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Tuesley KM, Spilsbury K, Pearson SA, Donovan P, Obermair A, Coory MD, Ali S, Pandeya N, Stewart L, Jordan SJ, Webb PM. Long-acting, progestin-based contraceptives and risk of breast, gynecological, and other cancers. J Natl Cancer Inst 2025; 117:1046-1055. [PMID: 39805314 PMCID: PMC12058256 DOI: 10.1093/jnci/djae282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 09/01/2024] [Accepted: 11/03/2024] [Indexed: 01/16/2025] Open
Abstract
BACKGROUND Use of long-acting, reversible contraceptives has increased over the past 20 years, but an understanding of how they could influence cancer risk is limited. METHODS We conducted a nested case-control study among a national cohort of Australian women (n = 176 601 diagnosed with cancer between 2004 and 2013; 882 999 matched control individuals) to investigate the associations between the levonorgestrel intrauterine system, etonogestrel implants, depot-medroxyprogesterone acetate and cancer risk and compared these results with the oral contraceptive pill. We used conditional logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI). RESULTS Levonorgestrel intrauterine system and etonogestrel implant use was associated with breast cancer risk (OR = 1.26, 95% CI = 1.21 to 1.31, and OR = 1.24, 95% CI = 1.17 to 1.32, respectively), but depot-medroxyprogesterone acetate was not, except when used for 5 or more years (OR = 1.23, 95% CI = 0.95 to 1.59). Reduced risks were seen for levonorgestrel intrauterine system (≥1 years of use) in endometrial cancer (OR = 0.80, 95% CI = 0.65 to 0.99), ovarian cancer (OR = 0.71, 95% CI = 0.57 to 0.88), and cervical cancer (OR = 0.62, 95% CI = 0.51 to 0.75); for etonogestrel implant in endometrial cancer (OR = 0.21, 95% CI = 0.13 to 0.34) and ovarian cancer (OR = 0.76, 95% CI = 0.57 to 1.02); and for depot-medroxyprogesterone acetate in endometrial cancer (OR = 0.21, 95% CI = 0.13 to 0.34). Although levonorgestrel intrauterine system, etonogestrel implant and depot-medroxyprogesterone acetate were all associated with increased cancer risk overall, for etonogestrel implant, the risk returned to baseline after cessation, similar to the oral contraceptive pill. We were unable to adjust for all potential confounders, but sensitivity analyses suggested that adjusting for parity, smoking, and obesity would not have materially changed our findings. CONCLUSION Long-acting, reversible contraceptives have similar cancer associations to the oral contraceptive pill (reduced endometrial and ovarian cancer risks and short-term increased breast cancer risk). This information may be helpful to women and their physicians when discussing contraception options.
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Affiliation(s)
- Karen M Tuesley
- School of Public Health, University of Queensland, Brisbane, QLD 4006, Australia
- Population Health Program, QIMR Berghofer Medical Research Institute, Brisbane, QLD 4006, Australia
| | - Katrina Spilsbury
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, WA 6160, Australia
| | - Sallie-Anne Pearson
- School of Population Health, University of New South Wales, Sydney, NSW 2052, Australia
- Centre of Research Excellence in Medicines Intelligence, University of New South Wales, Sydney, NSW 2052, Australia
| | - Peter Donovan
- Clinical Pharmacology Department, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4006, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD 4006, Australia
| | - Andreas Obermair
- Queensland Centre for Gynaecological Cancer, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4006, Australia
- Centre for Clinical Research, University of Queensland, Brisbane, QLD 4006, Australia
| | - Michael D Coory
- Mater Research Institute, University of Queensland, Brisbane, QLD 4101, Australia
| | - Sitwat Ali
- School of Public Health, University of Queensland, Brisbane, QLD 4006, Australia
- Population Health Program, QIMR Berghofer Medical Research Institute, Brisbane, QLD 4006, Australia
| | - Nirmala Pandeya
- School of Public Health, University of Queensland, Brisbane, QLD 4006, Australia
- Population Health Program, QIMR Berghofer Medical Research Institute, Brisbane, QLD 4006, Australia
| | - Louise Stewart
- School of Population and Global Health, The University of Western Australia, Perth, WA 6009, Australia
| | - Susan J Jordan
- School of Public Health, University of Queensland, Brisbane, QLD 4006, Australia
- Population Health Program, QIMR Berghofer Medical Research Institute, Brisbane, QLD 4006, Australia
| | - Penelope M Webb
- School of Public Health, University of Queensland, Brisbane, QLD 4006, Australia
- Population Health Program, QIMR Berghofer Medical Research Institute, Brisbane, QLD 4006, Australia
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Abhang A, Burgess DJ. Recent advancements and future applications of intrauterine drug delivery systems. Expert Opin Drug Deliv 2025:1-16. [PMID: 40193227 DOI: 10.1080/17425247.2025.2490266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2024] [Accepted: 04/03/2025] [Indexed: 04/10/2025]
Abstract
INTRODUCTION Intrauterine devices (IUDs) are drug-device combination products that are placed inside the uterus above the endometrium. IUDs contain a therapeutic agent used for contraception and have been shown to have other therapeutic benefits. Over the past century, intrauterine drug delivery systems (IUDDS) have revolutionized women's health, and they hold immense growth potential in the future for new developments in the therapeutic areas beyond contraception. AREAS COVERED The aim of this review is to offer a comprehensive description of the history, development, and current state of IUDDS, next-generation IUDDS, and future applications of IUDDS in therapeutic areas beyond contraception such as multi-purpose prevention technologies, hormone replacement therapy, endometriosis, uterine fibroids, and endometrial cancer. EXPERT OPINION The uterus's unique features make it an ideal site for controlled, prolonged, and localized delivery of drugs, ensuring maximum concentration at the target site. Currently, IUDs are the most widely used contraceptive method. Future IUDDS hold the potential to deliver therapeutic agents for broader therapeutic areas for women's health, potentially aiding in the treatment of various diseases and disorders of the female reproductive system. Further research in development, characterization, and translation is warranted to ensure IUDDS reach their potential in many areas of women's health.
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Affiliation(s)
- Ashwin Abhang
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, CT, USA
| | - Diane J Burgess
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, CT, USA
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3
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Peng C, Liu J, Ding H, Duan H, Chen L, Feng Z. The effect of hysteroscopic endometrial polypectomy combined with LNG-IUS treatment on polyp recurrence: a multicenter retrospective study. Front Surg 2025; 12:1557877. [PMID: 40115082 PMCID: PMC11922692 DOI: 10.3389/fsurg.2025.1557877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2025] [Accepted: 02/03/2025] [Indexed: 03/23/2025] Open
Abstract
Background Hysteroscopic polypectomy is a common method for treating endometrial polyps, but postoperative recurrence remains a key concern. Recently, the levonorgestrel intrauterine system (LNG-IUS) has been suggested to reduce the recurrence rate of polyps. This study aims to investigate the differences in recurrence rates and recurrence-free survival times between hysteroscopic polypectomy alone and hysteroscopic polypectomy combined with LNG-IUS, and to assess their impact on recurrence. Methods This study retrospectively included clinical data from 1,160 patients with endometrial polyps from 2020 to 2021, the follow-up period was 1 year. Patients were divided into two groups based on whether LNG-IUS was used after surgery: the Hysteroscopic Polypectomy group (n = 812) and the Hysteroscopic Polypectomy Combined with LNG-IUS group (n = 348). Based on the analysis, two multivariate logistic regression models were constructed: the first model included only the factors with significant differences from the statistical analysis, while the second model additionally included the treatment method. The predictive abilities of the two models for polyp recurrence were compared. The recurrence-free survival time differences between the two treatment methods were also analyzed. Results Univariate logistic regression analysis showed that birth history, menstrual symptoms, quality of life, and treatment method were significantly associated with polyp recurrence. In multivariate logistic regression models, the second model, which included the treatment method, had a higher AUC (0.703) compared to the first model (AUC = 0.676), which included only significant factors. The recurrence-free survival rate in the group that received hysteroscopic polypectomy combined with LNG-IUS was significantly higher than in the hysteroscopic polypectomy group. Conclusion Hysteroscopic polypectomy combined with LNG-IUS significantly reduces polyp recurrence and extends recurrence-free survival time. Multivariate logistic regression analysis indicates that including the treatment method improves the predictive ability of the model, suggesting that combined treatment plays an important role in reducing polyp recurrence and is worthy of further clinical promotion and application.
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Affiliation(s)
- Cheng Peng
- Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jie Liu
- Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hongmei Ding
- Department of Gynecology, YunFu People's Hospital, YunFu, China
| | - Hui Duan
- Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lan Chen
- Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zichang Feng
- Department of Gynecology, YunFu People's Hospital, YunFu, China
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Kouri A, Darby JP. Fertility Sparing Medical Management Options in Gynecologic Cancers. Curr Treat Options Oncol 2025; 26:157-166. [PMID: 39969757 PMCID: PMC11919979 DOI: 10.1007/s11864-025-01299-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2025] [Indexed: 02/20/2025]
Abstract
OPINION STATEMENT There is an increasing use of medical management for gynecologic cancers given the rise in neoadjuvant therapies, delayed childbearing, and use of assisted reproductive technology. Chemotherapy, albeit broadly used in most gynecologic cancers, lacks long term data with respect to its associated gonadotoxicity and potential adverse pregnancy outcomes. Immunotherapy and other targeted therapies that have demonstrated promising responses in other tumor types are increasingly being studied in gynecologic malignancies. These therapies may offer opportunities for enhanced treatment response in an effort to minimize more toxic, invasive, or surgical management approaches that could have significant negative implications on fertility. Given that some of these therapies do not represent the standard of care and currently only exist in the experimental setting, detailed counseling and careful selection of patients for fertility sparing treatment remains critical. It is reasonable for patients with early stage, low-risk endometrial cancers to attempt conservative management while establishing clear treatment objectives. Early involvement of fertility specialists is necessary in order to optimize these patients' pregnancy goals. An emphasis on lifestyle changes and in particular weight loss should also be discussed with these patients. Neoadjuvant chemotherapy followed by fertility sparing surgery in cervix cancer patients with low-risk, small tumors shows promising results that suggest this can be a safe treatment option. Patients with advanced stage disease of any primary tumor or aggressive histology such as in many cases of ovarian cancer are not appropriate candidates for prioritization of fertility sparing treatment options. Ongoing and future studies will help to better identify appropriate patients and maximize medical management options in early-stage gynecologic cancers.
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Affiliation(s)
- Ana Kouri
- Department of Obstetrics and Gynecology, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA.
| | - Janelle P Darby
- Department of Obstetrics and Gynecology, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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Wang CJ, Qin J, Pang CC, Chen CX, Li HY, Huang HT, Cao S, Yang XS. Meta-analysis and systematic review of factors predicting conversion to radical nephrectomy following robotic-assisted partial nephrectomy in renal cancer patients. J Robot Surg 2024; 18:377. [PMID: 39443332 DOI: 10.1007/s11701-024-02147-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2024] [Accepted: 10/14/2024] [Indexed: 10/25/2024]
Abstract
Evaluating the risk factors for the conversion from robotic-assisted partial nephrectomy (RAPN) to radical nephrectomy (RN). Through a comprehensive database search encompassing PubMed, Web of Science, Embase, and the Cochrane Library, we identified pertinent English-language research published by June 2024. We utilized the NOS scale for quality assessment. The aggregate effect was quantified via the odds ratio (OR), alongside a 95% confidence interval (CI). Sensitivity analyses were conducted using both fixed-effects and random-effects models to evaluate reliability. The meta-analytical process was facilitated by the Stata 18 software suite. Our meta-analysis encompassed a total of 8 retrospective studies and 3 prospective studies, totaling 4056 patients. We found that increasing patient age (OR: 1.04; 95% CI 1.00-1.08; P = 0.005), higher American Society of Anesthesiologists (ASA) scores (3 or above) (OR: 2.74; 95% CI 1.52-4.93; P = 0.001), elevated R.E.N.A.L. scores (7 or above) (OR: 2.49; 95% CI 1.57-3.95; P < 0.001), and the use of off-clamp RAPN (OR: 7.21; 95% CI 2.60-19.93; P < 0.001) significantly raised the odds of surgical conversion. On the other hand, male sex (OR: 1.04; 95% CI 0.67-1.62; P = 0.858), the side of the tumor (OR: 0.97; 95% CI 0.48-1.95; P = 0.936), tumor size (OR: 3.43; 95% CI 0.57-20.55; P = 0.177), body mass index (BMI) (OR: 1.03; 95% CI 0.96-1.11; P = 0.426), clinical stage (OR: 3.78; 95% CI 0.46-30.70; P = 0.214), and the use of single-port RAPN (OR: 0.54; 95% CI 0.16-1.78; P = 0.31) did not show a statistically significant link to an increased conversion risk. This meta-analysis elucidates the critical risk factors for the conversion from robotic-assisted partial nephrectomy to radical nephrectomy, providing significant guidance for preoperative risk assessment and clinical decision-making. However, our findings necessitate validation through studies with larger sample sizes.
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Affiliation(s)
- Chong-Jian Wang
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Jiao Qin
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Cheng-Cheng Pang
- Department of Emergency, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Cai-Xia Chen
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Hong-Yuan Li
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Hao-Tian Huang
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Song Cao
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xue-Song Yang
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China.
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China.
- Department of Emergency, Affiliated Hospital of North Sichuan Medical College, Nanchong, China.
- Health Management Center, Affiliated Hospital of North Sichuan Medical College, Nanchong, China.
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Alnemr AA, Harb OA, Atia H. The efficacy of the levonorgestrel intrauterine system versus oral megestrol acetate in treating atypical endometrial hyperplasia: a superior randomized controlled trial. J Gynecol Oncol 2024; 35:e62. [PMID: 38425141 PMCID: PMC11390252 DOI: 10.3802/jgo.2024.35.e62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 12/18/2023] [Accepted: 02/11/2024] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVE To compare the efficacy of the levonorgestrel intrauterine system (LNG-IUS) versus megestrol acetate (MA) in inducing complete regression among women with atypical endometrial hyperplasia (AEH) who declined hysterectomy. METHODS In this single-center, open-label randomized controlled trial, we included 148 women with AEH who declined hysterectomy. We randomized participants to receive either daily oral MA 160 mg (n=74) or apply LNG-IUS (n=74) and scheduled their follow-up by endometrial sampling at 3, 6, 9, 12, 18, and 24 months. The success rate and duration until complete regression were the primary outcomes. RESULTS The mean duration until complete regression was 5.52 months (95% confidence interval [CI]=4.85-6.18) for the LNG-IUS group versus 6.87 months (95% CI=6.09-7.64) for the megestrol group (log-rank test p-value=0.011). The cumulative regression rate after 12 months was 91.9% with the LNG-IUS versus 77% with MA (p=0.026). Weight gain in the MA group vs LNG-IUS group after one year (4.7±4 kg vs. 2.7±2.6 kg, 95% CI=0.89-3.12; p=0.001) and after two years of therapy (7.8±5.1 kg vs. 4.1±2.9 kg, 95% CI=2.29-5.06; p<0.001). CONCLUSION Compared to MA, the LNG-IUS was more efficacious in treating AEH in women who declined hysterectomy, especially those with moderate/severe obesity, with fewer adverse effects and less weight gain. Extending therapy to 12 months for persistent cases would improve regression rates with reasonable safety. Alternate hysteroscopic and office sampling seemed convenient for follow-up. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04385667.
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Affiliation(s)
- Amr A Alnemr
- Obstetrics & Gynecology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ola A Harb
- Pathology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hytham Atia
- Obstetrics & Gynecology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
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Cui J, Zhao YC, She LZ, Wang TJ. Comparative effects of progestin-based combination therapy for endometrial cancer or atypical endometrial hyperplasia: a systematic review and network meta-analysis. Front Oncol 2024; 14:1391546. [PMID: 38764577 PMCID: PMC11099254 DOI: 10.3389/fonc.2024.1391546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/22/2024] [Indexed: 05/21/2024] Open
Abstract
Objectives The objective of this network meta-analysis is to systematically compare the efficacy of diverse progestin-based combination regimens in treating patients diagnosed with endometrial cancer or atypical endometrial hyperplasia. The primary goal is to discern the optimal combination treatment regimen through a comprehensive examination of their respective effectiveness. Methods We systematically searched four prominent databases: PubMed, Web of Science, Embase, and Cochrane Central Register of Controlled Trials, for randomized controlled trials addressing the efficacy of progestins or progestin combinations in the treatment of patients with endometrial cancer or atypical endometrial hyperplasia. The search spanned from the inception of these databases to December 2023. Key outcome indicators encompassed survival indices, criteria for assessing efficacy, as well as pregnancy and relapse rate. This study was registered in PROSPERO (CRD42024496311). Results From the 1,558 articles initially retrieved, we included 27 studies involving a total of 5,323 subjects in our analysis. The results of the network meta-analysis revealed that the mTOR inhibitor+megestrol acetate (MA)+tamoxifen regimen secured the top rank in maintaining stable disease (SD) (SUCRA=73.4%) and extending progression-free survival (PFS) (SUCRA=72.4%). Additionally, the progestin combined with tamoxifen regimen claimed the leading position in enhancing the partial response (PR) (SUCRA=75.2%) and prolonging overall survival (OS) (SUCRA=80%). The LNG-IUS-based dual progestin regimen emerged as the frontrunner in improving the complete response (CR) (SUCRA=98.7%), objective response rate (ORR) (SUCRA=99.1%), pregnancy rate (SUCRA=83.7%), and mitigating progression (SUCRA=8.0%) and relapse rate (SUCRA=47.4%). In terms of safety, The LNG-IUS-based dual progestin regimen had the lowest likelihood of adverse events (SUCRA=4.2%), while the mTOR inhibitor regimen (SUCRA=89.2%) and mTOR inbitor+MA+tamoxifen regimen (SUCRA=88.4%) had the highest likelihood of adverse events. Conclusions Patients diagnosed with endometrial cancer or atypical endometrial hyperplasia exhibited the most favorable prognosis when undergoing progestin combination therapy that included tamoxifen, mTOR inhibitor, or LNG-IUS. Notably, among these options, the LNG-IUS-based dual progestin regimen emerged as particularly promising for potential application. Systematic review registration https://www.crd.york.ac.uk/PROSPERO, identifier CRD42024496311.
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Affiliation(s)
| | | | | | - Tie-Jun Wang
- Department of Radiation Oncology, The Second Hospital of Jilin University, Changchun, Jilin, China
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van der Woude H, Phan K, Kenwright DN, Goossens L, Hally KE, Currie MJ, Kokkinos J, Sharbeen G, Phillips PA, Henry CE. Development of a long term, ex vivo, patient-derived explant model of endometrial cancer. PLoS One 2024; 19:e0301413. [PMID: 38635728 PMCID: PMC11025966 DOI: 10.1371/journal.pone.0301413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 03/16/2024] [Indexed: 04/20/2024] Open
Abstract
Incidence of endometrial cancer (EC) is rising in the developed world. The current standard of care, hysterectomy, is often infeasible for younger patients and those with high body mass index. There are limited non-surgical treatment options and a lack of biologically relevant research models to investigate novel alternatives to surgery for EC. The aim of the present study was to develop a long-term, patient-derived explant (PDE) model of early-stage EC and demonstrate its use for investigating predictive biomarkers for a current non-surgical treatment option, the levonorgestrel intra-uterine system (LNG-IUS). Fresh tumour specimens were obtained from patients with early-stage endometrioid EC. Tumours were cut into explants, cultured on media-soaked gelatin sponges for up to 21 days and treated with LNG. Formalin-fixed, paraffin embedded (FFPE) blocks were generated for each explant after 21 days in culture. Tumour architecture and integrity were assessed by haematoxylin and eosin (H&E) and immunohistochemistry (IHC). IHC was additionally performed for the expression of five candidate biomarkers of LNG resistance. The developed ex vivo PDE model is capable of culturing explants from early-stage EC tumours long-term (21 Days). This model can complement existing models and may serve as a tool to validate results obtained in higher-throughput in vitro studies. Our study provides the foundation to validate the extent to which EC PDEs reflect patient response in future research.
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Affiliation(s)
- Hannah van der Woude
- Department of Obstetrics, Gynaecology and Women’s Health, University of Otago, Wellington, New Zealand
| | - Khoi Phan
- Department of Obstetrics, Gynaecology and Women’s Health, University of Otago, Wellington, New Zealand
| | - Diane N. Kenwright
- Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand
| | - Louise Goossens
- Medical Photography, Capital, Coast and Hutt Valley, Wellington, New Zealand
| | | | - Margaret Jane Currie
- Department of Pathology and Biomedical Science, University of Otago, Christchurch, New Zealand
| | - John Kokkinos
- Pancreatic Cancer Translational Research Group, School of Biomedical Sciences, Lowy Cancer Research Centre, UNSW Sydney, Sydney, Australia
| | - George Sharbeen
- Pancreatic Cancer Translational Research Group, School of Biomedical Sciences, Lowy Cancer Research Centre, UNSW Sydney, Sydney, Australia
| | - Phoebe A. Phillips
- Pancreatic Cancer Translational Research Group, School of Biomedical Sciences, Lowy Cancer Research Centre, UNSW Sydney, Sydney, Australia
| | - Claire Elizabeth Henry
- Department of Obstetrics, Gynaecology and Women’s Health, University of Otago, Wellington, New Zealand
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Kim NK, Choi CH, Seong SJ, Lee JM, Lee B, Kim K. Treatment outcomes according to various progestin treatment strategies in patients with atypical hyperplasia/endometrial intraepithelial neoplasia - Multicenter retrospective study (KGOG2033). Gynecol Oncol 2024; 183:68-73. [PMID: 38520881 DOI: 10.1016/j.ygyno.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/15/2024] [Accepted: 03/17/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVE To investigate pathologic complete response (pCR) and recurrence outcomes using various progestin treatment strategies in patients with atypical hyperplasia/endometrial intraepithelial neoplasia (AH/EIN). METHODS Medical records of patients diagnosed with AH/EIN and undergoing follow-up endometrial biopsy after progestin treatment between 2011 and 2020 were retrospectively reviewed. Clinical factors and treatment outcomes were analyzed according to initial progestin treatment (oral progestin [OP], levonorgestrel-releasing intrauterine device [LNG-IUD], and combination), OP dose, and maintenance treatment using Pearson's χ2, Fisher's exact test, and Kaplan-Meier analysis. RESULTS Of 124 patients included, 74, 37, and 13 were in the OP, LNG-IUD, and combination groups, respectively. The pCR rate was 79.8% and recurrence rate was 21.2%. The pCR rates within 3 and 6 months were significantly higher in the OP group than in the LNG-IUD group, but were not significantly different within 12 and 24 months. Recurrence rate was significantly higher in the OP group than in the LNG-IUD group. The pCR rate and recurrence rate had no significant differences between the combination group and the other groups. Excluding the LNG-IUD group, 53 and 34 patients received low- and high-dose OP, respectively. The pCR and recurrence rates were comparable between the low- and high-dose OP groups. Maintenance therapy was significantly associated with lower recurrence rate. CONCLUSIONS Although OP alone achieved more short-term pCR than the other groups, more recurrences occurred after pCR than LNG-IUD alone. High-dose OP as well as combination of OP and LNG-IUD did not increase pCR or reduce recurrence. Maintenance therapy may reduce the recurrence rate after pCR.
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Affiliation(s)
- Nam Kyeong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, 13620 Seongnam, Republic of Korea
| | - Chel Hun Choi
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 06351, Seoul, Republic of Korea
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University School of Medicine, 06135 Seoul, Republic of Korea
| | - Jong-Min Lee
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 05278 Seoul, Republic of Korea
| | - Banghyun Lee
- Department of Obstetrics and Gynecology, Inha University Hospital, Inha University School of Medicine, 22332 Incheon, Republic of Korea
| | - Kidong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, 13620 Seongnam, Republic of Korea.
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Shaha S, Rodrigues D, Mitragotri S. Locoregional drug delivery for cancer therapy: Preclinical progress and clinical translation. J Control Release 2024; 367:737-767. [PMID: 38325716 DOI: 10.1016/j.jconrel.2024.01.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 02/09/2024]
Abstract
Systemic drug delivery is the current clinically preferred route for cancer therapy. However, challenges associated with tumor localization and off-tumor toxic effects limit the clinical effectiveness of this route. Locoregional drug delivery is an emerging viable alternative to systemic therapies. With the improvement in real-time imaging technologies and tools for direct access to tumor lesions, the clinical applicability of locoregional drug delivery is becoming more prominent. Theoretically, locoregional treatments can bypass challenges faced by systemic drug delivery. Preclinically, locoregional delivery of drugs has demonstrated enhanced therapeutic efficacy with limited off-target effects while still yielding an abscopal effect. Clinically, an array of locoregional strategies is under investigation for the delivery of drugs ranging in target and size. Locoregional tumor treatment strategies can be classified into two main categories: 1) direct drug infusion via injection or implanted port and 2) extended drug elution via injected or implanted depot. The number of studies investigating locoregional drug delivery strategies for cancer treatment is rising exponentially, in both preclinical and clinical settings, with some approaches approved for clinical use. Here, we highlight key preclinical advances and the clinical relevance of such locoregional delivery strategies in the treatment of cancer. Furthermore, we critically analyze 949 clinical trials involving locoregional drug delivery and discuss emerging trends.
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Affiliation(s)
- Suyog Shaha
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Allston, MA 02134, USA; Wyss Institute for Biologically Inspired Engineering, Boston, MA 02115, USA
| | - Danika Rodrigues
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Allston, MA 02134, USA; Wyss Institute for Biologically Inspired Engineering, Boston, MA 02115, USA
| | - Samir Mitragotri
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Allston, MA 02134, USA; Wyss Institute for Biologically Inspired Engineering, Boston, MA 02115, USA.
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11
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Barr CE, Sergeant JC, Agnew HJ, Bolton J, McVey RJ, Crosbie EJ. Serum HE4 predicts progestin treatment response in endometrial cancer and atypical hyperplasia: A prognostic study. BJOG 2023; 130:941-948. [PMID: 36715558 DOI: 10.1111/1471-0528.17417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 01/12/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To investigate serum human epididymis-4 (HE4) as a predictive biomarker of intrauterine progestin response in endometrial cancer and atypical endometrial hyperplasia (AEH). DESIGN Prospective prognostic factor study. SETTING Consecutive sample of women attending a tertiary gynaecological oncology centre in northwest England. POPULATION Women with AEH or early-stage, low-grade endometrial cancer who were unfit for or declined primary surgical management. METHODS A total of 76 women, 32 with AEH and 44 with endometrial cancer, were treated with a levonorgestrel intrauterine system (LNG-IUS) for 12 months. Endometrial biopsies and imaging were performed to assess treatment response. Pretreatment serum HE4 was analysed by chemiluminescence immunoassay and diagnostic accuracy and logistic regression analyses were performed. MAIN OUTCOME MEASURES Progestin response at 12 months defined by histology and imaging. RESULTS The median age and body mass index (BMI) of the final cohort were 52 years (interquartile range [IQR] 33-62 years) and 46 kg/m2 (IQR 38-54 kg/m2 ), respectively. Baseline serum HE4 was significantly higher in non-responders than responders (119.2 pmol/L, IQR 94.0-208.4 pmol/L versus 71.8 pmol/L, IQR 56.1-84.2 pmol/L, p < 0.001). Older age (odds ratio [OR] 0.96, 95% CI 0.93-0.99, p = 0.02), baseline serum HE4 (OR 0.97, 95% CI 0.96-0.99, p = 0.001) and endometrial cancer histology (OR 0.22, 95% CI 0.72-0.68, p = 0.009) were associated with a lower likelihood of progestin treatment response. Serum HE4 remained independently associated with progestin treatment failure when adjusted for age and histology (adjusted hazard ratio 0.97, 95% CI 0.96-0.99, p = 0.008). CONCLUSION Serum HE4 shows promise as a predictive biomarker of progestin treatment response in endometrial cancer and AEH.
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Affiliation(s)
- Chloe E Barr
- Department of Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Jamie C Sergeant
- Faculty of Biology, Medicine and Health, School of Health Sciences, Centre for Biostatistics, University of Manchester, Manchester, UK
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Heather J Agnew
- Department of Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - James Bolton
- Department of Histopathology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Rhona J McVey
- Department of Histopathology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Emma J Crosbie
- Department of Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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12
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Aimagambetova G, Terzic S, Laganà AS, Bapayeva G, la Fleur P, Terzic M. Contemporary Fertility-Sparing Management Options of Early Stage Endometrioid Endometrial Cancer in Young Nulliparous Patients. J Clin Med 2021; 11:196. [PMID: 35011935 PMCID: PMC8746136 DOI: 10.3390/jcm11010196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/16/2021] [Accepted: 12/25/2021] [Indexed: 12/15/2022] Open
Abstract
Incidence of endometrial cancer (EC) has been increasing in recent years, especially in high-income countries. The disease commonly affects peri- and postmenopausal women; however, about 5% of women are diagnosed with EC in their reproductive age. Due to both the increasing incidence of EC among reproductive age women and trends to delayed childbearing, fertility-sparing treatment for young patients with EC has become extremely important for researchers and practitioners. Because the classic treatment with total hysterectomy and bilateral saplingo-oophorectomy is not an appropriate approach for young women demanding fertility preservation, several fertility-sparing options have been developed and summarized in this review. Utilization of different medications and their combination (progestagens, gonadotropin releasing hormones analogues, and metformin in different formulations) are tested and found as efficient for fertility-sparing treatment. New minimally invasive surgical techniques, combined with progestagens, are also confirmed as valuable. There are many novel conservative and surgical treatment approaches under investigation. Assuming that molecular biomarkers can be both diagnostic and prognostic to assist in prediction of response to a certain therapy, prognostic risk groups' stratification along with specific biomarkers' identification will ensure low recurrence and decrease mortality rates in young women with EC.
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Affiliation(s)
- Gulzhanat Aimagambetova
- Department of Biomedical Sciences, School of Medicine, Nazarbayev University, Nur-Sultan 010000, Kazakhstan
| | - Sanja Terzic
- Department of Medicine, School of Medicine, Nazarbayev University, Nur-Sultan 010000, Kazakhstan; (S.T.); (P.l.F.); (M.T.)
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, 21100 Varese, Italy;
| | - Gauri Bapayeva
- National Research Center of Mother and Child Health, Clinical Academic Department of Women’s Health, University Medical Center, Nur-Sultan 010000, Kazakhstan;
| | - Philip la Fleur
- Department of Medicine, School of Medicine, Nazarbayev University, Nur-Sultan 010000, Kazakhstan; (S.T.); (P.l.F.); (M.T.)
| | - Milan Terzic
- Department of Medicine, School of Medicine, Nazarbayev University, Nur-Sultan 010000, Kazakhstan; (S.T.); (P.l.F.); (M.T.)
- National Research Center of Mother and Child Health, Clinical Academic Department of Women’s Health, University Medical Center, Nur-Sultan 010000, Kazakhstan;
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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13
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Dore M, Filoche S, Danielson K, Henry C. Characterisation of Levonorgestrel-Resistant Endometrial Cancer Cells. Cancer Manag Res 2021; 13:7871-7884. [PMID: 34703309 PMCID: PMC8523362 DOI: 10.2147/cmar.s327381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/04/2021] [Indexed: 11/23/2022] Open
Abstract
Background Endometrial cancer (EC) is the most common gynaecologic malignancy in the developed world, and incidence is increasing in premenopausal women. The levonorgestrel intrauterine system (LNG-IUS) is gaining traction as an alternative treatment for hyperplasia and early-stage EC for women who are unable to undergo surgery. Thirty to 60% of the women do not respond to this treatment, making the unknown mechanisms of levonorgestrel (LNG) resistance a critical obstacle for the conservative management of EC. This study aimed to characterise LNG-IUS treatment resistance in early-stage endometrial cancer in cell-line models. Methods LNG-resistant endometrial cancer cell lines (MFE296R and MFE319R) and cultures from three early stage endometrial cancer patients were developed. The behavioural profile of MFE296R and MFE319R was analysed using proliferation, adhesion, migration (wound healing and transwell) and invasion (spheroid) assays. LNG-sensitive cell lines (MFE296S and MFE319S) were compared to LNGR cell lines (MFE296R and MFE319R). A literature search was conducted to identify possible candidate biomarkers of LNG resistance. RT-qPCR was used to analyse the mRNA expression of 17 candidate biomarkers in MFE296R and MFE319R. mRNA expression of the top differentially expressed genes was measured using RT-qPCR in primary cultures. Results LNG resistance did not affect proliferation or invasion in immortalised endometrial cancer cells. Transwell migration was significantly increased in MFE319R cells (p=0.03). Cellular adhesion significantly decreased in both MFE296R cells (p=0.012) and MFE319R cells (p=0.04). mRNA expression of KLF4 and SATB2 was significantly amplified in MFE296R and MFE319R cells. mRNA expression of KLF4 was significantly upregulated LNG-resistant primary cell lines. Conclusion LNG-resistant cells may have more oncogenic potential than their LNG-sensitive counterparts. Significant changes in the mRNA expression of KLF4 and SATB2 of LNG-resistant cells is a promising preliminary result in biomarker discovery for guiding LNG-IUS treatment of early stage endometrial cancer.
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Affiliation(s)
- Molly Dore
- Department of Obstetrics, Gynaecology & Women's Health, University of Otago, Wellington, New Zealand
| | - Sara Filoche
- Department of Obstetrics, Gynaecology & Women's Health, University of Otago, Wellington, New Zealand
| | - Kirsty Danielson
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Claire Henry
- Department of Obstetrics, Gynaecology & Women's Health, University of Otago, Wellington, New Zealand
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14
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HE4 as a Biomarker for Endometrial Cancer. Cancers (Basel) 2021; 13:cancers13194764. [PMID: 34638250 PMCID: PMC8507549 DOI: 10.3390/cancers13194764] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/10/2021] [Accepted: 09/17/2021] [Indexed: 12/24/2022] Open
Abstract
Simple Summary There are currently no blood biomarkers approved for routine clinical use in endometrial cancer. Serum human epididymis protein 4 (HE4) is significantly higher in patients with endometrial cancer compared to patients without endometrial cancer and is associated with a poorer prognosis. This makes HE4 an attractive candidate for clinical use in endometrial cancer. The aim of this review is to summarise the evidence for the use of serum HE4 in the detection, prognosis, prediction of therapy response and recurrence monitoring in endometrial cancer. The utility of combining HE4 with other biomarkers or imaging and clinical variables, and its detection in other biofluids is also discussed, as well as potential challenges for clinical use and recommended areas for future research. Abstract There are currently no blood biomarkers in routine clinical use in endometrial carcinoma (EC). Human epididymis protein 4 (HE4) is a glycoprotein that is overexpressed in the serum of patients with EC, making it a good candidate for use as a diagnostic and/or prognostic biomarker. HE4 is correlated with poor prognostic factors, including stage, myometrial invasion and lymph node metastases, which means it could be used to guide decisions regarding the extent of surgery and need for adjuvant therapy. Serum HE4 has also shown promise for predicting responses to progestin therapy in early-stage EC. The use of algorithms and indices incorporating serum HE4 and other biomarkers, including clinical and imaging variables, is an area of increasing interest. Serum HE4 levels rise with age and renal dysfunction, which may affect the interpretation of results. This review covers the evidence supporting the use of HE4 as an EC biomarker for diagnosis, prognosis, recurrence monitoring, and prediction of therapy response. The evidence for combining serum HE4 with other biomarkers, including clinical and imaging variables, its value as a biomarker in other biofluids and potential challenges of its clinical use are also discussed.
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15
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Ura B, Biffi S, Monasta L, Arrigoni G, Battisti I, Di Lorenzo G, Romano F, Aloisio M, Celsi F, Addobbati R, Valle F, Rampazzo E, Brucale M, Ridolfi A, Licastro D, Ricci G. Two Dimensional-Difference in Gel Electrophoresis (2D-DIGE) Proteomic Approach for the Identification of Biomarkers in Endometrial Cancer Serum. Cancers (Basel) 2021; 13:cancers13143639. [PMID: 34298850 PMCID: PMC8305989 DOI: 10.3390/cancers13143639] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/29/2021] [Accepted: 07/16/2021] [Indexed: 12/14/2022] Open
Abstract
Endometrial cancer is the most common gynecologic malignancy arising from the endometrium. Identification of serum biomarkers could be beneficial for its early diagnosis. We have used 2D-Difference In Gel Electrophoresis (2D-DIGE) coupled with Mass Spectrometry (MS) procedures to investigate the serum proteome of 15 patients with endometrial cancer and 15 non-cancer subjects. We have identified 16 proteins with diagnostic potential, considering only spots with a fold change in %V ≥ 1.5 or ≤0.6 in intensity, which were statistically significant (p < 0.05). Western blotting data analysis confirmed the upregulation of CLU, ITIH4, SERPINC1, and C1RL in endometrial and exosome cancer sera compared to those of control subjects. The application of the logistic regression constructed based on the abundance of these four proteins separated the controls from the cancers with excellent levels of sensitivity and specificity. After a validation phase, our findings support the potential of using the proposed algorithm as a diagnostic tool in the clinical stage.
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Affiliation(s)
- Blendi Ura
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34137 Trieste, Italy; (S.B.); (L.M.); (G.D.L.); (F.R.); (M.A.); (F.C.); (R.A.); (G.R.)
- Correspondence:
| | - Stefania Biffi
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34137 Trieste, Italy; (S.B.); (L.M.); (G.D.L.); (F.R.); (M.A.); (F.C.); (R.A.); (G.R.)
| | - Lorenzo Monasta
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34137 Trieste, Italy; (S.B.); (L.M.); (G.D.L.); (F.R.); (M.A.); (F.C.); (R.A.); (G.R.)
| | - Giorgio Arrigoni
- Department of Biomedical Sciences, University of Padova, 35131 Padova, Italy; (G.A.); (I.B.)
- Proteomics Center, University of Padova and Azienda Ospedaliera di Padova, 35131 Padova, Italy
- CRIBI Biotechnology Center, University of Padova, 35131 Padova, Italy
| | - Ilaria Battisti
- Department of Biomedical Sciences, University of Padova, 35131 Padova, Italy; (G.A.); (I.B.)
- Proteomics Center, University of Padova and Azienda Ospedaliera di Padova, 35131 Padova, Italy
| | - Giovanni Di Lorenzo
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34137 Trieste, Italy; (S.B.); (L.M.); (G.D.L.); (F.R.); (M.A.); (F.C.); (R.A.); (G.R.)
| | - Federico Romano
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34137 Trieste, Italy; (S.B.); (L.M.); (G.D.L.); (F.R.); (M.A.); (F.C.); (R.A.); (G.R.)
| | - Michelangelo Aloisio
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34137 Trieste, Italy; (S.B.); (L.M.); (G.D.L.); (F.R.); (M.A.); (F.C.); (R.A.); (G.R.)
| | - Fulvio Celsi
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34137 Trieste, Italy; (S.B.); (L.M.); (G.D.L.); (F.R.); (M.A.); (F.C.); (R.A.); (G.R.)
| | - Riccardo Addobbati
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34137 Trieste, Italy; (S.B.); (L.M.); (G.D.L.); (F.R.); (M.A.); (F.C.); (R.A.); (G.R.)
| | - Francesco Valle
- Consorzio Sistemi a Grande Interfase, Department of Chemistry, University of Firenze, 50019 Firenze, Italy; (F.V.); (M.B.); (A.R.)
- Consiglio Nazionale delle Ricerche, Istituto per lo Studio dei Materiali Nanostrutturati (CNRISMN), 40129 Bologna, Italy
| | - Enrico Rampazzo
- Department of Chemistry “Giacomo Ciamician”, University of Bologna, 40126 Bologna, Italy;
| | - Marco Brucale
- Consorzio Sistemi a Grande Interfase, Department of Chemistry, University of Firenze, 50019 Firenze, Italy; (F.V.); (M.B.); (A.R.)
- Consiglio Nazionale delle Ricerche, Istituto per lo Studio dei Materiali Nanostrutturati (CNRISMN), 40129 Bologna, Italy
| | - Andrea Ridolfi
- Consorzio Sistemi a Grande Interfase, Department of Chemistry, University of Firenze, 50019 Firenze, Italy; (F.V.); (M.B.); (A.R.)
- Consiglio Nazionale delle Ricerche, Istituto per lo Studio dei Materiali Nanostrutturati (CNRISMN), 40129 Bologna, Italy
- Department of Chemistry, University of Firenze, 50019 Firenze, Italy
| | - Danilo Licastro
- ARGO Laboratorio Genomica ed Epigenomica, AREA Science Park, Basovizza, 34149 Trieste, Italy;
| | - Giuseppe Ricci
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34137 Trieste, Italy; (S.B.); (L.M.); (G.D.L.); (F.R.); (M.A.); (F.C.); (R.A.); (G.R.)
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
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