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Menne Guricová K, Groen V, Pos F, Monninkhof E, Elias SG, Haustermans K, Smeenk RJ, van der Voort van Zyp J, Draulans C, Isebaert S, van Houdt PJ, Kerkmeijer LGW, van der Heide UA. Risk Modeling for Individualization of the FLAME Focal Boost Approach in External Beam Radiation Therapy for Patients With Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2024; 118:66-73. [PMID: 37725026 DOI: 10.1016/j.ijrobp.2023.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 07/16/2023] [Accepted: 07/29/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE The FLAME trial (NCT01168479) showed that isotoxic focal boosting to the intraprostatic lesion(s) in patients with intermediate- and high-risk prostate cancer improves 5-year disease-free survival (DFS). Although the near-minimum dose to the gross tumor volume (D98%) was associated with improved outcomes, a closer look suggested that this might not be the same for all patients. Therefore, we investigated whether risk factors that are associated with a benefit of focal boosting can be identified. METHODS AND MATERIALS We described the distribution of clinical characteristics and the number of high-risk factors with respect to the D98% in 526 FLAME trial patients. We used penalized Cox regression to develop a prediction model. To investigate a potential benefit in patient subgroups, we compared the model-based predictions of 5-year DFS assuming standard whole-gland radiation therapy of 77 Gy to the predictions assuming an additional focal boost with D98% of 95 Gy. RESULTS Patients with high-risk factors were well represented in the group of 120 patients that received D98% > 85 Gy and showed fewer recurrences compared with the group that received 77 Gy. Applying the model simulating a standard dose of 77 Gy, we predicted a high DFS for grade group (GG) 1 patients, whereas patients with high-risk characteristics appeared to show a low DFS. All risk groups showed a high level of DFS when simulating D98% of 95 Gy. CONCLUSIONS Our results suggest that GG 1 patients already show a low level of failure at a standard dose of 77 Gy, limiting the additional benefit of focal boosting. In contrast, patients with high-risk characteristics, especially GG 4 or 5, show a low 5-year DFS, while focal boosting might improve this substantially. This suggests that reaching a high focal boost dose may be particularly beneficial for these patients.
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Affiliation(s)
- Karolína Menne Guricová
- Department of Radiation Oncology, The Netherlands Cancer Institute (NKI-AVL), Amsterdam, The Netherlands
| | - Veerle Groen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Floris Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute (NKI-AVL), Amsterdam, The Netherlands
| | - Evelyn Monninkhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sjoerd G Elias
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Karin Haustermans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Cédric Draulans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Sofie Isebaert
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Petra J van Houdt
- Department of Radiation Oncology, The Netherlands Cancer Institute (NKI-AVL), Amsterdam, The Netherlands
| | - Linda G W Kerkmeijer
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute (NKI-AVL), Amsterdam, The Netherlands.
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2
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van den Elshout R, Herings SDA, Mannil M, Gijtenbeek AMM, ter Laan M, Smeenk RJ, Meijer FJA, Scheenen TWJ, Henssen DJHA. Apparent Diffusion Coefficient Metrics to Differentiate between Treatment-Related Abnormalities and Tumor Progression in Post-Treatment Glioblastoma Patients: A Retrospective Study. Cancers (Basel) 2023; 15:4990. [PMID: 37894355 PMCID: PMC10605800 DOI: 10.3390/cancers15204990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/08/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Distinguishing treatment-related abnormalities (TRA) from tumor progression (TP) in glioblastoma patients is a diagnostic imaging challenge due to the identical morphology of conventional MR imaging sequences. Diffusion-weighted imaging (DWI) and its derived images of the apparent diffusion coefficient (ADC) have been suggested as diagnostic tools for this problem. The aim of this study is to determine the diagnostic accuracy of different cut-off values of the ADC to differentiate between TP and TRA. In total, 76 post-treatment glioblastoma patients with new contrast-enhancing lesions were selected. Lesions were segmented using a T1-weighted, contrast-enhanced scan. The mean ADC values of the segmentations were compared between TRA and TP groups. Diagnostic accuracy was compared by use of the area under the curve (AUC) and the derived sensitivity and specificity values from cutoff points. Although ADC values in TP (mean = 1.32 × 10-3 mm2/s; SD = 0.31 × 10-3 mm2/s) were significantly different compared to TRA (mean = 1.53 × 10-3 mm2/s; SD = 0.28 × 10-3 mm2/s) (p = 0.003), considerable overlap in their distributions exists. The AUC of ADC values to distinguish TP from TRA was 0.71, with a sensitivity and specificity of 65% and 70%, respectively, at an ADC value of 1.47 × 10-3 mm2/s. These findings therefore indicate that ADC maps should not be used in discerning between TP and TRA at a certain timepoint without information on temporal evolution.
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Affiliation(s)
- Rik van den Elshout
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (S.D.A.H.); (F.J.A.M.); (T.W.J.S.); (D.J.H.A.H.)
- Radiologie Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Siem D. A. Herings
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (S.D.A.H.); (F.J.A.M.); (T.W.J.S.); (D.J.H.A.H.)
| | - Manoj Mannil
- University Clinic for Radiology, Westfälische Wilhelms-University Muenster and University Hospital Muenster, Albert-Schweitzer-Campus 1, DE-48149 Muenster, Germany;
| | - Anja M. M. Gijtenbeek
- Department of Neurology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
| | - Mark ter Laan
- Department of Neurosurgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
| | - Robert J. Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
| | - Frederick J. A. Meijer
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (S.D.A.H.); (F.J.A.M.); (T.W.J.S.); (D.J.H.A.H.)
| | - Tom W. J. Scheenen
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (S.D.A.H.); (F.J.A.M.); (T.W.J.S.); (D.J.H.A.H.)
| | - Dylan J. H. A. Henssen
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (S.D.A.H.); (F.J.A.M.); (T.W.J.S.); (D.J.H.A.H.)
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3
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De Cock L, Draulans C, Pos FJ, Isebaert S, De Roover R, van der Heide UA, Smeenk RJ, Kunze-Busch M, van der Voort van Zyp J, de Boer H, Kerkmeijer LGW, Haustermans K. From once-weekly to semi-weekly whole prostate gland stereotactic radiotherapy with focal boosting: Primary endpoint analysis of the multicenter phase II hypo-FLAME 2.0 trial. Radiother Oncol 2023; 185:109713. [PMID: 37178932 DOI: 10.1016/j.radonc.2023.109713] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/03/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND AND PURPOSE The hypo-FLAME trial showed that once-weekly (QW) focal boosted prostate stereotactic body radiotherapy (SBRT) is associated with acceptable acute genitourinary (GU) and gastrointestinal (GI) toxicity. Currently, we investigated the safety of reducing the overall treatment time (OTT) of focal boosted prostate SBRT from 29 to 15 days. MATERIAL AND METHODS Patients with intermediate- and high-risk prostate cancer were treated with SBRT delivering 35 Gy in 5 fractions to the whole prostate gland with an iso-toxic boost up to 50 Gy to the intraprostatic lesion(s) in a semi-weekly (BIW) schedule. The primary endpoint was radiation-induced acute toxicity (CTCAE v5.0). Changes in quality of life (QoL) were examined in terms of proportions achieving a minimal clinically important change (MCIC). Finally, acute toxicity and QoL scores of the BIW schedule were compared with the results of the prior QW hypo-FLAME schedule (n = 100). RESULTS Between August 2020 and February 2022, 124 patients were enrolled and treated BIW. No grade ≥3 GU or GI toxicity was observed. The 90-days cumulative incidence of grade 2 GU and GI toxicity rates were 47.5% and 7.4%, respectively. Patients treated QW scored significant less grade 2 GU toxicity (34.0%, p = 0.01). No significant differences in acute GI toxicity were observed. Furthermore, patients treated QW had a superior acute bowel and urinary QoL. CONCLUSION Semi-weekly prostate SBRT with iso-toxic focal boosting is associated with acceptable acute GU and GI toxicity. Based on the comparison between the QW and BIW schedule, patients should be counselled regarding the short-term advantages of a more protracted schedule. Registration number ClinicalTrials.gov: NCT04045717.
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Affiliation(s)
- Lisa De Cock
- Department of Oncology, KU Leuven, Leuven, Belgium.
| | | | - Floris J Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Sofie Isebaert
- Department of Oncology, KU Leuven, Leuven, Belgium; Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.
| | - Robin De Roover
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Martina Kunze-Busch
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | | | - Hans de Boer
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands.
| | - Linda G W Kerkmeijer
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands.
| | - Karin Haustermans
- Department of Oncology, KU Leuven, Leuven, Belgium; Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.
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Henssen D, Leijten L, Meijer FJA, van der Kolk A, Arens AIJ, Ter Laan M, Smeenk RJ, Gijtenbeek A, van de Giessen EM, Tolboom N, Oprea-Lager DE, Smits M, Nagarajah J. Head-To-Head Comparison of PET and Perfusion Weighted MRI Techniques to Distinguish Treatment Related Abnormalities from Tumor Progression in Glioma. Cancers (Basel) 2023; 15:cancers15092631. [PMID: 37174097 PMCID: PMC10177124 DOI: 10.3390/cancers15092631] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
The post-treatment imaging surveillance of gliomas is challenged by distinguishing tumor progression (TP) from treatment-related abnormalities (TRA). Sophisticated imaging techniques, such as perfusion-weighted magnetic resonance imaging (MRI PWI) and positron-emission tomography (PET) with a variety of radiotracers, have been suggested as being more reliable than standard imaging for distinguishing TP from TRA. However, it remains unclear if any technique holds diagnostic superiority. This meta-analysis provides a head-to-head comparison of the diagnostic accuracy of the aforementioned imaging techniques. Systematic literature searches on the use of PWI and PET imaging techniques were carried out in PubMed, Embase, the Cochrane Library, ClinicalTrials.gov and the reference lists of relevant papers. After the extraction of data on imaging technique specifications and diagnostic accuracy, a meta-analysis was carried out. The quality of the included papers was assessed using the QUADAS-2 checklist. Nineteen articles, totaling 697 treated patients with glioma (431 males; mean age ± standard deviation 50.5 ± 5.1 years) were included. The investigated PWI techniques included dynamic susceptibility contrast (DSC), dynamic contrast enhancement (DCE) and arterial spin labeling (ASL). The PET-tracers studied concerned [S-methyl-11C]methionine, 2-deoxy-2-[18F]fluoro-D-glucose ([18F]FDG), O-(2-[18F]fluoroethyl)-L-tyrosine ([18F]FET) and 6-[18F]-fluoro-3,4-dihydroxy-L-phenylalanine ([18F]FDOPA). The meta-analysis of all data showed no diagnostic superior imaging technique. The included literature showed a low risk of bias. As no technique was found to be diagnostically superior, the local level of expertise is hypothesized to be the most important factor for diagnostically accurate results in post-treatment glioma patients regarding the distinction of TRA from TP.
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Affiliation(s)
- Dylan Henssen
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
- Radboudumc Center of Expertise Neuro-Oncology, 6525 GA Nijmegen, The Netherlands
| | - Lars Leijten
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Frederick J A Meijer
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
- Radboudumc Center of Expertise Neuro-Oncology, 6525 GA Nijmegen, The Netherlands
| | - Anja van der Kolk
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
- Radboudumc Center of Expertise Neuro-Oncology, 6525 GA Nijmegen, The Netherlands
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Anne I J Arens
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Mark Ter Laan
- Radboudumc Center of Expertise Neuro-Oncology, 6525 GA Nijmegen, The Netherlands
- Department of Neurosurgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Robert J Smeenk
- Radboudumc Center of Expertise Neuro-Oncology, 6525 GA Nijmegen, The Netherlands
- Department of Radiation Oncology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Anja Gijtenbeek
- Radboudumc Center of Expertise Neuro-Oncology, 6525 GA Nijmegen, The Netherlands
- Department of Neurology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Elsmarieke M van de Giessen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Nelleke Tolboom
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Daniela E Oprea-Lager
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Marion Smits
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
- Brain Tumor Center, Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
- Medical Delta, 2629 JH Delft, The Netherlands
| | - James Nagarajah
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
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Jahreiß MC, Hoogeman M, K H Aben K, Dirkx M, Snieders R, Pos FJ, Janssen T, Dekker A, Vanneste B, Minken A, Hoekstra C, Smeenk RJ, Incrocci L, Heemsbergen WD. Advances in radiotherapy and its impact on second primary cancer risk: a multi-center cohort study in prostate cancer patients. Radiother Oncol 2023; 183:109659. [PMID: 37003369 DOI: 10.1016/j.radonc.2023.109659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 03/21/2023] [Accepted: 03/21/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Modelling studies suggest that advanced intensity-modulated radiotherapy may increase second primary cancer (SPC) risks, due to increased radiation exposure of tissues located outside the treatment fields. In the current study we investigated the association between SPC risks and characteristics of applied external beam radiotherapy (EBRT) protocols for localized prostate cancer (PCa). METHODS We collected EBRT protocol characteristics (2000-2016) from five Dutch RT institutes for the 3D-CRT and advanced EBRT era (N=7908). From the Netherlands Cancer Registry we obtained patient/tumour characteristics, SPC data, and survival information. Standardized incidence ratios (SIR) were calculated for pelvis and non-pelvis SPC. Nationwide SIRs were calculated as a reference, using calendar period as a proxy to label 3D-CRT/advanced EBRT. RESULTS From 2000-2006, 3D-CRT with 68-78 Gy in 2 Gy fractions, delivered with 10-23 MV and weekly portal imaging was the most dominant protocol. By the year 2010 all institutes routinely used advanced EBRT (IMRT, VMAT, tomotherapy), mainly delivering 78 Gy in 2Gy fractions, using various kV/MV imaging protocols. Sixteen percent (N=1268) developed ≥1 SPC. SIRs for pelvis and non-pelvis SPC (all institutes, advanced EBRT vs 3D-CRT) were 1.17 (1.00-1.36) vs 1.39 (1.21-1.59), and 1.01 (0.89-1.07) vs 1.03 (0.94-1.13), respectively. Nationwide non-pelvis SIR was 1.07 (1.01-1.13) vs 1.02 (0.98-1.07). Other RT protocol characteristics did not correlate with SPC endpoints. CONCLUSION None of the studied RT characteristics of advanced EBRT was associated with increased out-of-field SPC risks. With constantly evolving EBRT protocols, evaluation of associated SPC risks remains important.
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Affiliation(s)
- Marie-Christina Jahreiß
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mischa Hoogeman
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Katja K H Aben
- Department of Research & Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands; Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maarten Dirkx
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Renier Snieders
- Department of Research & Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
| | - Floris J Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute,Amsterdam, The Netherlands
| | - Tomas Janssen
- Department of Radiation Oncology, The Netherlands Cancer Institute,Amsterdam, The Netherlands
| | - Andre Dekker
- Department of Radiation Oncology (Maastro), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ben Vanneste
- Department of Radiation Oncology (Maastro), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands; Department of Human Structure and Repair; Department of Radiation Oncology, Ghent University Hospital, Belgium
| | - Andre Minken
- Radiotherapiegroep, Institute of Radiation Oncology, Arnhem/Deventer, The Netherlands
| | - Carel Hoekstra
- Radiotherapiegroep, Institute of Radiation Oncology, Arnhem/Deventer, The Netherlands
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luca Incrocci
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Wilma D Heemsbergen
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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6
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Mehra N, Kloots I, Vlaming M, Aluwini S, Dewulf E, Oprea-Lager DE, van der Poel H, Stoevelaar H, Yakar D, Bangma CH, Bekers E, van den Bergh R, Bergman AM, van den Berkmortel F, Boudewijns S, Dinjens WN, Fütterer J, van der Hulle T, Jenster G, Kroeze LI, van Kruchten M, van Leenders G, van Leeuwen PJ, de Leng WW, van Moorselaar RJA, Noordzij W, Oldenburg RA, van Oort IM, Oving I, Schalken JA, Schoots IG, Schuuring E, Smeenk RJ, Vanneste BG, Vegt E, Vis AN, de Vries K, Willemse PPM, Wondergem M, Ausems M. Genetic Aspects and Molecular Testing in Prostate Cancer: A Report from a Dutch Multidisciplinary Consensus Meeting. EUR UROL SUPPL 2023; 49:23-31. [PMID: 36874601 PMCID: PMC9975012 DOI: 10.1016/j.euros.2022.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 01/27/2023] Open
Abstract
Background Germline and tumour genetic testing in prostate cancer (PCa) is becoming more broadly accepted, but testing indications and clinical consequences for carriers in each disease stage are not yet well defined. Objective To determine the consensus of a Dutch multidisciplinary expert panel on the indication and application of germline and tumour genetic testing in PCa. Design setting and participants The panel consisted of 39 specialists involved in PCa management. We used a modified Delphi method consisting of two voting rounds and a virtual consensus meeting. Outcome measurements and statistical analysis Consensus was reached if ≥75% of the panellists chose the same option. Appropriateness was assessed by the RAND/UCLA appropriateness method. Results and limitations Of the multiple-choice questions, 44% reached consensus. For men without PCa having a relevant family history (familial PCa/BRCA-related hereditary cancer), follow-up by prostate-specific antigen was considered appropriate. For patients with low-risk localised PCa and a family history of PCa, active surveillance was considered appropriate, except in case of the patient being a BRCA2 germline pathogenic variant carrier. Germline and tumour genetic testing should not be done for nonmetastatic hormone-sensitive PCa in the absence of a relevant family history of cancer. Tumour genetic testing was deemed most appropriate for the identification of actionable variants, with uncertainty for germline testing. For tumour genetic testing in metastatic castration-resistant PCa, consensus was not reached for the timing and panel composition. The principal limitations are as follows: (1) a number of topics discussed lack scientific evidence, and therefore the recommendations are partly opinion based, and (2) there was a small number of experts per discipline. Conclusions The outcomes of this Dutch consensus meeting may provide further guidance on genetic counselling and molecular testing related to PCa. Patient summary A group of Dutch specialists discussed the use of germline and tumour genetic testing in prostate cancer (PCa) patients, indication of these tests (which patients and when), and impact of these tests on the management and treatment of PCa.
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Affiliation(s)
- Niven Mehra
- Department of Medical Oncology, Radboud UMC, Nijmegen, The Netherlands
- Corresponding author. Department of Medical Oncology, Radboud University Medical Centre, Postbus 9101, 6500 HB Nijmegen, The Netherlands. Tel. +31 243610354; Fax: +31 243615025.
| | - Iris Kloots
- Department of Medical Oncology, Radboud UMC, Nijmegen, The Netherlands
| | - Michiel Vlaming
- Division Laboratories, Pharmacy and biomedical Genetics, Department of Genetics, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Shafak Aluwini
- Department of Radiation Oncology, UMCG, Groningen, The Netherlands
| | - Els Dewulf
- Centre for Decision Analysis & Support, Ismar Healthcare NV, Lier, Belgium
| | - Daniela E. Oprea-Lager
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, VU University, Amsterdam, The Netherlands
| | - Henk van der Poel
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Urology, Amsterdam University Medical Centers, VU University, Amsterdam, The Netherlands
| | - Herman Stoevelaar
- Centre for Decision Analysis & Support, Ismar Healthcare NV, Lier, Belgium
| | - Derya Yakar
- Department of Radiology, UMCG, Groningen, The Netherlands
- Department of Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Chris H. Bangma
- Department of Urology, Erasmus MC, Rotterdam, The Netherlands
| | - Elise Bekers
- Department of Pathology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | | | - Andries M. Bergman
- Department of Medical Oncology and Oncogenomics, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | | | - Steve Boudewijns
- Department of Medical Oncology, Bravis Hospital, Roosendaal, The Netherlands
| | | | - Jurgen Fütterer
- Department of Medical Imaging, Radboud UMC, Nijmegen, The Netherlands
| | - Tom van der Hulle
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Guido Jenster
- Department of Urology, Erasmus MC, Rotterdam, The Netherlands
| | | | - Michel van Kruchten
- Department of Medical Oncology, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Pim J. van Leeuwen
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | | | | | - Walter Noordzij
- Department of Nuclear Medicine & Molecular Imaging, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | - Irma Oving
- Department of Internal Medicine, Ziekenhuis Groep Twente, Almelo, The Netherlands
| | | | - Ivo G. Schoots
- Department of Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Ed Schuuring
- Department of Pathology, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J. Smeenk
- Department of Radiation Oncology, Radboud UMC, Nijmegen, The Netherlands
| | - Ben G.L. Vanneste
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht UMC, Maastricht, The Netherlands
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Erik Vegt
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - André N. Vis
- Department of Urology, Amsterdam University Medical Centers, VU University, Amsterdam, The Netherlands
| | - Kim de Vries
- Department of Radiation Oncology, Erasmus MC, Rotterdam, The Netherlands
| | | | - Maurits Wondergem
- Department of Nuclear Medicine, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Margreet Ausems
- Division Laboratories, Pharmacy and biomedical Genetics, Department of Genetics, University Medical Centre Utrecht, Utrecht, The Netherlands
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Feldman E, Pos FJ, Smeenk RJ, van der Poel H, van Leeuwen P, de Feijter JM, Hulshof M, Budiharto T, Hermens R, de Ligt KM, Walraven I. Selecting a PRO-CTCAE-based subset for patient-reported symptom monitoring in prostate cancer patients: a modified Delphi procedure. ESMO Open 2023; 8:100775. [PMID: 36652781 PMCID: PMC10024147 DOI: 10.1016/j.esmoop.2022.100775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Clinician-based reporting of adverse events leads to underreporting and underestimation of the impact of adverse events on prostate cancer patients. Therefore, interest has grown in capturing adverse events directly from patients using the Patient-Reported Outcomes (PROs) version of the Common Terminology Criteria for Adverse Events (CTCAE). We aimed to develop a standardized PRO-CTCAE subset tailored to adverse event monitoring in prostate cancer patients. MATERIALS AND METHODS We used a mixed-method approach based on the 'phase I guideline for developing questionnaire modules' by the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life group, including a literature review, and interviews with patients (n = 30) and health care providers (HCPs, n = 16). A modified Delphi procedure was carried out to reach consensus on the final subset selected from the complete PRO-CTCAE item library. RESULTS Fourteen multidisciplinary HCPs and 12 patients participated in the Delphi rounds. Ninety percent agreed on the final subset, consisting of: 'ability to achieve and maintain erection', 'decreased libido', 'inability to reach orgasm', 'urinary frequency', 'urinary urgency', 'urinary incontinence', 'painful urination', 'fecal incontinence', 'fatigue', 'hot flashes', 'feeling discouraged', 'sadness', and 'concentration'. From 16 articles identified in the literature review, the following adverse events for which no PRO-CTCAE items are available, were included to the recommendation section: 'nocturia', 'blood and/or mucus in stool', 'hemorrhoids', 'hematuria', 'cystitis', 'neuropathy', and 'proctitis'. CONCLUSIONS The obtained PRO-CTCAE-subset can be used for multidisciplinary adverse event monitoring in prostate cancer care. The described method may guide development of future PRO-CTCAE subsets.
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Affiliation(s)
- E Feldman
- Department for Health Evidence, Radboud University Medical Center, Nijmegen
| | - F J Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam
| | - R J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen
| | - H van der Poel
- Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam; Department of Urology, Amsterdam University Medical Centers, Amsterdam
| | - P van Leeuwen
- Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam
| | - J M de Feijter
- Department of Internal Medicine, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam
| | - M Hulshof
- Department of Radiation Oncology, Academical Medical Center, University of Amsterdam, Amsterdam
| | - T Budiharto
- Department of Radiation Oncology, Catharina Hospital, Eindhoven
| | - R Hermens
- Scientific Institute for Quality in Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Radboud University Nijmegen, Nijmegen
| | - K M de Ligt
- Department of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - I Walraven
- Department for Health Evidence, Radboud University Medical Center, Nijmegen.
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8
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van den Elshout R, Scheenen TWJ, Driessen CML, Smeenk RJ, Meijer FJA, Henssen D. Diffusion imaging could aid to differentiate between glioma progression and treatment-related abnormalities: a meta-analysis. Insights Imaging 2022; 13:158. [PMID: 36194373 PMCID: PMC9532499 DOI: 10.1186/s13244-022-01295-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 09/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background In a considerable subgroup of glioma patients treated with (chemo) radiation new lesions develop either representing tumor progression (TP) or treatment-related abnormalities (TRA). Quantitative diffusion imaging metrics such as the Apparent Diffusion Coefficient (ADC) and Fractional Anisotropy (FA) have been reported as potential metrics to noninvasively differentiate between these two phenomena. Variability in performance scores of these metrics and absence of a critical overview of the literature contribute to the lack of clinical implementation. This meta-analysis therefore critically reviewed the literature and meta-analyzed the performance scores. Methods Systematic searching was carried out in PubMed, EMBASE and The Cochrane Library. Using predefined criteria, papers were reviewed. Diagnostic accuracy values of suitable papers were meta-analyzed quantitatively. Results Of 1252 identified papers, 10 ADC papers, totaling 414 patients, and 4 FA papers, with 154 patients were eligible for meta-analysis. Mean ADC values of the patients in the TP/TRA groups were 1.13 × 10−3mm2/s (95% CI 0.912 × 10–3–1.32 × 10−3mm2/s) and 1.38 × 10−3mm2/s (95% CI 1.33 × 10–3–1.45 × 10−3mm2/s, respectively. Mean FA values of TP/TRA was 0.19 (95% CI 0.189–0.194) and 0.14 (95% CI 0.137–0.143) respectively. A significant mean difference between ADC and FA values in TP versus TRA was observed (p = 0.005). Conclusions Quantitative ADC and FA values could be useful for distinguishing TP from TRA on a meta-level. Further studies using serial imaging of individual patients are warranted to determine the role of diffusion imaging in glioma patients.
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Affiliation(s)
- Rik van den Elshout
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 EZ, Nijmegen, The Netherlands
| | - Tom W J Scheenen
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 EZ, Nijmegen, The Netherlands
| | - Chantal M L Driessen
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frederick J A Meijer
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 EZ, Nijmegen, The Netherlands
| | - Dylan Henssen
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 EZ, Nijmegen, The Netherlands.
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Janssen J, Staal FHE, Brouwer CL, Langendijk JA, de Jong IJ, van Moorselaar RJA, Schuit E, Verzijlbergen JF, Smeenk RJ, Aluwini S. Androgen Deprivation therapy for Oligo-recurrent Prostate cancer in addition to radioTherapy (ADOPT): study protocol for a randomised phase III trial. BMC Cancer 2022; 22:482. [PMID: 35501744 PMCID: PMC9063099 DOI: 10.1186/s12885-022-09523-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/08/2022] [Indexed: 11/10/2022] Open
Abstract
Background More than 60% of oligo-recurrent prostate cancer (PCa) patients treated with metastasis-directed radiotherapy (MDRT) develop biochemical recurrence within 2 years. This recurrence rate emphasises the need for improved treatment and patient selection. In line with the treatment of primary PCa, the efficacy of MDRT may be enhanced when combined with androgen-deprivation therapy (ADT). Furthermore, the availability of PSMA PET/CT offers an excellent tool for optimal patient selection for MDRT. This phase III randomised controlled trial will investigate the role of the addition of ADT to MDRT in oligo-recurrent PCa patients selected with PSMA PET/CT to enhance oncological outcome. Methods Two hundred and eighty patients will be randomised in a 1:1 ratio to the standard treatment arm (MDRT alone) or the experimental arm (MDRT + 6 months ADT). Patients with biochemical recurrence after primary treatment of PCa presenting with ≤ 4 metastases will be included. The primary endpoint is the 2.5-year metastases progression-free survival (MPFS). Secondary endpoints are acute and late toxicity, quality of life, biochemical progression-free survival, overall survival, and the sensitivity of the PSMA PET/CT for detecting oligometastases at low PSA-levels. So far, between March 2020 and December 2021, one hundred patients have been included. Discussion This phase III randomised controlled trial will assess the possible benefit of the addition of 6 months ADT to MDRT on metastases progression-free survival, toxicity, QoL and survival in PCa patients with 1–4 recurrent oligometastatic lesions. Trial registration ClinicalTrials.gov, NCT04302454. Registered 10 March 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09523-2.
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Affiliation(s)
- J Janssen
- Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, Postbus 30 001, 9700 RB, Groningen, the Netherlands.
| | - F H E Staal
- Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, Postbus 30 001, 9700 RB, Groningen, the Netherlands
| | - C L Brouwer
- Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, Postbus 30 001, 9700 RB, Groningen, the Netherlands
| | - J A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, Postbus 30 001, 9700 RB, Groningen, the Netherlands
| | - I J de Jong
- Department of Urology, University Medical Center Groningen, Groningen, the Netherlands
| | - R J A van Moorselaar
- Department of Urology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - E Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - J F Verzijlbergen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - R J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - S Aluwini
- Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, Postbus 30 001, 9700 RB, Groningen, the Netherlands
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10
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Groen VH, Haustermans K, Pos FJ, Draulans C, Isebaert S, Monninkhof EM, Smeenk RJ, Kunze-Busch M, de Boer JCJ, van der Voort van Zijp J, Kerkmeijer LGW, van der Heide UA. Patterns of Failure Following External Beam Radiotherapy With or Without an Additional Focal Boost in the Randomized Controlled FLAME Trial for Localized Prostate Cancer. Eur Urol 2021; 82:252-257. [PMID: 34953603 DOI: 10.1016/j.eururo.2021.12.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 11/12/2021] [Accepted: 12/08/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Focal dose escalation in external beam radiotherapy (EBRT) showed an increase in 5-yr biochemical disease-free survival in the Focal Lesion Ablative Microboost in Prostate Cancer (FLAME) trial. OBJECTIVE To analyze the effect of a focal boost to intraprostatic lesions on local failure-free survival (LFS) and regional + distant metastasis-free survival (rdMFS). DESIGN, SETTING, AND PARTICIPANTS Patients with intermediate- or high-risk localized prostate cancer were included in FLAME, a phase 3, multicenter, randomized controlled trial. INTERVENTION Standard treatment of 77 Gy to the entire prostate in 35 fractions was compared to an additional boost to the macroscopic tumor of up to 95 Gy during EBRT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS LFS and rdMFS, measured via any type of imaging, were compared between the treatment arms using Kaplan-Meier and Cox regression analyses. Dose-response curves were created for local failure (LF) and regional + distant metastatic failure (rdMF) using logistic regression. RESULTS AND LIMITATIONS A total of 571 patients were included in the FLAME trial. Over median follow-up of 72 mo (interquartile range 58-86), focal boosting decreased LF (hazard ratio [HR] 0.33, 95% confidence interval [CI] 0.14-0.78) and rdMF (HR 0.58, 95% CI 0.35-0.93). Dose-response curves showed that a greater dose to the tumor resulted in lower LF and rdMF rates. CONCLUSIONS A clear dose-response relation for LF and rdMF was observed, suggesting that adequate focal dose escalation to intraprostatic lesions prevents undertreatment of the primary tumor, resulting in an improvement rdMF. PATIENT SUMMARY Radiotherapy is a treatment option for high-risk prostate cancer. The FLAME trial has shown that a high dose specifically targeted at the tumor within the prostate will result in better disease outcome, with less likelihood of regional and distant disease spread. The FLAME trial is registered on ClinicalTrials.gov as NCT01168479.
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Affiliation(s)
- Veerle H Groen
- Radiation Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Floris J Pos
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cédric Draulans
- Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Sofie Isebaert
- Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Evelyn M Monninkhof
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Robert J Smeenk
- Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Martina Kunze-Busch
- Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | | | - Linda G W Kerkmeijer
- Radiation Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands; Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
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11
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Jahreiß MC, Heemsbergen WD, van Santvoort B, Hoogeman M, Dirkx M, Pos FJ, Janssen T, Dekker A, Vanneste B, Minken A, Hoekstra C, Smeenk RJ, van Oort IM, Bangma CH, Incrocci L, Aben KKH. Impact of Advanced Radiotherapy on Second Primary Cancer Risk in Prostate Cancer Survivors: A Nationwide Cohort Study. Front Oncol 2021; 11:771956. [PMID: 34900722 PMCID: PMC8662556 DOI: 10.3389/fonc.2021.771956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/08/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose External Beam Radiotherapy (EBRT) techniques dramatically changed over the years. This may have affected the risk of radiation-induced second primary cancers (SPC), due to increased irradiated low dose volumes and scatter radiation. We investigated whether patterns of SPC after EBRT have changed over the years in prostate cancer (PCa) survivors. Materials and Methods PCa survivors diagnosed between 1990-2014 were selected from the Netherlands Cancer Registry. Patients treated with EBRT were divided in three time periods, representing 2-dimensional Radiotherapy (RT), 3-dimensional conformal RT (3D-CRT), and the advanced RT (AdvRT) era. Standardized incidence ratios (SIR) and absolute excess risks (AER) were calculated to estimate relative and excess absolute SPC risks. Sub-hazard ratios (sHRs) were calculated to compare SPC rates between the EBRT and prostatectomy cohort. SPCs were categorized by subsite and anatomic region. Results PCa survivors who received EBRT had an increased risk of developing a solid SPC (SIR=1.08; 1.05-1.11), especially in patients aged <70 years (SIR=1.13; 1.09-1.16). Pelvic SPC risks were increased (SIR=1.28; 1.23-1.34), with no obvious differences between the three EBRT eras. Non-pelvic SPC were only significantly increased in the AdvRT era (SIR=1.08; 1.02-1.14), in particular for the 1-5 year follow-up period. Comparing the EBRT cohort to the prostatectomy cohort, again an increased pelvic SPC risk was found for all EBRT periods (sHRs= 1.61, 1.47-1.76). Increased non-pelvic SPC risks were present for all RT eras and highest for the AdvRT period (sHRs=1.17, 1.06-1.29). Conclusion SPC risk in patients with EBRT is increased and remained throughout the different EBRT eras. The risk of developing a SPC outside the pelvic area changed unfavorably in the AdvRT era. Prolonged follow-up is needed to confirm this observation. Whether this is associated with increased irradiated low-dose volumes and scatter, or other changes in clinical EBRT practice, is the subject of further research.
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Affiliation(s)
| | - Wilma D Heemsbergen
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Bo van Santvoort
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, Netherlands
| | - Mischa Hoogeman
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Maarten Dirkx
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Floris J Pos
- The Netherlands Cancer Institute, Radiation Oncology, Amsterdam, Netherlands
| | - Tomas Janssen
- The Netherlands Cancer Institute, Radiation Oncology, Amsterdam, Netherlands
| | - Andre Dekker
- Department of Radiation Oncology (Maastro), GROW Institute for Oncology and Developmental Biology, Maastricht, Netherlands
| | - Ben Vanneste
- Department of Radiation Oncology (Maastro), GROW Institute for Oncology and Developmental Biology, Maastricht, Netherlands
| | - Andre Minken
- Department of Radiation Oncology, Radiotherapiegroep, Deventer, Netherlands
| | - Carel Hoekstra
- Department of Radiation Oncology, Radiotherapiegroep, Deventer, Netherlands
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Inge M van Oort
- Department of Urology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Chris H Bangma
- Department of Urology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Luca Incrocci
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Katja K H Aben
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, Netherlands.,Research Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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12
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Draulans C, Pos F, Smeenk RJ, Kerkmeijer L, Vogel WV, Nagarajah J, Janssen M, Mai C, Heijmink S, van der Leest M, Zámecnik P, Oyen R, Isebaert S, Maes F, Joniau S, Kunze-Busch M, De Roover R, Defraene G, van der Heide UA, Goffin K, Haustermans K. 68Ga-PSMA-11 PET, 18F-PSMA-1007 PET, and MRI for Gross Tumor Volume Delineation in Primary Prostate Cancer: Intermodality and Intertracer Variability. Pract Radiat Oncol 2021; 11:202-211. [PMID: 33941347 DOI: 10.1016/j.prro.2020.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 10/11/2020] [Accepted: 11/08/2020] [Indexed: 02/03/2023]
Abstract
PURPOSE To assess the intermodality and intertracer variability of gallium-68 (68Ga)- or fluorine-18 (18F)-labeled prostate-specific membrane antigen (PSMA) positron emission tomography (PET) and biparametric magnetic resonance imaging (bpMRI)-based gross tumor volume (GTV) delineation for focal boosting in primary prostate cancer. METHODS Nineteen prospectively enrolled patients with prostate cancer underwent a PSMA PET/MRI scan, divided into a 1:1 ratio between 68Ga-PSMA-11 and 18F-PSMA-1007, before radical prostatectomy (IWT140193). Four delineation teams performed manual contouring of the GTV based on bpMRI and PSMA PET imaging, separately. Index lesion coverage (overlap%) and interobserver variability were assessed. Furthermore, the distribution of the voxelwise normalized standardized uptake values (SUV%) was determined for the majority-voted (>50%) GTV (GTVmajority) and whole prostate gland to investigate intertracer variability. The median patientwise SUV% contrast ratio (SUV%-CR, calculated as median GTVmajority SUV% / median prostate gland without GTVmajority SUV%) was calculated according to the tracer used. RESULTS A significant difference in overlap% favoring PSMA PET compared with bpMRI was found in the 18F subgroup (median, 63.0% vs 53.1%; P = .004) but was not present in the 68Ga subgroup (32.5% vs 50.6%; P = .100). Regarding interobserver variability, measured Sørensen-Dice coefficients (0.58 vs 0.72) and calculated mean distances to agreement (2.44 mm vs 1.22 mm) were statistically significantly lower and higher, respectively, for the 18F cohort compared with the 68Ga cohort. For the bpMRI-based delineations, the median Sørensen-Dice coefficient and mean distance to agreement were 0.63 and 1.76 mm, respectively. Median patientwise SUV%-CRs of 1.8 (interquartile range [IQR], 1.6-2.7) for 18F-PSMA and 3.3 (IQR, 2.7-5.9) for 68Ga-PSMA PET images were found. CONCLUSIONS Both MRI and PSMA PET provided consistent intraprostatic GTV lesion detection. However, the PSMA tracer seems to have a major influence on the contour characteristics, owing to an apparent difference in SUV% distribution in the prostate gland.
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Affiliation(s)
- Cédric Draulans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium; Department of Oncology, KU Leuven, Leuven, Belgium
| | - Floris Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Linda Kerkmeijer
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Radiation Oncology, University Medical Centre, Utrecht, The Netherlands
| | - Wouter V Vogel
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - James Nagarajah
- Department of Radiology & Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marcel Janssen
- Department of Radiology & Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Cindy Mai
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Stijn Heijmink
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marloes van der Leest
- Department of Radiology & Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Patrik Zámecnik
- Department of Radiology & Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Raymond Oyen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Sofie Isebaert
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium; Department of Oncology, KU Leuven, Leuven, Belgium
| | - Frederik Maes
- Department of Electrical Engineering, ESAT/PSI, KU Leuven, Leuven, Belgium; Medical Imaging Research Centre, University Hospitals Leuven, Leuven, Belgium
| | - Steven Joniau
- Department of Urology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Martina Kunze-Busch
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robin De Roover
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium; Department of Oncology, KU Leuven, Leuven, Belgium
| | - Gilles Defraene
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium; Department of Oncology, KU Leuven, Leuven, Belgium
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Karolien Goffin
- Department of Nuclear Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Karin Haustermans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium; Department of Oncology, KU Leuven, Leuven, Belgium.
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13
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Houben J, McColl G, Ham Kaanders J, Smeenk RJ. Patient reported toxicity and quality of life after hypofractionated high-dose intensity-modulated radiotherapy for intermediate- and high risk prostate cancer. Clin Transl Radiat Oncol 2021; 29:40-46. [PMID: 34113724 PMCID: PMC8170415 DOI: 10.1016/j.ctro.2021.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/04/2021] [Accepted: 05/16/2021] [Indexed: 11/25/2022] Open
Abstract
Background and purpose For irradiation of localized prostate-cancer, moderately-hypofractionated regimens with a variety of dose per fraction are used. We adopted a regimen of 70 Gy in 28 fractions of 2.5 Gy, using state of the art radiotherapy (RT) and closely monitored the efficacy, toxicity and health-related quality of life (HRQoL) in a large cohort, using patient-reported outcomes. Materials and methods Between 2008 and 2016, 462 patients with intermediate- to high-risk localized prostate cancer were treated with RT, 28 fractions of 2.5 Gy, using IMRT/VMAT, an online fiducial-maker based correction protocol and a daily inserted endorectal balloon. Overall freedom from failure (no biochemical or clinical recurrence) , as well as self-reported genitourinary (GU) and gastrointestinal (GI) related toxicity and HRQoL are reported. Results Overall freedom from failure rates at 3 and 5 years were 92.0% (89.1–94.9%) and 83.5% (78.6–88.4%), respectively. Prevalence rates of grade ≥ 2 GU/GI-toxicity were 16.3%/6.3% and 22,1%/3.2% after 3 and 5 years respectively. The 5-year actuarial incidences of grade ≥ 2 GU/GI-toxicity were 43.5%/18.5%. HRQoL worsened during RT and gradually recovered thereafter, In accordance with the prevalence rates. Conclusion Treatment of intermediate- or high-risk localized prostate cancer with RT to 70 Gy in 28 fractions with IMRT/VMAT, using fiducial markers and an endorectal balloon leads to good long-term tumor control rates and acceptable patient reported toxicity rates. Furthermore, patient-reported outcomes, including HRQoL, are essential for a good comparison between different studies. Finally, prevalence rates show a better correlation with HRQoL than actuarial incidence rates do and might therefore better represent the burden of toxicity.
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Affiliation(s)
- Jeroen Houben
- Department of Radiation Oncology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Gill McColl
- Department of Radiation Oncology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Johannes Ham Kaanders
- Department of Radiation Oncology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands
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Privé BM, Peters SMB, Muselaers CHJ, van Oort IM, Janssen MJR, Sedelaar JPM, Konijnenberg MW, Zámecnik P, Uijen MJM, Schilham MGM, Eek A, Scheenen TWJ, Verzijlbergen JF, Gerritsen WR, Mehra N, Kerkmeijer LGW, Smeenk RJ, Somford DM, van Basten JPA, Heskamp S, Barentsz JO, Gotthardt M, Witjes JA, Nagarajah J. Lutetium-177-PSMA-617 in Low-Volume Hormone-Sensitive Metastatic Prostate Cancer: A Prospective Pilot Study. Clin Cancer Res 2021; 27:3595-3601. [PMID: 33883176 DOI: 10.1158/1078-0432.ccr-20-4298] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/25/2021] [Accepted: 04/16/2021] [Indexed: 12/09/2022]
Abstract
PURPOSE [177Lu]Lu-PSMA-617 radioligand therapy (177Lu-PSMA) is a novel treatment for metastatic castration-resistant prostate cancer (mCRPC), which could also be applied to patients with metastatic hormone-sensitive prostate cancer (mHSPC) with PSMA expression. In this prospective study (NCT03828838), we analyzed toxicity, radiation doses, and treatment effect of 177Lu-PSMA in pateints with low-volume mHSPC. PATIENTS AND METHODS Ten progressive patients with mHSPC following local treatment, with a maximum of ten metastatic lesions on [68Ga]Ga-PSMA-11 PET/diagnostic-CT imaging (PSMA-PET) and serum PSA doubling time <6 months received two cycles of 177Lu-PSMA. Whole-body single-photon emission CT/CT (SPECT/CT) and blood dosimetry was performed to calculate doses to the tumors and organs at risk (OAR). Adverse events (AE), laboratory values (monitoring response and toxicity), and quality of life were monitored until week 24 after cycle 2, the end of study (EOS). All patients underwent PSMA-PET at screening, 8 weeks after cycle 1, 12 weeks after cycle 2, and at EOS. RESULTS All patients received two cycles of 177Lu-PSMA without complications. No treatment-related grade III-IV adverse events were observed. According to dosimetry, none of the OAR reached threshold doses for radiation-related toxicity. Moreover, all target lesions received a higher radiation dose than the OAR. All 10 patients showed altered PSA kinetics, postponed androgen deprivation therapy, and maintained good quality of life. Half of the patients showed a PSA response of more than 50%. One patient had a complete response on PSMA-PET imaging until EOS and two others had only minimal residual disease. CONCLUSIONS 177Lu-PSMA appeared to be a feasible and safe treatment modality in patients with low-volume mHSPC.
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Affiliation(s)
- Bastiaan M Privé
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, the Netherlands
| | - Steffie M B Peters
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, the Netherlands
| | | | - Inge M van Oort
- Department of Urology, Radboudumc, Nijmegen, the Netherlands
| | - Marcel J R Janssen
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, the Netherlands
| | | | - Mark W Konijnenberg
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, the Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - Patrik Zámecnik
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, the Netherlands
| | - Maike J M Uijen
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, the Netherlands
| | - Melline G M Schilham
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, the Netherlands
| | - Annemarie Eek
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, the Netherlands
| | - Tom W J Scheenen
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, the Netherlands
| | - J Fred Verzijlbergen
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, the Netherlands
| | | | - Niven Mehra
- Department of Medical Oncology, Radboudumc, Nijmegen, the Netherlands
| | | | - Robert J Smeenk
- Department of Radiation Oncology, Radboudumc, Nijmegen, the Netherlands
| | - Diederik M Somford
- Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | | | - Sandra Heskamp
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, the Netherlands
| | - Jelle O Barentsz
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, the Netherlands
| | - Martin Gotthardt
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, the Netherlands
| | - J Alfred Witjes
- Department of Urology, Radboudumc, Nijmegen, the Netherlands
| | - James Nagarajah
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, the Netherlands. .,Department of Nuclear Medicine, Technische Universität München, Klinikum rechts der Isar, München, Germany
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15
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Draulans C, De Roover R, van der Heide UA, Kerkmeijer L, Smeenk RJ, Pos F, Vogel WV, Nagarajah J, Janssen M, Isebaert S, Maes F, Mai C, Oyen R, Joniau S, Kunze-Busch M, Goffin K, Haustermans K. Optimal 68Ga-PSMA and 18F-PSMA PET window levelling for gross tumour volume delineation in primary prostate cancer. Eur J Nucl Med Mol Imaging 2020; 48:1211-1218. [PMID: 33025093 DOI: 10.1007/s00259-020-05059-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/27/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE This study proposes optimal tracer-specific threshold-based window levels for PSMA PET-based intraprostatic gross tumour volume (GTV) contouring to reduce interobserver delineation variability. METHODS Nine 68Ga-PSMA-11 and nine 18F-PSMA-1007 PET scans including GTV delineations of four expert teams (GTVmanual) and a majority-voted GTV (GTVmajority) were assessed with respect to a registered histopathological GTV (GTVhisto) as the gold standard reference. The standard uptake values (SUVs) per voxel were converted to a percentage (SUV%) relative to the SUVmax. The statistically optimised SUV% threshold (SOST) was defined as those that maximises accuracy for threshold-based contouring. A leave-one-out cross-validation receiver operating characteristic (ROC) curve analysis was performed to determine the SOST for each tracer. The SOST analysis was performed twice, first using the GTVhisto contour as training structure (GTVSOST-H) and second using the GTVmajority contour as training structure (GTVSOST-MA) to correct for any limited misregistration. The accuracy of both GTVSOST-H and GTVSOST-MA was calculated relative to GTVhisto in the 'leave-one-out' patient of each fold and compared with the accuracy of GTVmanual. RESULTS ROC curve analysis for 68Ga-PSMA-11 PET revealed a median threshold of 25 SUV% (range, 22-27 SUV%) and 41 SUV% (40-43 SUV%) for GTVSOST-H and GTVSOST-MA, respectively. For 18F-PSMA-1007 PET, a median threshold of 42 SUV% (39-45 SUV%) for GTVSOST-H and 44 SUV% (42-45 SUV%) for GTVSOST-MA was found. A significant pairwise difference was observed when comparing the accuracy of the GTVSOST-H contours with the median accuracy of the GTVmanual contours (median, - 2.5%; IQR, - 26.5-0.2%; p = 0.020), whereas no significant pairwise difference was found for the GTVSOST-MA contours (median, - 0.3%; IQR, - 4.4-0.6%; p = 0.199). CONCLUSIONS Threshold-based contouring using GTVmajority-trained SOSTs achieves an accuracy comparable with manual contours in delineating GTVhisto. The median SOSTs of 41 SUV% for 68Ga-PSMA-11 PET and 44 SUV% for 18F-PSMA-1007 PET form a base for tracer-specific window levelling. TRIAL REGISTRATION Clinicaltrials.gov ; NCT03327675; 31-10-2017.
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Affiliation(s)
- Cédric Draulans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.
- Department of Oncology, KU Leuven, Leuven, Belgium.
| | - Robin De Roover
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Linda Kerkmeijer
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Radiation Oncology, University Medical Centre, Utrecht, The Netherlands
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Floris Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Wouter V Vogel
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - James Nagarajah
- Department of Radiology & Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marcel Janssen
- Department of Radiology & Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Sofie Isebaert
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - Frederik Maes
- Department of Electrical Engineering, ESAT/PSI, KU Leuven, Leuven, Belgium
- Medical Imaging Research Centre, University Hospitals Leuven, Leuven, Belgium
| | - Cindy Mai
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Raymond Oyen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Steven Joniau
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Martina Kunze-Busch
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Karolien Goffin
- Department of Nuclear Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Karin Haustermans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.
- Department of Oncology, KU Leuven, Leuven, Belgium.
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16
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Witjes JA, Babjuk M, Bellmunt J, Bruins HM, De Reijke TM, De Santis M, Gillessen S, James N, Maclennan S, Palou J, Powles T, Ribal MJ, Shariat SF, Van Der Kwast T, Xylinas E, Agarwal N, Arends T, Bamias A, Birtle A, Black PC, Bochner BH, Bolla M, Boormans JL, Bossi A, Briganti A, Brummelhuis I, Burger M, Castellano D, Cathomas R, Chiti A, Choudhury A, Compérat E, Crabb S, Culine S, De Bari B, De Blok W, De Visschere PJL, Decaestecker K, Dimitropoulos K, Dominguez-Escrig JL, Fanti S, Fonteyne V, Frydenberg M, Futterer JJ, Gakis G, Geavlete B, Gontero P, Grubmüller B, Hafeez S, Hansel DE, Hartmann A, Hayne D, Henry AM, Hernandez V, Herr H, Herrmann K, Hoskin P, Huguet J, Jereczek-Fossa BA, Jones R, Kamat AM, Khoo V, Kiltie AE, Krege S, Ladoire S, Lara PC, Leliveld A, Linares-Espinós E, Løgager V, Lorch A, Loriot Y, Meijer R, Mir MC, Moschini M, Mostafid H, Müller AC, Müller CR, N'Dow J, Necchi A, Neuzillet Y, Oddens JR, Oldenburg J, Osanto S, Oyen WJG, Pacheco-Figueiredo L, Pappot H, Patel MI, Pieters BR, Plass K, Remzi M, Retz M, Richenberg J, Rink M, Roghmann F, Rosenberg JE, Rouprêt M, Rouvière O, Salembier C, Salminen A, Sargos P, Sengupta S, Sherif A, Smeenk RJ, Smits A, Stenzl A, Thalmann GN, Tombal B, Turkbey B, Lauridsen SV, Valdagni R, Van Der Heijden AG, Van Poppel H, Vartolomei MD, Veskimäe E, Vilaseca A, Rivera FAV, Wiegel T, Wiklund P, Willemse PPM, Williams A, Zigeuner R, Horwich A. Corrigendum to 'EAU-ESMO Consensus Statements on the Management of Advanced and Variant Bladder Cancer-An International Collaborative Multistakeholder Effort Under the Auspices of the EAU-ESMO Guidelines Committees' [European Urology 77 (2020) 223-250]. Eur Urol 2020; 78:e48-e50. [PMID: 32446863 DOI: 10.1016/j.eururo.2020.03.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- J Alfred Witjes
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Marek Babjuk
- Department of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Joaquim Bellmunt
- IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain; Harvard Medical School, Boston, Massachusetts, USA
| | - H Maxim Bruins
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Theo M De Reijke
- Department of Urology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Maria De Santis
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Charité University Hospital, Berlin, Germany
| | - Silke Gillessen
- Division of Cancer Sciences, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK; Division of Oncology and Haematology, Kantonsspital St Gallen, St Gallen, Switzerland; University of Bern, Bern, Switzerland
| | - Nicholas James
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | | | - Juan Palou
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Tom Powles
- The Royal Free NHS Trust, London, UK; Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Maria J Ribal
- Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Spain
| | - Shahrokh F Shariat
- Department of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, New York, USA; Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Theo Van Der Kwast
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Evanguelos Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Paris Descartes University, Paris, France
| | - Neeraj Agarwal
- Huntsman Cancer Institute, University of Utah (NCI-CCC), Salt Lake City, Utah, USA
| | - Tom Arends
- Urology Department, Canisius-Wilhelmina Ziekenhuis Nijmegen, The Netherlands
| | - Aristotle Bamias
- 2nd Propaedeutic Dept of Internal Medicine, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Alison Birtle
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Rosemere Cancer Centre, Lancashire Teaching Hospitals, Preston, UK
| | - Peter C Black
- Department of Urologic Sciences, Vancouver Prostate Centre, University of British Columbia, Vancouver, British Colombia, Canada
| | - Bernard H Bochner
- Department of Urology, Weill Cornell Medical College, New York, New York, USA; Urology Service, Department of Urology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michel Bolla
- Emeritus Professor of Radiation Oncology, Grenoble-Alpes University, Grenoble, France
| | - Joost L Boormans
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Alberto Bossi
- Department of Radiation Oncology, Gustave Roussy Institute, Villejuif, France
| | - Alberto Briganti
- Department of Urology, Urological Research Institute, Milan, Italy; Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - Iris Brummelhuis
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Max Burger
- Department of Urology, Caritas-St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Daniel Castellano
- Medical Oncology Department, 12 de Octubre University Hospital (CIBERONC), Madrid, Spain
| | - Richard Cathomas
- Departement Innere Medizin, Abteilung Onkologie und Hämatologie, Kantonsspital Graubünden, Chur, Switzerland
| | - Arturo Chiti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Humanitas Research Hospital, Milan, Italy
| | - Ananya Choudhury
- Division of Cancer Sciences, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK
| | - Eva Compérat
- Department of Pathology, Tenon Hospital, HUEP, Paris, France; Sorbonne University, Paris, France
| | - Simon Crabb
- Cancer Sciences Unit, University of Southampton, Southampton, UK
| | - Stephane Culine
- Department of Cancer Medicine, Hôpital Saint Louis, Paris, France
| | - Berardino De Bari
- Radiation Oncology Department, Centre Hospitalier Régional Universitaire "Jean Minjoz" of Besançon, INSERM UMR 1098, Besançon, France; Radiation Oncology Department, Centre Hospitalier Universitaire Vaudois, Université de Lausanne, Lausanne, Switzerland
| | - Willem De Blok
- Department of Oncological Urology, University Medical Center, Utrecht Cancer Center, Utrecht, The Netherlands
| | - Pieter J L De Visschere
- Department of Radiology and Nuclear Medicine, Division of Genitourinary Radiology and Mammography, Ghent University Hospital, Ghent, Belgium
| | | | | | | | - Stefano Fanti
- Department of Nuclear Medicine, Policlinico S Orsola, University of Bologna, Italy
| | - Valerie Fonteyne
- Department of Radiotherapy Oncology, Ghent University Hospital, Ghent, Belgium
| | - Mark Frydenberg
- Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
| | - Jurgen J Futterer
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Georgios Gakis
- Department of Urology and Paediatric Urology, University Hospital of Würzburg, Julius-Maximillians University, Würzburg, Germany
| | - Bogdan Geavlete
- Department of Urology, Saint John Emergency Clinical Hospital, Bucharest, Romania
| | - Paolo Gontero
- Division of Urology, Molinette Hospital, University of Studies of Torino, Torino, Italy
| | | | - Shaista Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Donna E Hansel
- Department of Urology, University of California, San Diego Pathology, La Jolla, California, USA
| | - Arndt Hartmann
- Institute of Pathology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Dickon Hayne
- Department of Urology, UWA Medical School, University of Western Australia, Perth, Australia
| | - Ann M Henry
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Virginia Hernandez
- Department of Urology, Hospital Universitario Fundación de Alcorcón, Madrid, Spain
| | - Harry Herr
- Urology Service, Department of Urology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ken Herrmann
- Department of Nuclear Medicine, Universitätsklinikum Essen, Essen, Germany
| | - Peter Hoskin
- Division of Cancer Sciences, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK; Mount Vernon Centre for Cancer Treatment, London, UK
| | - Jorge Huguet
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Barbara A Jereczek-Fossa
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy; Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Rob Jones
- Institute of Cancer Sciences, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Ashish M Kamat
- Department of Urology - Division of Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Vincent Khoo
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, UK; Department of Medicine, University of Melbourne, Australia; Monash University, Melbourne, Australia
| | - Anne E Kiltie
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - Susanne Krege
- Department of Urology, Pediatric Urology and Urologic Oncology, Kliniken Essen-Mitte, Essen, Germany
| | - Sylvain Ladoire
- Department of Medical Oncology, Centre Georges François Leclerc, Dijon, France
| | - Pedro C Lara
- Department of Oncology, Hospital Universitario San Roque, Spain; Universidad Fernando Pessoa, Canarias, Spain
| | - Annemarie Leliveld
- Department of Urology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Vibeke Løgager
- Department of Radiology, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Anja Lorch
- Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland
| | - Yohann Loriot
- Département de Médecine Oncologique, Gustave Roussy, INSERM U981, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Richard Meijer
- UMC Utrecht Cancer Center, MS Oncologic Urology, Utrecht, The Netherlands
| | - M Carmen Mir
- Servicio de Urología, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - Marco Moschini
- Department of Urology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Hugh Mostafid
- Department of Urology, Royal Surrey County Hospital, Guildford, UK
| | | | | | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK; Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Andrea Necchi
- Department of Medical Oncology, Istituto Nazionale Tumori of Milan, Milan, Italy
| | - Yann Neuzillet
- Department of Urology, Hospital Foch, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Jorg R Oddens
- Department of Urology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Jan Oldenburg
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Susanne Osanto
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Wim J G Oyen
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Humanitas Research Hospital, Milan, Italy; Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Luís Pacheco-Figueiredo
- Department of Urology, Centro Hospitalar São João, Porto, Portugal; Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
| | - Helle Pappot
- Department of Oncology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Manish I Patel
- Department of Urology, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Bradley R Pieters
- Department Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Karin Plass
- EAU Guidelines Office, Arnhem, The Netherlands
| | - Mesut Remzi
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Margitta Retz
- Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, Munich, Germany
| | - Jonathan Richenberg
- Department of Imaging and Nuclear Medicine, Royal Sussex County Hospital, Brighton, UK; Brighton and Sussex Medical School, Brighton, UK
| | - Michael Rink
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Roghmann
- Department of Urology, Ruhr-University Bochum, Marien Hospital, Herne, Germany
| | - Jonathan E Rosenberg
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
| | - Morgan Rouprêt
- Department of Urology, Sorbonne Université, GRC n_5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Olivier Rouvière
- Hospices Civils de Lyon, Service d'Imagerie Urinaire et Vasculaire, Hôpital Edouard Herriot, Lyon, France; Université de Lyon, Université Lyon 1, faculté de médecine Lyon Est, Lyon, France
| | - Carl Salembier
- Department of Radiation Oncology, Europe Hospitals Brussels, Belgium
| | - Antti Salminen
- Department of Urology, University Hospital of Turku, Finland
| | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France
| | - Shomik Sengupta
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, Australia; Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Amir Sherif
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå university, Umeå, Sweden
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anita Smits
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arnulf Stenzl
- Department of Urology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - George N Thalmann
- Department of Urology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Bertrand Tombal
- Division of Urology, IREC, Cliniques Universitaires Saint Luc, UCL, Brussels, Belgium
| | - Baris Turkbey
- Molecular Imaging Program, National Cancer Institute, Bethesda, Maryland, USA
| | - Susanne Vahr Lauridsen
- Department of Urology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Riccardo Valdagni
- Department of Oncology and Hemato-oncology, Università degli Studi di Milano, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | | | - Mihai D Vartolomei
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Cell and Molecular Biology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
| | - Erik Veskimäe
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | - Antoni Vilaseca
- Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Spain
| | - Franklin A Vives Rivera
- Clinica HematoOncologica Bonadona Prevenir, Universidad Metropolitana, Clinica Club de Leones, Barranquilla, Colombia
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Peter Wiklund
- Icahn School of Medicine, Mount Sinai Health System New York City, New York, USA; Department of Urology, Karolinska Institutet, Stockholm, Sweden
| | - Peter-Paul M Willemse
- Department of Oncological Urology, University Medical Center, Utrecht Cancer Center, Utrecht, The Netherlands
| | - Andrew Williams
- Department of Urology, Auckland City Hospital, Auckland, New Zealand
| | - Richard Zigeuner
- Department of Urology, Medizinische Universität Graz, Graz, Austria
| | - Alan Horwich
- Emeritus Professor, The Institute of Cancer Research, London, UK
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Witjes JA, Babjuk M, Bellmunt J, Bruins HM, De Reijke TM, De Santis M, Gillessen S, James N, Maclennan S, Palou J, Powles T, Ribal MJ, Shariat SF, Der Kwast TV, Xylinas E, Agarwal N, Arends T, Bamias A, Birtle A, Black PC, Bochner BH, Bolla M, Boormans JL, Bossi A, Briganti A, Brummelhuis I, Burger M, Castellano D, Cathomas R, Chiti A, Choudhury A, Compérat E, Crabb S, Culine S, De Bari B, De Blok W, J L De Visschere P, Decaestecker K, Dimitropoulos K, Dominguez-Escrig JL, Fanti S, Fonteyne V, Frydenberg M, Futterer JJ, Gakis G, Geavlete B, Gontero P, Grubmüller B, Hafeez S, Hansel DE, Hartmann A, Hayne D, Henry AM, Hernandez V, Herr H, Herrmann K, Hoskin P, Huguet J, Jereczek-Fossa BA, Jones R, Kamat AM, Khoo V, Kiltie AE, Krege S, Ladoire S, Lara PC, Leliveld A, Linares-Espinós E, Løgager V, Lorch A, Loriot Y, Meijer R, Mir MC, Moschini M, Mostafid H, Müller AC, Müller CR, N'Dow J, Necchi A, Neuzillet Y, Oddens JR, Oldenburg J, Osanto S, J G Oyen W, Pacheco-Figueiredo L, Pappot H, Patel MI, Pieters BR, Plass K, Remzi M, Retz M, Richenberg J, Rink M, Roghmann F, Rosenberg JE, Rouprêt M, Rouvière O, Salembier C, Salminen A, Sargos P, Sengupta S, Sherif A, Smeenk RJ, Smits A, Stenzl A, Thalmann GN, Tombal B, Turkbey B, Lauridsen SV, Valdagni R, Van Der Heijden AG, Van Poppel H, Vartolomei MD, Veskimäe E, Vilaseca A, Rivera FAV, Wiegel T, Wiklund P, Williams A, Zigeuner R, Horwich A. EAU-ESMO Consensus Statements on the Management of Advanced and Variant Bladder Cancer-An International Collaborative Multistakeholder Effort †: Under the Auspices of the EAU-ESMO Guidelines Committees. Eur Urol 2020; 77:223-250. [PMID: 31753752 DOI: 10.1016/j.eururo.2019.09.035] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/26/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial. OBJECTIVE To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management. DESIGN A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts prior to voting during a consensus conference. SETTING Online Delphi survey and consensus conference. PARTICIPANTS The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), and 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus). RESULTS AND LIMITATIONS Overall, 116 statements were included in the Delphi survey. Of these statements, 33 (28%) achieved level 1 consensus and 49 (42%) achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease, and the evolving role of checkpoint inhibitor therapy in metastatic disease. CONCLUSIONS These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time when further evidence is available to guide our approach. PATIENT SUMMARY This report summarises findings from an international, multistakeholder project organised by the EAU and ESMO. In this project, a steering committee identified areas of bladder cancer management where there is currently no good-quality evidence to guide treatment decisions. From this, they developed a series of proposed statements, 71 of which achieved consensus by a large group of experts in the field of bladder cancer. It is anticipated that these statements will provide further guidance to health care professionals and could help improve patient outcomes until a time when good-quality evidence is available.
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Affiliation(s)
- J Alfred Witjes
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Marek Babjuk
- Depatment of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Joaquim Bellmunt
- IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain; Harvard Medical School, Boston, Massachusetts, USA
| | - H Maxim Bruins
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Theo M De Reijke
- Department of Urology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Maria De Santis
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Charité University Hospital, Berlin, Germany
| | - Silke Gillessen
- Division of Cancer Sciences, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK; Division of Oncology and Haematology, Kantonsspital St Gallen, St Gallen, Switzerland; University of Bern, Bern, Switzerland
| | - Nicholas James
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | | | - Juan Palou
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Tom Powles
- The Royal Free NHS Trust, London, UK; Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Maria J Ribal
- Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Spain
| | - Shahrokh F Shariat
- Depatment of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, New York, USA; Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Theo Van Der Kwast
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Evanguelos Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Paris Descartes University, Paris, France
| | - Neeraj Agarwal
- Huntsman Cancer Institute, University of Utah (NCI-CCC), Salt Lake City, Utah, USA
| | - Tom Arends
- Urology Department, Canisius-Wilhelmina Ziekenhuis Nijmegen, The Netherlands
| | - Aristotle Bamias
- 2nd Propaedeutic Dept of Internal Medicine, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Alison Birtle
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Rosemere Cancer Centre, Lancashire Teaching Hospitals, Preston, UK
| | - Peter C Black
- Department of Urologic Sciences, Vancouver Prostate Centre, University of British Columbia, Vancouver, British Colombia, Canada
| | - Bernard H Bochner
- Department of Urology, Weill Cornell Medical College, New York, New York, USA; Urology Service, Department of Urology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michel Bolla
- Emeritus Professor of Radiation Oncology, Grenoble - Alpes University, Grenoble, France
| | - Joost L Boormans
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Alberto Bossi
- Department of Radiation Oncology, Gustave Roussy Institute, Villejuif, France
| | - Alberto Briganti
- Department of Urology, Urological Research Institute, Milan; Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - Iris Brummelhuis
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Max Burger
- Department of Urology, Caritas-St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Daniel Castellano
- Medical Oncology Department, 12 de Octubre University Hospital (CIBERONC), Madrid, Spain
| | - Richard Cathomas
- Departement Innere Medizin, Abteilung Onkologie und Hämatologie, Kantonsspital Graubünden, Chur, Switzerland
| | - Arturo Chiti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Humanitas Research Hospital, Milan, Italy
| | - Ananya Choudhury
- Division of Cancer Sciences, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK
| | - Eva Compérat
- Department of Pathology, Tenon hospital, HUEP, Paris, France; Sorbonne University, Paris, France
| | - Simon Crabb
- Cancer Sciences Unit, University of Southampton, Southampton, UK
| | - Stephane Culine
- Department of Cancer Medicine, Hôpital Saint Louis, Paris, France
| | - Berardino De Bari
- Radiation Oncology Department, Centre Hospitalier Régional Universitaire "Jean Minjoz" of Besançon, INSERM UMR 1098, Besançon, France; Radiation Oncology Department, Centre Hospitalier Universitaire Vaudois, Université de Lausanne, Lausanne, Switzerland
| | - Willem De Blok
- Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pieter J L De Visschere
- Department of Radiology and Nuclear Medicine, Division of Genitourinary Radiology and Mammography, Ghent University Hospital, Ghent, Belgium
| | | | | | | | - Stefano Fanti
- Department of Nuclear Medicine, Policlinico S Orsola, University of Bologna, Italy
| | - Valerie Fonteyne
- Department of Radiotherapy Oncology, Ghent University Hospital, Ghent, Belgium
| | - Mark Frydenberg
- Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
| | - Jurgen J Futterer
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Georgios Gakis
- Department of Urology and Paediatric Urology, University Hospital of Würzburg, Julius-Maximillians University, Würzburg, Germany
| | - Bogdan Geavlete
- Department of Urology, Saint John Emergency Clinical Hospital, Bucharest, Romania
| | - Paolo Gontero
- Division of Urology, Molinette Hospital, University of Studies of Torino, Torino, Italy
| | | | - Shaista Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Donna E Hansel
- Department of Urology, University of California, San Diego Pathology, La Jolla, California, USA
| | - Arndt Hartmann
- Institute of Pathology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Dickon Hayne
- Department of Urology, UWA Medical School, University of Western Australia, Perth, Australia
| | - Ann M Henry
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Virginia Hernandez
- Department of Urology, Hospital Universitario Fundación de Alcorcón, Madrid, Spain
| | - Harry Herr
- Urology Service, Department of Urology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ken Herrmann
- Department of Nuclear Medicine, Universitätsklinikum Essen, Essen, Germany
| | - Peter Hoskin
- Division of Cancer Sciences, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK; Mount Vernon Centre for Cancer Treatment, London, UK
| | - Jorge Huguet
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Barbara A Jereczek-Fossa
- Department of Oncology and Hemato-oncology, University of Milan, Milan; Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Rob Jones
- Institute of Cancer Sciences, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Ashish M Kamat
- Department of Urology - Division of Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Vincent Khoo
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, UK; Department of Medicine, University of Melbourne; Monash University, Melbourne, Australia
| | - Anne E Kiltie
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - Susanne Krege
- Department of Urology, Pediatric Urology and Urologic Oncology, Kliniken Essen-Mitte, Essen, Germany
| | - Sylvain Ladoire
- Department of Medical Oncology, Centre Georges François Leclerc, Dijon, France
| | - Pedro C Lara
- Department of Oncology, Hospital Universitario San Roque; Universidad Fernando Pessoa, Canarias, Spain
| | - Annemarie Leliveld
- Department of Urology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Vibeke Løgager
- Department of Radiology, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Anja Lorch
- Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland
| | - Yohann Loriot
- Département de Médecine Oncologique, Gustave Roussy, INSERM U981, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Richard Meijer
- UMC Utrecht Cancer Center, MS Oncologic Urology, Utrecht, The Netherlands
| | - M Carmen Mir
- Servicio de Urología, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - Marco Moschini
- Department of Urology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Hugh Mostafid
- Department of Urology, Royal Surrey County Hospital, Guildford, UK
| | | | | | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK; Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Andrea Necchi
- Department of Medical Oncology, Istituto Nazionale Tumori of Milan, Milan, Italy
| | - Yann Neuzillet
- Department of Urology, Hospital Foch, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Jorg R Oddens
- Department of Urology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Jan Oldenburg
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Susanne Osanto
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Wim J G Oyen
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Humanitas Research Hospital, Milan, Italy; Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Luís Pacheco-Figueiredo
- Department of Urology, Centro Hospitalar São João, Porto, Portugal; Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
| | - Helle Pappot
- Department of Oncology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Manish I Patel
- Department of Urology, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Bradley R Pieters
- Department Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Karin Plass
- EAU Guidelines Office, Arnhem, The Netherlands
| | - Mesut Remzi
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Margitta Retz
- Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, Munich, Germany
| | - Jonathan Richenberg
- Department of Imaging and Nuclear Medicine, Royal Sussex County Hospital, Brighton, UK; Brighton and Sussex Medical School, Brighton, UK
| | - Michael Rink
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Roghmann
- Department of Urology, Ruhr-University Bochum, Marien Hospital, Herne, Germany
| | - Jonathan E Rosenberg
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
| | - Morgan Rouprêt
- Department of Urology, Sorbonne Université, GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Olivier Rouvière
- Hospices Civils de Lyon, Service d'Imagerie Urinaire et Vasculaire, Hôpital Edouard Herriot, Lyon, France; Université de Lyon, Université Lyon 1, faculté de médecine Lyon Est, Lyon, France
| | - Carl Salembier
- Department of Radiation Oncology, Europe Hospitals Brussels, Belgium
| | - Antti Salminen
- Department of Urology, University Hospital of Turku, Finland
| | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France
| | - Shomik Sengupta
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, Australia; Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Amir Sherif
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå university, Umeå, Sweden
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anita Smits
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arnulf Stenzl
- Department of Urology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - George N Thalmann
- Department of Urology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Bertrand Tombal
- Division of Urology, IREC, Cliniques Universitaires Saint Luc, UCL, Brussels, Belgium
| | - Baris Turkbey
- Molecular Imaging Program, National Cancer Institute, Bethesda, Maryland, USA
| | - Susanne Vahr Lauridsen
- Department of Urology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Riccardo Valdagni
- Department of Oncology and Hemato-oncology, Università degli Studi di Milano, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | | | - Mihai D Vartolomei
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Cell and Molecular Biology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
| | - Erik Veskimäe
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | - Antoni Vilaseca
- Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Spain
| | - Franklin A Vives Rivera
- Clinica HematoOncologica Bonadona Prevenir, Universidad Metropolitana, Clinica Club de Leones, Barranquilla, Colombia
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Peter Wiklund
- Icahn School of Medicine, Mount Sinai Health System New York City, New York, USA; Department of Urology, Karolinska Institutet, Stockholm, Sweden
| | - Andrew Williams
- Department of Urology, Auckland City Hospital, Auckland, New Zealand
| | - Richard Zigeuner
- Department of Urology, Medizinische Universität Graz, Graz, Austria
| | - Alan Horwich
- Emeritus Professor, The Institute of Cancer Research, London, UK
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18
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Horwich A, Babjuk M, Bellmunt J, Bruins HM, De Reijke TM, De Santis M, Gillessen S, James N, Maclennan S, Palou J, Powles T, Ribal MJ, Shariat SF, Van Der Kwast T, Xylinas E, Agarwal N, Arends T, Bamias A, Birtle A, Black PC, Bochner BH, Bolla M, Boormans JL, Bossi A, Briganti A, Brummelhuis I, Burger M, Castellano D, Cathomas R, Chiti A, Choudhury A, Compérat E, Crabb S, Culine S, De Bari B, DeBlok W, De Visschere PJL, Decaestecker K, Dimitropoulos K, Dominguez-Escrig JL, Fanti S, Fonteyne V, Frydenberg M, Futterer JJ, Gakis G, Geavlete B, Gontero P, Grubmüller B, Hafeez S, Hansel DE, Hartmann A, Hayne D, Henry AM, Hernandez V, Herr H, Herrmann K, Hoskin P, Huguet J, Jereczek-Fossa BA, Jones R, Kamat AM, Khoo V, Kiltie AE, Krege S, Ladoire S, Lara PC, Leliveld A, Linares-Espinós E, Løgager V, Lorch A, Loriot Y, Meijer R, Carmen Mir M, Moschini M, Mostafid H, Müller AC, Müller CR, N'Dow J, Necchi A, Neuzillet Y, Oddens JR, Oldenburg J, Osanto S, Oyen WJG, Pacheco-Figueiredo L, Pappot H, Patel MI, Pieters BR, Plass K, Remzi M, Retz M, Richenberg J, Rink M, Roghmann F, Rosenberg JE, Rouprêt M, Rouvière O, Salembier C, Salminen A, Sargos P, Sengupta S, Sherif A, Smeenk RJ, Smits A, Stenzl A, Thalmann GN, Tombal B, Turkbey B, Vahr Lauridsen S, Valdagni R, Van Der Heijden AG, Van Poppel H, Vartolomei MD, Veskimäe E, Vilaseca A, Vives Rivera FA, Wiegel T, Wiklund P, Williams A, Zigeuner R, Witjes JA. EAU-ESMO consensus statements on the management of advanced and variant bladder cancer-an international collaborative multi-stakeholder effort: under the auspices of the EAU and ESMO Guidelines Committees†. Ann Oncol 2019; 30:1697-1727. [PMID: 31740927 PMCID: PMC7360152 DOI: 10.1093/annonc/mdz296] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial. OBJECTIVE To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management. DESIGN A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts before voting during a consensus conference. SETTING Online Delphi survey and consensus conference. PARTICIPANTS The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus). RESULTS AND LIMITATIONS Overall, 116 statements were included in the Delphi survey. Of these, 33 (28%) statements achieved level 1 consensus and 49 (42%) statements achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease and the evolving role of checkpoint inhibitor therapy in metastatic disease. CONCLUSIONS These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time where further evidence is available to guide our approach.
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Affiliation(s)
- A Horwich
- Emeritus Professor, The Institute of Cancer Research, London, UK; Emeritus Professor, The Institute of Cancer Research, London, UK.
| | - M Babjuk
- Depatment of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - J Bellmunt
- IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain; Harvard Medical School, Boston, USA
| | - H M Bruins
- Department of Urology, Radboud University Medical Center, Nijmegen
| | - T M De Reijke
- Department of Urology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - M De Santis
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Charité University Hospital, Berlin, Germany
| | - S Gillessen
- Division of Cancer Sciences, University of Manchester, Manchester; The Christie NHS Foundation Trust, Manchester, UK; Division of Oncology and Haematology, Kantonsspital St Gallen, St Gallen; University of Bern, Bern, Switzerland
| | - N James
- University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham
| | - S Maclennan
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - J Palou
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - T Powles
- The Royal Free NHS Trust, London; Barts Cancer Institute, Queen Mary University of London, London, UK
| | - M J Ribal
- Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - S F Shariat
- Depatment of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York; Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - T Van Der Kwast
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - E Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris; Paris Descartes University, Paris, France
| | - N Agarwal
- Huntsman Cancer Institute, University of Utah (NCI-CCC), Salt Lake City, USA
| | - T Arends
- Urology Department, Canisius-Wilhelmina Ziekenhuis Nijmegen, Nijmegen, The Netherlands
| | - A Bamias
- 2nd Propaedeutic Dept of Internal Medicine, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - A Birtle
- Division of Cancer Sciences, University of Manchester, Manchester; Rosemere Cancer Centre, Lancashire Teaching Hospitals, Preston, UK
| | - P C Black
- Department of Urologic Sciences, Vancouver Prostate Centre, University of British Columbia, Vancouver, Canada
| | - B H Bochner
- Department of Urology, Weill Cornell Medical College, New York; Urology Service, Department of Urology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - M Bolla
- Emeritus Professor of Radiation Oncology, Grenoble - Alpes University, Grenoble, France
| | - J L Boormans
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A Bossi
- Department of Radiation Oncology, Gustave Roussy Institute, Villejuif, France
| | - A Briganti
- Department of Urology, Urological Research Institute, Milan; Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - I Brummelhuis
- Department of Urology, Radboud University Medical Center, Nijmegen
| | - M Burger
- Department of Urology, Caritas-St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - D Castellano
- Medical Oncology Department, 12 de Octubre University Hospital (CIBERONC), Madrid, Spain
| | - R Cathomas
- Department Innere Medizin, Abteilung Onkologie und Hämatologie, Kantonsspital Graubünden, Chur, Switzerland
| | - A Chiti
- Department of Biomedical Sciences, Humanitas University, Milan; Humanitas Research Hospital, Milan, Italy
| | - A Choudhury
- Division of Cancer Sciences, University of Manchester, Manchester; The Christie NHS Foundation Trust, Manchester, UK
| | - E Compérat
- Department of Pathology, Tenon Hospital, HUEP, Paris; Sorbonne University, Paris, France
| | - S Crabb
- Cancer Sciences Unit, University of Southampton, Southampton, UK
| | - S Culine
- Department of Cancer Medicine, Hôpital Saint Louis, Paris
| | - B De Bari
- Radiation Oncology Department, Centre Hospitalier Régional Universitaire "Jean Minjoz" of Besançon, INSERM UMR 1098, Besançon, France; Radiation Oncology Department, Centre Hospitalier Universitaire Vaudois, Université de Lausanne, Lausanne, Switzerland
| | - W DeBlok
- Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P J L De Visschere
- Department of Radiology and Nuclear Medicine, Division of Genitourinary Radiology and Mammography, Ghent University Hospital, Ghent
| | - K Decaestecker
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - K Dimitropoulos
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - J L Dominguez-Escrig
- Servicio de Urología, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - S Fanti
- Department of Nuclear Medicine, Policlinico S Orsola, University of Bologna, Bologna, Italy
| | - V Fonteyne
- Department of Radiotherapy Oncology, Ghent University Hospital, Ghent, Belgium
| | - M Frydenberg
- Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
| | - J J Futterer
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - G Gakis
- Department of Urology and Paediatric Urology, University Hospital of Würzburg, Julius-Maximillians University, Würzburg, Germany
| | - B Geavlete
- Department of Urology, Saint John Emergency Clinical Hospital, Bucharest, Romania
| | - P Gontero
- Division of Urology, Molinette Hospital, University of Studies of Torino, Torino, Italy
| | - B Grubmüller
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - S Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London; Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, UK
| | - D E Hansel
- Department of Urology, University of California, San Diego Pathology, La Jolla, USA
| | - A Hartmann
- Institute of Pathology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - D Hayne
- Department of Urology, UWA Medical School, University of Western Australia, Perth, Australia
| | - A M Henry
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - V Hernandez
- Department of Urology, Hospital Universitario Fundación de Alcorcón, Madrid, Spain
| | - H Herr
- Urology Service, Department of Urology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - K Herrmann
- Department of Nuclear Medicine, Universitätsklinikum Essen, Essen, Germany
| | - P Hoskin
- Division of Cancer Sciences, University of Manchester, Manchester; The Christie NHS Foundation Trust, Manchester, UK; Mount Vernon Centre for Cancer Treatment, London, UK
| | - J Huguet
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - B A Jereczek-Fossa
- Department of Oncology and Hemato-oncology, University of Milan, Milan; Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - R Jones
- Institute of Cancer Sciences, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - A M Kamat
- Department of Urology - Division of Surgery, The University of Texas, MD Anderson Cancer Center, Houston, USA
| | - V Khoo
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London; Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, UK; Department of Medicine, University of Melbourne, Melbourne; Monash University, Melbourne, Australia
| | - A E Kiltie
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - S Krege
- Department of Urology, Pediatric Urology and Urologic Oncology, Kliniken Essen-Mitte, Essen, Germany
| | - S Ladoire
- Department of Medical Oncology, Centre Georges François Leclerc, Dijon, France
| | - P C Lara
- Department of Oncology, Hospital Universitario San Roque, Canarias; Universidad Fernando Pessoa, Canarias, Spain
| | - A Leliveld
- Department of Urology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - V Løgager
- Department of Radiology, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - A Lorch
- Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland
| | - Y Loriot
- Département de Médecine Oncologique, Gustave Roussy, INSERM U981, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - R Meijer
- UMC Utrecht Cancer Center, MS Oncologic Urology, Utrecht, The Netherlands
| | - M Carmen Mir
- Servicio de Urología, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - M Moschini
- Department of Urology, Luzerner Kantonsspital, Luzern, Switzerland
| | - H Mostafid
- Department of Urology, Royal Surrey County Hospital, Guildford, UK
| | - A-C Müller
- Department of Radiation Oncology, Eberhard Karls University, Tübingen, Germany
| | - C R Müller
- Cancer Treatment Centre, Sorlandet Hospital, Kristiansand, Norway
| | - J N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK; Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - A Necchi
- Department of Medical Oncology, Istituto Nazionale Tumori of Milan, Milan, Italy
| | - Y Neuzillet
- Department of Urology, Hospital Foch, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - J R Oddens
- Department of Urology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - J Oldenburg
- Department of Oncology, Akershus University Hospital, Lørenskog; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - S Osanto
- Department of Clinical Oncology, Leiden University Medical Center, Leiden
| | - W J G Oyen
- Department of Biomedical Sciences, Humanitas University, Milan; Humanitas Research Hospital, Milan, Italy; Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - L Pacheco-Figueiredo
- Department of Urology, Centro Hospitalar São João, Porto; Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
| | - H Pappot
- Department of Oncology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - M I Patel
- Department of Urology, Westmead Hospital, University of Sydney, Sydney, Australia
| | - B R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam
| | - K Plass
- EAU Guidelines Office, Arnhem, The Netherlands
| | - M Remzi
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - M Retz
- Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, Munich, Germany
| | - J Richenberg
- Department of Imaging and Nuclear Medicine, Royal Sussex County Hospital, Brighton; Brighton and Sussex Medical School, Brighton, UK
| | - M Rink
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - F Roghmann
- Department of Urology, Ruhr-University Bochum, Marien Hospital, Herne, Germany
| | - J E Rosenberg
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York; Weill Cornell Medical College, New York, USA
| | - M Rouprêt
- Department of Urology, Sorbonne Université, GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris
| | - O Rouvière
- Hospices Civils de Lyon, Service d'Imagerie Urinaire et Vasculaire, Hôpital Edouard Herriot, Lyon; Université de Lyon, Université Lyon 1, Faculté de Médecine Lyon Est, Lyon, France
| | - C Salembier
- Department of Radiation Oncology, Europe Hospitals Brussels, Brussels, Belgium
| | - A Salminen
- Department of Urology, University Hospital of Turku, Turku, Finland
| | - P Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France
| | - S Sengupta
- Department of Surgery, Austin Health, University of Melbourne, Melbourne; Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - A Sherif
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | - R J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A Smits
- Department of Urology, Radboud University Medical Center, Nijmegen
| | - A Stenzl
- Department of Urology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - G N Thalmann
- Department of Urology, Inselspital, Bern University Hospital, Berne, Switzerland
| | - B Tombal
- Division of Urology, IREC, Cliniques Universitaires Saint Luc, UCL, Brussels, Belgium
| | - B Turkbey
- Molecular Imaging Program, National Cancer Institute, Bethesda, USA
| | - S Vahr Lauridsen
- Department of Urology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - R Valdagni
- Department of Oncology and Hemato-oncology, Università degli Studi di Milano, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - H Van Poppel
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - M D Vartolomei
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Cell and Molecular Biology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, Romania
| | - E Veskimäe
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | - A Vilaseca
- Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - F A Vives Rivera
- Clinica HematoOncologica Bonadona Prevenir, Universidad Metropolitana, Clinica Club de Leones, Barranquilla, Colombia
| | - T Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - P Wiklund
- Icahn School of Medicine, Mount Sinai Health System, New York City, USA; Department of Urology, Karolinska Institutet, Stockholm, Sweden
| | - A Williams
- Department of Urology, Auckland City Hospital, Auckland, New Zealand
| | - R Zigeuner
- Department of Urology, Medizinische Universität Graz, Graz, Austria
| | - J A Witjes
- Department of Urology, Radboud University Medical Center, Nijmegen
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19
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Roach D, Holloway LC, Jameson MG, Dowling JA, Kennedy A, Greer PB, Krawiec M, Rai R, Denham J, De Leon J, Lim K, Berry ME, White RT, Bydder SA, Tan HT, Croker JD, McGrath A, Matthews J, Smeenk RJ, Ebert MA. Multi-observer contouring of male pelvic anatomy: Highly variable agreement across conventional and emerging structures of interest. J Med Imaging Radiat Oncol 2019; 63:264-271. [PMID: 30609205 DOI: 10.1111/1754-9485.12844] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 11/27/2018] [Indexed: 12/16/2022]
Abstract
INTRODUCTION This study quantified inter-observer contouring variations for multiple male pelvic structures, many of which are of emerging relevance for prostate cancer radiotherapy progression and toxicity response studies. METHODS Five prostate cancer patient datasets (CT and T2-weighted MR) were distributed to 13 observers for contouring. CT structures contoured included the clinical target volume (CTV), seminal vesicles, rectum, colon, bowel bag, bladder and peri-rectal space (PRS). MR contours included CTV, trigone, membranous urethra, penile bulb, neurovascular bundle and multiple pelvic floor muscles. Contouring variations were assessed using the intraclass correlation coefficient (ICC), Dice similarity coefficient (DSC), and multiple additional metrics. RESULTS Clinical target volume (CT and MR), bladder, rectum and PRS contours showed excellent inter-observer agreement (median ICC = 0.97; 0.99; 1.00; 0.95; 0.90, DSC = 0.83 ± 0.05; 0.88 ± 0.05; 0.93 ± 0.03; 0.81 ± 0.07; 0.80 ± 0.06, respectively). Seminal vesicle contours were more variable (ICC = 0.75, DSC = 0.73 ± 0.14), while colon and bowel bag contoured volumes were consistent (ICC = 0.97; 0.97), but displayed poor overlap (DSC = 0.58 ± 0.22; 0.67 ± 0.21). Smaller MR structures showed significant inter-observer variations, with poor overlap for trigone, membranous urethra, penile bulb, and left and right neurovascular bundles (DSC = 0.44 ± 0.22; 0.41 ± 0.21; 0.66 ± 0.21; 0.16 ± 0.17; 0.15 ± 0.15). Pelvic floor muscles recorded moderate to strong inter-observer agreement (ICC = 0.50-0.97), although large outlier variations were observed. CONCLUSIONS Inter-observer contouring variation was significant for multiple pelvic structures contoured on MR.
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Affiliation(s)
- Dale Roach
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Lois C Holloway
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.,Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, New South Wales, Australia
| | - Michael G Jameson
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.,Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, New South Wales, Australia
| | - Jason A Dowling
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.,Australian e-Health Research Centre, CSIRO, Royal Brisbane Hospital, Brisbane, Queensland, Australia.,School of Mathematical and Physical Sciences, University of Newcastle, Newcastle, New South Wales, Australia
| | - Angel Kennedy
- Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Peter B Greer
- School of Mathematical and Physical Sciences, University of Newcastle, Newcastle, New South Wales, Australia.,Calvary Mater Newcastle Hospital, Newcastle, New South Wales, Australia
| | - Michele Krawiec
- Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Robba Rai
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, New South Wales, Australia
| | - Jim Denham
- School of Medicine and Population Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Jeremiah De Leon
- Illawarra Cancer Care Centre, Wollongong, New South Wales, Australia
| | - Karen Lim
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Megan E Berry
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Rohen T White
- Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Sean A Bydder
- Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Hendrick T Tan
- Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | | | - Alycea McGrath
- Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - John Matthews
- Radiation Oncology, Auckland City Hospital, Auckland, New Zealand
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Martin A Ebert
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.,Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Physics and Astrophysics, Faculty of Science, University of Western Australia, Perth, Western Australia, Australia
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Krol R, McColl GM, Hopman WPM, Smeenk RJ. Anal and rectal function after intensity-modulated prostate radiotherapy with endorectal balloon. Radiother Oncol 2018; 128:364-368. [PMID: 29716753 DOI: 10.1016/j.radonc.2018.03.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 03/27/2018] [Accepted: 03/29/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE Late anorectal toxicity influences quality of life after external beam radiotherapy (EBRT) for prostate cancer. A daily inserted endorectal balloon (ERB) during EBRT aims to reduce anorectal toxicity. Our goal is to objectify anorectal function over time after prostate intensity-modulated radiotherapy (IMRT) with ERB. MATERIAL AND METHODS Sixty men, irradiated with IMRT and an ERB, underwent barostat measurements and anorectal manometry prior to EBRT and 6 months, one year and 2 years after radiotherapy. Primary outcome measures were rectal distensibility and rectal sensibility in response to stepwise isobaric distensions and anal pressures. RESULTS Forty-eight men completed all measurements. EBRT reduced maximal rectal capacity 2 years after EBRT (250 ± 10 mL vs. 211 ± 10 mL; p < 0.001), area under the pressure-volume curve (2878 ± 270 mL mmHg vs. 2521 ± 305 mL mmHg; p = 0.043) and rectal compliance (NS). Sensory pressure thresholds for first sense and first urge (both p < 0.01) increased. Anal maximum pressure diminished after IMRT (p = 0.006). CONCLUSIONS Rectal capacity and sensory function are increasingly affected over time after radiotherapy. There is an indication that these reductions are affected less with IMRT + ERB compared to conventional radiation techniques.
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Affiliation(s)
- Robin Krol
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Gill M McColl
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Wim P M Hopman
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Krol R, Smeenk RJ, van Lin ENJT, Hopman WPM. [Anorectal symptoms after prostate radiotherapy]. Ned Tijdschr Geneeskd 2015; 160:A9635. [PMID: 26959731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Prostate cancer is the most common cancer in Dutch men and has a relatively good survival rate. Anorectal symptoms after irradiation of the prostate, including rectal blood loss and faecal incontinence, can have a serious impact on quality of life. On endoscopy, the Vienna Rectoscopy Score may reveal telangiectasia or other mucosal changes, but there may also be other causes of blood loss. Endoscopy or watchful waiting can be considered in patients with rectal bleeding. Sucralfate enemas, argon plasma coagulation and hyperbaric oxygen therapy are effective treatments. Increase in frequency of defaecation, faecal urgency or incontinence are related to decreased rectal compliance or to lowered anal resting pressure. Dietary measures can be considered in patients with faecal urgency or incontinence, but scientific evidence for the effectiveness of this is marginal. More accurate radiation techniques and the use of a spacer or endorectal balloon will probably contribute to maintaining rectal and anal function.
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Abstract
BACKGROUND Late anorectal toxicity is a frequent adverse event of external beam radiotherapy (EBRT) for prostate cancer. The pathophysiology of anorectal toxicity remains unknown, but we speculate that rectal distensibility is impaired due to fibrosis. Our goal was to determine whether EBRT induces changes of rectal distensibility as measured by an electronic barostat and to explore whether anorectal complaints are related to specific changes of anorectal function. METHODS Thirty-two men, irradiated for localized prostate carcinoma, underwent barostat measurements, anorectal manometry, and completed a questionnaire prior to and 1 year after radiotherapy. The primary outcome measure was rectal distensibility in response to stepwise isobaric distensions. In addition, we assessed sensory thresholds, anal pressures, and anorectal complaints. KEY RESULTS External beam radiotherapy reduced maximal rectal capacity (227 ± 14 mL vs 277 ± 15 mL; P < 0.001), area under the pressure-volume curve (3212 ± 352 mL mmHg vs 3969 ± 413 mL mmHg; P < 0.005), and rectal compliance (15.7 ± 1.2 mL mmHg(-1) vs 17.6 ± 0.9 mL mmHg(-1) ; P = 0.12). Sensory pressure thresholds did not significantly change. Sixteen of the 32 patients (50%) had one or more anorectal complaints. Patients with urgency (n = 10) had a more reduced anal squeeze and maximum pressure (decrease 29 ± 11 mmHg vs 1 ± 7 mmHg; P < 0.05 and 31 ± 12 mmHg vs 2 ± 8 mmHg; P < 0.05 respectively) compared with patients without complaints, indicating a deteriorated external anal sphincter function. CONCLUSIONS & INFERENCES Irradiation for prostate cancer leads to reduced rectal distensibility. In patients with urgency symptoms, anal sphincter function was also impaired.
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Affiliation(s)
- R Krol
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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23
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Swaak AJ, van den Brink HG, Smeenk RJ, Manger K, Kalden JR, Tosi S, Domljan Z, Rozman B, Logar D, Pokorny G, Kovacs L, Kovacs A, Vlachoyiannopoulos PG, Moutsopoulos HM, Chwalinska-Sadowska H, Kiss E, Cikes N, Anic B, Schneider M, Fischer R, Bombardieri S, Mosca M, Graninger W, Smolen JS. Systemic lupus erythematosus. Disease outcome in patients with a disease duration of at least 10 years: second evaluation. Lupus 2001; 10:51-8. [PMID: 11243510 DOI: 10.1191/096120301666282314] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Data related to the disease course of patients with systemic lupus erythematosus (SLE) with special attention to the persistence of disease activity in the long term are scarce. At this moment reliable figures are only known about the survival rate as a measure of outcome. The aim of this multicenter study was to describe the outcome of SLE patients with a disease duration of greater than 10 y. Outcome parameters were two disease activity-scoring systems (SLEDAI and ECLAM), the end organ damage (SLICC/ACR damage index) and treatment. Our results are derived from 187 SLE patients followed at 10 different centres in Europe over a period of 1 y. Serious clinical signs or exacerbations, defined by the occurrence or detoriation of already existing symptoms of renal and cerebral nervous systems were observed in 2-11% of the patients, seizures and psychosis in 3%, proteinuria in 11% and an increase in serum creatinine in 5% of the patients. No change took place in the overall damage index. Yet, the disease course in most patients was characterized by periods of tiredness (42-60%), arthritis (20-25%), skin involvement such as malar rash (32-40%), migraine (15-20%), anaemia (15%) and leucopenia (17-19%). Summarizing these results it is shown that patients, still under care after such a long time of having this disease, do have a disease that is far from extinguished.
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Affiliation(s)
- A J Swaak
- Department of Rheumatology, Medisch Centrum Rijnmond Zuid, Rotterdam, The Netherlands
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24
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Swaak AJ, van de Brink H, Smeenk RJ, Manger K, Kalden JR, Tosi S, Marchesoni A, Domljan Z, Rozman B, Logar D, Pokorny G, Kovacs L, Kovacs A, Vlachoyiannopoulos PG, Moutsopoulos HM, Chwalinska-Sadowska H, Dratwianka B, Kiss E, Cikes N, Anic B, Schneider M, Fischer R, Bombardieri S, Mosca M, Graninger W, Smolen JS. Incomplete lupus erythematosus: results of a multicentre study under the supervision of the EULAR Standing Committee on International Clinical Studies Including Therapeutic Trials (ESCISIT). Rheumatology (Oxford) 2001; 40:89-94. [PMID: 11157147 DOI: 10.1093/rheumatology/40.1.89] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Patients characterized with antinuclear antibodies (ANA) and disease symptoms related to one organ system can be described as having incomplete systemic lupus erythematosus (SLE). The aim of this multicentre study was to describe the outcome of these so-called incomplete SLE patients. Two aspects of the outcome were studied: (i) the disease course, defined by the presence or absence of clinical symptoms; and (ii) the number of patients that eventually developed full SLE. METHODS Outcome parameters were the ACR criteria, the SLE disease Activity Index (SLEDAI), the European Consensus Lupus Activity Measure (ECLAM) and the requirement for treatment. In 10 European rheumatology centres, patients who had been evaluated in the last 3 months of 1994 and had been diagnosed as having incomplete SLE on clinical grounds for at least 1 yr were included in the study. All 122 patients who were included in the study were evaluated annually during 3 yr of follow-up. RESULTS Our results are confined to a patient cohort defined by disease duration of at least 1 yr, being under clinical care at the different centres in Europe. These patients showed disease activity that was related mostly to symptoms of the skin and the musculoskeletal system, and leucocytopenia. During the follow-up, low doses of prednisolone were still being prescribed in 43% of the patients. On recruitment to the study, 22 of the 122 incomplete SLE patients already fulfilled the ACR criteria for the diagnosis of SLE. In the 3 yr of follow-up only three patients developed SLE. CONCLUSIONS A high proportion of patients in our cohort defined on clinical grounds as having incomplete SLE eventually showed disease activity defined by the SLEDAI as well as ECLAM. However, only three cases developed to SLE during the follow-up. This suggests that incomplete SLE forms a subgroup of SLE that has a good prognosis.
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Affiliation(s)
- A J Swaak
- Department of Rheumatology, Zuiderziekenhuis, Groene Hilledijk 315, 3075 EA Rotterdam, The Netherlands
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25
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Charles PJ, Smeenk RJ, De Jong J, Feldmann M, Maini RN. Assessment of antibodies to double-stranded DNA induced in rheumatoid arthritis patients following treatment with infliximab, a monoclonal antibody to tumor necrosis factor alpha: findings in open-label and randomized placebo-controlled trials. Arthritis Rheum 2000. [PMID: 11083258 DOI: 10.1002/1529-0131(200011)43:11<2383::aid-anr2>3.0.co;2-d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To compare the incidence of anti-double-stranded DNA (anti-dsDNA) antibodies in rheumatoid arthritis (RA) patients receiving either single or multiple doses of a chimeric anti-tumor necrosis factor alpha (anti-TNFalpha) antibody or placebo infusions, with or without methotrexate, in open-label, randomized, placebo-controlled trials. METHODS Multiple sera obtained from 156 patients before and after treatment with infliximab and from 37 patients treated with placebo infusions were tested for anti-dsDNA antibodies by 3 methods: Crithidia luciliae indirect immunofluorescence test (CLIFT), a commercial Farr assay (Ortho Diagnostics radioimmunoassay [RIA]) in which the antigen source is mammalian DNA, and a Farr assay employing 125I-labeled circular plasmid DNA (Central Laboratory of The Netherlands Red Cross Blood Transfusion Service [CLB] RIA). Patients with positive findings on the CLIFT were also tested for antibodies to histones (H1-H5) and chromatin and for IgM rheumatoid factors (IgM-RFs). RESULTS None of the RA patients had a serum sample that was positive for anti-dsDNA antibodies by the CLIFT prior to infliximab therapy. Of the 22 patients who developed a positive CLIFT result, 11 (7% of 156 exposed to infliximab) also had positive findings on the Ortho RIA at a concentration of >10 units/ml and another 8 (5%) were positive at a concentration of >25 units/ml. In all but 1 patient, the anti-dsDNA antibodies were solely of the IgM isotype. Only 1 patient had detectable anti-dsDNA antibodies by the CLB RIA. All sera containing anti-dsDNA by the CLIFT contained antibodies to chromatin, and sera from 2 patients also contained antibodies to histones. IgM-RF titers showed a significant reduction following infliximab therapy in these 22 patients. One patient developed anti-dsDNA antibodies of IgG, IgA, and IgM isotype and had positive results on both Farr assays (peaking at 22 weeks and resolving by 54 weeks); this was associated with a reversible lupus syndrome. CONCLUSION Anti-dsDNA antibodies of IgM class are induced by infliximab therapy; the frequency is dependent on the assay method used. Only 1 of the 156 patients who were treated with infliximab developed a self-limiting clinical lupus syndrome; that patient developed high titers of anti-dsDNA antibodies of IgG, IgM, and IgA class, as detected by the CLIFT and by 2 different Farr assays.
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Affiliation(s)
- P J Charles
- Kennedy Institute of Rheumatology, London, UK
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Charles PJ, Smeenk RJ, De Jong J, Feldmann M, Maini RN. Assessment of antibodies to double-stranded DNA induced in rheumatoid arthritis patients following treatment with infliximab, a monoclonal antibody to tumor necrosis factor alpha: findings in open-label and randomized placebo-controlled trials. Arthritis Rheum 2000; 43:2383-90. [PMID: 11083258 DOI: 10.1002/1529-0131(200011)43:11<2383::aid-anr2>3.0.co;2-d] [Citation(s) in RCA: 389] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare the incidence of anti-double-stranded DNA (anti-dsDNA) antibodies in rheumatoid arthritis (RA) patients receiving either single or multiple doses of a chimeric anti-tumor necrosis factor alpha (anti-TNFalpha) antibody or placebo infusions, with or without methotrexate, in open-label, randomized, placebo-controlled trials. METHODS Multiple sera obtained from 156 patients before and after treatment with infliximab and from 37 patients treated with placebo infusions were tested for anti-dsDNA antibodies by 3 methods: Crithidia luciliae indirect immunofluorescence test (CLIFT), a commercial Farr assay (Ortho Diagnostics radioimmunoassay [RIA]) in which the antigen source is mammalian DNA, and a Farr assay employing 125I-labeled circular plasmid DNA (Central Laboratory of The Netherlands Red Cross Blood Transfusion Service [CLB] RIA). Patients with positive findings on the CLIFT were also tested for antibodies to histones (H1-H5) and chromatin and for IgM rheumatoid factors (IgM-RFs). RESULTS None of the RA patients had a serum sample that was positive for anti-dsDNA antibodies by the CLIFT prior to infliximab therapy. Of the 22 patients who developed a positive CLIFT result, 11 (7% of 156 exposed to infliximab) also had positive findings on the Ortho RIA at a concentration of >10 units/ml and another 8 (5%) were positive at a concentration of >25 units/ml. In all but 1 patient, the anti-dsDNA antibodies were solely of the IgM isotype. Only 1 patient had detectable anti-dsDNA antibodies by the CLB RIA. All sera containing anti-dsDNA by the CLIFT contained antibodies to chromatin, and sera from 2 patients also contained antibodies to histones. IgM-RF titers showed a significant reduction following infliximab therapy in these 22 patients. One patient developed anti-dsDNA antibodies of IgG, IgA, and IgM isotype and had positive results on both Farr assays (peaking at 22 weeks and resolving by 54 weeks); this was associated with a reversible lupus syndrome. CONCLUSION Anti-dsDNA antibodies of IgM class are induced by infliximab therapy; the frequency is dependent on the assay method used. Only 1 of the 156 patients who were treated with infliximab developed a self-limiting clinical lupus syndrome; that patient developed high titers of anti-dsDNA antibodies of IgG, IgM, and IgA class, as detected by the CLIFT and by 2 different Farr assays.
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Affiliation(s)
- P J Charles
- Kennedy Institute of Rheumatology, London, UK
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Hylkema MN, van Bruggen MC, ten Hove T, de Jong J, Swaak AJ, Berden JH, Smeenk RJ. Histone-containing immune complexes are to a large extent responsible for anti-dsDNA reactivity in the Farr assay of active SLE patients. J Autoimmun 2000; 14:159-68. [PMID: 10677247 DOI: 10.1006/jaut.1999.0354] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Increased titres of anti-dsDNA antibodies, especially if of high avidity, are associated with renal exacerbations in patients with systemic lupus erythematosus (SLE). One of the most reliable assays to measure anti-dsDNA antibodies, the Farr assay, is believed to detect preferentially high avidity antibodies. Purified non-complexed monoclonal antibodies (mAbs) against nucleosomes, obtained from mice with SLE, are not reactive in the Farr assay, but can become so once complexed to nucleosomes. These Farr-positive, nucleosome containing, immune complexes were also able to bind in vivo to the glomerular basement membrane (GBM), predominantly via heparan sulphate (HS). To evaluate whether in SLE patients the same kind of immune complexes are responsible for Farr reactivity, IgG from serum or plasma was isolated under dissociating and physiological conditions. We observed that after purification under dissociating conditions, Farr reactivity was significantly decreased (P<0.0001) in contrast to reactivity with histones and two 'control' antigens: Epstein Barr Virus (EBV) and Ro/SS-A. Reactivity with nucleosomes also decreased after purification, although to a lesser extent. Plasma purified under physiological conditions showed no decrease in Farr reactivity. The importance of histones for the generation of immune complexes is supported by the two following observations. Firstly, the presence of histones could be demonstrated in serum and plasma of SLE patients but not in serum of healthy controls or in IgG preparations purified under dissociating conditions. Secondly, Farr reactivity of purified IgG preparations could be restored by addition of purified histones. From these studies we conclude that histones containing immune complexes are responsible for a large part of the Farr reactivity in active SLE, and are therefore indirectly implicated in the pathogenesis of lupus nephritis.
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Affiliation(s)
- M N Hylkema
- Department of Autoimmune Diseases, CLB, Amsterdam, The Netherlands
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Swaak AJ, van den Brink HG, Smeenk RJ, Manger K, Kalden JR, Tosi S, Marchesoni A, Domljan Z, Rozman B, Logar D, Pokorny G, Kovacs L, Kovacs A, Vlachoyiannopoulos PG, Moutsopoulos HM, Chwalinska-Sadowska H, Dratwianka B, Kiss E, Cikes N, Branimir A, Schneider M, Fischer R, Bombardieri S, Mosca M, Smolen JS. Systemic lupus erythematosus: clinical features in patients with a disease duration of over 10 years, first evaluation. Rheumatology (Oxford) 1999; 38:953-8. [PMID: 10534545 DOI: 10.1093/rheumatology/38.10.953] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Most information available about the disease course of patients with systemic lupus erythematosus (SLE) is restricted to the first 5 yr after disease onset. Data about the disease course 10 yr after disease onset are rare. The aim of this multicentre study was to describe the outcome of SLE patients with a disease duration of >10 yr. METHODS Outcome parameters were the SLE Disease Activity Index (SLEDAI), the European Consensus Lupus Activity Measure (ECLAM), the Systemic Lupus International Collaborative Clinics/American College of Rheumatology Damage Index (SLICC/ACR), a global damage index (DI) and required treatment. In 10 different European rheumatology centres, all SLE patients who were evaluated in the last 3 months of 1994, and who had been diagnosed with SLE at least 10 yr ago, were included in the study. RESULTS It should be stressed that our results are confined to a patient cohort, defined by a disease duration of at least 10 yr, and who are still under clinical care at the different centres in Europe. These SLE patients still showed some disease activity, related to symptoms of the skin and musculoskeletal systems, next to the presence of renal involvement. A total of 72% of the patients needed treatment with prednisolone (</=7.5 mg). The cumulative damage was overall related to clinical features of the central nervous system (14%) and renal involvement (14%), next to deforming arthritis (14%), osteoporosis (15%) and hypertension (40%). The prevalences of obesity, Cushing appearance and diabetes are highly suggestive that the ongoing treatment and that in the past might have had an impact on the total sum of end-organ damage. CONCLUSIONS After 10 yr, a high proportion of patients in our cohort continued to show evidence of active disease, defined by the SLEDAI as well as ECLAM. The DI was related to the involvement of the central nervous system, renal involvement and the presence of hypertension.
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Affiliation(s)
- A J Swaak
- Department of Rheumatology, Zuiderzeikenhuis, Groene Hilledijk, Rotterdam, The Netherlands
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Out TA, Smeenk RJ, Hooijkaas H. [Immunology in medical practice. XXI. Laboratory tests for immunologic diseases]. Ned Tijdschr Geneeskd 1999; 143:1027-33. [PMID: 10368728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Clinical immunology has gained its firm place in health care. There are now established laboratory tests giving insight into the functioning of the immune system in the normal and diseased individual. The laboratory diagnostic tests are related to immune deficiencies, infectious diseases, allergic diseases, autoimmune diseases (both generalized and organ-specific ones), the HLA system and malignancies of immune cells. In this review the application of a number of laboratory tests in the diagnosis of immunological diseases is discussed. In the Netherlands a laboratory specialist, the 'medical immunologist' deals with the development, implementation and performance of the immunological diagnostic tests in health care.
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Affiliation(s)
- T A Out
- Academisch Medisch Centrum, Specieel Klinisch Immunologisch Laboratorium, Amsterdam
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van Lopik T, Bijl M, Hart M, Boeije L, Gesner T, Creasy AA, Kallenberg CG, Aarden LA, Smeenk RJ. Patients with systemic lupus erythematosus with high plasma levels of sFas risk relapse. J Rheumatol Suppl 1999; 26:60-7. [PMID: 9918241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
OBJECTIVE We related soluble Fas (sFas) levels to the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) in a longitudinal series of plasma samples of patients with SLE to evaluate the relation between excessive production of sFas and disease activity. METHODS We generated 21 monoclonal antibodies against Fas. Two of these were used to develop and validate a sensitive sandwich ELISA for the longitudinal analysis of sFas levels in plasma of 30 patients and 25 controls. RESULTS At the start of followup, a significant elevation (p<0.0001) was found in sFas levels in SLE (1167+/-347 pg/ml sFas) compared to controls (618+/-98 pg/ml sFas). Also, at the start of the followup a significant difference (p = 0.0028) existed between patients who were going to have a relapse (1236+/-402 pg/ml sFas) during followup and patients who were not (809+/-276 pg/ml sFas). While sFas did not fluctuate with disease activity in individual patients, we found a strong correlation (r = 0.75, p<0.0001) between sFas and SLEDAI, but only at the time of relapse, when we analyzed the patients as a group. CONCLUSION In individual patients with SLE, sFas does not fluctuate with disease activity. However, patients with high plasma levels of sFas are at risk of relapse.
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Affiliation(s)
- T van Lopik
- CLB, Sanguin Blood Supply Foundation, Academical Medical Center, University of Amsterdam, The Netherlands
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Bijl M, van Lopik T, Limburg PC, Spronk PE, Jaegers SM, Aarden LA, Smeenk RJ, Kallenberg GG. Do elevated levels of serum-soluble fas contribute to the persistence of activated lymphocytes in systemic lupus erythematosus? J Autoimmun 1998; 11:457-63. [PMID: 9802929 DOI: 10.1006/jaut.1998.0233] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Systemic lupus erythematosus (SLE) is characterized by generalized immune activation. Part of this might be explained by a decreased rate of apoptosis, possibly related to elevated levels of soluble Fas (sFas) which can inhibit Fas mediated apoptosis of lymphocytes. In order to substantiate the relation between levels of sFas and lymphocyte activation in SLE we monitored sFas levels, lymphocyte activation and disease activity in 25 SLE patients. SLEDAI scores were registered and sera were assayed for sFas levels by an enzyme-linked immunosorbent assay. Flow cytometry was used to monitor the state of activation of lymphocyte subsets. Eighteen healthy, age-matched volunteers served as controls. Soluble Fas levels were elevated in SLE patients (n=25) compared to healthy controls (n=18, P=0.002). Soluble Fas levels correlated with SLEDAI scores (r=0.45, P=0.02). Levels of sFas correlated with the percentages of activated B cells defined as CD20(+)CD38(+) cells (r=0.47, P=0.009). Percentages of CD20(+)CD38(+) cells were increased in quiescent SLE compared to healthy controls (P=0.003). The expression of activation markers on CD4(+) T lymphocytes (IL-2R, P=0.04; HLA-DR, P=0.01) and CD8(+) T lymphocytes (HLA-DR, P=0.007) was also increased in quiescent SLE compared to controls. Activation markers on all lymphocyte subsets tended to increase further during disease activity. No correlation was observed between percentages of activated T lymphocyte subsets and levels of sFas. In conclusion, soluble Fas levels are increased in SLE patients and correlate with disease activity as measured by the SLEDAI score and B and T cell subsets are activated even during quiescent SLE. Serum levels of sFas correlate with percentages of activated B cells but not with that of activated T cells.
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Affiliation(s)
- M Bijl
- Department of Clinical Immunology, University Hospital, Groningen, The Netherlands.
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Tan EM, Feltkamp TE, Smolen JS, Butcher B, Dawkins R, Fritzler MJ, Gordon T, Hardin JA, Kalden JR, Lahita RG, Maini RN, McDougal JS, Rothfield NF, Smeenk RJ, Takasaki Y, Wiik A, Wilson MR, Koziol JA. Range of antinuclear antibodies in "healthy" individuals. Arthritis Rheum 1997. [PMID: 9324014 DOI: 10.1002/1529-0131(199709)40: 9< 1601: : aid-art9> 3.0.co; 2-t] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine the range of antinuclear antibodies (ANA) in "healthy" individuals compared with that in patients with systemic lupus erythematosus (SLE), systemic sclerosis (SSc; scleroderma), Sjögren's syndrome (SS), rheumatoid arthritis (RA), or soft tissue rheumatism (STR). METHODS Fifteen international laboratories experienced in performing tests for ANA by indirect immunofluorescence participated in analyzing coded sera from healthy individuals and from patients in the 5 different disease groups described above. Except for the stipulation that HEp-2 cells should be used as substrate, each laboratory used its own in-house methodology so that the data might be expected to reflect the output of a cross-section of worldwide ANA reference laboratories. The sera were analyzed at 4 dilutions: 1:40, 1:80, 1:160, and 1:320. RESULTS In healthy individuals, the frequency of ANA did not differ significantly across the 4 age subgroups spanning 20-60 years of age. This putatively normal population was ANA positive in 31.7% of individuals at 1:40 serum dilution, 13.3% at 1:80, 5.0% at 1:160, and 3.3% at 1:320. In comparison with the findings among the disease groups, a low cutoff point at 1:40 serum dilution (high sensitivity, low specificity) could have diagnostic value, since it would classify virtually all patients with SLE, SSc, or SS as ANA positive. Conversely, a high positive cutoff at 1:160 serum dilution (high specificity, low sensitivity) would be useful to confirm the presence of disease in only a portion of cases, but would be likely to exclude 95% of normal individuals. CONCLUSION It is recommended that laboratories performing immunofluorescent ANA tests should report results at both the 1:40 and 1:160 dilutions, and should supply information on the percentage of normal individuals who are positive at these dilutions. A low-titer ANA is not necessarily insignificant and might depend on at least 4 specific factors. ANA assays can be a useful discriminant in recognizing certain disease conditions, but can create misunderstanding when the limitations are not fully appreciated.
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Affiliation(s)
- E M Tan
- The Scripps Research Institute, La Jolla, California 92037, USA
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Affiliation(s)
- D A Bell
- Department of Medicine, University of West Ontario, London Health Sciences Center, Canada
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Tan EM, Feltkamp TE, Smolen JS, Butcher B, Dawkins R, Fritzler MJ, Gordon T, Hardin JA, Kalden JR, Lahita RG, Maini RN, McDougal JS, Rothfield NF, Smeenk RJ, Takasaki Y, Wiik A, Wilson MR, Koziol JA. Range of antinuclear antibodies in "healthy" individuals. Arthritis Rheum 1997; 40:1601-11. [PMID: 9324014 DOI: 10.1002/art.1780400909] [Citation(s) in RCA: 507] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine the range of antinuclear antibodies (ANA) in "healthy" individuals compared with that in patients with systemic lupus erythematosus (SLE), systemic sclerosis (SSc; scleroderma), Sjögren's syndrome (SS), rheumatoid arthritis (RA), or soft tissue rheumatism (STR). METHODS Fifteen international laboratories experienced in performing tests for ANA by indirect immunofluorescence participated in analyzing coded sera from healthy individuals and from patients in the 5 different disease groups described above. Except for the stipulation that HEp-2 cells should be used as substrate, each laboratory used its own in-house methodology so that the data might be expected to reflect the output of a cross-section of worldwide ANA reference laboratories. The sera were analyzed at 4 dilutions: 1:40, 1:80, 1:160, and 1:320. RESULTS In healthy individuals, the frequency of ANA did not differ significantly across the 4 age subgroups spanning 20-60 years of age. This putatively normal population was ANA positive in 31.7% of individuals at 1:40 serum dilution, 13.3% at 1:80, 5.0% at 1:160, and 3.3% at 1:320. In comparison with the findings among the disease groups, a low cutoff point at 1:40 serum dilution (high sensitivity, low specificity) could have diagnostic value, since it would classify virtually all patients with SLE, SSc, or SS as ANA positive. Conversely, a high positive cutoff at 1:160 serum dilution (high specificity, low sensitivity) would be useful to confirm the presence of disease in only a portion of cases, but would be likely to exclude 95% of normal individuals. CONCLUSION It is recommended that laboratories performing immunofluorescent ANA tests should report results at both the 1:40 and 1:160 dilutions, and should supply information on the percentage of normal individuals who are positive at these dilutions. A low-titer ANA is not necessarily insignificant and might depend on at least 4 specific factors. ANA assays can be a useful discriminant in recognizing certain disease conditions, but can create misunderstanding when the limitations are not fully appreciated.
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Affiliation(s)
- E M Tan
- The Scripps Research Institute, La Jolla, California 92037, USA
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Abstract
Isolated congenital heart block (CHB) in children is strongly associated with the occurrence of autoantibodies to Ro/SS-A and La/SS-B in the circulation of the mother. Although these antibodies are generally found in patients with generalized autoimmune diseases, they may also occur in symptomless mothers of CHB patients. It is thought that anti-Ro/SS-A and anti-La/SS-B may reach the fetal circulation via transplacental transport, starting around the 20th week of gestation. Although several hypotheses have been put forward, the exact mechanism through which these autoantibodies bind the fetal conduction system and elicit a local inflammatory response is still unclear. Also, the induction of the autoantibody response in the mother remains largely obscure, although a putative role of viral infection has been suggested. In this overview, the structure of the involved antigens will be discussed, followed by the nature of the antibodies. Recent data regarding the etiology of the anti-Ro/SS-A and anti-La/SS-B response and the role of these autoantibodies in the pathogenesis of CHB will be presented.
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Affiliation(s)
- R J Smeenk
- Central Laboratory of The Netherlands Red Cross Blood transfusion Service, Amsterdam, The Netherlands
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van Bruggen MC, Walgreen B, Rijke TP, Tamboer W, Kramers K, Smeenk RJ, Monestier M, Fournie GJ, Berden JH. Antigen specificity of anti-nuclear antibodies complexed to nucleosomes determines glomerular basement membrane binding in vivo. Eur J Immunol 1997; 27:1564-9. [PMID: 9209511 DOI: 10.1002/eji.1830270636] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Monoclonal anti-nuclear antibodies which are complexed to nucleosomes are able to bind to the glomerular basement membrane (GBM) in vivo, whereas purified antibodies do not bind. The positively charged histone moieties in the nucleosome are-responsible for the binding to anionic determinants in the GBM. We tested the hypothesis that the specificity of the autoantibodies complexed to the nucleosome influences the glomerular binding of the antibody-nucleosome complex. We induced the formation of these immune complexes in vivo, by intraperitoneal inoculation of hybridomas producing monoclonal anti-nuclear antibodies (four anti-histone, three anti-double stranded (ds)DNA and three anti-nucleosome antibodies) into nude BALB/c mice. In ascites and plasma from the mice inoculated with these hybridomas, nucleosome/autoantibody complexes were detected in comparable amounts. Immunofluorescence of kidney sections revealed that about 60% of the mice inoculated with anti-nucleosome or anti-dsDNA hybridomas had immunoglobulin deposits in the GBM, whereas only 15% of the mice with anti-histone hybridomas showed these deposits (p < or = 0.04). In the Matrigel-ELISA (used as a GBM surrogate) ascites from anti-nucleosome or anti-DNA hybridomas displayed significantly higher titers (p < or = 0.002) than ascites from anti-histone hybridomas. In conclusion, nucleosome/immunoglobulin complexes comprising anti-nucleosome or anti-dsDNA auto-antibodies do bind more frequently to the GBM in vivo than nucleosome/immunoglobulin complexes containing anti-histone antibodies. It therefore appears that the specificity of the antibody bound to the nucleosome is a critical determinant for the nephritogenic potential of the nucleosome-autoantibody complex.
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Affiliation(s)
- M C van Bruggen
- Division of Nephrology, University Hospital Nijmegen, The Netherlands.
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39
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Abstract
In this study we have used a number of monoclonal antibodies with various anti-Sm specificities originating from MRL/lpr mice to map B cell epitopes of the Sm-B/B' and Sm-D1 proteins. Selection of Sm-B subfragments reactive with the Sm-B/B'-specific monoclonal antibody ANA125 from a DNaseI fragment expression library revealed that the epitope recognized by this monoclonal antibody is located between amino acids 146 and 158: GRGTVAAAAAAAT. The epitopes recognized by two distinct Sm-D1-specific monoclonal antibodies, 7.13 and ANA127, appeared to be located in the carboxy-terminal region of the protein as revealed by immunoprecipitation of in vitro translated deletion mutants of Sm-D1. These epitopes are probably identical and not simply composed of a GR repeat, which is a characteristic feature of this part of the protein. Immunoprecipitation of in vitro translated deletion mutants of both Sm-B and Sm-D1 was also employed to determine the sequence requirements for recognition by two monoclonal antibodies that are cross-reactive with several Sm proteins, Y12 and ANA128. The epitope recognized by these two monoclonal antibodies is probably also identical and composed by the juxtaposition of several regions in the folded protein. The low, but significant, level of immunoprecipitation of truncated versions of both Sm-B and Sm-D1, suggests that the Sm domain, which is shared by all Sm proteins, in particular the amino-terminal part of the Sm1 motif of Sm-B and Sm-D1, plays an important role in formation of the cross-reactive epitope and might contribute to cross-reactivity with other Sm proteins. The results of immunoprecipitation experiments with cellular extracts show that the epitopes recognized by all anti-Sm monoclonal antibodies used in this study are accessible in the assembled snRNPs.
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Affiliation(s)
- G J Pruijn
- Department of Biochemistry, University of Nijmegen, The Netherlands
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Meilof JF, Veldhoven CH, Swaak AJ, Smeenk RJ. Production of anti-Ro/SS-A and anti-La/SS-B autoantibodies is closely coordinated in systemic lupus erythematosus and independent of anti-dsDNA production. J Autoimmun 1997; 10:67-75. [PMID: 9080301 DOI: 10.1006/jaut.1996.0110] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Autoimmune diseases such as Sjögren's Syndrome and systemic lupus erythematosus (SLE) are characterized by serum autoantibodies against protein components of small cytoplasmic ribonucleoproteins (scRNPs). The origin and regulation of these anti-Ro/SS-A and anti-La/SS-B antibodies is not well understood. Regular co-occurrence of these two autoantibodies in humans together with murine studies on antibody responses against scRNPs after immunization suggest a role for scRNPs as common antigen. We sought additional evidence for this hypothesis in a longitudinal serological study of patients with SLE. Quantitative measurement of the antibody responses against Ro/SS-A and La/SS-B proteins and for comparison to dsDNA in 852 serum samples was performed. These samples were collected from nine patients during an average observation period of more than 10 years. A significant and strong correlation between the two anti-scRNP responses emerged during 90% of follow-up. In contrast, correlation of anti-scRNP with anti-dsDNA responses was remarkably absent in the same patients. Our results confirm the unique relationship between anti-Ro/SS-A and anti-La/ SS-B responses and could thus be interpreted as support for a model wherein induction and perpetuation of autoantibody production is dependent on scRNPs containing both proteins as antigen.
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Affiliation(s)
- J F Meilof
- Dept. of Autoimmune Diseases, Central Laboratory of the Netherlands Red Cross Blood Transfusion Service, Amsterdam, The Netherlands
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van Bruggen MC, Kramers C, Walgreen B, Elema JD, Kallenberg CG, van den Born J, Smeenk RJ, Assmann KJ, Muller S, Monestier M, Berden JH. Nucleosomes and histones are present in glomerular deposits in human lupus nephritis. Nephrol Dial Transplant 1997; 12:57-66. [PMID: 9027774 DOI: 10.1093/ndt/12.1.57] [Citation(s) in RCA: 100] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Recently we showed that antinuclear autoantibodies complexed to nucleosomes can bind to heparan sulphate (HS) in the glomerular basement membrane (GBM) via the histone part of the nucleosome. Histones have been identified in glomerular deposits in human and murine lupus nephritis. In addition, a decreased HS staining in the GBM was found, most probably due to masking by deposition of antibodies complexed to nucleosomes. METHODS In this study we first investigated whether histones or nucleosomes could be identified in glomerular deposits in human lupus nephritis, and secondly whether the presence of these nuclear components was correlated with absence of HS staining. Kidney biopsies of SLE patients (11 with diffuse proliferative glomerulonephritis (DPGN) and six with membranous glomerulonephritis (MGN)) and non-SLE glomerular diseases were stained for histones. DNA, nucleosomes, IgG and HS. RESULTS Using a polyclonal anti-H3 1 21 antiserum, histones were detected in all patients with DPGN and in two of six patients with SLE-MGN (P < 0.01). Using a monoclonal antihistone antibody, histones were stained in three patients with DPGN, but in none of the biopsies with MGN. Using nucleosome specific monoclonal antibodies, nucleosomes were detected in five patients with DPGN, in two patients with MGN, but in none of the biopsies with non-SLE glomerulonephritis. HS staining was nearly absent in DPGN, whereas staining was only moderately reduced in patients with MGN and controls (P = 0.001). CONCLUSION Using polyclonal and monoclonal antihistone antisera, histones were identified in all patients with DPGN and their presence was associated with a decrease of HS staining. Nucleosomes were identified in five of 11 patients with DPGN and in two of six patients with MGN. This is the first demonstration of nucleosomes in glomerular deposits in SLE nephritis.
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Affiliation(s)
- M C van Bruggen
- Division of Nephrology, University Hospital Nijmegen, The Netherlands
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Kramers K, Stemmer C, Monestier M, van Bruggen MC, Rijke-Schilder TP, Hylkema MN, Smeenk RJ, Muller S, Berden JH. Specificity of monoclonal anti-nucleosome auto-antibodies derived from lupus mice. J Autoimmun 1996; 9:723-9. [PMID: 9115574 DOI: 10.1006/jaut.1996.0094] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Recently, anti-nucleosome antibodies, which do not bind to DNA or to individual histones, have been identified in longitudinal studies in lupus mice. These anti-nucleosome antibodies occur early in spontaneous SLE and are formed prior to other anti-nuclear specificities. However, nucleosomal epitopes are yet to be fully characterized. We selected a panel of six monoclonal anti-nucleosome antibodies (mAbs) (#2, #32, #34, PL2-6, LG8-1 and LG10-1) derived from lupus mice. These mAbs were tested in ELISA on subnucleosome structures and on a panel of 53 histone peptides, covering the entire sequence of the five histones. Two mAbs reacted with one of these peptides, but the reactivity hardly exceeded the background reactivity. Based on the nucleosome and subnucleosome ELISA we identified different recognition patterns. Three mAbs showed the highest reactivity towards the intact nucleosome. For two of them (#32 and LG8-1) the nucleosomal epitope was primarily located on H2A-H2B/DNA, whereas for mAb #34 this primary epitope was located on H3/H4/DNA. Two mAbs (#2 and PL2-6) showed the highest reactivity with H2A-H2B/DNA and one mAb (LG10-1) recognized H3-H4/DNA. In the subnucleosome ELISA all but one (mAb #32) recognized more than one epitope, including DNA complexed to a variety of cationic molecules. Comparing these reactivities we identified for all mAbs one specific nucleosomal epitope, whereas reactivity with other subnucleosomes was comparable to the reactivity towards DNA complexed with cationic molecules. In inhibition experiments both in ELISA and in immunofluorescence it was found that only one of the mAbs (i.e. PL2-6), recognizing an epitope on H2A-H2B/DNA as primary epitope, could be inhibited by H2A-H2B/DNA in fluid phase. The two mAbs recognizing an epitope on H3-H4/DNA as primary epitope could be inhibited by H3-H4/DNA in fluid phase. From these analyses, we conclude first that for these nucleosome specific mAbs linear histone peptides are not very important. Second, that these mAbs all recognize different epitopes on both H2A/H2B-DNA and H3/H4-DNA and third that some solid phase H2A/H2B-DNA epitopes are not expressed on fluid phase H2A/H2B-DNA. Our findings suggest that in SLE the nucleosome can act as auto-antigen and that there is no immunodominant beta cell epitope within the nucleosome.
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Affiliation(s)
- K Kramers
- Division of Nephrology, University Hospital Nijmegen, The Netherlands
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Smeenk RJ, Aarden LA, Swaak TJ. Laboratory tests as predictors of disease exacerbations in systemic lupus erythematosus: comment on the article by Esdaile et al. Arthritis Rheum 1996; 39:2083-5. [PMID: 8961919 DOI: 10.1002/art.1780391225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Swaak AJ, Smeenk RJ. Following the disease course in systemic lupus erythematosus: are serologic variables of any use? J Rheumatol 1996; 23:1842-4. [PMID: 8923353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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van Bruggen MC, Walgreen B, Rijke TP, Corsius MJ, Assmann KJ, Smeenk RJ, van Dedem GW, Kramers K, Berden JH. Heparin and heparinoids prevent the binding of immune complexes containing nucleosomal antigens to the GBM and delay nephritis in MRL/lpr mice. Kidney Int 1996; 50:1555-64. [PMID: 8914022 DOI: 10.1038/ki.1996.471] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Monoclonal anti-nucleosome antibodies (mAbs) complexed to nucleosomal antigens can bind to DNA and to heparan sulfate (HS) in ELISA and to the GBM in vivo in a rat renal perfusion system, whereas non-complexed mAbs do not bind [1]. In this study, we analyzed whether heparin (HEP) or N-desulfated/acetylated heparins (DSA-HEP), structurally and functionally strongly related to HS, are able to prevent the binding of these complexed mAbs to DNA and to HS in vitro and to rat GBM in vivo. In ELISA the binding of nucleosome complexed antinucleosome antibodies to DNA and HS was inhibited dose-dependently by HEP, DSA-HEP and low molecular weight (LMW) DSA-HEP. Intravenous injection of nucleosome/anti-nucleosome immune complexes without heparin/heparinoids in BALB/c mice led to GBM binding, while simultaneous injection of heparin/heparinoids with complexed antibodies or pretreatment with heparin subcutaneously prior to injection of complexes prevented this binding. Subsequently, we tested the preventive effect of HEP, DSA-HEP and LMW-DSA-HEP on progression of renal disease in MRL/lpr mice. Treatment was started at an age of eight weeks in a dose of 50 micrograms daily. With all three drugs albuminuria was significantly delayed compared to PBS treated controls (cumulative incidence of proteinuria at 20 weeks in controls 60% vs. 13%, 14% and 6% respectively for HEP, DSA-HEP and LMW-DSA-HEP; P < 0.05). At week 21 the glomerulonephritis was histologically less severe in heparin/heparinoid treated animals (P = 0.02). In immunofluorescence the amount of immunoglobulin and C3 deposits in the glomerular capillary wall tended to be less in heparin/heparinoid treated mice compared to PBS treated controls (P = 0.07). Furthermore, at 20 weeks anti-HS levels in plasma of heparin/heparinoid treated mice were significantly lower (P < 0.05). We conclude that interaction of heparin or heparin analogs with HS reactive immune complexes containing nucleosomal antigens prevents the binding of these immune complexes to the GBM and delays nephritis in MRL/lpr mice.
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Affiliation(s)
- M C van Bruggen
- Department of Pathology, University Hospital Nijmegen, The Netherlands
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van der Pouw Kraan TC, Boeije LC, Snijders A, Smeenk RJ, Wijdenes J, Aarden LA. Regulation of IL-12 production by human monocytes and the influence of prostaglandin E2. Ann N Y Acad Sci 1996; 795:147-57. [PMID: 8958925 DOI: 10.1111/j.1749-6632.1996.tb52663.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- T C van der Pouw Kraan
- The Netherlands, Red Cross Blood Transfusion Service, Department of Auto-immune Diseases, Amsterdam, The Netherlands
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van Bruggen MC, Kramers C, Hylkema MN, Smeenk RJ, Berden JH. Significance of anti-nuclear and anti-extracellular matrix autoantibodies for albuminuria in murine lupus nephritis; a longitudinal study on plasma and glomerular eluates in MRL/l mice. Clin Exp Immunol 1996; 105:132-9. [PMID: 8697621 PMCID: PMC2200474 DOI: 10.1046/j.1365-2249.1996.d01-731.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The relationship between autoantibody reactivities and nephritis in systemic lupus erythematosus (SLE) is unclear. We studied MRL/l mice which developed a considerable albuminuria (either mice with short ( < 1 week) or heavy and prolonged (3 weeks) albuminuria) and compared them with non-albuminuric age-matched controls, with young (12 weeks old) non-albuminuric mice and with mice which were followed for 36 weeks and did not develop albuminuria. In a longitudinal prospective study on plasma samples we correlated a variety of anti-nuclear reactivities and reactivities against extracellular matrix (ECM) components, with the onset of albuminuria. We found that at the onset of albuminuria, anti-DNA was higher while anti-nucleosome and anti-H2A/H2B-DNA subnucleosome reactivities were lower compared with age-matched non-albuminuric mice. We also studied glomerular eluates of these mice in ELISA and in indirect immunofluorescence (IF). In the eluates we found with IF that anti-glomerular basement membrane (GBM)-tubular basement membrane (TBM) antibodies were already present in 12-week-old non-albuminuric mice. These eluates showed no anti-nuclear antibodies. In eluates of albuminuric mice more immunoglobulin was deposited, and anti-ECM, anti-DNA and anti-nucleosome reactivities were higher than in eluates of age-matched non-albuminuric mice. The deposition of anti-nucleosome antibodies preceded the deposition of anti-DNA antibodies since they were deposited to a greater extent in mice with a short albuminuria. We conclude that anti-GBM-TBM antibodies are the first autoantibodies that deposit in glomeruli of MRL/l mice at an early age. The onset of albuminuria is associated with additional deposition of both anti-ECM and anti-nuclear (anti-nucleosome and anti-DNA) antibodies, but the difference with non-albuminuric mice seems to be more quantitative than qualitative.
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Affiliation(s)
- M C van Bruggen
- Division of Nephrology, University Hospital Nijmegen, The Netherlands
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Kramers K, van Bruggen MC, Rijke-Schilder TP, Dijkman HB, Hylkema MN, Croes HJ, Fransen JA, Assmann KJ, Tax WJ, Smeenk RJ, Berden JH. In vivo ANA is a fixation artifact: nucleosome-complexed antinucleosome autoantibodies bind to the cell surface and are internalized. J Am Soc Nephrol 1996; 7:946-54. [PMID: 8793805 DOI: 10.1681/asn.v76946] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
It has been suggested that binding of anti-double-standed DNA antibodies to cell surfaces, followed by internalization and nuclear binding (so called in vivo ANA) is of pathophysiological significance for tissue damage in systemic lupus erythematosus. We have shown before that pathogenic antinuclear antibodies complexed to nucleosomal antigens can bind to heparan sulfate in the glomerular basement membrane in vivo. Because nucleosomes are also reported to bind to the cell surface, we hypothesized that in vivo ANA is a property of antinuclear antibodies bound to nucleosomal antigens. Therefore, we studied three antinucleosome monoclonal antibodies (mAb) that exhibit in vivo ANA as seen by immunofluorescence in mice inoculated intraperitoneally with the hybridoma producing the mAb. The same mAb complexed to nucleosomal antigens after intravenous injection into mice induced in vivo ANA, in contrast to purified noncomplexed mAb. To study this in more detail, we incubated complexed mAb with various cell lines and found binding to the cell surface and subsequent internalization into cytoplasmic vesicles. However, no binding to the nucleus was observed by immunoelectron microscopy (IEM) and confocal laser microscopy. Noncomplexed mAb did not bind to the cell surface. Next, from mice bearing the hybridomas producing the mAb intraperitoneally, a small part of the kidney was snap frozen in liquid N2, fixed with acetone, and studied in immunofluorescence, whereas the remaining part of the kidney was fixed in vivo by renal perfusion with a mixture of 0.01 M sodium periodate, 0.075 M lysine HCl, 0.0375 M Na2HPO4, and 2% paraformaldehyde (PLP) and studied in both immunofluorescence and IEM. In the acetone-fixed kidney sections obtained without in vivo fixation we again observed in vivo ANA. However, after in vivo PLP perfusion fixation, no nuclear binding was found. In IEM, localization in cytoplasmic vesicles was seen. In conclusion, antinucleosome antibodies complexed to nucleosomal antigens can bind to the cell surface and are transported into the cytoplasm, but do not bind to the nucleus. The reported nuclear localization of antinuclear antibodies is caused by a fixation artifact.
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Affiliation(s)
- K Kramers
- Department of Nephrology, University Hospital, Nijmegen, The Netherlands
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Hylkema MN, van Bruggen MC, van de Lagemaat R, Kramers K, Berden JH, Smeenk RJ. Heparan sulfate staining of the glomerular basement membrane in relation to circulating anti-DNA and anti-heparan sulfate reactivity: a longitudinal study in NZB/W F1 mice. J Autoimmun 1996; 9:41-50. [PMID: 8845053 DOI: 10.1006/jaut.1996.0006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Reactivity of serum antibodies with heparan sulfate (HS) has been associated with human and murine lupus nephritis, although the aetiological significance of this association is not clear. Recent work from our laboratories showed that binding of these antibodies to HS could be mediated by histone containing immune complexes. In human lupus nephritis we found a strong decrease in HS staining in the glomerular basement membrane (GBM). The aim of this study was to elucidate the correlation in experimental systemic lupus erythematosus (SLE) between albuminuria, staining of HS in the GBM and anti-DNA and anti-HS reactivity in plasma. We therefore studied NZB/W F1 mice during different stages of glomerular disease and compared them with age matched control NZB/W F1 mice without albuminuria. Anti-DNA and anti-HS reactivity were measured in longitudinally collected plasma samples and correlated with the onset of albuminuria, staining of HS in the glomerular basement membrane and deposition of immunoglobulins (Ig). HS staining was significantly decreased in the glomerular capillary loops of mice with prolonged proteinuria in comparison with age matched control mice (P = 0.0013). This decreased HS staining was correlated with increased Ig deposition in the capillary loops (tau = -0.42, P < 0.001), albuminuria (tau = -0.508, P < 0.001) and a decreased in anti-DNA levels measured in plasma (tau = 0.758, P < 0.005). Altered anti-HS reactivity in plasma did correlate with increased Ig deposition in the kidney (tau = 0.33, P < 0.05) but was not correlated with decreased staining of HS in the kidney. In conclusion, our study demonstrates that disappearance of staining of HS in the glomerular capillary loops is associated with albuminuria, increased Ig deposition in the glomerulus and decreased anti-DNA reactivity in plasma. Our findings are compatible with a model in which interaction ('masking') of HS with immune complexes consisting of anti-DNA antibodies and nucleosomes takes place.
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Affiliation(s)
- M N Hylkema
- Department of Autoimmune Diseases, Central Laboratory of the Netherlands Red Cross Blood Transfusion Service (C.L.B.), Amsterdam, The Netherlands
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Affiliation(s)
- A A Kruize
- Dept of Internal Medicine, University Hospital Utrecht, The Netherlands
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