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Tentori CA, Zhao LP, Tinterri B, Strange KE, Zoldan K, Dimopoulos K, Feng X, Riva E, Lim B, Simoni Y, Murthy V, Hayes MJ, Poloni A, Padron E, Cardoso BA, Cross M, Winter S, Santaolalla A, Patel BA, Groarke EM, Wiseman DH, Jones K, Jamieson L, Manogaran C, Daver N, Gallur L, Ingram W, Ferrell PB, Sockel K, Dulphy N, Chapuis N, Kubasch AS, Olsnes AM, Kulasekararaj A, De Lavellade H, Kern W, Van Hemelrijck M, Bonnet D, Westers TM, Freeman S, Oelschlaegel U, Valcarcel D, Raddi MG, Grønbæk K, Fontenay M, Loghavi S, Santini V, Almeida AM, Irish JM, Sallman DA, Young NS, van de Loosdrecht AA, Adès L, Della Porta MG, Cargo C, Platzbecker U, Kordasti S. Immune-monitoring of myelodysplastic neoplasms: Recommendations from the i4MDS consortium. Hemasphere 2024; 8:e64. [PMID: 38756352 PMCID: PMC11096644 DOI: 10.1002/hem3.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/03/2024] [Indexed: 05/18/2024] Open
Abstract
Advancements in comprehending myelodysplastic neoplasms (MDS) have unfolded significantly in recent years, elucidating a myriad of cellular and molecular underpinnings integral to disease progression. While molecular inclusions into prognostic models have substantively advanced risk stratification, recent revelations have emphasized the pivotal role of immune dysregulation within the bone marrow milieu during MDS evolution. Nonetheless, immunotherapy for MDS has not experienced breakthroughs seen in other malignancies, partly attributable to the absence of an immune classification that could stratify patients toward optimally targeted immunotherapeutic approaches. A pivotal obstacle to establishing "immune classes" among MDS patients is the absence of validated accepted immune panels suitable for routine application in clinical laboratories. In response, we formed International Integrative Innovative Immunology for MDS (i4MDS), a consortium of multidisciplinary experts, and created the following recommendations for standardized methodologies to monitor immune responses in MDS. A central goal of i4MDS is the development of an immune score that could be incorporated into current clinical risk stratification models. This position paper first consolidates current knowledge on MDS immunology. Subsequently, in collaboration with clinical and laboratory specialists, we introduce flow cytometry panels and cytokine assays, meticulously devised for clinical laboratories, aiming to monitor the immune status of MDS patients, evaluating both immune fitness and identifying potential immune "risk factors." By amalgamating this immunological characterization data and molecular data, we aim to enhance patient stratification, identify predictive markers for treatment responsiveness, and accelerate the development of systems immunology tools and innovative immunotherapies.
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Affiliation(s)
- Cristina A. Tentori
- Humanitas Clinical and Research Center–IRCCS & Department of Biomedical SciencesHumanitas UniversityMilanItaly
- Comprehensive Cancer Centre, King's CollegeLondonUK
| | - Lin P. Zhao
- Hématologie seniorsHôpital Saint‐Louis, Assistance Publique des Hôpitaux de Paris (APHP)ParisFrance
- INSERM UMR_S1160, Institut de Recherche Saint LouisUniversité Paris CitéParisFrance
| | - Benedetta Tinterri
- Humanitas Clinical and Research Center–IRCCS & Department of Biomedical SciencesHumanitas UniversityMilanItaly
| | - Kathryn E. Strange
- Comprehensive Cancer Centre, King's CollegeLondonUK
- Research Group of Molecular ImmunologyFrancis Crick InstituteLondonUK
| | - Katharina Zoldan
- Department of Medicine 1, Haematology, Cellular Therapy, Hemostaseology and Infectious DiseasesUniversity Medical Center LeipzigLeipzigGermany
| | - Konstantinos Dimopoulos
- Department of Clinical BiochemistryBispebjerg and Frederiksberg HospitalCopenhagenDenmark
- Department of Pathology, RigshospitaletCopenhagen University HospitalCopenhagenDenmark
| | - Xingmin Feng
- Hematology Branch, National Heart, Lung and Blood InstituteBethesdaMarylandUSA
| | - Elena Riva
- Humanitas Clinical and Research Center–IRCCS & Department of Biomedical SciencesHumanitas UniversityMilanItaly
| | | | - Yannick Simoni
- Université Paris Cité, CNRS, INSERM, Institut CochinParisFrance
| | - Vidhya Murthy
- Centre for Clinical Haematology, University Hospitals of BirminghamBirminghamUK
| | - Madeline J. Hayes
- Cell & Developmental BiologyVanderbilt University School of MedicineNashvilleTennesseeUSA
- Pathology, Microbiology and Immunology, Vanderbilt University Medical CenterNashvilleTennesseeUSA
- Vanderbilt‐Ingram Cancer Center, Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Antonella Poloni
- Department of Clinical and Molecular SciencesUniversità Politecnica delle MarcheAnconaItaly
| | - Eric Padron
- Moffitt Cancer Center, Malignant Hematology DepartmentTampaUSA
| | - Bruno A. Cardoso
- Universidade Católica PortuguesaFaculdade de MedicinaPortugal
- Universidade Católica Portuguesa, Centro de Investigação Interdisciplinar em SaúdePortugal
| | - Michael Cross
- Department of Medicine 1, Haematology, Cellular Therapy, Hemostaseology and Infectious DiseasesUniversity Medical Center LeipzigLeipzigGermany
| | - Susann Winter
- Medical Clinic I, University Hospital Carl Gustav Carus, TU DresdenDresdenGermany
| | | | - Bhavisha A. Patel
- Hematology Branch, National Heart, Lung and Blood InstituteBethesdaMarylandUSA
| | - Emma M. Groarke
- Hematology Branch, National Heart, Lung and Blood InstituteBethesdaMarylandUSA
| | - Daniel H. Wiseman
- Division of Cancer SciencesThe University of ManchesterManchesterUK
- The Christie NHS Foundation TrustManchesterUK
| | - Katy Jones
- Immunophenotyping Laboratory (Synnovis Analytics LLP)Southeast Haematological Malignancy Diagnostic Service, King's College HospitalLondonUK
| | - Lauren Jamieson
- Immunophenotyping Laboratory (Synnovis Analytics LLP)Southeast Haematological Malignancy Diagnostic Service, King's College HospitalLondonUK
| | - Charles Manogaran
- Immunophenotyping Laboratory (Synnovis Analytics LLP)Southeast Haematological Malignancy Diagnostic Service, King's College HospitalLondonUK
| | - Naval Daver
- University of TexasMD Anderson Cancer CenterHouston, TexasUSA
| | - Laura Gallur
- Hematology Department, Vall d'hebron University Hospital, Vall d'hebron Institut of Oncology (VHIO)Vall d'Hebron Barcelona Hospital CampusBarcelonaSpain
| | - Wendy Ingram
- Department of HaematologyUniversity Hospital of WalesCardiffUK
| | - P. Brent Ferrell
- Vanderbilt‐Ingram Cancer Center, Vanderbilt University Medical CenterNashvilleTennesseeUSA
- Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Katja Sockel
- Medical Clinic I, University Hospital Carl Gustav Carus, TU DresdenDresdenGermany
| | - Nicolas Dulphy
- INSERM UMR_S1160, Institut de Recherche Saint LouisUniversité Paris CitéParisFrance
- Laboratoire d'Immunologie et d‘Histocompatibilité, Assistance Publique des Hôpitaux de Paris (APHP), Hôpital Saint‐LouisParisFrance
- Institut Carnot OPALE, Institut de Recherche Saint‐Louis, Hôpital Saint‐LouisParisFrance
| | - Nicolas Chapuis
- Université Paris Cité, CNRS, INSERM, Institut CochinParisFrance
- Assistance Publique‐Hôpitaux de Paris Centre, Hôpital CochinParisFrance
| | - Anne S. Kubasch
- Department of Medicine 1, Haematology, Cellular Therapy, Hemostaseology and Infectious DiseasesUniversity Medical Center LeipzigLeipzigGermany
| | - Astrid M. Olsnes
- Section for Hematology, Department of MedicineHaukeland University HospitalBergenNorway
- Department of Clinical ScienceFaculty of Medicine, University of BergenBergenNorway
| | | | | | | | | | - Dominique Bonnet
- Hematopoietic Stem Cell LaboratoryFrancis Crick InstituteLondonUK
| | - Theresia M. Westers
- Department of Hematology, Cancer Center AmsterdamAmsterdam University Medical Centers, location VU University Medical CenterAmsterdamThe Netherlands
| | - Sylvie Freeman
- Institute of Immunology and ImmunotherapyUniversity of BirminghamBirminghamUK
| | - Uta Oelschlaegel
- Medical Clinic I, University Hospital Carl Gustav Carus, TU DresdenDresdenGermany
| | - David Valcarcel
- Hematology Department, Vall d'hebron University Hospital, Vall d'hebron Institut of Oncology (VHIO)Vall d'Hebron Barcelona Hospital CampusBarcelonaSpain
| | - Marco G. Raddi
- Myelodysplastic Syndrome Unit, Hematology DivisionAzienda Ospedaliero‐Universitaria Careggi, University of FlorenceFlorenceItaly
| | - Kirsten Grønbæk
- Department of Hematology, RigshospitaletCopenhagen University HospitalCopenhagenDenmark
- Biotech Research and Innovation Center (BRIC)University of CopenhagenCopenhagenDenmark
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Michaela Fontenay
- Université Paris Cité, CNRS, INSERM, Institut CochinParisFrance
- Assistance Publique‐Hôpitaux de Paris Centre, Hôpital CochinParisFrance
| | - Sanam Loghavi
- University of TexasMD Anderson Cancer CenterHouston, TexasUSA
| | - Valeria Santini
- Myelodysplastic Syndrome Unit, Hematology DivisionAzienda Ospedaliero‐Universitaria Careggi, University of FlorenceFlorenceItaly
| | - Antonio M. Almeida
- Hematology DepartmentHospital da Luz LisboaLisboaPortugal
- DeaneryFaculdade de Medicina, UCPLisboaPortugal
| | - Jonathan M. Irish
- Cell & Developmental BiologyVanderbilt University School of MedicineNashvilleTennesseeUSA
- Pathology, Microbiology and Immunology, Vanderbilt University Medical CenterNashvilleTennesseeUSA
- Vanderbilt‐Ingram Cancer Center, Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | | | - Neal S. Young
- Hematology Branch, National Heart, Lung and Blood InstituteBethesdaMarylandUSA
| | - Arjan A. van de Loosdrecht
- Department of Hematology, Cancer Center AmsterdamAmsterdam University Medical Centers, location VU University Medical CenterAmsterdamThe Netherlands
| | - Lionel Adès
- Hématologie seniorsHôpital Saint‐Louis, Assistance Publique des Hôpitaux de Paris (APHP)ParisFrance
- Université Paris Cité, CNRS, INSERM, Institut CochinParisFrance
| | - Matteo G. Della Porta
- Humanitas Clinical and Research Center–IRCCS & Department of Biomedical SciencesHumanitas UniversityMilanItaly
| | | | - Uwe Platzbecker
- Department of Medicine 1, Haematology, Cellular Therapy, Hemostaseology and Infectious DiseasesUniversity Medical Center LeipzigLeipzigGermany
| | - Shahram Kordasti
- Comprehensive Cancer Centre, King's CollegeLondonUK
- Department of Clinical and Molecular SciencesUniversità Politecnica delle MarcheAnconaItaly
- Haematology DepartmentGuy's and St Thomas NHS TrustLondonUK
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Arenillas L, Calvo X, Luño E, Senent L, Alonso E, Ramos F, Ardanaz MT, Pedro C, Tormo M, Marco V, Montoro J, Díez-Campelo M, Brunet S, Arrizabalaga B, Xicoy B, Andreu R, Bonanad S, Jerez A, Nomdedeu B, Ferrer A, Sanz GF, Florensa L. Considering Bone Marrow Blasts From Nonerythroid Cellularity Improves the Prognostic Evaluation of Myelodysplastic Syndromes. J Clin Oncol 2016; 34:3284-92. [PMID: 27382099 DOI: 10.1200/jco.2016.66.9705] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE WHO classification of myeloid malignancies is based mainly on the percentage of bone marrow (BM) blasts. This is considered from total nucleated cells (TNCs), unless there is erythroid-hyperplasia (erythroblasts ≥ 50%), calculated from nonerythroid cells (NECs). In these instances, when BM blasts are ≥ 20%, the disorder is classified as erythroleukemia, and when BM blasts are < 20%, as myelodysplastic syndrome (MDS). In the latter, the percentage of blasts is considered from TNCs. PATIENTS AND METHODS We assessed the percentage of BM blasts from TNCs and NECs in 3,692 patients with MDS from the Grupo Español de Síndromes Mielodisplásicos, 465 patients with erythroid hyperplasia (MDS-E) and 3,227 patients without erythroid hyperplasia. We evaluated the relevance of both quantifications on classification and prognostication. RESULTS By enumerating blasts systematically from NECs, 22% of patients with MDS-E and 12% with MDS from the whole series diagnosed within WHO categories with < 5% BM blasts, were reclassified into higher-risk categories and showed a poorer overall survival than did those who remained in initial categories (P = .006 and P = .001, respectively). Following WHO recommendations, refractory anemia with excess blasts (RAEB)-2 diagnosis is not possible in MDS-E, as patients with 10% to < 20% BM blasts from TNCs fulfill erythroleukemia criteria; however, by considering blasts from NECs, 72 patients were recoded as RAEB-2 and showed an inferior overall survival than did patients with RAEB-1 without erythroid hyperplasia. Recalculating the International Prognostic Scoring System by enumerating blasts from NECs in MDS-E and in the overall MDS population reclassified approximately 9% of lower-risk patients into higher-risk categories, which indicated the survival expected for higher-risk patients. CONCLUSION Regardless of the presence of erythroid hyperplasia, calculating the percentage of BM blasts from NECs improves prognostic assessment of MDS. This fact should be considered in future WHO classification reviews.
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Affiliation(s)
- Leonor Arenillas
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain.
| | - Xavier Calvo
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Elisa Luño
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Leonor Senent
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Esther Alonso
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Fernando Ramos
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - María Teresa Ardanaz
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Carme Pedro
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Mar Tormo
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Víctor Marco
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Julia Montoro
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - María Díez-Campelo
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Salut Brunet
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Beatriz Arrizabalaga
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Blanca Xicoy
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Rafael Andreu
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Santiago Bonanad
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Andrés Jerez
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Benet Nomdedeu
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Ana Ferrer
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Guillermo F Sanz
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
| | - Lourdes Florensa
- Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain
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