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Song Z, Zhang J, Sun Y, Jiang Z, Liu X. Establishment and validation of an immune infiltration predictive model for ovarian cancer. BMC Med Genomics 2023; 16:227. [PMID: 37759229 PMCID: PMC10538244 DOI: 10.1186/s12920-023-01657-x] [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: 11/08/2022] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The most prevalent mutation in ovarian cancer is the TP53 mutation, which impacts the development and prognosis of the disease. We looked at how the TP53 mutation associates the immunophenotype of ovarian cancer and the prognosis of the disease. METHODS We investigated the state of TP53 mutations and expression profiles in culturally diverse groups and datasets and developed an immune infiltration predictive model relying on immune-associated genes differently expressed between TP53 WT and TP53 MUT ovarian cancer cases. We aimed to construct an immune infiltration predictive model (IPM) to enhance the prognosis of ovarian cancer and investigate the impact of the IPM on the immunological microenvironment. RESULTS TP53 mutagenesis affected the expression of seventy-seven immune response-associated genes. An IPM was implemented and evaluated on ovarian cancer patients to distinguish individuals with low- and high-IPM subgroups of poor survival. For diagnostic and therapeutic use, a nomogram is thus created. According to pathway enrichment analysis, the pathways of the human immune response and immune function abnormalities were the most associated functions and pathways with the IPM genes. Furthermore, patients in the high-risk group showed low proportions of macrophages M1, activated NK cells, CD8+ T cells, and higher CTLA-4, PD-1, PD-L1, and TIM-3 than patients in the low-risk group. CONCLUSIONS The IPM model may identify high-risk patients and integrate other clinical parameters to predict their overall survival, suggesting it is a potential methodology for optimizing ovarian cancer prognosis.
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Affiliation(s)
- Zhenxia Song
- Department of Obstetrics, Qingdao women and childeren's hospital, #6 Tongfu Road, Shibei District, Qingdao, Shandong, 266000, P. R. China
| | - Jingwen Zhang
- Department of Obstetrics, Qingdao women and childeren's hospital, #6 Tongfu Road, Shibei District, Qingdao, Shandong, 266000, P. R. China
| | - Yue Sun
- Department of Obstetrics, Qingdao women and childeren's hospital, #6 Tongfu Road, Shibei District, Qingdao, Shandong, 266000, P. R. China
| | - Zhongmin Jiang
- Department of Pathology, Tian Jin Fifth's Central Hospital, #41 Zhejiang Road, Binhai District, Tianjin, 300450, P. R. China
| | - Xiaoning Liu
- Department of Obstetrics, Qingdao women and childeren's hospital, #6 Tongfu Road, Shibei District, Qingdao, Shandong, 266000, P. R. China.
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Fanale D, Brando C, Corsini LR, Cutaia S, Di Donna MC, Randazzo U, Filorizzo C, Lisanti C, Magrin L, Gurrera V, Romano R, Dimino A, Bazan Russo TD, Olive D, Vieni S, Pantuso G, Giordano A, Chiantera V, Russo A, Bazan V, Iovanna JL. Low plasma PD-L1 levels, early tumor onset and absence of peritoneal carcinomatosis improve prognosis of women with advanced high-grade serous ovarian cancer. BMC Cancer 2023; 23:437. [PMID: 37179293 PMCID: PMC10183131 DOI: 10.1186/s12885-023-10911-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND The most common subtype of ovarian cancer (OC) showing immunogenic potential is represented by the high-grade serous ovarian cancer (HGSOC), which is characterized by the presence of tumor-infiltrating immune cells able to modulate immune response. Because several studies showed a close correlation between OC patient's clinical outcome and expression of programmed cell death protein-1 or its ligand (PD-1/PD-L1), the aim of our study was to investigate if plasma levels of immunomodulatory proteins may predict prognosis of advanced HGSOC women. PATIENTS AND METHODS Through specific ELISA tests, we analyzed plasma concentrations of PD-L1, PD-1, butyrophilin sub-family 3A/CD277 receptor (BTN3A1), pan-BTN3As, butyrophilin sub-family 2 member A1 (BTN2A1), and B- and T-lymphocyte attenuator (BTLA) in one hundred patients affected by advanced HGSOC, before surgery and therapy. The Kaplan-Meier method was used to generate the survival curves, while univariate and multivariate analysis were performed using Cox proportional hazard regression models. RESULTS For each analyzed circulating biomarker, advanced HGSOC women were discriminated based on long (≥ 30 months) versus short progression-free survival (PFS < 30 months). The concentration cut-offs, obtained by receiver operating characteristic (ROC) analysis, allowed to observe that poor clinical outcome and median PFS ranging between 6 and 16 months were associated with higher baseline levels of PD-L1 (> 0.42 ng/mL), PD-1 (> 2.48 ng/mL), BTN3A1 (> 4.75 ng/mL), pan-BTN3As (> 13.06 ng/mL), BTN2A1 (> 5.59 ng/mL) and BTLA (> 2.78 ng/mL). Furthermore, a lower median PFS was associated with peritoneal carcinomatosis, age at diagnosis > 60 years or Body Mass Index (BMI) > 25. A multivariate analysis also suggested that plasma concentrations of PD-L1 ≤ 0.42 ng/mL (HR: 2.23; 95% CI: 1.34 to 3.73; p = 0.002), age at diagnosis ≤ 60 years (HR: 1.70; 95% CI: 1.07 to 2.70; p = 0.024) and absence of peritoneal carcinomatosis (HR: 1.87; 95% CI: 1.23 to 2.85; p = 0.003) were significant prognostic marker for a longer PFS in advanced HGSOC patients. CONCLUSIONS The identification of high-risk HGSOC women could be improved through determination of the plasma PD-L1, PD-1, BTN3A1, pan-BTN3As, BTN2A1 and BTLA levels.
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Affiliation(s)
- Daniele Fanale
- Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, Palermo, 90127, Italy.
| | - Chiara Brando
- Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, Palermo, 90127, Italy
| | - Lidia Rita Corsini
- Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, Palermo, 90127, Italy
| | - Sofia Cutaia
- Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, Palermo, 90127, Italy
| | | | - Ugo Randazzo
- Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, Palermo, 90127, Italy
| | - Clarissa Filorizzo
- Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, Palermo, 90127, Italy
| | - Chiara Lisanti
- Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, Palermo, 90127, Italy
| | - Luigi Magrin
- Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, Palermo, 90127, Italy
| | - Vittorio Gurrera
- Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, Palermo, 90127, Italy
| | - Raffaella Romano
- Department of Gynecologic Oncology, University of Palermo, Palermo, 90127, Italy
| | - Alessandra Dimino
- Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, Palermo, 90127, Italy
| | | | - Daniel Olive
- Team Immunity and Cancer, Centre de Recherche en Cancérologie de Marseille (CRCM), INSERM U1068, CNRS UMR 7258, Aix-Marseille Université and Institut Paoli-Calmettes, Marseille, France
| | - Salvatore Vieni
- Division of General and Oncological Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, 90127, Italy
| | - Gianni Pantuso
- Division of General and Oncological Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, 90127, Italy
| | - Antonio Giordano
- Sbarro Institute for Cancer Research and Molecular Medicine and Center of Biotechnology, College of Science and Technology, Temple University, PA, Philadelphia, 19122, USA
| | - Vito Chiantera
- Department of Gynecologic Oncology, University of Palermo, Palermo, 90127, Italy
| | - Antonio Russo
- Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, Palermo, 90127, Italy.
- Sbarro Institute for Cancer Research and Molecular Medicine and Center of Biotechnology, College of Science and Technology, Temple University, PA, Philadelphia, 19122, USA.
| | - Viviana Bazan
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, 90127, Italy
| | - Juan Lucio Iovanna
- Centre de Recherche en Cancérologie de Marseille (CRCM), INSERM U1068, CNRS UMR 7258, Aix-Marseille Université and Institut Paoli-Calmettes, Parc Scientifique Et Technologique de Luminy, Marseille, 13288, France
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PD-L1 near Infrared Photoimmunotherapy of Ovarian Cancer Model. Cancers (Basel) 2022; 14:cancers14030619. [PMID: 35158887 PMCID: PMC8833482 DOI: 10.3390/cancers14030619] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/22/2022] [Indexed: 12/14/2022] Open
Abstract
(1) Background: Despite advances in surgical approaches and drug development, ovarian cancer is still a leading cause of death from gynecological malignancies. Patients diagnosed with late-stage disease are treated with aggressive surgical resection and chemotherapy, but recurrence with resistant disease is often observed following treatment. There is a critical need for effective therapy for late-stage ovarian cancer. Photoimmunotherapy (PIT), using an antibody conjugated to a near infrared (NIR) dye, constitutes an effective theranostic strategy to detect and selectively eliminate targeted cell populations. (2) Methods: Here, we are targeting program death ligand 1 (PD-L1) using NIR-PIT in a syngeneic mouse model of ovarian cancer. PD-L1 PIT-mediated cytotoxicity was quantified in RAW264.7 macrophages and ID8-Defb29-VEGF cells in culture, and in vivo with orthotopic ID8-Defb29-VEGF tumors. (3) Results: Treatment efficacy was observed both in vitro and in vivo. (4) Conclusions: Our data highlight the need for further investigations to assess the potential of using NIR-PIT for ovarian cancer therapy to improve the treatment outcome of ovarian cancer.
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Leary A, Tan D, Ledermann J. Immune checkpoint inhibitors in ovarian cancer: where do we stand? Ther Adv Med Oncol 2021; 13:17588359211039899. [PMID: 34422119 PMCID: PMC8377306 DOI: 10.1177/17588359211039899] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 07/29/2021] [Indexed: 11/16/2022] Open
Abstract
Numerous retrospective studies have demonstrated that the density of intra-tumoral immune cell infiltration is prognostic in epithelial ovarian cancer (OC). These observations together with reports of programmed death ligand-1 (PD-L1) expression in advanced OC provided the rationale for investigating the benefit of programmed death-1 (PD1) or PD-L1 inhibition in OC. Unfortunately clinical trials to date evaluating PD1/PD-L1 inhibition in patients with relapsed OC have been disappointing. In this review we will discuss early results from single agent PD1/PD-L1 inhibitors and the strategies to enhance benefit from immune-oncology agents in OC, including proposing anti-PD-L1 in combination with other agents (cytotoxics, anti-angiogenics, poly(ADP-ribose) polymerase. (PARP) inhibitors, targeted therapies or other immunotherapies), as well as evaluating these agents earlier in the disease course, or in biomarker selected patients.
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Affiliation(s)
- Alexandra Leary
- Institut Gustave Roussy, 114 rue Edouard Vaillant, Villejuif 94805, France, Université Paris-Saclay, INSERM U981, Villejuif, France
| | - David Tan
- Department of Haematology–Oncology, National University Cancer Institute, Singapore, Cancer Science Institute, National University of Singapore, Singapore
| | - Jonathan Ledermann
- UCL Cancer Institute, Cancer Research UK and UCL Trials Centre, London, UK
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Santos JM, Heiniö C, Cervera-Carrascon V, Quixabeira DCA, Siurala M, Havunen R, Butzow R, Zafar S, de Gruijl T, Lassus H, Kanerva A, Hemminki A. Oncolytic adenovirus shapes the ovarian tumor microenvironment for potent tumor-infiltrating lymphocyte tumor reactivity. J Immunother Cancer 2020; 8:jitc-2019-000188. [PMID: 31940588 PMCID: PMC7057530 DOI: 10.1136/jitc-2019-000188] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2019] [Indexed: 01/01/2023] Open
Abstract
Background Ovarian cancers often contain significant numbers of tumor-infiltrating lymphocytes (TILs) that can be readily harnessed for adoptive T-cell therapy (ACT). However, the immunosuppressive ovarian tumor microenvironment and lack of tumor reactivity in TILs can limit the effectiveness of the therapy. We hypothesized that by using an oncolytic adenovirus (Ad5/3-E2F-D24-hTNFa-IRES-hIL2; TILT-123) to deliver tumor necrosis factor alpha (TNFa) and interleukin-2 (IL-2), we could counteract immunosuppression, and enhance antitumor TIL responses in ovarian cancer (OVCA). Methods We established ex vivo tumor cultures freshly derived from patients with advanced OVCA and evaluated the effects of Ad5/3-E2F-D24-hTNFa-IRES-hIL2 or Ad5/3-E2F-D24 (the control virus without TNFa and IL-2) on TILs, cytokine response and tumor viability. Tumor reactivity was assessed by determining interferon gamma (IFNg) response of clinically relevant TILs towards autologous T-cell-depleted ex vivo tumor cultures pretreated with or without the aforementioned oncolytic adenoviruses. Results Treatment of ex vivo tumor cultures with Ad5/3-E2F-D24-hTNFa-IRES-hIL2 caused a substantial rise in proinflammatory signals: increased secretion of IFNg, CXCL10, TNFa and IL-2, and concomitant activation of CD4+ and CD8+ TILs. Potent tumor reactivity was seen, as clinically relevant TIL secreted high levels of IFNg in response to autologous T-cell-depleted ovarian ex vivo tumor cultures treated with Ad5/3-E2F-D24-hTNFa-IRES-hIL2. This phenomenon was independent of PD-L1 expression in tumor cells, a factor that determined the variability of IFNg responses seen in different patient samples. Conclusions Overall, oncolytic adenovirus Ad5/3-E2F-D24-hTNFa-IRES-hIL2 was able to rewire the ovarian tumor microenvironment to accommodate heightened antitumor TIL reactivity. Such effects may improve the clinical effectiveness of ACT with TILs in patients with advanced OVCA.
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Affiliation(s)
- João Manuel Santos
- Cancer Gene Therapy Group, Translational Immunology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,TILT Biotherapeutics, Helsinki, Finland
| | - Camilla Heiniö
- Cancer Gene Therapy Group, Translational Immunology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Victor Cervera-Carrascon
- Cancer Gene Therapy Group, Translational Immunology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,TILT Biotherapeutics, Helsinki, Finland
| | - Dafne C A Quixabeira
- Cancer Gene Therapy Group, Translational Immunology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Mikko Siurala
- Cancer Gene Therapy Group, Translational Immunology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,TILT Biotherapeutics, Helsinki, Finland
| | - Riikka Havunen
- Cancer Gene Therapy Group, Translational Immunology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,TILT Biotherapeutics, Helsinki, Finland
| | - Ralf Butzow
- Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland
| | - Sadia Zafar
- Cancer Gene Therapy Group, Translational Immunology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tanja de Gruijl
- Cancer Center Amsterdam, Departments of Medical Oncology and Radiation Oncology, University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Heini Lassus
- Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki, Finland
| | - Anna Kanerva
- Cancer Gene Therapy Group, Translational Immunology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki, Finland
| | - Akseli Hemminki
- Cancer Gene Therapy Group, Translational Immunology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland .,TILT Biotherapeutics, Helsinki, Finland
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James NE, Woodman M, DiSilvestro PA, Ribeiro JR. The Perfect Combination: Enhancing Patient Response to PD-1-Based Therapies in Epithelial Ovarian Cancer. Cancers (Basel) 2020; 12:cancers12082150. [PMID: 32756436 PMCID: PMC7466102 DOI: 10.3390/cancers12082150] [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: 06/24/2020] [Revised: 07/28/2020] [Accepted: 08/01/2020] [Indexed: 12/17/2022] Open
Abstract
Epithelial ovarian cancer (EOC) is the most lethal gynecologic malignancy, with an overall 5-year survival of only 47%. As the development of novel targeted therapies is drastically necessary in order to improve patient survival, current EOC clinical trials have heavily focused on immunotherapeutic approaches, centered upon programmed cell death 1 (PD-1) inhibitors. While PD-1 monotherapies have only exhibited modest responses for patients, it has been theorized that in order to enhance EOC patient response to immunotherapy, combinatorial regimens must be investigated. In this review, unique challenges to EOC PD-1 response will be discussed, along with a comprehensive description of both preclinical and clinical studies evaluating PD-1-based combinatorial therapies. Promising aspects of PD-1-based combinatorial approaches are highlighted, while also discussing specific preclinical and clinical areas of research that need to be addressed, in order to optimize EOC patient immunotherapy response.
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Affiliation(s)
- Nicole E. James
- Program in Women’s Oncology, Department of Obstetrics and Gynecology, Women and Infants Hospital, Providence, RI 02905, USA; (N.E.J.); (M.W.); (P.A.D.)
| | - Morgan Woodman
- Program in Women’s Oncology, Department of Obstetrics and Gynecology, Women and Infants Hospital, Providence, RI 02905, USA; (N.E.J.); (M.W.); (P.A.D.)
| | - Paul A. DiSilvestro
- Program in Women’s Oncology, Department of Obstetrics and Gynecology, Women and Infants Hospital, Providence, RI 02905, USA; (N.E.J.); (M.W.); (P.A.D.)
- Department of Obstetrics and Gynecology, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, USA
| | - Jennifer R. Ribeiro
- Program in Women’s Oncology, Department of Obstetrics and Gynecology, Women and Infants Hospital, Providence, RI 02905, USA; (N.E.J.); (M.W.); (P.A.D.)
- Department of Obstetrics and Gynecology, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, USA
- Correspondence:
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Henriksen JR, Nederby L, Donskov F, Waldstrøm M, Adimi P, Jakobsen A, Steffensen KD. Prognostic significance of baseline T cells, B cells and neutrophil-lymphocyte ratio (NLR) in recurrent ovarian cancer treated with chemotherapy. J Ovarian Res 2020; 13:59. [PMID: 32414391 PMCID: PMC7229632 DOI: 10.1186/s13048-020-00661-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/06/2020] [Indexed: 12/27/2022] Open
Abstract
Purpose Biomarkers are needed to guide treatment decisions in recurrent ovarian cancer, as a high proportion of patients do not benefit from treatments. Data on immune subsets in patients receiving chemotherapy are scarce. We investigated the impact of T cells, B cells, neutrophils and the neutrophil-lymphocyte ratio (NLR) in ovarian cancer patients receiving palliative chemotherapy. Methods Blood samples were collected prospectively at baseline in recurrent ovarian cancer (N = 72) receiving chemotherapy. T cells, B cells, neutrophils, and NLR were analyzed. Primary and secondary endpoints were overall survival (OS) and treatment response, respectively. Cut-offs for T and B cells were predefined. Results In patients with low vs. high T and B cells counts, OS was 6.1 months vs 12.0 months (P = 0.017) and 6.1 months vs 12.0 months (P = 0.011, respectively. Low T and B cells analyzed as continuous variables were also associated with unfavorable OS, P = 0.011 and P = 0.007, respectively. Neutrophils had no significant prognostic impact. Median NLR was 4.1. High vs. low NLR was associated with poor survival, 7.4 months vs. 15.9 months (P = 0.012). In multivariate analysis including platinum sensitivity, number of prior lines of chemotherapy, and performance status, high NLR remained an independent poor prognostic factor HR: 2.17 (95% CI 1.21–3.88) (P = 0.009). High NLR was also significantly associated with lack of response, OR 0.15 (95% CI: 0.04–0.51) (P = 0.002). Conclusion In recurrent ovarian cancer patients undergoing palliative chemotherapy, low T and B lymphocyte counts had an unfavorable prognostic impact. High NLR was associated with lack of response and a poor prognosis, and the parameter may be used in patient counselling and treatment decisions.
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Affiliation(s)
- Jon Røikjær Henriksen
- Department of Oncology, Vejle Hospital - University Hospital of Southern Denmark, Vejle, Denmark. .,Faculty of Health Sciences, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - Line Nederby
- Biochemistry and Immunology, Vejle Hospital - University Hospital of Southern Denmark, Vejle, Denmark
| | - Frede Donskov
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Marianne Waldstrøm
- Faculty of Health Sciences, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Pathology, Vejle Hospital - University Hospital of Southern Denmark, Vejle, Denmark
| | - Parvin Adimi
- Department of Oncology, Vejle Hospital - University Hospital of Southern Denmark, Vejle, Denmark
| | - Anders Jakobsen
- Department of Oncology, Vejle Hospital - University Hospital of Southern Denmark, Vejle, Denmark.,Faculty of Health Sciences, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Karina Dahl Steffensen
- Department of Oncology, Vejle Hospital - University Hospital of Southern Denmark, Vejle, Denmark.,Faculty of Health Sciences, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
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