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Barry A Siegel

Publications and source records attributed to Barry A Siegel.

At least 19 recordsLinked to original sources
PubMed2006

FDG-PET/CT in the evaluation of anal carcinoma.

PURPOSE: Surgical staging and treatment of anal carcinoma has been replaced by noninvasive staging studies and combined modality therapy. In this study, we compare computed tomography (CT) and physical examination to [(18)F]-fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography (FDG-PET/CT) in the staging of carcinoma of the anal canal, with special emphasis on determination of spread to inguinal lymph nodes. METHODS AND MATERIALS: Between July 2003 and July 2005, 41 consecutive patients with biopsy-proved anal carcinoma underwent a complete staging evaluation including physical examination, CT, and 2-FDG-PET/CT. Patients ranged in age from 30 to 89 years. Nine men were HIV-positive. Treatment was with standard Nigro regimen. RESULTS: [(18)F]-fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography (FDG-PET/CT) detected 91% of nonexcised primary tumors, whereas CT visualized 59%. FDG-PET/CT detected abnormal uptake in pelvic nodes of 5 patients with normal pelvic CT scans. FDG-PET/CT detected abnormal nodes in 20% of groins that were normal by CT, and in 23% without abnormality on physical examination. Furthermore, 17% of groins negative by both CT and physical examination showed abnormal uptake on FDG-PET/CT. HIV-positive patients had an increased frequency of PET-positive lymph nodes. CONCLUSION: [(18)F]-fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography detects the primary tumor more often than CT. FDG-PET/CT detects substantially more abnormal inguinal lymph nodes than are identified by standard clinical staging with CT and physical examination.

Adult↗
PubMed2006

Cost-effectiveness of routine mediastinoscopy in computed tomography- and positron emission tomography-screened patients with stage I lung cancer.

OBJECTIVE: Accurate preoperative staging is essential for the optimal management of patients with lung cancer. An important goal of preoperative staging is to identify mediastinal lymph node metastasis. Computed tomography and positron emission tomography may identify mediastinal lymph node metastasis with sufficient sensitivity to allow omission of mediastinoscopy. This study utilizes our experience with patients with clinical stage I lung cancer to perform a decision analysis addressing whether mediastinoscopy should be performed in clinical stage I lung cancer patients staged by computed tomography and positron emission tomography. METHODS: We retrospectively reviewed our thoracic surgery database for cases between May 1999 and May 2004. Patients deemed clinical stage I by computed tomography and positron emission tomography were chosen for further study. Individual computed tomography, positron emission tomography, and operative and pathology reports were reviewed. The postresection pathologic staging and long-term survival were recorded. A decision model was created using TreeAgePro software and our observed data for the prevalence of mediastinal lymph node metastases and for the rate of benign nodules. Data reported in the literature were also utilized to complete the decision analysis model. A sensitivity analysis of key variables was performed. RESULTS: A total of 248 patients with clinical stage I lung tumors were identified. One hundred seventy-eight patients (72%) underwent mediastinoscopy before resection, and 5/178 (3%) showed N2 disease. An additional 9 patients were found to have N2 metastasis in the final resected specimen, resulting in a total of 14/248 patients (5.6%) with occult mediastinal lymph node metastases. Benign nodules were found in 19/248 (8%) of patients. Decision analysis determined that mediastinoscopy added 0.008 years of life expectancy at a cost of 250,989 dollars per life-year gained. The outcome was sensitive to the prevalence of N2 disease in the population and the benefit of induction versus adjuvant therapy for N2 lung cancer. If the prevalence of N2 disease exceeds 10%, the sensitivity analysis predicts that mediastinoscopy would lengthen life at a cost of less than 100,000 dollars per life-year gained. CONCLUSION: Patients with clinical stage I lung cancer staged by computed tomography and positron emission tomography benefit little from mediastinoscopy. The survival advantage it confers is very small and is dependent on the prevalence of N2 metastasis and the unproven superiority of induction therapy over adjuvant therapy.

Bromhexine↗
PubMed2006

Yield of brain 18F-FDG PET in evaluating patients with potentially operable non-small cell lung cancer.

UNLABELLED: The American College of Surgeons Oncology Group recently completed a trial evaluating the role of PET with 18F-FDG in patients with documented or suspected non-small cell lung cancer. Subjects underwent standard imaging to exclude metastatic disease before PET. Here, we report the yield of brain PET in evaluating, for potential intracranial metastases, patients who have undergone previous brain CT or MRI with negative findings. METHODS: A total of 287 evaluable patients who had been registered from 22 institutions underwent whole-body 18F-FDG PET, including dedicated PET of the brain, after routine staging procedures had found no suggestion of metastatic disease. Patients were followed postoperatively for disease-free and overall survival, with a minimum follow-up of 6 mo. Patients with specific brain abnormalities identified by PET were further examined, and the findings were evaluated along with the results of CT and MRI, clinical management, and follow-up. RESULTS: In 4 patients, PET found focal 18F-FDG uptake in the brain suggestive of metastatic disease; however, metastatic disease was excluded clinically in all 4 by negative findings on further brain imaging. All 4 patients remained alive at follow-up (mean duration, 10.5 mo; range, 6-16 mo). CONCLUSION: In patients with suspected or proven non-small cell lung cancer considered resectable by standard imaging, including routine preoperative contrast-enhanced CT or MRI of the brain, PET of the brain provides no additional information regarding metastatic disease.

Aged↗
PubMed2006

18F-FDG PET definition of gross tumor volume for radiotherapy of non-small cell lung cancer: is a single standardized uptake value threshold approach appropriate?

UNLABELLED: PET with (18)F-FDG has been used in radiation treatment planning for non-small cell lung cancer (NSCLC). Thresholds of 15%-50% the maximum standardized uptake value (SUV(max)) have been used for gross tumor volume (GTV) delineation by PET (PET(GTV)), with 40% being the most commonly used value. Recent studies indicated that 15%-20% may be more appropriate. The purposes of this study were to determine which threshold generates the best volumetric match to GTV delineation by CT (CT(GTV)) for peripheral NSCLC and to determine whether that threshold can be generalized to tumors of various sizes. METHODS: Data for patients who had peripheral NSCLC with well-defined borders on CT and SUV(max) of greater than 2.5 were reviewed. PET/CT datasets were reviewed, and a volume of interest was determined to represent the GTV. The CT(GTV) was delineated by using standard lung windows and reviewed by a radiation oncologist. The PET(GTV) was delineated automatically by use of various percentages of the SUV(max). The PET(GTV)-to-CT(GTV) ratios were compared at various thresholds, and a ratio of 1 was considered the best match, or the optimal threshold. RESULTS: Twenty peripheral NSCLCs with volumes easily defined on CT were evaluated. The SUV(max) (mean +/- SD) was 12 +/- 8, and the mean CT(GTV) was 198 cm(3) (97.5% confidence interval, 5-1,008). The SUV(max) were 16 +/- 5, 13 +/- 9, and 3.0 +/- 0.4 for tumors measuring greater than 5 cm, 3-5 cm, and less than 3 cm, respectively. The optimal thresholds (mean +/- SD) for the best match were 15% +/- 6% for tumors measuring greater than 5 cm, 24% +/- 9% for tumors measuring 3-5 cm, 42% +/- 2% for tumors measuring less than 3 cm, and 24% +/- 13% for all tumors. The PET(GTV) at the 40% and 20% thresholds underestimated the CT(GTV) for 16 of 20 and 14 of 20 lesions, respectively. The mean difference in the volumes (PET(GTV) minus CT(GTV) [PET(GTV) - CT(GTV)]) at the 20% threshold was 79 cm(3) (97.5% confidence interval, -922 to 178). The PET(GTV) at the 20% threshold overestimated the CT(GTV) for all 4 tumors measuring less than 3 cm and underestimated the CT(GTV) for all 6 tumors measuring greater than 5 cm. The CT(GTV) was inversely correlated with the PET(GTV) - CT(GTV) at the 20% threshold (R(2) = 0.90, P < 0.0001). The optimal threshold was inversely correlated with the CT(GTV) (R(2) = 0.79, P < 0.0001). CONCLUSION: No single threshold delineating the PET(GTV) provides accurate volume definition, compared with that provided by the CT(GTV), for the majority of NSCLCs. The strong correlation of the optimal threshold with the CT(GTV) warrants further investigation.

Carcinoma, Non-Small-Cell Lung↗
PubMed2005

Preoperative lymph node staging of early-stage cervical carcinoma by [18F]-fluoro-2-deoxy-D-glucose-positron emission tomography.

BACKGROUND: Increasing evidence has documented the value of positron emission tomography (PET) in oncology, but only limited data are available comparing PET findings with the pathologic status of regional lymph nodes in patients with cervical carcinoma. The objective of this study was to determine the sensitivity and specificity of PET in detecting lymph node metastasis in women with early-stage cervical carcinoma. METHODS: The authors performed a retrospective review of all patients with Stage IA-IIA cervical carcinoma who underwent PET before surgery from 1999 to 2004. The status of the regional lymph nodes was correlated with lymph node pathology. RESULTS: Fifty-nine patients were identified. Pelvic lymph node metastases were present in 32% of the patients and were detected by PET with a sensitivity of 53%, a specificity of 90%, a positive predictive value (PPV) of 71%, and a negative predictive value (NPV) of 80%. Paraaortic lymph node disease was present in 9% of patients and was detected by PET with a sensitivity of 25%, a specificity 98%, a PPV of 50%, and an NPV of 93%. The mean size of the tumor deposits was larger in the PET-positive pelvic nodes (15.2 mm; range, 2-35 mm) than in the PET-negative lymph nodes (7.3 mm; range, 0.3-20 mm; P = 0.002). Computed tomography (CT) scans were obtained before surgery in 42 patients. The combined sensitivity of PET and CT in these patients was 75%. PET alone detected 9 (36%) of the positive lymph node groups, whereas CT alone detected 3 (12%) of the positive lymph node groups. Neither PET nor CT detected the positive lymph node groups in 8 patients (32%). CONCLUSIONS: Pathologic validation of PET imaging demonstrated a low sensitivity and a high specificity for PET in patients with early-stage cervical carcinoma.

Female↗
PubMed2005

F-18 fluorodeoxyglucose uptake in primary cervical cancer as an indicator of prognosis after radiation therapy.

PURPOSE: We evaluated the prognostic significance of tumor metabolic activity on pretreatment positron emission tomography using the glucose analog F-18 fluorodeoxyglucose (FDG-PET) in patients with carcinoma of the cervix undergoing radiotherapy with or without concurrent chemotherapy. METHODS: We studied 96 consecutive patients who underwent FDG-PET prior to initiation of radiotherapy with or without concurrent chemotherapy for carcinoma of the cervix. Pretreatment FDG uptake of the primary tumor was assessed with the semiquantitative standardized uptake value (SUV) and correlated with disease-free and overall survival. Survival was estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed with the logistic likelihood ratio test and the Cox proportional hazards model, respectively. RESULTS.: Five-year disease-free survivals in patients with maximal SUV <10.2 and > or =10.2 were 71% and 52% (P = 0.0289) respectively, while overall survivals were 72% and 69% (P = 0.4), respectively. On multivariate analysis, lymph node metastasis on FDG-PET was found to be predictive of disease-free survival (P < 0.0001). Both the SUV for FDG and FIGO Stage I disease were found to be marginally predictive of disease-free survival (P = 0.055 and P = 0.058, respectively). CONCLUSIONS: FDG uptake within primary cervical cancer, as measured by SUV, is predictive of disease-free survival in patients undergoing radiotherapy for cervical cancer. High FDG uptake may be useful in identifying patients who may require more aggressive initial therapy.

Adult↗
PubMed2005

FDG-PET evaluation of vaginal carcinoma.

PURPOSE: To compare the results of CT and positron emission tomography (PET) and F-18 fluorodeoxyglucose (FDG) in the detection of the primary tumor and lymph node metastases in carcinoma of the vagina. METHODS AND MATERIALS: This was a prospective registry study of 23 consecutive patients with carcinoma of the vagina, in which we respectively compared the results of CT and whole-body FDG-PET. The tumor was clinical Stage II in 16 patients, Stage III in 6, and Stage IVa in 1 patient. The primary tumor ranged in size from 2 to 10 cm (mean 4.9), and 4 patients had palpable groin lymph nodes. All patients were treated with external beam radiotherapy and brachytherapy, 14 received concurrent chemotherapy, and 2 underwent primary tumor excision before the imaging evaluation. The median follow-up was 21 months in those patients alive without disease. Survival was estimated by the Kaplan-Meier method. RESULTS: Of the 21 patients with an intact primary tumor, CT visualized it in 9 (43%). CT also demonstrated abnormally enlarged groin lymph nodes in 3 patients and both groin and pelvic lymph nodes in 1 patient (4 of 23, 17%). FDG-PET identified abnormal uptake in all 21 intact primary tumors (100%). Abnormal uptake was found in the groin lymph nodes in 4 patients, pelvic lymph nodes in 2, and both groin and pelvic lymph nodes in 2 patients (8 of 23, 35%). The 3-year progression-free and overall survival estimate was 73% and 68%, respectively. CONCLUSION: The results of this study have demonstrated that FDG-PET detects the primary tumor and abnormal lymph nodes more often than does CT.

Carcinoma↗
PubMed2005

Progress and promise of FDG-PET imaging for cancer patient management and oncologic drug development.

2-[(18)F]Fluoro-2-deoxyglucose positron emission tomography (FDG-PET) assesses a fundamental property of neoplasia, the Warburg effect. This molecular imaging technique offers a complementary approach to anatomic imaging that is more sensitive and specific in certain cancers. FDG-PET has been widely applied in oncology primarily as a staging and restaging tool that can guide patient care. However, because it accurately detects recurrent or residual disease, FDG-PET also has significant potential for assessing therapy response. In this regard, it can improve patient management by identifying responders early, before tumor size is reduced; nonresponders could discontinue futile therapy. Moreover, a reduction in the FDG-PET signal within days or weeks of initiating therapy (e.g., in lymphoma, non-small cell lung, and esophageal cancer) significantly correlates with prolonged survival and other clinical end points now used in drug approvals. These findings suggest that FDG-PET could facilitate drug development as an early surrogate of clinical benefit. This article reviews the scientific basis of FDG-PET and its development and application as a valuable oncology imaging tool. Its potential to facilitate drug development in seven oncologic settings (lung, lymphoma, breast, prostate, sarcoma, colorectal, and ovary) is addressed. Recommendations include initial validation against approved therapies, retrospective analyses to define the magnitude of change indicative of response, further prospective validation as a surrogate of clinical benefit, and application as a phase II/III trial end point to accelerate evaluation and approval of novel regimens and therapies.

Fluorodeoxyglucose F18↗
PubMed2005

Positron tomographic assessment of androgen receptors in prostatic carcinoma.

PURPOSE: The purpose of this study was to evaluate the feasibility of androgen receptor (AR) imaging with 16beta-[18F]fluoro-5alpha-dihydrotestosterone (FDHT) by positron emission tomography (PET) and to assess the binding selectivity of FDHT to AR in patients with prostate cancer. METHODS: Twenty men (age range 56-87 years) with advanced prostate cancer were studied. All except one had metastatic disease confirmed by biopsy and/or radiological studies. One patient who had radiological findings suggesting a single hepatic metastasis was found to have focal fatty infiltration on biopsy obtained after FDHT-PET and was excluded from further data analysis. FDHT uptake was assessed semiquantitatively by determination of the standardized uptake value (SUV) and tumor-to-muscle ratio (T/M). Additionally, to assess the AR binding selectivity of FDHT, patients with one or more foci of abnormally increased FDHT accumulation were studied after administration of an AR antagonist (flutamide). RESULTS: Conventional imaging demonstrated innumerable lesions in two patients and 43 lesions in the remaining 17 patients with advanced prostate cancer. FDHT-PET was positive in 12 of 19 patients (sensitivity of 63%), including the two patients with innumerable lesions. FDHT-PET detected 24 of 28 known lesions (86%) in the remaining ten patients. In addition, FDHT-PET detected 17 unsuspected lesions in five of these ten patients. All 12 patients with positive FDHT-PET underwent a repeat PET study after receiving flutamide for 1 day (250 mg t.i.d.). In all of these patients, there was a decrease in tumor FDHT uptake after flutamide; the mean (+/- standard deviation) SUV and T/M decreased from 7.0+/-4.7 and 6.9+/-3.9, respectively, to 3.0+/-1.5 and 3.0+/-1.6, respectively (p=0.002). The mean PSA in patients with positive FDHT-PET was significantly higher than that in patients with negative FDHT-PET (p=0.006). CONCLUSION: Our results document the feasibility of PET imaging of prostate cancer with FDHT and suggest that tumor uptake of FDHT is a receptor-mediated process. Positive PET studies were associated with higher PSA levels and thus, presumably, with greater tumor burden.

Adenocarcinoma↗
PubMed2005

Lack of benefit of concurrent chemotherapy in patients with cervical cancer and negative lymph nodes by FDG-PET.

PURPOSE: To compare the outcome of patients with cervical cancer and negative lymph nodes by fluorodeoxyglucose-positron emission tomography (FDG-PET) treated with irradiation (RT) and concurrent chemotherapy or RT alone. METHODS AND MATERIALS: This was a prospective data registry of 65 patients with cervical cancer and negative lymph nodes by whole-body FDG-PET. The tumor stage was IB2 in 11, IIB in 37, and IIIB in 17 patients. RT alone was administered to 15 and RT with concurrent weekly cisplatin to 50 patients. RESULTS: The 5-year overall survival estimate was 85% with RT and 81% with RT and concurrent chemotherapy (p = 0.91). The corresponding 5-year cause-specific survival estimates were 78% and 74% (p = 0.98). The differences in the sites of recurrence (pelvis vs. distant metastasis) were not statistically significant between the two groups (p = 0.77). A Cox proportional hazards model of survival outcome did not identify chemotherapy, overall treatment time, or radiation dose as statistically significant prognostic factors. Severe complications included one rectovaginal fistula, one rectal stricture requiring colostomy (both in the concurrent chemotherapy group), and one death from chemotherapy-related complications. CONCLUSION: Irradiation with concurrent cisplatin was not advantageous compared with RT alone in patients with negative lymph nodes on FDG-PET.

Adenocarcinoma↗
PubMed2005

FDG uptake in colonic villous adenomas.

Colonic adenomas constitute 70-80% of all colorectal polyps, and their clinical significance relates primarily to their relationship with colorectal cancer. The malignant potential of the polyps detected by FDG-PET is unknown, as not all the colonic lesions identified by FDG-PET represent colorectal malignancies. The purpose of this study was to investigate the rate of FDG-PET positivity within colonic villous adenomas. A pathology database search was performed to identify all patients diagnosed with colonic villous adenoma between June 1, 1996 and December 1, 2000. Patients with a pathologic diagnosis of colonic villous adenoma and who also had a FDG-PET study up to 1 month before colonoscopy were included in this study. FDG-PET findings were compared with pathological features. Of more than 4,000 patients, six patients were diagnosed with colonic adenoma on subsequent colonoscopy following FDG-PET study. Based on the pathological findings, these 6 patients had a total of 2 villous and 9 tubulovillous adenomas. Five of the 6 patients showed foci of increased FDG uptake in the region of the colon that corresponded to the villous adenoma(s) detected on colonoscopy, which accounted for a true-positive rate of 83.3% (5/6 subjects). Focal lesions in the colon seen on FDG-PET examinations need to be investigated further, even though some of these will prove to be villous adenomas rather than colorectal carcinomas. Future studies in a larger number of patients are needed to evaluate the relationship of histopathological features of colonic polyps and detectability of these lesions by FDG-PET.

Adenoma, Villous↗
PubMed2005

Oncologic PET/CT: current status and controversies.

The introduction of integrated PET/CT has dramatically increased the worldwide rate of growth for PET, predominantly for oncologic imaging with the glucose analog 18F-fluorodeoxyglucose (FDG). A rapidly expanding body of literature demonstrates that the use of FDG-PET/CT and the resultant ability to interpret coregistered and fused PET and CT images lead to improved observer confidence and improved diagnostic performance by comparison with PET alone, CT alone, and visually correlated PET and CT. The value of PET/CT is likely to be even greater with new PET radiopharmaceuticals under development, many of which produce PET images with even fewer anatomical landmarks than FDG images. PET/CT is also likely to lead to the resurrection of 18F-fluoride as a principal agent for radionuclide bone imaging. There are a number of controversies related to PET/CT, including minimum training and experience requirements for interpreting physicians and defining new models for technical and professional reimbursement.

Clinical Competence↗
PubMed2005

Concurrent PET/CT with an integrated imaging system: intersociety dialogue from the joint working group of the American College of Radiology, the Society of Nuclear Medicine, and the Society of Computed Body Tomography and Magnetic Resonance.

Rapid advances in imaging technology are a challenge for health care professionals, who must determine how best to use these technologies to optimize patient care and outcomes. Hybrid imaging instrumentation, combining 2 or more new or existing technologies, each with its own separate history of clinical evolution, such as PET and CT, may be especially challenging. CT and PET provide complementary anatomic information and molecular information, respectively, with PET giving specificity to anatomic findings and CT offering precise localization of metabolic activity. Historically, the acquisition and interpretation of the 2 image sets have been performed separately and very often at different times and locales. Recently, integrated PET/CT systems have become available; these systems provide PET and CT images that are acquired nearly simultaneously and are capable of producing superimposed, coregistered images, greatly facilitating interpretation. As the implementation of this integrated technology has become more widespread in the setting of oncologic imaging, questions and concerns regarding equipment specifications, image acquisition protocols, supervision, interpretation, professional qualifications, and safety have arisen. This article summarizes the discussions and observations surrounding these issues by a collaborative working group consisting of representatives from the American College of Radiology, the Society of Nuclear Medicine, and the Society of Computed Body Tomography and Magnetic Resonance.

Humans↗
PubMed2004

Positron emission tomography in limited-stage small-cell lung cancer: a prospective study.

PURPOSE: To determine how often positron emission tomography with [(18)F]fluoro-2-deoxy-D-glucose (FDG-PET) detects extensive-stage small-cell lung cancer (SCLC) in patients considered to have limited-stage disease based on conventional staging procedures, and to determine the impact of PET on treatment planning for presumed limited-stage SCLC. PATIENTS AND METHODS: We prospectively performed pretreatment FDG-PET on 24 patients determined by conventional staging methods to have limited-stage SCLC (defined as disease that could be encompassed within a reasonable radiotherapy portal, excluding bilateral supraclavicular disease). PET images were evaluated for evidence of extensive-stage disease. Tumor-node-metastasis system staging was also assigned for each patient, with and without PET information. RESULTS: FDG-PET demonstrated findings consistent with extensive-stage SCLC in three of 24 patients. FDG-PET correctly upstaged two (8.3%) of 24 patients to extensive-stage disease (95% CI, 1.03% to 27.0%). PET correctly identified tumor in each SCLC mass (primary or nodal) that was suspected on computed tomography (CT) imaging, thus giving a lesion-based sensitivity relative to CT of 100%. PET identified unsuspected regional nodal metastasis in six (25%) of 24 patients, and the radiation therapy plan was significantly altered to include the PET-positive/CT-negative nodes within the high-dose region in each of these patients. Brain PET images in 23 patients disclosed no evidence of brain metastasis. CONCLUSION: FDG-PET has high sensitivity for SCLC and appears to be of value for initial staging and treatment planning of patients with presumed limited-stage disease.

Adult↗
PubMed2004

Lymph node control in cervical cancer.

PURPOSE: The aim was to evaluate pretreatment lymph node size, irradiation dose, and failure patterns. METHODS: Pretreatment PET and CT were performed in 208 patients. Lymph nodes were scored as either positive or negative by PET and lymph node size was measured by CT. Lymph node irradiation dose and sites of failure were recorded. RESULTS: The mean pelvic lymph node doses were: PET negative nodes, < or =1 cm, 66.8 Gy, and 0/76 failures; PET positive nodes, < or =1 cm, 66.8 Gy, and 3/89 failures; 1.1-< or =2 cm, 66.9 Gy, and 0/21 failures; 2.1-< or =3 cm, 69.4 Gy, and 2/15 failures; and 3.1 to < or =4 cm, 74.1 Gy, and 0/5 failures. The mean paraaortic lymph node dose was 43.3 Gy and there were no paraaortic failures for 24 patients with PET positive < or =1 cm nodes, 0/5 failures for 1.1 to < or =2 cm, and 0/4 failures for 2.1 to < or =3 cm. The most common site of failure was distant metastases. CONCLUSIONS: The irradiation doses given in this study were adequate to control most lymph node metastases. Positive lymph nodes of any size at diagnosis were the most significant predictor for developing distant metastases.

Adult↗