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Neuroendocrine Tumors: Etiology, Diagnosis, and Therapy

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Oncology".

Deadline for manuscript submissions: closed (15 September 2023) | Viewed by 22665

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Dr. Roberta Elisa Rossi

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Gastroenterology and Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
Interests: celiac disease; autoimmune atrophic gastritis; diet; nutrition; micronutrient deficiency
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Dr. Sara Massironi

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Division of Gastroenterology, San Gerardo Hospital, University of Milano-Bicocca School of Medicine, 20900 Monza, Italy
Interests: gastroenterology; neuroendocrine tumors
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Neuroendocrine neoplasms (NENs) are rare and heterogeneous tumors whose incidence has increased in recent years due to better disease knowledge and improvements in diagnostic tools, particularly endoscopy and nuclear medicine. They frequently arise from the gastro–enteropancreatic (GEP) tract, representing approximately 2% of all malignant tumors of the GEP system.

Given their rarity and clinical and biological heterogeneity, there is an urgent need for standardized guidelines for the proper management of these neoplasms, which should always be referred to tertiary referral centers. Novel research strategies are needed to better define diagnostic and therapeutic algorithms, particularly for some specific subgroup of poorly known tumors, including duodenal NENs and functioning tumors. The cooperation between referral centers and the creation of international disease registries should be encouraged to better understand the biology and the natural history of these neoplasms and to consequently improve their management.

The focus of this Special Issue is to consider the following research aspects of NENs: 1) epidemiology and risk factors to define specific subgroups of patients characterized by dismal prognosis; 2) genomic characterization; 3) innovations in multidisciplinary management in both diagnosis and treatment, including surgery (resection and liver transplant), loco-regional treatments, and medical therapy in adjuvant, neoadjuvant and metastatic settings.

Dr. Roberta Elisa Rossi
Dr. Sara Massironi
Guest Editors

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Keywords

neuroendocrine neoplasms
epidemiology
prognosis
diagnosis
treatment
adjuvant treatment
neoadjuvant treatment.

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Neuroendocrine Tumors: Etiology, Diagnosis, and Therapy—2nd Edition in Journal of Clinical Medicine (2 articles)

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Editorial

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4 pages, 195 KiB

Open AccessEditorial

The Increasing Incidence of Neuroendocrine Neoplasms Worldwide: Current Knowledge and Open Issues

by Roberta Elisa Rossi and Sara Massironi

J. Clin. Med. 2022, 11(13), 3794; https://doi.org/10.3390/jcm11133794 - 30 Jun 2022

Cited by 21 | Viewed by 1750

Abstract

Neuroendocrine neoplasms (NENs) include a heterogeneous group of tumors derived from neuroendocrine cells, most commonly arising from the gastro-entero-pancreatic (GEP) and bronchopulmonary tracts [...] Full article

(This article belongs to the Special Issue Neuroendocrine Tumors: Etiology, Diagnosis, and Therapy)

Research

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13 pages, 736 KiB

Open AccessArticle

Role of Selected Circulating Tumor Biomarkers in Patients with Skeletal Metastatic Pancreatic Neuroendocrine Neoplasms

by Violetta Rosiek, Ksenia Janas, Magdalena Witkowska and Beata Kos-Kudła

J. Clin. Med. 2023, 12(14), 4687; https://doi.org/10.3390/jcm12144687 - 14 Jul 2023

Viewed by 1054

Abstract

We investigated the diagnostic capacity of selected circulating biomarkers (CBMs) for the early detection of bone metastasis (BMets) in patients with pancreatic neuroendocrine neoplasms (PanNENs). A total of 115 patients with PanNENs and 40 controls were enrolled. We measured the serum levels of ferritin, cytokeratin 18 (CY18), CA19-9, CA125, AFP, CEA, and beta-2 microglobulin (B2M). A total of eight PanNEN patients developed BMets, and one hundred seven remained BMets-free. We observed a significantly higher level of CA125 and CY18 in BMets patients vs. non-BMets patients (p = 0.01 and p = 0.04, respectively). CA125, CY18, and B2M area under receiver operator characteristic (AUROC) analyses differentiated both patients groups; CA125 area under the curve (AUC) 0.77, p < 0.01; CY18 AUC data were 0.72, p = 0.03, and B2M AUC 0.67, p = 0.02. On the basis of CBM metrics in both subgroups, we reached a sensitivity/specificity for CA125 of 75/76%; for CY18 of 75/69%, for B2M of 100/50%, for CA125, and the CY18 combination of 93/90%, respectively. According to current results, CA125 and CY18 seem to have the potential capacity as fair biomarkers for BMets detection, despite the small number of cases. Further studies are warranted in the larger PanNEN patient group. Full article

(This article belongs to the Special Issue Neuroendocrine Tumors: Etiology, Diagnosis, and Therapy)

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7 pages, 1739 KiB

Open AccessArticle

Bone Loss in Patients with Pancreatic Neuroendocrine Tumors

by He Tong, Miaomiao Wang, Jingjing Liu, Chuangen Guo, Zhongqiu Wang, Jianhua Wang and Xiao Chen

J. Clin. Med. 2022, 11(22), 6701; https://doi.org/10.3390/jcm11226701 - 12 Nov 2022

Viewed by 1301

Abstract

Background: Pancreatic diseases may affect nutritional status, which is one of the important associated factors of bone health. High prevalence of osteoporosis or osteopenia has been reported in patients with pancreatitis. The bone loss in pancreatic neuroendocrine tumors (PNETs) has not been reported. In this study, we showed the prevalence of bone loss and possible associated factors in PNET patients. Methods: A total of 91 PNET patients were included. Bone status was evaluated based on computed tomography (CT) attenuation (Housfield units, HU): >160 HU, normal bone mineral density; osteopenia, 135 HU ≤ CT value ≤ 160 HU; osteoporosis, <135 HU. Associated factors for bone loss were identified by logistic regression analyses. Results: The average age was 55.76 years old in PNET patients. The prevalence of osteoporosis and low bone mass was 37.4% and 60.4%, respectively. Higher prevalence of osteoporosis was observed in patients older than 50 years (64.0%). Multivariate logistic analysis showed that age was an associated factor for low bone mass (odds ratio (OR) = 1.13, 95% confidence interval (CI): 1.04–1.22) and osteoporosis (OR = 1.14, 95% CI: 1.03–1.20). Diabetes was also associated with bone loss in PNET patients after adjusting with confounders (OR = 13.56, 95% CI: 1.02–132.4). Conclusions: Our data show that bone loss is common in patients with PNETs. Age and diabetes are associated with bone loss in PNET patients. Full article

(This article belongs to the Special Issue Neuroendocrine Tumors: Etiology, Diagnosis, and Therapy)

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11 pages, 2226 KiB

Open AccessArticle

The Antiproliferative Activity of High-Dose Somatostatin Analogs in Gastro-Entero-Pancreatic Neuroendocrine Tumors: A Systematic Review and Meta-Analysis

by Francesco Panzuto, Claudio Ricci, Maria Rinzivillo, Ludovica Magi, Matteo Marasco, Giuseppe Lamberti, Riccardo Casadei and Davide Campana

J. Clin. Med. 2022, 11(20), 6127; https://doi.org/10.3390/jcm11206127 - 18 Oct 2022

Cited by 6 | Viewed by 1598

Abstract

Background: The antiproliferative activity of a high dose of somatostatin analogs (HD-SSA) in treating gastro-entero-pancreatic neuroendocrine neoplasms (GEP-NENs) remains under debate. Methods: A systematic review and proportion meta-analysis were made. The primary endpoint was the efficacy measured as incidence density ratio (IDR) at one year. The secondary endpoints were the disease control rate (DCR) and severe adverse events (SAEs). The heterogeneity (I2), when high (>50%), was interpreted by performing a univariate metaregression analysis, analyzing as covariates: type and design of the study, location (Europe or USA), sample size, grading according to 2017 WHO, the metastatic disease rate, previous therapy including surgery, and quality of the study. Results: A total of 11 studies with 783 patients were included. The IDR was 62 new progressions of 100 patients treated with HD-SSA every one year. The heterogeneity was high. The study’s year, type and design, primary tumor, grading, previous treatments, and quality of the studies did not influence the IDR. The IDR was significantly higher in USA centers and studies with more than 50 patients. The IDR was lower when a high rate of metastatic patients was present in the studies. The DCR was 45%. The heterogeneity was high. The DCR was lower in USA studies and in prospective trials. Conclusion: Given the limited efficacy of HD-SSA in preventing the disease progression in unresectable GEP-NENs after failure of standard dose SSA, the use of this therapeutic approach is advisable in selected cases when other antiproliferative treatments are not feasible. Full article

(This article belongs to the Special Issue Neuroendocrine Tumors: Etiology, Diagnosis, and Therapy)

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9 pages, 387 KiB

Open AccessArticle

The Clinical Characteristics of Pheochromocytomas and Paragangliomas with Negative Catecholamines

by Lin Zhao, Xiaoran Zhang, Xu Meng, Ting Zhang, Hua Fan, Qiongyu Zhang, Yecheng Liu, Xianliang Zhou and Huadong Zhu

J. Clin. Med. 2022, 11(19), 5583; https://doi.org/10.3390/jcm11195583 - 23 Sep 2022

Cited by 1 | Viewed by 1605

Abstract

Pheochromocytomas and paragangliomas (PPGLs) associated with negative catecholamines are not uncommon. However, few studies have examined clinical features of patients with these tumors. In the absence of available data, it is difficult to identify characteristics of patients with potential PPGLs and normal serum and urine screens. Therefore, an analysis of patients with PPGLs was conducted retrospectively to compare the clinical features of patients with positive and negative catecholamines. This study included 214 patients, including 69 patients with negative catecholamines. Prevalence rates of diabetes (p < 0.001) and hypertension (p < 0.001) were lower and tumor diameter (p < 0.001) was smaller in the negative-catecholamine group compared with the positive-catecholamine group. Multivariable logistic regression analysis showed that extra-adrenal PPGLs were independently positively associated with negative catecholamines (p = 0.004); hypertension (p = 0.001) and tumor diameter (p = 0.016) were independently negatively associated with negative catecholamines. There was no significant difference in tumor recurrence between the two groups (mean follow-up, 20.54 ± 11.83 months) (p = 0.44). The results demonstrated that PPGL patients with negative catecholamines were more likely to have extra-adrenal tumors and less likely to have comorbidities, and these patients should also be closely monitored for tumor recurrence. Full article

(This article belongs to the Special Issue Neuroendocrine Tumors: Etiology, Diagnosis, and Therapy)

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13 pages, 4163 KiB

Open AccessArticle

Surgical Outcomes, Long-Term Survivals and Staging Systems of World Health Organization G3 Pancreatic Neuroendocrine Tumors

by Min Yang, Lin Zeng, Shengzhong Hou, Bole Tian, Shuguang Jin and Yi Zhang

J. Clin. Med. 2022, 11(18), 5253; https://doi.org/10.3390/jcm11185253 - 6 Sep 2022

Cited by 2 | Viewed by 1469

Abstract

Background: In 2017, the World Health Organization (WHO) defined a new category of pancreatic neuroendocrine neoplasms named G3 pancreatic neuroendocrine tumors (p-NETs), whose surgical outcomes, long-term survivals and staging systems have not been well documented. Methods: Data from eligible patients with G3 p-NETs defined using the WHO 2017 grading classification at our institute were retrospectively analyzed. Results: Our study enrolled 80 patients with WHO G3 p-NETs, including 50 women and 30 men. The accumulative 5-year overall survival (OS) of G3 p-NETs was 29.7%. The current staging system by the American Joint Committee on Cancer (AJCC) failed to discriminate the survival difference between Stage II and Stage III (p = 0.172), while notable differences with regard to the OS were statistically offered between each stage using the modified tumor–node–metastasis (mTNM) staging system (all p < 0.05). The OS of patients receiving surgical resection was significantly better than those with palliative operation (p < 0.05). Both the current AJCC system and proposed mTNM system were independent predictors for the OS of G3 p-NETs (p = 0.017 and p = 0.032, respectively). The 95% confidence intervals of the proposed mTNM staging system were smaller than that of the current AJCC system (0.626–8.217 and 0.329–10.013, respectively), indicating a relatively more accurate predictive ability. Conclusion: Our demonstration revealed that surgical resection was an independent predictor for the favorable prognosis of patients with G3 p-NETs. Moreover, the new mTNM staging system was more suitable and practical than the current AJCC system for stratifying G3 p-NETs into prognostic groups. Full article

(This article belongs to the Special Issue Neuroendocrine Tumors: Etiology, Diagnosis, and Therapy)

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13 pages, 1495 KiB

Open AccessArticle

Surgical Outcomes and Prognostic Factors of G3 Pancreatic Neuroendocrine Carcinomas: A Consecutive Analysis Based on Previous Study Results

by Xinmei Luo, Min Yang, Bole Tian, Xubao Liu, Kaiti Duan and Yi Zhang

J. Clin. Med. 2022, 11(11), 3176; https://doi.org/10.3390/jcm11113176 - 2 Jun 2022

Viewed by 1406

Abstract

In 2017, the World Health Organization (WHO) officially defined pancreatic neuroendocrine neoplasms into well-differentiated tumors, namely G1/G2/G3 pancreatic neuroendocrine tumors, and poorly differentiated carcinomas referring to G3 pancreatic neuroendocrine carcinomas (p-NECs). However, the surgical outcomes and prognostic factors of G3 p-NECs are still unclear. Methods: We retrospectively collected and analyzed the data of eligible patients with G3 p-NECs defined by the WHO 2017 grading classification. Results: We eventually identified 120 patients with G3 p-NECs, including 72 females and 48 males, with a median age of 53 y. The 3-year overall survival (OS) of G3 p-NECs by Kaplan–Meier method was 37.3%. The 3-year OS for functional G3 p-NECs was 57.4%, which was statistically longer than 23.0% of non-functional ones (p = 0.002). Patients with surgical resection presented a significantly better 3-year OS than those with palliative operation (43.3% vs. 13.1%; p < 0.001). The 3-year OS for Stage Ⅰ, Stage Ⅱ, Stage Ⅲ, and Stage Ⅳ was 87.1%, 56.5%, 12.9%, and not applicable, respectively (p < 0.001). We demonstrated in a Cox regression model that palliative operation (p = 0.013), vascular infiltration (p = 0.039), lymph node involvement (p = 0.024), and distant metastasis (p = 0.016) were independent predictors of poor outcome for patients with surgically treated G3 p-NECs. Conclusion: Our data in the present analysis indicated that patients with G3 p-NECs could significantly benefit from surgical resection. Meanwhile, vascular infiltration, lymph node involvement, and distant metastasis were independent predictors of poor outcome for these patients. Full article

(This article belongs to the Special Issue Neuroendocrine Tumors: Etiology, Diagnosis, and Therapy)

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8 pages, 673 KiB

Open AccessArticle

Duodenal Gastric Metaplasia and Duodenal Neuroendocrine Neoplasms: More Than a Simple Coincidence?

by Sara Massironi, Roberta Elisa Rossi, Anna Caterina Milanetto, Valentina Andreasi, Davide Campana, Gennaro Nappo, Stefano Partelli, Camilla Gallo, Miki Scaravaglio, Alessandro Zerbi, Francesco Panzuto, Claudio Pasquali, Massimo Falconi, Pietro Invernizzi and on behalf of ItaNet (Italian Association for Neuroendocrine Tumours) Study Group

J. Clin. Med. 2022, 11(9), 2658; https://doi.org/10.3390/jcm11092658 - 9 May 2022

Cited by 3 | Viewed by 3856

Abstract

Background: Duodenal gastric metaplasia (DGM) is considered a precancerous lesion. No data are available regarding its possible role as a risk factor for duodenal neuroendocrine neoplasms (dNENs). Aims: To assess the prevalence of DGM in a cohort of dNENs. Methods: Subgroup analysis of a retrospective study including dNEN patients who underwent surgical resection between 2000 and 2019 and were observed at eight Italian tertiary referral centers. Results: 109 dNEN patients were evaluated. Signs of DGM associated with the presence of dNEN were reported in 14 patients (12.8%). Among these patients, nine (64.4%) had a dNEN of the superior part of the duodenum, one (7.1%) a periampullary lesion, three (21.4%) a dNEN located in the second portion of the duodenum, with a different localization distribution compared to patients without DGM (p = 0.0332). Ten were G1, three G2, and in one patient the Ki67 was not available. In the group with DGM, six patients (35.7%) were classified at stage I, five (28.6%) at stage II, three (21.4%) at stage III, and no one at stage IV. In the group without DGM, 20 patients (31%) were at stage I, 15 (15%) at stage II, 42 (44%) at stage III, and 19 (20%) at stage IV (p = 0.0236). At the end of the study, three patients died because of disease progression. Conclusions: our findings might suggest that DGM could represent a feature associated with the occurrence of dNEN, especially for forms of the superior part of the duodenum, which should be kept in mind in the endoscopic follow up of patients with DGM. Interestingly, dNEN inside DGM showed a more favorable staging, with no patients in stage IV. The actual relationship and the clinical relevance of this possible association require further clarification. Full article

(This article belongs to the Special Issue Neuroendocrine Tumors: Etiology, Diagnosis, and Therapy)

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12 pages, 2902 KiB

Open AccessArticle

Survival According to Therapy Regimen for Small Intestinal Neuroendocrine Tumors

by Christine Koch, Cornelia Bambey, Natalie Filmann, Marc Stanke, Oliver Waidmann, Gabriele Husmann and Joerg Bojunga

J. Clin. Med. 2022, 11(9), 2358; https://doi.org/10.3390/jcm11092358 - 22 Apr 2022

Cited by 3 | Viewed by 1896

Abstract

Introduction: Scarce data exist for therapy regimens other than somatostatin analogues (SSA) and peptide receptor radiotherapy (PRRT) for siNET. We analyzed real world data for differences in survival according to therapy. Patients and methods: Analysis of 145 patients, diagnosed between 1993 and 2018 at a single institution, divided in treatment groups. Group (gr.) 0: no treatment (n = 10), gr 1: TACE and/or PRRT (n = 26), gr. 2: SSA (n = 32), gr. 3: SSA/PRRT (n = 8), gr. 4: chemotherapy (n = 8), gr. 5: not metastasized (at diagnosis), surgery only (n = 53), gr. 6 = metastasized (at diagnosis), surgery only (n = 10). Results: 45.5% female, median age 60 years (range, 27–84). A total of 125/145 patients with a resection of the primary tumor. For all patients, 1-year OS (%) was 93.8 (95%-CI: 90–98), 3-year OS = 84.3 (CI: 78–90) and 5-year OS = 77.5 (CI: 70–85). For analysis of survival according to therapy, only stage IV patients (baseline) that received treatment were included. Compared with reference gr. 2 (SSA only), HR for OS was 1.49 (p = 0.47) for gr. 1, 0.72 (p = 0.69) for gr. 3, 2.34 (p = 0.19) for gr. 4. The 5 y OS rate of patients whose primary tumor was resected (n = 125) was 73.1%, and without PTR was 33.3% (HR: 4.31; p = 0.003). Individual patients are represented in swimmer plots. Conclusions: For stage IV patients in this analysis (limited by low patient numbers in co. 3/4), multimodal treatment did not significantly improve survival over SSA treatment alone. A resection of primary tumor significantly improves survival. Full article

(This article belongs to the Special Issue Neuroendocrine Tumors: Etiology, Diagnosis, and Therapy)

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Review

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Open AccessReview

Multidisciplinary Approach to the Diagnosis of Occult Primary Neuroendocrine Neoplasm: A Clinical Challenge

by Roberta Elisa Rossi, Francesca Corti, Sara Pusceddu, Massimo Milione, Jorgelina Coppa, Benedetta Masoni, Simone Oldani, Giovanna Sabella, Pietro Cafaro and Alessandro Repici

J. Clin. Med. 2023, 12(17), 5537; https://doi.org/10.3390/jcm12175537 - 25 Aug 2023

Cited by 3 | Viewed by 1433

Abstract

Approximately 11% to 14% of subjects with neuroendocrine neoplasms (NENs) have metastatic lesions with unknown primary origin (UPO), with the majority of UPO-NENs found in the small bowel. Herein, we assessed the available literature on UPO-NENs, focusing on clinical presentation and diagnostic techniques to identify the primary site. The identification of the primary tumor is important as it affects the prognosis; however, the clinical presentation can be non-specific in non-functioning forms. In the presence of metastatic disease, the histological sample is fundamental to obtain immunohistochemical markers that might orientate the clinician in the search for the primary tumor through radiology, functional imaging and endoscopic techniques. In summary, multidisciplinary management plays a key role in UPO-NENs, even more than in other NENs. Molecular biology and gene-expression profiling represent areas of great interest which might be developed in the near future for both the diagnosis and the treatment of these neoplasms. Full article

(This article belongs to the Special Issue Neuroendocrine Tumors: Etiology, Diagnosis, and Therapy)

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17 pages, 353 KiB

Open AccessReview

Circulating Neuroendocrine Tumor Biomarkers: Past, Present and Future

by Paweł Komarnicki, Jan Musiałkiewicz, Alicja Stańska, Adam Maciejewski, Paweł Gut, George Mastorakos and Marek Ruchała

J. Clin. Med. 2022, 11(19), 5542; https://doi.org/10.3390/jcm11195542 - 21 Sep 2022

Cited by 15 | Viewed by 2224

Abstract

Neuroendocrine tumors are a heterogeneous group of neoplasms originating from the diffuse endocrine system. Depending on primary location and hormonal status, they range in terms of clinical presentation, prognosis and treatment. Functional tumors often develop symptoms indicating an excess of hormones produced by the neoplasm (exempli gratia insulinoma, glucagonoma and VIPoma) and can be diagnosed using monoanalytes. For non-functional tumors (inactive or producing insignificant amounts of hormones), universal biomarkers have not been established. The matter remains an important unmet need in the field of neuroendocrine tumors. Substances researched over the years, such as chromogranin A and neuron-specific enolase, lack the desired sensitivity and specificity. In recent years, the potential use of Circulating Tumor Cells or multianalytes such as a circulating microRNA and NETest have been widely discussed. They offer superior diagnostic parameters in comparison to traditional biomarkers and depict disease status in a more comprehensive way. Despite a lot of promise, no international standards have yet been developed regarding their routine use and clinical application. In this literature review, we describe the analytes used over the years and cover novel biomarkers that could find a use in the future. We discuss their pros and cons while showcasing recent advances in the field of neuroendocrine tumor biomarkers. Full article

(This article belongs to the Special Issue Neuroendocrine Tumors: Etiology, Diagnosis, and Therapy)

Other

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16 pages, 4608 KiB

Open AccessCase Report

Pancreatic Neuroendocrine Tumor (Pan-NET) Presented by Abdominal Pain: A Case Report and Literature Review

by Matteo Regolo, Nicolas Cardaci, Clara Salmeri, Alfredo Laudani, Michele Colaci, Massimo Ippolito, Fabio Motta, Salvatore Magrì, Stefanie Parisi, Alfredo Gaetano Torcitto and Lorenzo Malatino

J. Clin. Med. 2023, 12(20), 6617; https://doi.org/10.3390/jcm12206617 - 19 Oct 2023

Viewed by 1832

Abstract

A pancreatic neuroendocrine tumor (Pan-NET) is a rare neoplasm originating in the neuroendocrine system. Carcinoid syndrome occurs in approximately 19% of patients with functional Pan-NETs, typically when liver metastases occur. In this paper, we describe the case of a patient with a low-grade non-functional Pan-NET, but with a typical clinical presentation of carcinoid syndrome. An 81-year-old male was admitted to our Department of Internal Medicine at Cannizzaro Hospital (Catania, Italy) because of the onset of abdominal pain with nausea, loose stools, and episodic flushing. Firstly, an abdominal contrast-enhanced CT scan showed a small pancreatic hyper-vascular mass; then, a gallium-68 DOTATOC integrated PET/CT revealed an elevated expression of SSTR receptors. Serum chromogranin A and urinary 5-HIAA measurements were negative. We performed an endoscopic ultrasonography (EUS) by a fine-needle biopsy (EUS-FNB), allowing the immunostaining of a small mass (0.8 cm) and the diagnosis of a low-grade (G1) non-functional Pan-NET (NF-Pan-NET). Surgery was waived, while a follow-up strategy was chosen. The early recognition of Pan-NETs, although rare, is necessary to improve the patient’s survival. Although helpful to allow for immunostaining, EUS-FNB needs to be warranted in future studies comparing EUS-FNB to EUS-FNA (fine-needle aspiration), which is, to date, reported as the tool of choice to diagnose Pan-NETs. Full article

(This article belongs to the Special Issue Neuroendocrine Tumors: Etiology, Diagnosis, and Therapy)

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