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Pham A, Garai I, Árpád K, Dér Á, Szanto E, Hascsi Z, Bátyi F, Berényi E, Pham TM. Impact of Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography on Therapeutic Decisions and Radiotherapy Planning in Head and Neck Squamous Carcinoma: A Retrospective Study of 46 Patients. Med Sci Monit 2024; 30:e942122. [PMID: 38243589 PMCID: PMC10807175 DOI: 10.12659/msm.942122] [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: 08/10/2023] [Accepted: 11/15/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Positron emission tomography/computed tomography (PET/CT) using fluorodeoxyglucose (FDG) is essential in oncology for precise tumor delineation. This study evaluated FDG PET/CT's impact on therapeutic decisions in head and neck cancer, comparing metabolic tumor volumes (MTV) measured by different methods with radiotherapy targets, crucial for treatment planning and patient outcomes. MATERIAL AND METHODS We retrospectively analyzed 46 patients with histologically confirmed head and neck cancer who underwent FDG PET/CT examination before radiotherapy. The mean age was 62 years (46-78 years). Then, we calculated MTV of the primary tumor or local recurrence using a local threshold of 41% of the standard uptake volume (SUV) corrected for lean body mass (SULmax) of the lesion and absolute threshold of SUV 2.5. Descriptive analysis of the recruited patients was assessed based on the clinical database (Medsol). RESULTS The study included 45 patients with squamous carcinoma and 1 with sarcoid cell carcinoma. PET/CT examination led to therapeutic decision changes in 11 cases. No significant difference was found in median values of Gross Tumor Volume (GTV) and MTV absolute (p=0.130). However, significant differences were observed in MTV local, MTV absolute, and GTV median values (p<0.001), with both MTVs showing significant correlation with GTV (p<0.01), especially MTV absolute (r=0.886). CONCLUSIONS FDG PET/CT examination prior to radiotherapy significantly influences therapeutic decisions in head and neck cancer patients. Based on our findings, the absolute threshold method (SUV: 2.5) appears to be an effective approach for calculating MTV for radiotherapy planning purposes.
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Affiliation(s)
- Anh Pham
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Ildiko Garai
- Division of Nuclear Medicine and Translational Imaging, Department of Medical Imaging, University of Debrecen, Debrecen, Hungary
| | - Kovács Árpád
- Department of Oncoradiology, University of Debrecen, Debrecen, Hungary
| | - Ádám Dér
- Department of Oncoradiology, University of Debrecen, Debrecen, Hungary
| | - Erika Szanto
- Department of Oncoradiology, University of Debrecen, Debrecen, Hungary
| | - Zsolt Hascsi
- Division of Nuclear Medicine and Translational Imaging, Department of Medical Imaging, University of Debrecen, Debrecen, Hungary
| | - Ferenc Bátyi
- Division of Nuclear Medicine and Translational Imaging, Department of Medical Imaging, University of Debrecen, Debrecen, Hungary
| | - Ervin Berényi
- Division of Nuclear Medicine and Translational Imaging, Department of Medical Imaging, University of Debrecen, Debrecen, Hungary
| | - Thong Minh Pham
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
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Oliveira FRA, Santos ADO, de Lima MDCL, Toro IFC, de Souza TF, Amorim BJ, Barbeiro AS, Etchebehere E. The ratio between the whole-body and primary tumor burden, measured on 18F-FDG PET/CT studies, as a prognostic indicator in advanced non-small cell lung cancer. Radiol Bras 2021; 54:289-294. [PMID: 34602663 PMCID: PMC8475165 DOI: 10.1590/0100-3984.2020.0054] [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: 05/08/2020] [Accepted: 09/01/2020] [Indexed: 11/22/2022] Open
Abstract
Objective To determine whether the whole-body tumor burden, as quantified by 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT), is a prognostic indicator in advanced (stage III or IV) non-small cell lung cancer (NSCLC). Materials and Methods This was a prospective study in which we evaluated 18F-FDG PET/CT staging parameters to quantify tumor burdens in patients with stage III or IV NSCLC. The following parameters were evaluated for the whole body (including the primary tumor) and for the primary tumor alone, respectively: maximum standardized uptake volume (wbSUVmax and tuSUVmax); metabolic tumor volume (wbMTV and tuMTV); and total lesion glycolysis (wbTLG and tuTLG). To determine whether the 18F-FDG PET/CT parameters were associated with overall survival (OS) and progression-free survival (PFS), we evaluated the wbSUVmax/tuSUVmax, wbMTV/tuMTV, and wbTLG/tuTLG ratios. Results 18F-FDG PET/CT was performed for staging in 52 patients who were followed for a median of 11.0 months (mean, 11.7 months). The estimated median PFS and OS were 9.6 months and 11.6 months, respectively. In the univariate analysis, OS was found to correlate significantly with wbTLG (hazard ratio [HR] = 1.001; 95% confidence interval [95 CI]: 1.000-1.001; p = 0.0361) and with the wbTLG/tuTLG ratio (HR = 1.705; 95% CI: 1.232-2.362; p = 0.0013). In the multivariate analysis, only the wbTLG/tuTLG ratio was independently associated with OS (HR = 1.660; 95% CI: 1.193-2.310; p = 0.0027). Conclusion The wbTLG/tuTLG ratio is an independent prognostic indicator of OS in advanced-stage NSCLC.
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Affiliation(s)
| | - Allan de Oliveira Santos
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-Unicamp), Campinas, SP, Brazil
| | | | | | - Thiago Ferreira de Souza
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-Unicamp), Campinas, SP, Brazil
| | - Bárbara Juarez Amorim
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-Unicamp), Campinas, SP, Brazil
| | | | - Elba Etchebehere
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-Unicamp), Campinas, SP, Brazil
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Ke L, Wu L, Yu J, Meng X. Feasibility of semiquantitative 18F-fluorodeoxyglucose PET/computed tomography in patients with advanced lung cancer for interim treatment evaluation of combining immunotherapy and chemotherapy. Nucl Med Commun 2021; 42:1017-1023. [PMID: 33899782 PMCID: PMC8357040 DOI: 10.1097/mnm.0000000000001428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 03/22/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE This study aimed to investigate the prognosis value of 18F-fluorodeoxyglucose PET/computed tomography (18F-FDG PET/CT) in advanced lung cancer patients with immunotherapy combined with chemotherapy. METHODS Fifty-one advanced lung cancer patients were included in this retrospective study, who underwent 18F-FDG PET/CT imaging before four cycles of immunotherapy combined with chemotherapy at our institution between January 2018 and January 2020. The following PET/CT parameters were calculated: standardized uptake value SUVmax, SUVmean, SUVpeak, SUVsd, metabolic tumor volume (MTV), total lesion glycolysis (TLG), MTV25%, MTV42%, MTV50%, MTV75%, global lung glycolysis (GLG), target-to-background ratio (TBR), SUVpeakwb, MTVwb, TLGwb, SUVmeanwb, SUVmaxwb. Logistics regression analyses were used for assessing the association between baseline metabolic parameters and response to treatment. Kaplan-Meier estimator curves and the log-rank test were constructed for survival analyses. RESULTS According to RECIST, nine patients (18%) showed partial response, 25 (49%) had SD, and 17 (33%) had progressive disease. The mean ± SD of SUVmax, SUVpeak, MTV were lower in clinical benefit (CB) group than no-clinical benefit (no-CB) group (all P < 0.05). Median PFS was 3.7 months in no-CB group and 9.9 months in CB group (P < 0.001). Multivariate logistic analysis indicated that SUVmax and histology were independent factors significantly related to the evaluation of therapeutic efficiency. Furthermore, SUVmax is an independent predictor of efficacy in non-small cell lung cancer. CONCLUSION SUVmax can be used to predict interim treatment response of immunotherapy combination with chemotherapy for advanced lung cancer. Moreover, the combination of SUVmax and histology may predict treatment response with acceptable reliability. However, a large prospective multicenter trial is still needed to examine the above finding for lacking limited evidence.
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Affiliation(s)
- Linping Ke
- Department of Clinical Medicine, Weifang Medical University, Weifang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences
| | - Leilei Wu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences
- Department of Radiation Oncology, School of Medicine, Shandong University, Jinan, Shandong, China
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences
| | - Xue Meng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences
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Choi YH, Lee SH, You MS, Shin BS, Paik WH, Ryu JK, Kim YT, Kwon W, Jang JY, Kim SW. Prognostic Factors for Patients with Borderline Resectable or Locally Advanced Pancreatic Cancer Receiving Neoadjuvant FOLFIRINOX. Gut Liver 2021; 15:315-323. [PMID: 32235008 PMCID: PMC7960979 DOI: 10.5009/gnl19182] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 12/18/2019] [Accepted: 02/25/2020] [Indexed: 12/13/2022] Open
Abstract
Background/Aims There has been growing evidence on the utility of neoadjuvant FOLFIRINOX in borderline resectable (BR) or locally advanced (LA) pancreatic cancer. However, factors predicting survival in these patients remain to be identified, and we aimed to identify these prognostic factors. Methods Between January 2013 and April 2017, patients with BR or LA pancreatic cancer who received FOLFIRINOX as their initial treatment were identified. Demographic data and clinical outcomes, including the chemotherapy response, conversion to resection, and survival, were reviewed. Results A total of 117 patients with BR (n=39) or LA (n=78) pancreatic cancer were included. Of these patients, 29 (24.8%) underwent curative surgery, and R0 resection was achieved in 21 patients (72.4%). The median progression-free survival and overall survival time of all patients were 11.6 and 19.0 months, respectively. In resected patients, the median relapse-free survival and overall survival times were 14.8 and 28.6 months, respectively. In the multivariate Cox model, the lowest level of serum carbohydrate antigen 19-9 (CA 19-9) and resection after FOLFIRINOX were independent factors for improved overall survival. In the subgroup analysis of patients with initial 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) images, the maximum standardized uptake value (SUVmax) of the pancreatic mass was also shown as an independent factor for improved overall survival. Conclusions In patients with BR or LA pancreatic cancer, FOLFIRINOX is a valuable neoadjuvant treatment that enables curative surgery in approximately one-quarter of patients and significantly improves overall survival. In these patients, the prognosis can be estimated using the lowest level of serum CA 19-9, operative status, and initial FDG-PET SUVmax.
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Affiliation(s)
- Young Hoon Choi
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.,Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Min Su You
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Bang Sup Shin
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Kon Ryu
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yong-Tae Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Rogasch JMM, Furth C, Bluemel S, Radojewski P, Amthauer H, Hofheinz F. Asphericity of tumor FDG uptake in non-small cell lung cancer: reproducibility and implications for harmonization in multicenter studies. EJNMMI Res 2020; 10:134. [PMID: 33140213 PMCID: PMC7606415 DOI: 10.1186/s13550-020-00725-y] [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: 09/16/2020] [Accepted: 10/21/2020] [Indexed: 11/15/2022] Open
Abstract
Background Asphericity (ASP) of the primary tumor’s metabolic tumor volume (MTV) in FDG-PET/CT is independently predictive for survival in patients with non-small cell lung cancer (NSCLC). However, comparability between PET systems may be limited. Therefore, reproducibility of ASP was evaluated at varying image reconstruction and acquisition times to assess feasibility of ASP assessment in multicenter studies.
Methods This is a retrospective study of 50 patients with NSCLC (female 20; median age 69 years) undergoing pretherapeutic FDG-PET/CT (median 3.7 MBq/kg; 180 s/bed position). Reconstruction used OSEM with TOF4/16 (iterations 4; subsets 16; in-plane filter 2.0, 6.4 or 9.5 mm), TOF4/8 (4 it; 8 ss; filter 2.0/6.0/9.5 mm), PSF + TOF2/17 (2 it; 17 ss; filter 2.0/7.0/10.0 mm) or Bayesian-penalized likelihood (Q.Clear; beta, 600/1750/4000). Resulting reconstructed spatial resolution (FWHM) was determined from hot sphere inserts of a NEMA IEC phantom. Data with approx. 5-mm FWHM were retrospectively smoothed to achieve 7-mm FWHM. List mode data were rebinned for acquisition times of 120/90/60 s. Threshold-based delineation of primary tumor MTV was followed by evaluation of relative ASP/SUVmax/MTV differences between datasets and resulting proportions of discordantly classified cases.
Results Reconstructed resolution for narrow/medium/wide in-plane filter (or low/medium/high beta) was approx. 5/7/9 mm FWHM. Comparing different pairs of reconstructed resolution between TOF4/8, PSF + TOF2/17, Q.Clear and the reference algorithm TOF4/16, ASP differences was lowest at FWHM of 7 versus 7 mm. Proportions of discordant cases (ASP > 19.5% vs. ≤ 19.5%) were also lowest at 7 mm (TOF4/8, 2%; PSF + TOF2/17, 4%; Q.Clear, 10%). Smoothing of 5-mm data to 7-mm FWHM significantly reduced discordant cases (TOF4/8, 38% reduced to 2%; PSF + TOF2/17, 12% to 4%; Q.Clear, 10% to 6%), resulting in proportions comparable to original 7-mm data. Shorter acquisition time only increased proportions of discordant cases at < 90 s. Conclusions ASP differences were mainly determined by reconstructed spatial resolution, and multicenter studies should aim at comparable FWHM (e.g., 7 mm; determined by in-plane filter width). This reduces discordant cases (high vs. low ASP) to an acceptable proportion for TOF and PSF + TOF of < 5% (Q.Clear: 10%). Data with better resolution (i.e., lower FWHM) could be retrospectively smoothed to the desired FWHM, resulting in a comparable number of discordant cases.
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Affiliation(s)
- Julian M M Rogasch
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Christian Furth
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Stephanie Bluemel
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Piotr Radojewski
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Holger Amthauer
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Frank Hofheinz
- Institute for Radiopharmaceutical Cancer Research, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
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廖 栩, 王 荣, 刘 萌, 陈 雪, 熊 焰, 农 琳, 殷 雷, 张 炳, 杜 毓. [Semiquantitative parameters of 18F-FDG PET/CT, gene mutation states of epidermal growth factor receptor and anaplastic lymphoma kinase in prognosis evaluation of patients with lung adenocarcinoma]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2020; 53:246-254. [PMID: 33879893 PMCID: PMC8072443 DOI: 10.19723/j.issn.1671-167x.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To explore the valuable predictors for evaluating progression-free survival (PFS) in patients with lung adenocarcinoma, we analyzed the potential roles of standardized uptake value (SUV)-derived parameters from 18F-FDG PET/CT, combining with the gene mutation states of epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK), and other clinical characteristics. METHODS Data of 84 lung adenocarcinoma patients pre-treated, who underwent 18F-FDG PET/CT scans, EGFR gene mutations test, ALK rearrangement assay and other relative tests, were retrospectively collected. Then a series of clinical parameters including EGFR/ALK mutation status and SUV-derived features [maximum standardized uptake value (SUVmax), average of standardized uptake value (SUVmean), metabolic tumor volume (MTV), and total lesion glycolysis (TLG)] were evaluated. Best possible cutoff points for all measuring parameters were calculated using receiver operating characteristic curve (ROC) analysis. Survival analysis was performed using Cox proportional hazards model to determine the prognostic markers for progression-free survival (PFS). Survival curves were obtained through Log-rank test and Kaplan-Meier curve. RESULTS The median follow-up period was 31 months (24 to 58 months). It was found that SUVmax (≥3.01), SUVmean (≥2.25), MTV (≥25.41 cm3), and TLG (≥55.02) of the primary tumors were significantly associated with PFS in univariate Cox proportional hazards regression. Then regardless of age, gender, co-morbidity, EGFR/ALK mutation status, and treatment program, TLG (≥ 55.02, HR=4.965, 95%CI: 1.360-18.133), TNM stage (Ⅲ/Ⅳ, HR=7.811, 95%CI: 2.977-20.489), pro-gastrin releasing peptide (proGRP) (≥45.65 ng/L, HR=4.070, 95%CI: 1.442-11.487), tissue polypeptide antigen (TPA) (≥68.20 U/L, HR=6.996, 95%CI: 1.458-33.574), alkaline phosphatase (ALP) (≥82.50 IU/L, HR=4.160, 95%CI: 1.416-12.219) and ratio of activated partial thromboplastin time (aPTTR) (≥1.16: HR=4.58, 95%CI: 1.913-10.946) showed the independently relevant to PFS through multivariate Cox proportional hazards analysis. The EGFR mutant (P=0.343) and ALK rearrangement (P=0.608) were not significant either in survival analysis. CONCLUSION High SUV-derived parameters (SUVmax, SUVmean, MTV and TLG) might provide prognostic value to some extent. Especially, TLG, and other clinical features [TNM stage, proGRP, TPA, ALP, and aPTTR] could be independently and significantly associated with PFS of lung adenocarcinoma patients. However, EGFR/ALK gene status could not be effectively relevant to PFS in lung adenocarcinoma patients.
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Affiliation(s)
- 栩鹤 廖
- 北京大学第一医院核医学科,北京 100034Department of Nuclear Medicine, Peking University First Hospital, Beijing 100034, China
| | - 荣福 王
- 北京大学第一医院核医学科,北京 100034Department of Nuclear Medicine, Peking University First Hospital, Beijing 100034, China
| | - 萌 刘
- 北京大学第一医院核医学科,北京 100034Department of Nuclear Medicine, Peking University First Hospital, Beijing 100034, China
| | - 雪祺 陈
- 北京大学第一医院核医学科,北京 100034Department of Nuclear Medicine, Peking University First Hospital, Beijing 100034, China
| | - 焰 熊
- 北京大学第一医院病理科,北京 100034Department of Pathology, Peking University First Hospital, Beijing 100034, China
| | - 琳 农
- 北京大学第一医院病理科,北京 100034Department of Pathology, Peking University First Hospital, Beijing 100034, China
| | - 雷 殷
- 北京大学第一医院核医学科,北京 100034Department of Nuclear Medicine, Peking University First Hospital, Beijing 100034, China
| | - 炳晔 张
- 北京大学第一医院核医学科,北京 100034Department of Nuclear Medicine, Peking University First Hospital, Beijing 100034, China
| | - 毓菁 杜
- 北京大学第一医院核医学科,北京 100034Department of Nuclear Medicine, Peking University First Hospital, Beijing 100034, China
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Kim SH, Lee SO. Developing Consilience Medicine: Positron Emission Tomography Scan and Transcriptomics in Pancreatic Cancer. Gut Liver 2019; 13:225-226. [PMID: 31092726 PMCID: PMC6529166 DOI: 10.5009/gnl19116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Seong Hun Kim
- Department of Internal Medicine, Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, Korea.,Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Korea
| | - Seung Ok Lee
- Department of Internal Medicine, Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, Korea.,Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Korea
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