The impact of drainage pathways on the detection of nodal metastases in prostate cancer: a phase II randomized comparison of intratumoral vs intraprostatic tracer injection for sentinel node detection

External validation of a nomogram for unilateral pelvic lymph node dissection in prostate cancer

OBJECTIVES

To explore the rationale of unilateral extended pelvic lymph node dissection (ePLND) during radical prostatectomy (RP) by external validation of a nomogram for unilateral ePLND (unilat-NG) and comparison to the Briganti 2019 nomogram.

PATIENTS AND METHODS

Patients with magnetic resonance imaging-fusion biopsy and consecutive RP with bilateral ePLND were identified within an institutional database. The primary endpoint was the detection rate of lymph node invasion (LNI) contralateral to the prostatic lobe with adverse cancer characteristics. The performance of the unilat-NG and the Briganti 2019 nomogram to detect contralateral LNI was assessed using descriptive analysis, the receiver operating characteristic curve-derived area under the curve (AUC), and multivariable logistic regression analyses.

RESULTS

Of the overall 406 consecutive patients, 68/406 (16.7%) presented with pathological (p)N1 disease at RP. The AUC for the unilat-NG with a 1%, 2% and 2.5% cut-off was 0.58 (95% confidence interval [CI] 0.53-0.63), 0.67 (95% CI 0.59-0.75), and 0.69 (95% CI 0.60-0. 77), respectively; compared to an AUC of 0.72 (95% CI 0.66-0.78) for the Briganti 2019 nomogram with a 7% cut-off. Applying the unilat-NG with a 2.5% cut-off, contralateral ePLND could be omitted in 303/406 (74.6%) patients, misclassifying 10/406 (2.5%) patients with pN0 disease.

CONCLUSION

The Briganti 2019 nomogram outperformed the novel unilat-NG in contralateral LNI prediction. Yet, a significant proportion of patients undergoing unilateral ePLND would be falsely classified with pN0 disease using any of the nomograms. Therefore, bilateral ePLND should remain the standard of care if PLND is indicated.

Novel Radiopharmaceuticals and Future of Theranostics in Genitourinary Cancers

BACKGROUND AND OBJECTIVE

This review aims to provide an overview of novel diagnostic and therapeutic radiopharmaceuticals tested recently or used currently in genitourinary cancers within prospective phase 1-2 clinical trials, summarizing progresses and future directions.

METHODS

A systematic search was conducted using the PubMed/MEDLINE and ClinicalTrials.gov databases for original prospective research studies following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

KEY FINDINGS AND LIMITATIONS

Forty-six papers were systematically reviewed; 74 ongoing clinical trials were identified. The results of 27 novel radiopharmaceuticals (ie, not approved by the Food and Drug Administration/European Medicines Agency and not listed in the Pharmacopeia) prospectively investigated in genitourinary cancers, mostly prostate, for diagnostic, theranostic, or therapeutic purposes (21, one, and five of the 27 radiopharmaceuticals, respectively) over the past 5 yr were presented. Most were prostate-specific membrane antigen-targeting agents (17/27); other targets included gastrin-releasing peptide receptor, carbonic anhydrase IX, Cu, six transmembrane epithelial antigen of the prostate 1, tumor-associated glycoprotein 42, and urokinase-type plasminogen activator receptor. Ongoing research confirms the same trend. Fibroblast activation protein inhibitor, PD-L1, CD8, nectin-4, and HER2 are other targets under investigation. Among the 22 ongoing therapeutic trials (out of the 74 ongoing clinical trials), targeted alpha therapy is being explored in 12, and five are evaluating combinations of radioligand therapy with other treatments. We confirmed the safety of radiopharmaceuticals (regardless of the diagnostic/therapeutic purpose) and showed promising results in terms of diagnostic accuracy and therapeutic efficacy in genitourinary cancers.

CONCLUSIONS AND CLINICAL IMPLICATIONS

There continues to be expansion in radiopharmaceutical approaches to genitourinary cancers, reflecting a strong emphasis on improving tumor detection and treatment, which will likely impact future management across the disease spectrum, with the potential for improved patient care and outcomes.

The diagnostic performance of indocyanine green for the sentinel node biopsy in prostate cancer: A systematic review and meta-analysis

Objective

Almost 15% of prostate cancer (PCa) patients were found to have lymph node metastases (LNMs), which are associated with higher risk of biochemical recurrence. Using indocyanine green (ICG) for the sentinel node biopsy (SNB) before surgery was proposed to detect LNMs in PCa patients. However, its diagnostic performance still remains controversial. This study aimed to investigate the diagnostic performance of ICG for the SNB in PCa.

Methods

This systematic review and meta-analysis has been reported in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The protocol has been registered in the International Prospective Register of Systematic Reviews database, and the register number is CRD42023421911. Four bibliographic databases were searched, i.e., PubMed, EMBASE, Cochrane Library, and Web of Science, to retrieve articles studying the diagnostic performance of ICG for the SNB in PCa from the inception to Sep 9, 2023. We calculated the pooled sensitivity, specificity, likelihood ratios, diagnostic odds ratios and their 95% confidence intervals (CIs). Subgroup analyses and meta-regression analyses were also conducted.

Results

A total of 17 articles from databases are enrolled in this study. Using lymph node-based data, our results showed that the pooled sensitivity and specificity of applying ICG alone in PCa were 71% (95% CI 52%-85%) and 68% (95% CI 64%-72%), respectively. The pooled sensitivity and specificity of applying ICG-technetium-99m-nanocolloid in PCa were 49% (95% CI 39%-59%) and 69% (95% CI 67%-71%), respectively.

Conclusion

The efficacy of using ICG or ICG-technetium-99m-nanocolloid for the SNB in PCa is relatively unsatisfactory. ICG cannot yet substitute extended pelvic lymph node dissection for detecting LNMs accurately. More research or novel tracers are needed to achieve the goal of precise surgery.

Progress of fluorescence imaging in lymph node dissection surgery for prostate and bladder cancer

Fluorescence imaging is a relatively new imaging method used to visualize different tissue structures to help guide intraoperative operations, which has potential advantages with high sensitivity and contrast compared to conventional imaging. In this work, we review fluorescent contrast agents and devices used for lymphatic system imaging. Indocyanine green is the most widely utilized due to its high sensitivity, specificity, low background fluorescence, and safety profile. In prostate and bladder cancer lymph node dissection, the complex lymphatic drainage can result in missed metastatic nodes and extensive dissection increases the risk of complications like lymphocele, presenting a significant challenge for urologists. Fluorescence-guided sentinel lymph node dissection facilitates precise tumor staging. The combination of fluorescence and radiographic imaging improves the accuracy of lymph node staging. Multimodal imaging presents new potential for precisely identifying metastatic pelvic lymph nodes.

Integration of photomagnetic bimodal imaging to monitor an autogenous exosome loaded platform: unveiling strong targeted retention effects for guiding the photothermal and magnetothermal therapy in a mouse prostate cancer model

BACKGROUND

Prostate cancer (PCa) is the most prevalent cancer among males, emphasizing the critical need for precise diagnosis and treatment to enhance patient prognosis. Recent studies have extensively utilized urine exosomes from patients with cancer for targeted delivery. This study aimed to employ highly sensitive magnetic particle imaging (MPI) and fluorescence molecular imaging (FMI) to monitor the targeted delivery of an exosome-loaded platform at the tumour site, offering insights into a potential combined photothermal and magnetic thermal therapy regime for PCa.

RESULTS

MPI and FMI were utilized to monitor the in vivo retention performance of exosomes in a prostate tumour mouse model. The exosome-loaded platform exhibited robust homologous targeting ability during imaging (SPIONs@EXO-Dye:66·48%±3·85%; Dye-SPIONs: 34·57%±7·55%, **P<0·01), as verified by in vitro imaging and in vitro tissue Prussian blue staining.

CONCLUSIONS

The experimental data underscore the feasibility of using MPI for in vivo PCa imaging. Furthermore, the exosome-loaded platform may contribute to the precise diagnosis and treatment of PCa.

Analysis of biopsy pathology and risk factors of lymph node metastasis in prostate cancer

OBJECTIVE

To explore the relationship between biopsy pathology and lymph node metastasis in patients with prostate cancer (PCa), and to identify risk factors of lymph node metastasis (LNM).

PATIENTS AND METHODS

Patients diagnosed with prostate cancer were respective screened between Jan 2015 and May 2022. Patients diagnosed PCa via 13-core ultrasound-guided biopsies and underwent radical prostatectomy and lymph node dissection were identified. The clinicopathological characteristics of the patients were recorded. Relationships between LNM and non-LNM were analyzed using chi-square and independent samples t-test. Logistic regression model was fitted to analyze the risk factors of lymph node metastases.

RESULTS

Two hundreds and fifteen patients were included, sixty-seven patients had lymph node metastasis. Gleason scores in LNM group were higher than that in non-LNM group (8.5 ± 0.9 VS 7.5 ± 1.5, p < 0.001), positive biopsy in non-LNM group was significantly lower than that in LNM group (p < 0.001), Binary logistic regression analysis indicated number of positive biopsy and number of removed lymph nodes increased the risks of LNM (odds ratio, OR = 1.28, 95% confidence interval, CI = 1.16-1.42, p < 0.001; OR = 1.11, 95% CI = 1.06-1.17, p < 0.001; respectively). Number of positive biopsy in internal gland but not external gland was significant associated with LNM (OR = 1.66, 95% CI = 1.34-2.06, p < 0.001; OR = 1.19, 95% CI = 0.88-1.61, p = 0.262; respectively). The patients with lymph nodes dissection more than 13 were about four times more likely to detect lymph node metastasis than those fewer than 13 (OR = 3.92, 95% CI = 2.10-7.33, p < 0.001).

CONCLUSIONS

The risk of lymph node metastasis increased with the number of positive prostate biopsy cores, and tumors in the internal gland were more likely to cause lymph node metastasis. In addition, lymph node metastasis was more likely to be found when the number of lymph nodes dissection was greater than 13.

Personalised indocyanine-guided lymphadenectomy for prostate cancer: a randomised clinical trial

OBJECTIVES

To study the safety and efficacy of a personalised indocyanine-guided pelvic lymph node dissection (PLND) against extended PLND (ePLND) during radical prostatectomy (RP).

PATIENTS AND METHODS

Patients who were candidates for RP and lymphadenectomy, with intermediate- or high-risk prostate cancer (PCa) according to the National Comprehensive Cancer Network guidelines, were enrolled in this randomised clinical trial. Randomisation was made 1:1 to indocyanine green (ICG)-PLND (only ICG-stained LNs) or ePLND (obturator fossa, external, internal, and common iliac and presacral LNs). The primary endpoint was the complication rate within 3 months after RP. Secondary endpoints included: rate of major complications (Clavien-Dindo Grade III-IV), time to drainage removal, length of stay, percentage of patients classified as pN1, number of LNs removed, number of metastatic LNs, rate of patients with undetectable prostate-specific antigen (PSA), biochemical recurrence (BCR)-free survival, and rate of patients with androgen-deprivation therapy at 24 months.

RESULTS

A total of 108 patients were included with a median follow-up of 16 months. In all, 54 were randomised to ICG-PLND and 54 to ePLND. The postoperative complication rate was higher in the ePLND (70%) vs the ICG-PLND group (32%) (P < 0.001). Differences between major complications in both groups were not statically significant (P = 0.7). The pN1 detection rate was higher in the ICG-PLND group (28%) vs the ePLND group (22%); however, this difference was not statistically significant (P = 0.7). The rate of undetectable PSA at 12 months was 83% in the ICG-PLND vs 76% in the ePLND group, which was not statistically significant. Additionally, there were no statistically significant differences in BCR-free survival between groups at the end of the analysis.

CONCLUSIONS

Personalised ICG-guided PLND is a promising technique to stage patients with intermediate- and high-risk PCa properly. It has shown a lower complication rate than ePLND with similar oncological outcomes at short-term follow-up.

A Systematic Review of New Imaging Technologies for Robotic Prostatectomy: From Molecular Imaging to Augmented Reality

New imaging technologies play a pivotal role in the current management of patients with prostate cancer. Robotic assisted radical prostatectomy (RARP) is a standard of care for localized disease and through the already imaging-based console subject of research towards combinations of imaging technologies and RARP as well as their impact on surgical outcomes. Therefore, we aimed to provide a comprehensive analysis of the currently available literature for new imaging technologies for RARP. On 24 January 2023, we performed a systematic review of the current literature on Pubmed, Scopus and Web of Science according to the PRISMA guidelines and Oxford levels of evidence. A total of 46 studies were identified of which 19 studies focus on imaging of the primary tumor, 12 studies on the intraoperative tumor detection of lymph nodes and 15 studies on the training of surgeons. While the feasibility of combined approaches using new imaging technologies including MRI, PSMA-PET CT or intraoperatively applied radioactive and fluorescent dyes has been demonstrated, the prospective confirmation of improvements in surgical outcomes is currently ongoing.

Sentinel Lymph Node Biopsy in Prostate Cancer: An Overview of Diagnostic Performance, Oncological Outcomes, Safety, and Feasibility

Sentinel node biopsy (SNB) for prostate cancer (PCa) represents an innovative technique aimed at improving nodal staging accuracy. The routinary adoption of this procedure in patients undergoing radical prostatectomy (RP) might be crucial to identify candidates who could effectively benefit from extensive pelvic lymph nodal dissection (ePLND). Despite some promising results, SNB for PCa is still considered experimental due to the lack of solid evidence and procedural standardization. In this regard, our narrative review aimed to analyze the most recent literature in this field, providing an overview of both the diagnostic accuracy measures and the oncological outcomes of SNB.

A hybrid radioactive and fluorescence approach is more than the sum of its parts; outcome of a phase II randomized sentinel node trial in prostate cancer patients

OBJECTIVE

To determine the diagnostic accuracy of the hybrid tracer indocyanine green (ICG)-Technetium-99 m(99mTc)-nanocolloid compared to sequential tracers of 99mTc-nanocolloid and free-ICG in detecting tumor-positive lymph nodes (LN) during primary surgery in prostate cancer (PCa) patients.

INTRODUCTION

Image-guided surgery strategies can help visualize individual lymphatic drainage patterns and sentinel lymph nodes (SLNs) in PCa patients. For lymphatic mapping radioactive, fluorescent and hybrid tracers are being clinically exploited. In this prospective randomized phase II trial, we made a head-to-head comparison between ICG-99mTc-nanocolloid (hybrid group) and 99mTc-nanocolloid and subsequent free-ICG injection (sequential group).

METHODS

PCa patients with a  >5% risk of lymphatic involvement according to the 2012 Briganti nomogram and planned for prostatectomy were included and randomized (1:1) between ultrasound-guided intraprostatic tracer administration of ICG-99mTc-nanocolloid (n = 69) or 99mTc-nanocolloid (n = 69) 5 h before surgery. Preoperative lymphoscintigraphy and SPECT/CT were performed to define the locations of the SLNs. Additionally, all participants in the sequential group received an injection of free-ICG at time of surgery. Subsequently, all (S)LNs were dissected using fluorescence guidance followed by an extended pelvic lymph node dissection (ePLND). The primary outcome was the total number of surgically removed (S)LNs and tumor-positive (S)LNs.

RESULTS

The total number of surgically removed (S)LN packages was 701 and 733 in the hybrid and sequential groups, respectively (p = 0.727). The total number of fluorescent LNs retrieved was 310 and 665 nodes in the hybrid and sequential groups, respectively (p < 0.001). However, no statistically significant difference was observed in the corresponding number of tumor-positive nodes among the groups (44 vs. 33; p = 0.470). Consequently, the rate of tumor-positive fluorescent LNs was higher in the hybrid group (7.4%) compared to the sequential group (2.6%; p = 0.002), indicating an enhanced positive predictive value for the hybrid approach. There was no difference in complications within 90 days after surgery (p = 0.78).

CONCLUSIONS

The hybrid tracer ICG-99mTc-nanocolloid improved the positive predictive value for tumor-bearing LNs while minimizing the number of fluorescent nodes compared to the sequential tracer approach. Consequently, the hybrid tracer ICG-99mTc-nanocolloid enables the most reliable and minimal invasive method for LN staging in PCa patients.

Exploring the Applications of Indocyanine Green in Robot-Assisted Urological Surgery: A Comprehensive Review of Fluorescence-Guided Techniques

This comprehensive review aims to explore the applications of indocyanine green (ICG) in robot-assisted urological surgery through a detailed examination of fluorescence-guided techniques. An extensive literature search was conducted in PubMed/MEDLINE, EMBASE and Scopus, using keywords such as "indocyanine green," "ICG", "NIRF", "Near Infrared Fluorescence", "robot-assisted", and "urology". Additional suitable articles were collected by manually cross-referencing the bibliography of previously selected papers. The integration of the Firefly^® technology in the Da Vinci^® robotic system has opened new avenues for the advancement and exploration of different urological procedures. ICG is a fluorophore widely used in near-infrared fluorescence-guided techniques. The synergistic combination of intraoperative support, safety profiles and widespread availability comprises an additional asset that empowers ICG-guided robotic surgery. This overview of the current state of the art illustrates the potential advantages and broad applications of combining ICG-fluorescence guidance with robotic-assisted urological surgery.

Real-Time Identification of Nodal Metastases With 99mTc-Prostate-Specific Membrane Antigen-Based Radioguidance and Indocyanine Green Fluorescence Imaging in Primary Prostate Cancer Surgery-On the Road to Hybrid Image-Guided Surgery

ABSTRACT

Recent developments in image-guided prostate cancer surgery focus on extending prostate-specific membrane antigen-directed radioguidance with optical tumor detection using fluorescence, as radio- and fluorescence signals complement each other with in-depth detection and real-time visualization, respectively. As a step in this direction, we report here the integration of indocyanine green fluorescence imaging into a 99mTc-prostate-specific membrane antigen-targeted radioguided surgery workflow.

Sentinel Lymph Node Techniques in Urologic Oncology: Current Knowledge and Application

Lymph node (LN) metastases have a significant negative impact on the prognosis of urological malignancies. Unfortunately, current imaging modalities are insufficient when it comes to detecting micrometastases; thus, surgical LN removal is commonly used. However, there is still no established ideal lymph node dissection (LND) template, leading to unnecessary invasive staging and the possibility of missing LN metastases located outside the standard template. To address this issue, the sentinel lymph node (SLN) concept has been proposed. This technique involves identifying and removing the first group of draining LNs, which can accurately stage cancer. While successful in breast cancer and melanoma, the SLN technique in urologic oncology is still considered experimental due to high false-negative rates and lack of data in prostate, bladder, and kidney cancer. Nevertheless, the development of new tracers, imaging modalities, and surgical techniques may improve the potential of the SLN procedures in urological oncology. In this review, we aim to discuss the current knowledge and future contributions of the SLN procedure in the management of urological malignancies.

Non-invasive molecular imaging for precision diagnosis of metastatic lymph nodes: opportunities from preclinical to clinical applications

Lymph node metastasis is an indicator of the invasiveness and aggressiveness of cancer. It is a vital prognostic factor in clinical staging of the disease and therapeutic decision-making. Patients with positive metastatic lymph nodes are likely to develop recurrent disease, distant metastasis, and succumb to death in the coming few years. Lymph node dissection and histological analysis are needed to detect whether regional lymph nodes have been infiltrated by cancer cells and determine the likely outcome of treatment and the patient's chances of survival. However, these procedures are invasive, and tissue biopsies are prone to sampling error. In recent years, advanced molecular imaging with novel imaging probes has provided new technologies that are contributing to comprehensive management of cancer, including non-invasive investigation of lymphatic drainage from tumors, identifying metastatic lymph nodes, and guiding surgeons to operate efficiently in patients with complex lesions. In this review, first, we outline the current status of different molecular imaging modalities applied for lymph node metastasis management. Second, we summarize the multi-functional imaging probes applied with the different imaging modalities as well as applications of cancer lymph node metastasis from preclinical studies to clinical translations. Third, we describe the limitations that must be considered in the field of molecular imaging for improved detection of lymph node metastasis. Finally, we propose future directions for molecular imaging technology that will allow more personalized treatment plans for patients with lymph node metastasis.

Sentinel Lymph Node Biopsy in Prostate Cancer Patients: Results From an Injection Technique Targeting the Index Lesion in the Prostate Gland

Objectives

To determine the accuracy of nodal staging in patients with prostate cancer (PCa) when ^99mTc-nanocolloid radiotracer is injected into an index lesion (IL).

Methods

This prospective study was conducted at our institution between June 2016 and October 2020. It included 64 patients with localized PCa with at least a 5% possibility for lymph node involvement in the Memorial Sloan Kettering Cancer Center nomogram, suitable for surgical treatment. All patients underwent magnetic resonance imaging (MRI) with IL and were pathologically confirmed. The day before surgery, transrectal ultrasound-guided injection (TRUS) of ^99mTc-nanocolloid into the IL was performed. Surgical procedures included radical prostatectomy (RP), sentinel lymph node biopsy (SLNB), and extended pelvic lymphadenectomy (ePLND). Analysis was performed, including histopathological findings of RP, ePLND, and SLNB. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), false negative (FN), false positive (FP), diagnostic yield, and non-diagnostic rate were calculated.

Results

A total of 1,316 lymph nodes were excised, including 1,102 from the ePLND (83.7%) and 214 (16.3%) sentinel lymph nodes (SLN). 26 SLN were dissected outside the ePLND template. The final pathology demonstrated 46 (3.5%) lymph node metastasis, 31 (67.4%) in the SLNB and 15 (32.6%) in the non-SLN ePLND. At the patient level, 18 (28.1%) patients had pN1. With a mean follow-up of 33.1 months, 4/19 (21.1%) pN1 patients had undetectable PSA, and 3/19 (15.8%) had a PSA < 0.1 ng/mL. Lymph node dissection included 20.6 lymph nodes per patient (IQR 15–24.2), with 3.3 SLNB nodes per patient (IQR 2–4.2). PPV and NPV were 100 and 97.8%, respectively. Sensitivity and specificity were 94.4 and 100%, respectively. FN was 5.5% and FP was 4.3%. Diagnostic yields were 95.3% and the non-diagnostic rate was 4.7%.

Conclusion

Radiotracer injection into the prostate IL offers promising results for staging purposes in cases in which ePLND is considered. Negative SLNB is a predictor of negative ePLND. Patients with a limited burden of nodal metastasis have a significant chance of remaining free of biochemical recurrence at mid-term follow-up.

Optical magnetic multimodality imaging of plectin-1-targeted imaging agent for the precise detection of orthotopic pancreatic ductal adenocarcinoma in mice

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is a lethal malignancy worldwide, and the precise detection is challenging currently. Magnetic particle imaging (MPI) is suitable for imaging deep and internal PDAC tumours because of its high sensitivity and unlimited imaging depth. The purpose of this study was to utilize the MPI, in combination with fluorescence molecular imaging (FMI) and magnetic resonance imaging (MRI), to advance the in vivo precise detection of PDAC xenografts.

METHODS

The PDAC targeted plectin-1 peptide and IRDye800CW were conjugated to the superparamagnetic iron oxide nanoparticles (PTP-Fe3O4-IRDye800CW) for the PDAC-targeting triple-modality imaging. Subcutaneous and orthotopic PDAC mouse models were established. FMI, MPI, and MRI were performed for dynamic and quantitative observation of PDAC tumours. Histological staining analyses were used for ex vivo validation.

FINDINGS

PTP-Fe3O4-IRDye800CW nanoparticles possessed great triple-modality imaging performance and specific targeting to plectin-1 expressed on PDAC cells. For in vivo multi-modality imaging of orthotopic PDAC models, the PTP-Fe3O4-IRDye800CW nanoparticles demonstrated higher specificity, even distribution, and longer retention effects in tumours for over 7 d compared with Con-Fe3O4-IRDye800CW nanoparticles. (MPI, 2d post-injection: PTP-Fe3O4-IRDye800CW: 85.72% ± 1.53% vs. Con-Fe3O4-IRDye800CW: 74.41% ± 1.91%, **P < 0.01 (Student's t test)). Ex vivo histological and Prussian blue stainings were performed to validate the distribution of probes.

INTERPRETATION

These data demonstrate the feasibility of utilizing MPI for in vivo PDAC imaging and complement with FMI/MRI for a precise and comprehensive in vivo characterization of PDAC. This may benefit PDAC patients for precise diagnosis and guidance of therapy.

FUNDING

This study was funded by the National Natural Science Foundation of China (Grant No. 62027901, 82071896, 81871422, 81871514, 81227901), Ministry of Science and Technology of China under Grant No. 2017YFA0205200, 2017YFA0700401, Beijing Natural Science Foundation (Grant No. 7212207), Elite Program of Dong Cheng District of Beijing (2020-dchrcpyzz-28), and Peking University Third Hospital (BYSYZD2019018, and jyzc2018-02).