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Chauhan PS, Chen K, Babbra RK, Feng W, Pejovic N, Nallicheri A, Harris PK, Dienstbach K, Atkocius A, Maguire L, Qaium F, Szymanski JJ, Baumann BC, Ding L, Cao D, Reimers MA, Kim EH, Smith ZL, Arora VK, Chaudhuri AA. Urine tumor DNA detection of minimal residual disease in muscle-invasive bladder cancer treated with curative-intent radical cystectomy: A cohort study. PLoS Med 2021; 18:e1003732. [PMID: 34464379 PMCID: PMC8407541 DOI: 10.1371/journal.pmed.1003732] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 07/12/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The standard of care treatment for muscle-invasive bladder cancer (MIBC) is radical cystectomy, which is typically preceded by neoadjuvant chemotherapy. However, the inability to assess minimal residual disease (MRD) noninvasively limits our ability to offer bladder-sparing treatment. Here, we sought to develop a liquid biopsy solution via urine tumor DNA (utDNA) analysis. METHODS AND FINDINGS We applied urine Cancer Personalized Profiling by Deep Sequencing (uCAPP-Seq), a targeted next-generation sequencing (NGS) method for detecting utDNA, to urine cell-free DNA (cfDNA) samples acquired between April 2019 and November 2020 on the day of curative-intent radical cystectomy from 42 patients with localized bladder cancer. The average age of patients was 69 years (range: 50 to 86), of whom 76% (32/42) were male, 64% (27/42) were smokers, and 76% (32/42) had a confirmed diagnosis of MIBC. Among MIBC patients, 59% (19/32) received neoadjuvant chemotherapy. utDNA variant calling was performed noninvasively without prior sequencing of tumor tissue. The overall utDNA level for each patient was represented by the non-silent mutation with the highest variant allele fraction after removing germline variants. Urine was similarly analyzed from 15 healthy adults. utDNA analysis revealed a median utDNA level of 0% in healthy adults and 2.4% in bladder cancer patients. When patients were classified as those who had residual disease detected in their surgical sample (n = 16) compared to those who achieved a pathologic complete response (pCR; n = 26), median utDNA levels were 4.3% vs. 0%, respectively (p = 0.002). Using an optimal utDNA threshold to define MRD detection, positive utDNA MRD detection was highly correlated with the absence of pCR (p < 0.001) with a sensitivity of 81% and specificity of 81%. Leave-one-out cross-validation applied to the prediction of pathologic response based on utDNA MRD detection in our cohort yielded a highly significant accuracy of 81% (p = 0.007). Moreover, utDNA MRD-positive patients exhibited significantly worse progression-free survival (PFS; HR = 7.4; 95% CI: 1.4-38.9; p = 0.02) compared to utDNA MRD-negative patients. Concordance between urine- and tumor-derived mutations, determined in 5 MIBC patients, was 85%. Tumor mutational burden (TMB) in utDNA MRD-positive patients was inferred from the number of non-silent mutations detected in urine cfDNA by applying a linear relationship derived from The Cancer Genome Atlas (TCGA) whole exome sequencing of 409 MIBC tumors. We suggest that about 58% of these patients with high inferred TMB might have been candidates for treatment with early immune checkpoint blockade. Study limitations included an analysis restricted only to single-nucleotide variants (SNVs), survival differences diminished by surgery, and a low number of DNA damage response (DRR) mutations detected after neoadjuvant chemotherapy at the MRD time point. CONCLUSIONS utDNA MRD detection prior to curative-intent radical cystectomy for bladder cancer correlated significantly with pathologic response, which may help select patients for bladder-sparing treatment. utDNA MRD detection also correlated significantly with PFS. Furthermore, utDNA can be used to noninvasively infer TMB, which could facilitate personalized immunotherapy for bladder cancer in the future.
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Affiliation(s)
- Pradeep S. Chauhan
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Kevin Chen
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Ramandeep K. Babbra
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Wenjia Feng
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Nadja Pejovic
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Armaan Nallicheri
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Peter K. Harris
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Katherine Dienstbach
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Siteman Cancer Center, Barnes Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Andrew Atkocius
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Siteman Cancer Center, Barnes Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Lenon Maguire
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Siteman Cancer Center, Barnes Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Faridi Qaium
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Jeffrey J. Szymanski
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Brian C. Baumann
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Siteman Cancer Center, Barnes Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Li Ding
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Siteman Cancer Center, Barnes Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, United States of America
- Department of Genetics, Washington University School of Medicine, St. Louis, Missouri, United States of America
- McDonnell Genome Institute, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Division of Biology and Biomedical Sciences, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Dengfeng Cao
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Melissa A. Reimers
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Siteman Cancer Center, Barnes Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Eric H. Kim
- Siteman Cancer Center, Barnes Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, United States of America
- Division of Urology, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Zachary L. Smith
- Siteman Cancer Center, Barnes Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, United States of America
- Division of Urology, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Vivek K. Arora
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Siteman Cancer Center, Barnes Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Aadel A. Chaudhuri
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Siteman Cancer Center, Barnes Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, United States of America
- Department of Genetics, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Division of Biology and Biomedical Sciences, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Department of Biomedical Engineering, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Department of Computer Science and Engineering, Washington University in St. Louis, St. Louis, Missouri, United States of America
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Chen K, Chauhan PS, Babbra RK, Feng W, Pejovic N, Nallicheri A, Harris PK, Dienstbach K, Atkocius A, Maguire L, Qaium F, Szymanski JJ, Baumann BC, Ding L, Cao D, Reimers MA, Kim EH, Smith ZL, Arora VK, Chaudhuri AA. Tracking minimal residual disease with urine tumor DNA in muscle-invasive bladder cancer after neoadjuvant chemotherapy. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e16514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e16514 Background: Standard-of-care for muscle-invasive bladder cancer (MIBC) consists of neoadjuvant chemotherapy (NAC) followed by radical cystectomy. The inability to noninvasively assess minimal residual disease (MRD) after NAC limits our ability to offer bladder-sparing treatment. We perform urine tumor DNA (utDNA) analysis to identify pathologic complete response (pCR) at the time of cystectomy in patients receiving NAC. Methods: We applied CAPP-Seq to urine cell-free DNA samples acquired on the day of radical cystectomy from 19 MIBC patients treated with NAC. utDNA variant-calling was performed without prior tumor mutational knowledge using a panel of 49 consensus driver genes mutated in MIBC. The utDNA level for each patient was represented by the duplex-supported non-silent driver mutation with the highest variant allele fraction (vAF) after removing germline variants. We also serially tracked utDNA variants in two patients before, during, and after NAC. Results: Comparing patients with residual disease detected in their cystectomy specimen ( n = 10) to those who achieved a pCR ( n = 9), median utDNA levels were 2.4% vs. 0%, respectively ( P = 0.006). Using an optimal utDNA threshold to define MRD detection, positive utDNA MRD was highly correlated with the absence of pCR ( P = 0.003). Analysis of two patients’ serial urine samples revealed utDNA dynamics that were consistent with treatment responses in real-time. In one patient who ultimately achieved a pCR, four non-silent driver mutations were detectable pre-NAC, including ERCC2 N238S (7.8% vAF) associated with increased chemosensitivity. One week after starting NAC, ERCC2 N238S increased by 1.6-fold in urine, as did PIK3CA E726K which increased by 8.4-fold. Four weeks post-NAC, however, all mutations previously detected in this patient’s urine became undetectable, consistent with the patient’s pCR and long-term disease-free survival. Conversely, another patient harbored two non-silent driver mutations in PLEKHS1 (1.9% vAF) and KMT2D (4.9% vAF) pre-NAC. One week after starting NAC, both mutations decreased dramatically by 8.0- and 4.3-fold, respectively. By three weeks post-NAC, however, these mutations progressively increased by 5.2-fold on average, which correlated with a lack of pCR as well as post-treatment disease progression. Two newly detected non-silent driver mutations in ARID1A and ERBB2 also emerged on NAC and persisted following completion of chemotherapy , likely reflecting the development of treatment resistance. Conclusions: utDNA MRD after NAC but before radical cystectomy for MIBC correlated significantly with pathologic response, which could help personalize patient selection for bladder-sparing treatments in the future. Serial monitoring of utDNA variants during NAC can reveal dynamic mutational changes that reflect real-time treatment responses as well as ultimate disease-free survival.
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Affiliation(s)
- Kevin Chen
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Pradeep S Chauhan
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Ramandeep K Babbra
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Wenjia Feng
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Nadja Pejovic
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Armaan Nallicheri
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Peter K Harris
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Katherine Dienstbach
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Andrew Atkocius
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Lenon Maguire
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Faridi Qaium
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Jeffrey J Szymanski
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Brian C Baumann
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Li Ding
- McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO
| | - Dengfeng Cao
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO
| | - Melissa Andrea Reimers
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Eric H Kim
- Division of Urology, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Zachary L Smith
- Division of Urology, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Vivek K Arora
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Aadel A Chaudhuri
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
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Carson KD, Grimes SB, McGinley JM, Thornton MT, Mulhall J, Bourke AM, McCrory C, Marsh B, Hone R, Phelan D, White M, Fabry J, Hughes D, Carson K, Donnelly M, Shanahan E, Fitzpatrick GJ, Bourke M, Warde D, Buggy D, Hughes N, Taylor A, Dowd N, Markham T, Blunnie W, Nicholson G, O’Leary E, Cunningham AJ, Dwyer R, McMechan S, Cullen C, Dempsey G, Wright G, MacKenzie G, Anderson J, Adgey J, Walsh M, O’Callaghan P, Graham I, O’Hare JA, Geoghegan M, Iman N, Shah P, Chander R, Lavin F, Daly K, Johnston PW, Imam Z, Adgey AAJ, Rusk RA, Richardson SG, Hale A, Kinsella BM, FitzGerald GA, King G, Crean P, Gearty G, Cawley T, Docherty JR, Geraghty J, Osborne H, Upton J, D’Arcy G, Stinson J, Cooke T, Colgan MP, Hall M, Tyrrell J, Gaffney K, Grouden M, Moore DJ, Shanik G, Feely J, Delanty N, Reilly M, Lawson JA, Fitzgerald DJ, Reilly MP, McAdam BF, Bergin C, Walshe MJ, Herity NA, Allen JD, Silke B, Singh HP, O’Neill S, Hargrove M, Coleman E, Shorten E, Aherne T, Kelly BE, Hill DH, McIlrath E, Morrow BC, Lavery GG, Blackwood B, Fee JPH, Kevin L, Doran M, Tansey D, Boylan I, McShane AJ, O’Reilly G, Tuohy B, Grainger P, Larkin T, Mahady J, Malone J, Condon C, Donoghue T, O’Leary J, Lyons JF, Tay YK, Tham SN, Khoo Tan HS, Gibson G, O’Grady A, Leader M, Walshe J, Carmody M, Donohoe J, Murphy GM, O’Connor W, Barnes L, Watson R, Darby C, O’Moore R, Mulcahy F, O’Toole E, O’Briain DS, Young MM, Buckley D, Healy E, Rogers S, Ni Scannlain N, McKenna MJ, McBrinn Y, Murray B, Freaney R, Barrett E, Razza Q, Abuaisha F, Powell D, Murray TM, Powell AM, O’Mongain E, O’Neill J, Kernan RP, O’Connor P, Clarke D, Fearon U, Cunningham SK, McKenna TJ, Hayes F, Heffernan A, Sheahan K, Harper R, Johnston GD, Atkinson AB, Sheridan B, Bell PM, Heaney AP, Loughrey G, McCance DR, Hadden DR, Kennedy AL, McNamara P, O’Shaughnessy C, Loughrey HC, Reid I, Teahan S, Caldwell M, Walsh TN, McSweeney J, Hennessy TP, Caldwell MTP, Byrne PJ, Hennessy TPJ, El-Magbri AA, Stevens FM, O’Sullivan R, McCarthy CF, Laundon J, Heneghan MA, Kearns M, Goulding J, Egan EL, McMahon BP, Hegarty F, Malone JF, Merriman R, MacMathuna P, Crowe J, Lennon J, White P, Clarke E, Prabhakar MC, Ryan E, Graham D, Yeoh PL, Kelly P, McKeogh D, O’Keane C, Kitching A, Mulligan E, Gorey TF, Mahmud N, O’Connell M, Goggins M, Keeling PWN, Weir DG, Kelleher D, McDonald GSA, Maguire D, O’Sullivan G, Harvey B, Cherukuri A, McGrath JP, Timon C, Lawlor P, O’Shea J, Buckley M, English L, Walsh T, O’Morain C, Lavelle SM, Kanagaratnam B, Harding B, Murphy B, Kavanagh J, Kerr D, Lavelle E, O’Gorman T, Liston S, Fitzpatrick C, Fitzpatrick P, Turner M, Murphy AW, Cafferty D, Dowling J, Bury G, Kaf Al-Ghazal S, Zimmermann E, O’Donoghue J, McCann J, Sheehan C, Boissel L, Lynch M, Cryan B, Fanning S, O’Meara D, Fennell J, Byrne PM, Lyons D, Mulcahy R, Pooransingh A, Walsh JB, Coakley D, O’Neill D, Ryall N, Connolly P, Namushi R, Lawler M, Locasciulli A, Bacigalupo A, Humphries P, McCann SR, Pamphilon D, Reidy M, Madden M, Finch T, Borton M, Barnes CA, Lawlor SE, Gardiner N, Egan LJ, Orren A, Doherty J, Curran C, O’Hanlon D, Kent P, Kerin M, Maher D, Given HF, Lynch S, McManus R, O’Farrelly C, Madrigal L, Feighery C, O’Donoghue D, Whelan CA, Rea IM, Stewart M, Campbell P, Alexander HD, Crockard AD, Morris TCM, Maguire H, Davidson F, Kaminski GZ, Butler K, Hillary IB, Parfrey NA, Crowley B, McCreary C, Keane C, O’Reilly M, Goh J, Kennedy M, Fitzgerald M, Scott T, Murphy S, Hildebrand J, Holliman R, Smith C, Kengasu K, Riain UN, Cormican M, Flynn J, Glennon M, Smith T, Whyte D, Keane CT, Barry T, Noone D, Maher M, Dawson M, Gilmartin JJ, Gannon F, Eljamel MS, Allcut D, Pidgeon CN, Phillips J, Rawluk D, Young S, Toland J, Deveney AM, Waddington JL, O’Brien DP, Hickey A, Maguire E, Phillips JP, Al-Ansari N, Cunney R, Smyth E, Sharif S, Eljamel M, Pidgeon C, Maguire EA, Burke ET, Staunton H, O’Riordan JI, Hutchinson M, Norton M, McGeeney B, O’Connor M, Redmond JMT, Feely S, Boyle G, McAuliffe F, Foley M, Kelehan P, Murphy J, Greene RA, Higgins J, Darling M, Byrne P, Kondaveeti U, Gordon AC, Hennelly B, Woods T, Harrison RF, Geary M, Sutherst JR, Turner MJ, DeLancey JOL, Donnelly VS, O’Connell PR, O’Herlihy C, Barry-Kinsella C, Sharma SC, Drury L, Lewis S, Stratton J, Ni Scanaill S, Stuart B, Hickey K, Coulter-Smith S, Moloney A, Robson MS, Murphy M, Keane D, Stronge J, Boylan P, Gonsalves R, Blankson S, McGuinness E, Sheppard B, Bonnar J, MacDonagh-White CM, Kelleher CC, Newell J, White O, Young Y, Hallahan C, Carroll K, Tipton K, McDermott EW, Reynolds JV, Nolan N, McCann A, Rafferty R, Sweeney P, Carney D, O’Higgins NJ, Duffy MJ, Grimes H, Gallagher S, O’Hanlon DM, Strattan J, Lenehan P, Robson M, Cusack YA, O’Riordain D, Mercer PM, Smyth PPA, Gallagher HJ, Moule B, Cooke TG, McArdle CS, Burke C, Vance A, Saidtéar C, Early A, Eustace P, Maguire L, Cullinane ABP, Prosser ES, Coca-Prados M, Harvey BJ, Saidléar C, Orwa S, Fitzsimons RB, Bradley O, Hogan M, Zimmerman L, Wang J, Kuliszewski M, Liu J, Post M, Premkumar, Conran MJ, Nolan G, Duff D, Oslizlok P, Denham B, O’Connell PA, Birthistle K, Hitchcock R, Carrington D, Calvert S, Holmes K, Smith DF, Hetherton AM, Mott MG, Oakhill A, Foreman N, Foot A, Dixon J, Walsh S, Mortimer G, O’Sullivan C, Kilgallen CM, Sweeney EC, Brayden DJ, Kelly JG, McCormack PME, Hayes C, Johnson Z, Dack P, Hosseini J, O’Connell T, Hemeryck L, Condren L, McCormack P, McAdam B, Lawson J, Keimowitz R, O’Leary A, Pilkington R, Adebayo GI, Gaffney P, McGettigan P, McManus J, O’Shea B, Wen Y, Killalea S, Golden J, Swanwick G, Clare AW, Mulvany F, Byrne M, O’Callaghan E, Byrne H, Cannon N, Kinsella T, Cassidy B, Shepard N, Horgan R, Larkin C, Cotter D, Coffey VP, Sham PC, Murray LH, Lane A, Kinsella A, Murphy P, Colgan K, Sloan D, Gilligan P, McEnri J, Ennis JT, Stack J, Corcoran E, Walsh D, Thornton L, Temperley I, Lawlor E, Tobin A, Hillary I, Nelson HG, Martin M, Ryan FM, Christie MA, Murray D, Keane E, Holmes E, Hollyer J, Strangeways J, Foster P, Stanwell-Smith R, Griffin E, Conlon T, Hayes E, Clarke T, Fogarty J, Moloney AC, Killeen P, Farrell S, Clancy L, Hynes M, Conlon C, Foley-Nolan C, Shelley E, Collins C, McNamara E, Hayes B, Creamer E, LaFoy M, Costigan P, Al fnAnsari N, Cunney RJ, Smyth EG, Johnson H, McQuoid G, Gilmer B, Browne G, Keogh JAB, Jefferson A, Smith M, Hennessy S, Burke CM, Sreenan S, Power CK, Pathmakanthan S, Poulter LW, Chan A, Sheehan M, Maguire M, O’Connor CM, FitzGerald MX, Southey A, Costello CM, McQuaid K, Urbach V, Thomas S, Horwitz ER, Mulherin D, FitzGerald O, Bresnihan B, Kirk G, Veale DJ, Belch JJF, Mofidi A, Mofidi R, Quigley C, McLaren M, Veale D, D’Arrigo C, Couto JC, Woof J, Greer M, Cree I, Belch J, Hone S, Fenton J, Hamilton S, McShane D. National Scientific Medical Meeting 1994 Abstracts. Ir J Med Sci 1994. [DOI: 10.1007/bf02943102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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