 patient, gastric cancer duodenal invasion and GOO; and 2 patients, cancer involving the distal resection margin and GOO. FLP construction was successful, and no patient developed complications of DSL. The average hospital stay was 11.9 days, and the patients were discharged without any morbidities after surgery. Conclusions: Therefore, the FLP can be used to prevent DSL among high-risk patients after gastrectomy.
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Affiliation(s)
- Jae Hun Chung
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Su Jin Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Sun-Hwi Hwang
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Si-Hak Lee
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
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Occult Omental Metastasis in Gastric Adenocarcinoma: An Analysis of Incidence, Predictors, and Outcomes. South Asian J Cancer 2022; 11:299-308. [PMID: 36756092 PMCID: PMC9902107 DOI: 10.1055/s-0042-1751096] [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] [Indexed: 10/15/2022] Open
Abstract
Negine PaulIntroduction Traditionally, the concept of complete omentectomy during gastric resection for cancer was based on lymphatic drainage and the occurrence of occult omental metastasis (OM). However, recent emerging evidence has challenged this concept of complete omentectomy. We, therefore, aim to find the incidence and risk factors of occult OM and also evaluate the outcome of patients with and without such metastasis. Methods This is a single institutional, retrospective study of patients with gastric cancer who underwent curative radical gastrectomy for a period of 3 years (April 1, 2016, to March 31, 2019). A complete omentectomy was performed in all patients and the omentum and nodal stations were dissected in the resected specimen and sent for pathological analysis. Clinical and epidemiological data were collected from the hospital patient database and analysis was done. Results A total of 185 patients have been included in the study, with a mean age of 53.84 years. Twenty of the 185 patients had OM (10.8%). Age, sex, location of the tumor, and neoadjuvant chemotherapy were not statistically significant in predicting OM. However, tumor size and tumor depth were found to have a significant association with OM. The occurrence of OM was more likely to be associated with disease recurrence, especially in the peritoneum. The mean overall survival was 38.15 months (±3.33 SD), whereas patients with OM had lower survival, 23.31 months (±7.79 SD), with a p -value of 0.012. Conclusion OM was not encountered in T1 and T2 gastric cancers and the incidence of OM in T3 and T4 tumors was approximately 12.7%. Therefore, complete omentectomy may be omitted in early T1/T2 tumors. OM was associated with poor prognosis, increased peritoneal recurrence, and decreased overall survival, in spite of a complete omentectomy, and may serve as a prognostic indicator for disease recurrence and overall survival.
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Chen M, He FQ, Liao MS, Yang C, Chen XD. Gastrectomy with omentum preservation versus gastrectomy with omentectomy for locally advanced gastric cancer: A systematic review and meta-analysis. Int J Surg 2021; 96:106176. [PMID: 34763112 DOI: 10.1016/j.ijsu.2021.106176] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/14/2021] [Accepted: 11/04/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Omentectomy has been traditionally a part of standard radical gastrectomy. Its clinical benefit for locally advanced gastric cancer (LAGC) remains controversial. This study aimed at evaluating the impact of gastrectomy with omentum preservation (GOP) on survival, recurrence, surgical outcomes and postoperative complications by comparing with gastrectomy with omentum resection (GOR). METHODS Original studies comparing GOP with GOR in LAGC were searched. Meta-analysis was performed using RevMan 5.4. RESULTS Seven studies involving 1879 patients were analyzed. Compared with GOR, GOP achieved significantly better overall survival (HR = 0.75 [0.60, 0.95], P = 0.01), with similar relapse-free survival (HR = 0.84 [0.68, 1.03], P = 0.10). The two groups had similar total recurrence rate (OR = 0.86 [0.68, 1.08], P = 0.19) and no significant differences in rates of peritoneal, hematogenous, locoregional or distant lymph node recurrences. GOP had significantly less blood loss (MD = -83 [-139, -28] ml, P = 0.003) and tended to have shorter operation time (MD = -28 [-58, 2] min, P = 0.06), with similar harvested number of lymph nodes (MD = -0.4 [-2.6, 1.8], P = 0.70). The incidences of total all grade and major complications were similar in GOP and GOR (all grade: 31.8% vs. 30.3%, OR = 1.08 [0.79, 1.46], P = 0.64; major: 9.2% vs. 10.1%, OR = 1.14 [0.55, 2.34], P = 0.73). There were no significant differences in incidences of complication or postoperative mortality. CONCLUSIONS Omentum preservation did not affect curability or survival in LAGC. These findings require validation in randomized controlled trials with large sample sizes.
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Affiliation(s)
- Mi Chen
- Department of Surgery, Sichuan Cancer Hospital, School of Medicine, University of Electronic Science and Technology of China, China The Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, China Department of Laboratory Medicine, Santai People's Hospital, China Department of Gastrointestinal Surgery, Sichuan Cancer Hospital, School of Medicine, University of Electronic Science and Technology of China, China
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Shin CI, Kim SH. Normal and Abnormal Postoperative Imaging Findings after Gastric Oncologic and Bariatric Surgery. Korean J Radiol 2020; 21:793-811. [PMID: 32524781 PMCID: PMC7289697 DOI: 10.3348/kjr.2019.0822] [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: 11/04/2019] [Revised: 01/10/2020] [Accepted: 02/11/2020] [Indexed: 11/15/2022] Open
Abstract
Surgical resection remains the primary choice of treatment and the only potentially curative option for gastric carcinoma, and is increasingly performed laparoscopically. Gastric resection represents a challenging procedure, with a significant morbidity and non-negligible postoperative mortality. The interpretation of imaging after gastric surgery can be challenging due to significant modifications of the normal anatomy. After the surgery, the familiarity with expected imaging appearances is crucial for diagnosis and appropriate management of potentially life-threatening complications in patients who underwent gastric surgery. We review various surgical techniques used in gastric surgery and describe fluoroscopic and cross-sectional imaging appearances of normal postoperative anatomic changes as well as early and late complications after gastric surgery.
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Affiliation(s)
- Cheong Il Shin
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Se Hyung Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea.
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Javed AA, Bagante F, Hruban RH, Weiss MJ, Makary MA, Hirose K, Cameron JL, Wolfgang CL, Fishman EK. Postoperative Omental Infarct After Distal Pancreatectomy: Appearance, Etiology Management, and Review of Literature. J Gastrointest Surg 2015; 19:2028-37. [PMID: 26302877 DOI: 10.1007/s11605-015-2920-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 08/10/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The clinico-radiological characteristics and the natural history of postoperative omental infarct (OI) in patients who underwent distal pancreatectomy (DP) and splenectomy have not been defined. MATERIALS AND METHODS Twelve patients who underwent DP over a period of 2 years and were postoperatively diagnosed with OI based on computed tomography (CT) findings were identified. RESULTS A total of 12 patients were diagnosed with an OI based on their postoperative imaging. Seven (58.3 %) patients had previously undergone laparoscopic DP, one (8.3 %) had undergone a robotic DP, and in one (8.3 %), a laparoscopic DP was converted to an open procedure. The remaining three (25.1 %) were treated with open DP. In five (41.6 %) patients, the diagnosis of OI was made during routine follow-up. One patient underwent surgical resection of OI, and two had drains placed in the mass. Nine patients were managed conservatively. During the study period, on review of CT imaging, the minimum prevalence of postoperative OI after DP was found to be 22.8 %. A review of literature identified nine articles that reported a total of 34 patients who were diagnosed with OI after abdominal surgery. CONCLUSION The management of an asymptomatic postoperative OI should be conservative while an early invasive intervention should be performed in patients who are symptomatic or have infected OI.
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Affiliation(s)
- Ammar A Javed
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 North Wolfe St, Halsted 608, Baltimore, MD, 21287, USA
| | - Fabio Bagante
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 North Wolfe St, Halsted 608, Baltimore, MD, 21287, USA
- Department of Surgery, Chirurgia Generale e Epatobiliare, G.B. Rossi University Hospital,, University of Verona, Verona, Italy
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Matthew J Weiss
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 North Wolfe St, Halsted 608, Baltimore, MD, 21287, USA
| | - Martin A Makary
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 North Wolfe St, Halsted 608, Baltimore, MD, 21287, USA
| | - Kenzo Hirose
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 North Wolfe St, Halsted 608, Baltimore, MD, 21287, USA
| | - John L Cameron
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 North Wolfe St, Halsted 608, Baltimore, MD, 21287, USA
| | - Christopher L Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 North Wolfe St, Halsted 608, Baltimore, MD, 21287, USA
| | - Elliot K Fishman
- Department of Radiology, The Johns Hopkins Hospital, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
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Yang DM, Kim HC, Kim SW, Choi SI. Dropped omental fat post laparoscopy-assisted distal gastrectomy with omentectomy mistaken for malignant peritoneal seeding on sonography. JOURNAL OF CLINICAL ULTRASOUND : JCU 2014; 42:305-307. [PMID: 24926494 DOI: 10.1002/jcu.22104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
We report the sonographic findings in a case of dropped omental fat post laparoscopy-assisted distal gastrectomy with omentectomy for stomach cancer mistaken for malignant intraperitoneal seeding. Gray-scale sonography revealed an ovoid-shaped hyperechoic mass with central poorly defined hypoechoic portion in the right perihepatic space. Color Doppler sonography showed no blood flow within the mass. Contrast-enhanced CT scan of the liver revealed an oval-shaped fatty mass with a CT number of -100 HU
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Chassagnon G, Metrard G, Besse H, Gauvain S. 18F-FDG PET imaging in a patient with late omental infarction after treatment of pancreatic adenocarcinoma. Clin Nucl Med 2014; 39:567-9. [PMID: 24806607 DOI: 10.1097/rlu.0000000000000424] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We report a case of late omental infarction visualized by F-FDG PET/CT during follow-up for pancreatic adenocarcinoma. The 65-year-old patient was referred for imaging 8 months after pancreaticoduodenectomy and 2 months after completion of a course of chemotherapy. PET/CT showed an FDG-avid omental lesion that suggested peritoneal carcinomatosis. The appearance and evolution at follow-up studies confirmed the diagnosis of omental infarction, a rare complication of pancreatic surgery. This case revealed the possibility of late FDG uptake in omental infarction.
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Affiliation(s)
- Guillaume Chassagnon
- From the Department of Nuclear Medicine, Orléans Hospital Center, Orléans, France
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