The pectoralis major musculocutaneous (PMMC) flap has been a useful technique for head and neck reconstruction since its first description by Ariyan in 1979. However, techniques in microvascular surgery have since evo...The pectoralis major musculocutaneous (PMMC) flap has been a useful technique for head and neck reconstruction since its first description by Ariyan in 1979. However, techniques in microvascular surgery have since evolved and recently free tissue transfer has played an important role in head and neck reconstruction. Although we use free flaps as the first choice for head and neck reconstruction, similar to many other institutions, some patients at our hospital have undergone reconstruction with PMMC flaps. We retrospectively analyzed the indications and outcomes of this reconstructive technique from our experience with 12 patients. The medical records of all patients who underwent PMMC flaps at Hokkaido Cancer Center from 2001 to 2010 were reviewed. Data concerning diagnosis, main indication, site of reconstruction, previous treatment, and postoperative complications were analyzed. Of the 12 PMMC flap surgeries performed, 3 were carried out as primary reconstructive procedures, whereas 9 were done as “salvage” procedures. Flap-related complications were observed in 6 cases. Partial flap loss developed in 4 patients, although there were no cases of total flap loss. There were 3 recurrent fistulae following reconstruction with PMMC flaps. The preoperative goals of performing PMMC flap surgery were met in 83% of our cases. The authors conclude that while free flap transfer is usually the first choice for head and neck reconstruction, PMMC flaps can produce acceptable results in certain situations.展开更多
Objectives: Recent studies have introduced middle ear volume(MEV) as a novel determinant of perforation-induced conductive hearing loss(CHL) in a mechanism driven by trans-tympanic membrane pressure differences. The p...Objectives: Recent studies have introduced middle ear volume(MEV) as a novel determinant of perforation-induced conductive hearing loss(CHL) in a mechanism driven by trans-tympanic membrane pressure differences. The primary aims of this preliminary report are to: 1) correlate CHL with perforation size; 2) describe the relationship between CHL and MEV; and 3) compare CHL across a range of cholesteatoma involvement.Design: A retrospective pilot study was performed in 31 subjects with audiometry indicative of conductive hearing loss, temporal bone CT scans,and no prior middle ear surgery. Perforation size and MEV were analyzed with respect to CHL in a cohort of 10 perforated ears with no cholesteatoma. CHLs were compared in 3 groups defined by extent of cholesteatoma involvement.Results: Ears with large and small perforations showed mean ABG values of 32.0 ± 15.7 dB and 16.0 ± 16.4 dB, respectively. A direct relationship was observed between MEV and CHL for ears with large perforations across all frequencies, whereas this relationship for small perforations was frequency-dependent. Finally, a statistically significant increase in CHL was found across ears with increasing cholesteatoma involvement at 1000 Hz(X^2(2) = 9.786, p = 0.008),2000 Hz(x^2(2) = 8.455, p = 0.015),and 4000 Hz(x^2(2)= 8.253, p = 0.016).Conclusions: These pilot data suggest that greater perforation-induced conductive hearing losses may be associated with larger perforation sizes and cholesteatoma. The correlation between MEV and CHL may require additional study.展开更多
Introduction: Superior semicircular canal dehiscence(SCD) remains difficult to diagnose despite advances in high-resolution computed tomography(HRCT) imaging. We hypothesize possible associations between gross tempora...Introduction: Superior semicircular canal dehiscence(SCD) remains difficult to diagnose despite advances in high-resolution computed tomography(HRCT) imaging. We hypothesize possible associations between gross temporal bone anatomy and sub-millimeter pathology of the semicircular canals, which may supplement imaging and clinical suspicion. This pilot study investigates differences in gross temporal bone anatomic parameters between temporal bones with and without SCD.Methods: Records were reviewed for 18 patients referred to an otology clinic complaining of dizziness with normal caloric stimulation results indicative of non-vestibular findings. Eleven patients had normal temporal bone anatomy while seven had SCD. Three-dimensional reconstruction of every patient's temporal bone anatomy was created from patient-specific computational tomography images. Surface area(SA),volume(V), and SA to V ratios(SA:V) were computed across temporal bone anatomical parameters.Results: SCD temporal bones have significantly smaller V, and larger temporal bone SA. Mean(±SD) V was 21,484 ± 3,921 mm^3 in temporal bones without SCD and 16,343 ± 34,471 mm^3 for those with SCD. Their respective SA were 13,733 ± 1,603 mm^2 and 18,073 ± 3,002 mm^2.Temporal bone airspaces and lateral semicircular canals did not demonstrate significant differences where SCD was and was not present. Plots of MV_(warm)response against computed SCD temporal bone anatomic parameters(SA, V and SA:V) showed moderate to strong correlations:temporal bone SA:V(r= 0.64), temporal bone airspace V(r= 0.60), temporal bone airspace SA(r= 0.55), LSCC SA(r= 0.51), and LSCC-toTM Distance(r= 0.65).Conclusions: This analysis demonstrated that SCD is associated with decreased temporal bone volume and density. The defect in SCD does not appear to influence caloric responses.展开更多
Background:Thermal ablation of thyroid nodules is new modality for the management of the benign and malign lesions.This minimally invasive treatment is performed as an outpatient,local anesthetic,single professional p...Background:Thermal ablation of thyroid nodules is new modality for the management of the benign and malign lesions.This minimally invasive treatment is performed as an outpatient,local anesthetic,single professional procedure that can treat neoplastic lesions without removing normal thyroid tissue and thus avoiding hypothyroidism.Method:A comprehensive review of the most relevant literature regarding the thermal ablation of benign and malign nodules was performed in order to currently define its role on the management of the nodular thyroid disease.The data was divided into benign and malign literature.Results:The benign nodules can be effectively treated by radiofrequency ablation(RFA)but some limitation exists regarding the nodule’s size but not nodules characteristics.The RFA of primary malign tumors of the thyroid recently demonstrated positive and safe long-term follow-up and encouraged additional investigation and possibly a definitive role in the management of these low risk nodules.Conclusion:RFA is a safe,cost-effective minimally invasive procedure that avoids thyroid tissue removal while destroying neoplastic one thus,preventing hypothyroidism.展开更多
AIM: To investigate the rate of occult lymph node disease in elective parotidectomy and neck dissection specimens in patients with advanced auricular cutaneous squamous cell carcinoma(cS CC). METHODS: At a single inst...AIM: To investigate the rate of occult lymph node disease in elective parotidectomy and neck dissection specimens in patients with advanced auricular cutaneous squamous cell carcinoma(cS CC). METHODS: At a single institution, from 2000 to 2010, 17 patients with advanced auricular cS CC were considered high risk for occult regional parotid and/or neck nodal metastases and, thus, underwent an auriculectomy and elective regional lymphadenectomy(parotidectomy and/or neck dissection). Indications for elective regional lymphadenectomy were large tumor size, locally invasive tumors, post-surgical and post-radiation recurrence, and being an immunosuppressed patient. We determined the presence of microscopic disease in the regional(parotid and neck dissection) pathology specimens.RESULTS: There were 17 advanced auricular c SCC patients analyzed for this study. Fifteen(88%) patients were men. The average age was 69(range: 33 to 86). Ten(59%) patients presented with post-surgical recurrence. Five(29%) patients presented with postradiation recurrence. Four(24%) patients presentedwith both post-surgical and post-radiation recurrence. Four(24%) patients were immunosuppressed(2(12%) were liver transplant patients, 2(12%) were chronic lymphocytic leukemia patients, and 1(6%) was both). The subsite distribution of c SCC included helix(3, 18%), antihelix(2, 12%), conchal bowl(7, 41%), tragus(2, 12%), and postauricular sulcus(3, 18%). Four(24%) patients presented with multifocal auricular cS CC. No patients had bilateral disease. All patients were confirmed to have c SCC on final pathology. The tumors were well(5, 29%), moderately(10, 59%), and poorly(2, 12%) differentiated SCC. The average size of the cS CC tumor was 2.9 cm(range: 1.7 to 7 cm). Twelve(70%) tumors were greater than 2 cm. Six(35%) patients underwent partial auriculectomy. Eleven(65%) patients underwent total auriculectomy. Eight(47%) patients underwent elective parotidectomy and elective neck dissections; 3(18%) underwent only elective parotidectomy; 3(18%) underwent only an elective neck dissection; 2(12%) underwent an elective parotidectomy and therapeutic neck dissection; and 1(6%) underwent a therapeutic parotidectomy and an elective neck dissection. None of the elective parotidectomy or neck dissection specimens were found to contain any malignant disease. All therapeutic parotidectomy and neck dissection specimens contained metastatic SCC. Fourteen(82%) underwent parotidectomy. Of these, 10(71%) underwent superficial parotidectomy whereas 4(29%) underwent total parotidectomy. Fourteen(82%) underwent neck dissections [levels Ⅱ/Ⅴa(1, 7%), levels Ⅱ/Ⅲ/Ⅴa(2, 14%), levels Ⅰ/Ⅱ/Ⅲ/Ⅴa(2, 14%), and complete levels Ⅰ-Ⅴ(9, 64%)]. Three(18%) underwent concurrent temporal bone resections for tumor extension from the auricle. The average follow-up for our patients was 44 mo(range: 4 to 123 mo). At the time of the review, 6(35%) patients were alive and 11(65%) had passed away. CONCLUSION: This study suggests that, in patients with advanced auricular cutaneous SCC, elective regional lymphadenectomy is not necessary. However,furtherprospective studies are necessary to assess the necessity.展开更多
Anaplastic thyroid cancer is an uncommon malignancy with a poor prognosis. Elderly patients are most commonly afflicted and survival past 3 years occurs in less than 5% of patients. Management of these patients is cha...Anaplastic thyroid cancer is an uncommon malignancy with a poor prognosis. Elderly patients are most commonly afflicted and survival past 3 years occurs in less than 5% of patients. Management of these patients is challenging, and the importance of palliation, airway protection, and aggressive resection is debated. In this report, we describe a patient with anaplastic thyroid carcinoma who presented with respiratory distress due to invasion of the tracheal cartilage. The patient was managed with cricotracheal resection, total thyroidectomy and thyrotracheal anastomosis. The patient is currently disease free 3.5 years after resection and postoperative radiation therapy with interval neck dissection.展开更多
Background:The cochlear implant has become the standard of care for severe or worse losses in hearing and indeed has produced the first substantial restoration of a lost or absent human sense using a medical intervent...Background:The cochlear implant has become the standard of care for severe or worse losses in hearing and indeed has produced the first substantial restoration of a lost or absent human sense using a medical intervention.However,the devices are not perfect and many efforts to narrow the remaining gaps between prosthetic and normal hearing are underway.Objective:To assess the present status of cochlear implants and to describe possibilities for improving them.Results:The present-day devices work well in quiet conditions for the great majority of users.However,not all users have high levels of speech reception in quiet and nearly all users struggle with speech reception in typically noisy acoustic environments.In addition,perception of sounds more complex than speech,such as most music,is generally poor unless residual hearing at low frequencies can be stimulated acoustically in conjunction with the electrical stimuli provided by the implant.Possibilities for improving the present devices include increasing the spatial specificity of neural excitation by reducing masking effects or with new stimulus modes;prudent pruning of interfering or otherwise detrimental electrodes from the stimulation map;a further relaxation in the criteria for implant candidacy,based on recent evidence from persons with high levels of residual hearing and to allow many more people to benefit from cochlear implants;and 'top down' or 'brain centric' approaches to implant designs and applications.Conclusions:Progress in the development of the cochlear implant and related treatments has been remarkable but room remains for improvements.The future looks bright as there are multiple promising possibilities for improvements and many talented teams are pursuing them.展开更多
Advances in imaging for preoperative localization have propelled the widespread adoption of minimally invasive/focused parathyroidectomy in primary hyperparathyroidism.Though it is performed through a relatively small...Advances in imaging for preoperative localization have propelled the widespread adoption of minimally invasive/focused parathyroidectomy in primary hyperparathyroidism.Though it is performed through a relatively small incision,studies have shown that the presence of a neck scar increases attentional bias towards the neck resulting in compromised quality of life.Transoral endoscopic parathyroidectomy vestibular approach(TOEPVA)eliminates a neck scar.While indications for TOEPVA are the same as that of minimally invasive open parathyroidectomy,confident preoperative localization of the parathyroid with a surgeon performed ultrasound along with concordant localization with SPECT CT is an essential prerequisite before offering patients this approach for parathyroidectomy.Early data has demonstrated the feasibility and safety of this approach.展开更多
Lymph node metastasis is common in differentiated thyroid cancer especially papillary thyroid cancer.Presence of lymph node metastasis does not have an impact on survival in younger patients.Therapeutic central and la...Lymph node metastasis is common in differentiated thyroid cancer especially papillary thyroid cancer.Presence of lymph node metastasis does not have an impact on survival in younger patients.Therapeutic central and lateral neck dissection in the presence of clinically or radiologically evident lymph nodes has resulted in good overall survival.However,disease persistence in the lymph node/early recurrences may be seen in patients owing to lymph nodes that may be missed during the initial neck dissection.These observed locations are retropharyngeal and parapharyngeal nodal location,retro carotid location,sublingual,axillary,and intraparotid locations,supraclavicular and superficial to the sternothyroid muscle.We aim to highlight these locations with the goal to minimize persistence or early recurrence of disease at these locations.展开更多
文摘The pectoralis major musculocutaneous (PMMC) flap has been a useful technique for head and neck reconstruction since its first description by Ariyan in 1979. However, techniques in microvascular surgery have since evolved and recently free tissue transfer has played an important role in head and neck reconstruction. Although we use free flaps as the first choice for head and neck reconstruction, similar to many other institutions, some patients at our hospital have undergone reconstruction with PMMC flaps. We retrospectively analyzed the indications and outcomes of this reconstructive technique from our experience with 12 patients. The medical records of all patients who underwent PMMC flaps at Hokkaido Cancer Center from 2001 to 2010 were reviewed. Data concerning diagnosis, main indication, site of reconstruction, previous treatment, and postoperative complications were analyzed. Of the 12 PMMC flap surgeries performed, 3 were carried out as primary reconstructive procedures, whereas 9 were done as “salvage” procedures. Flap-related complications were observed in 6 cases. Partial flap loss developed in 4 patients, although there were no cases of total flap loss. There were 3 recurrent fistulae following reconstruction with PMMC flaps. The preoperative goals of performing PMMC flap surgery were met in 83% of our cases. The authors conclude that while free flap transfer is usually the first choice for head and neck reconstruction, PMMC flaps can produce acceptable results in certain situations.
基金supported by the National Institutes of Health under Award Numbers 5T32DC013018-03 and TL1TR001116
文摘Objectives: Recent studies have introduced middle ear volume(MEV) as a novel determinant of perforation-induced conductive hearing loss(CHL) in a mechanism driven by trans-tympanic membrane pressure differences. The primary aims of this preliminary report are to: 1) correlate CHL with perforation size; 2) describe the relationship between CHL and MEV; and 3) compare CHL across a range of cholesteatoma involvement.Design: A retrospective pilot study was performed in 31 subjects with audiometry indicative of conductive hearing loss, temporal bone CT scans,and no prior middle ear surgery. Perforation size and MEV were analyzed with respect to CHL in a cohort of 10 perforated ears with no cholesteatoma. CHLs were compared in 3 groups defined by extent of cholesteatoma involvement.Results: Ears with large and small perforations showed mean ABG values of 32.0 ± 15.7 dB and 16.0 ± 16.4 dB, respectively. A direct relationship was observed between MEV and CHL for ears with large perforations across all frequencies, whereas this relationship for small perforations was frequency-dependent. Finally, a statistically significant increase in CHL was found across ears with increasing cholesteatoma involvement at 1000 Hz(X^2(2) = 9.786, p = 0.008),2000 Hz(x^2(2) = 8.455, p = 0.015),and 4000 Hz(x^2(2)= 8.253, p = 0.016).Conclusions: These pilot data suggest that greater perforation-induced conductive hearing losses may be associated with larger perforation sizes and cholesteatoma. The correlation between MEV and CHL may require additional study.
基金supported in part by the National Institutes of Health (United States of America) under Award Numbers 5T32DC013018-03 and TL1TR001116
文摘Introduction: Superior semicircular canal dehiscence(SCD) remains difficult to diagnose despite advances in high-resolution computed tomography(HRCT) imaging. We hypothesize possible associations between gross temporal bone anatomy and sub-millimeter pathology of the semicircular canals, which may supplement imaging and clinical suspicion. This pilot study investigates differences in gross temporal bone anatomic parameters between temporal bones with and without SCD.Methods: Records were reviewed for 18 patients referred to an otology clinic complaining of dizziness with normal caloric stimulation results indicative of non-vestibular findings. Eleven patients had normal temporal bone anatomy while seven had SCD. Three-dimensional reconstruction of every patient's temporal bone anatomy was created from patient-specific computational tomography images. Surface area(SA),volume(V), and SA to V ratios(SA:V) were computed across temporal bone anatomical parameters.Results: SCD temporal bones have significantly smaller V, and larger temporal bone SA. Mean(±SD) V was 21,484 ± 3,921 mm^3 in temporal bones without SCD and 16,343 ± 34,471 mm^3 for those with SCD. Their respective SA were 13,733 ± 1,603 mm^2 and 18,073 ± 3,002 mm^2.Temporal bone airspaces and lateral semicircular canals did not demonstrate significant differences where SCD was and was not present. Plots of MV_(warm)response against computed SCD temporal bone anatomic parameters(SA, V and SA:V) showed moderate to strong correlations:temporal bone SA:V(r= 0.64), temporal bone airspace V(r= 0.60), temporal bone airspace SA(r= 0.55), LSCC SA(r= 0.51), and LSCC-toTM Distance(r= 0.65).Conclusions: This analysis demonstrated that SCD is associated with decreased temporal bone volume and density. The defect in SCD does not appear to influence caloric responses.
文摘Background:Thermal ablation of thyroid nodules is new modality for the management of the benign and malign lesions.This minimally invasive treatment is performed as an outpatient,local anesthetic,single professional procedure that can treat neoplastic lesions without removing normal thyroid tissue and thus avoiding hypothyroidism.Method:A comprehensive review of the most relevant literature regarding the thermal ablation of benign and malign nodules was performed in order to currently define its role on the management of the nodular thyroid disease.The data was divided into benign and malign literature.Results:The benign nodules can be effectively treated by radiofrequency ablation(RFA)but some limitation exists regarding the nodule’s size but not nodules characteristics.The RFA of primary malign tumors of the thyroid recently demonstrated positive and safe long-term follow-up and encouraged additional investigation and possibly a definitive role in the management of these low risk nodules.Conclusion:RFA is a safe,cost-effective minimally invasive procedure that avoids thyroid tissue removal while destroying neoplastic one thus,preventing hypothyroidism.
文摘AIM: To investigate the rate of occult lymph node disease in elective parotidectomy and neck dissection specimens in patients with advanced auricular cutaneous squamous cell carcinoma(cS CC). METHODS: At a single institution, from 2000 to 2010, 17 patients with advanced auricular cS CC were considered high risk for occult regional parotid and/or neck nodal metastases and, thus, underwent an auriculectomy and elective regional lymphadenectomy(parotidectomy and/or neck dissection). Indications for elective regional lymphadenectomy were large tumor size, locally invasive tumors, post-surgical and post-radiation recurrence, and being an immunosuppressed patient. We determined the presence of microscopic disease in the regional(parotid and neck dissection) pathology specimens.RESULTS: There were 17 advanced auricular c SCC patients analyzed for this study. Fifteen(88%) patients were men. The average age was 69(range: 33 to 86). Ten(59%) patients presented with post-surgical recurrence. Five(29%) patients presented with postradiation recurrence. Four(24%) patients presentedwith both post-surgical and post-radiation recurrence. Four(24%) patients were immunosuppressed(2(12%) were liver transplant patients, 2(12%) were chronic lymphocytic leukemia patients, and 1(6%) was both). The subsite distribution of c SCC included helix(3, 18%), antihelix(2, 12%), conchal bowl(7, 41%), tragus(2, 12%), and postauricular sulcus(3, 18%). Four(24%) patients presented with multifocal auricular cS CC. No patients had bilateral disease. All patients were confirmed to have c SCC on final pathology. The tumors were well(5, 29%), moderately(10, 59%), and poorly(2, 12%) differentiated SCC. The average size of the cS CC tumor was 2.9 cm(range: 1.7 to 7 cm). Twelve(70%) tumors were greater than 2 cm. Six(35%) patients underwent partial auriculectomy. Eleven(65%) patients underwent total auriculectomy. Eight(47%) patients underwent elective parotidectomy and elective neck dissections; 3(18%) underwent only elective parotidectomy; 3(18%) underwent only an elective neck dissection; 2(12%) underwent an elective parotidectomy and therapeutic neck dissection; and 1(6%) underwent a therapeutic parotidectomy and an elective neck dissection. None of the elective parotidectomy or neck dissection specimens were found to contain any malignant disease. All therapeutic parotidectomy and neck dissection specimens contained metastatic SCC. Fourteen(82%) underwent parotidectomy. Of these, 10(71%) underwent superficial parotidectomy whereas 4(29%) underwent total parotidectomy. Fourteen(82%) underwent neck dissections [levels Ⅱ/Ⅴa(1, 7%), levels Ⅱ/Ⅲ/Ⅴa(2, 14%), levels Ⅰ/Ⅱ/Ⅲ/Ⅴa(2, 14%), and complete levels Ⅰ-Ⅴ(9, 64%)]. Three(18%) underwent concurrent temporal bone resections for tumor extension from the auricle. The average follow-up for our patients was 44 mo(range: 4 to 123 mo). At the time of the review, 6(35%) patients were alive and 11(65%) had passed away. CONCLUSION: This study suggests that, in patients with advanced auricular cutaneous SCC, elective regional lymphadenectomy is not necessary. However,furtherprospective studies are necessary to assess the necessity.
文摘Anaplastic thyroid cancer is an uncommon malignancy with a poor prognosis. Elderly patients are most commonly afflicted and survival past 3 years occurs in less than 5% of patients. Management of these patients is challenging, and the importance of palliation, airway protection, and aggressive resection is debated. In this report, we describe a patient with anaplastic thyroid carcinoma who presented with respiratory distress due to invasion of the tracheal cartilage. The patient was managed with cricotracheal resection, total thyroidectomy and thyrotracheal anastomosis. The patient is currently disease free 3.5 years after resection and postoperative radiation therapy with interval neck dissection.
文摘Background:The cochlear implant has become the standard of care for severe or worse losses in hearing and indeed has produced the first substantial restoration of a lost or absent human sense using a medical intervention.However,the devices are not perfect and many efforts to narrow the remaining gaps between prosthetic and normal hearing are underway.Objective:To assess the present status of cochlear implants and to describe possibilities for improving them.Results:The present-day devices work well in quiet conditions for the great majority of users.However,not all users have high levels of speech reception in quiet and nearly all users struggle with speech reception in typically noisy acoustic environments.In addition,perception of sounds more complex than speech,such as most music,is generally poor unless residual hearing at low frequencies can be stimulated acoustically in conjunction with the electrical stimuli provided by the implant.Possibilities for improving the present devices include increasing the spatial specificity of neural excitation by reducing masking effects or with new stimulus modes;prudent pruning of interfering or otherwise detrimental electrodes from the stimulation map;a further relaxation in the criteria for implant candidacy,based on recent evidence from persons with high levels of residual hearing and to allow many more people to benefit from cochlear implants;and 'top down' or 'brain centric' approaches to implant designs and applications.Conclusions:Progress in the development of the cochlear implant and related treatments has been remarkable but room remains for improvements.The future looks bright as there are multiple promising possibilities for improvements and many talented teams are pursuing them.
文摘Advances in imaging for preoperative localization have propelled the widespread adoption of minimally invasive/focused parathyroidectomy in primary hyperparathyroidism.Though it is performed through a relatively small incision,studies have shown that the presence of a neck scar increases attentional bias towards the neck resulting in compromised quality of life.Transoral endoscopic parathyroidectomy vestibular approach(TOEPVA)eliminates a neck scar.While indications for TOEPVA are the same as that of minimally invasive open parathyroidectomy,confident preoperative localization of the parathyroid with a surgeon performed ultrasound along with concordant localization with SPECT CT is an essential prerequisite before offering patients this approach for parathyroidectomy.Early data has demonstrated the feasibility and safety of this approach.
文摘Lymph node metastasis is common in differentiated thyroid cancer especially papillary thyroid cancer.Presence of lymph node metastasis does not have an impact on survival in younger patients.Therapeutic central and lateral neck dissection in the presence of clinically or radiologically evident lymph nodes has resulted in good overall survival.However,disease persistence in the lymph node/early recurrences may be seen in patients owing to lymph nodes that may be missed during the initial neck dissection.These observed locations are retropharyngeal and parapharyngeal nodal location,retro carotid location,sublingual,axillary,and intraparotid locations,supraclavicular and superficial to the sternothyroid muscle.We aim to highlight these locations with the goal to minimize persistence or early recurrence of disease at these locations.
