1
|
Liu M, Guo T, Ma Z, Du L, Hou J, Tian Y, Meng M, Chen X. Correlation Between N-Demethyl Imatinib Trough Concentration and Serious Adverse Reactions in Patients with Gastrointestinal Stromal Tumors: A Retrospective Cohort Study. Ther Drug Monit 2024; 46:344-350. [PMID: 38176855 DOI: 10.1097/ftd.0000000000001160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 06/04/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Imatinib is the first-line treatment for gastrointestinal stromal tumors; however, the clinical prognosis and adverse reactions of patients vary owing to individualized discrepancies in plasma exposure. METHODS To determine the safe interval for steady-state plasma trough concentrations (C min ) of imatinib and its active metabolite, N-demethyl imatinib (NDI), 328 plasma samples from 273 patients treated with imatinib were retrospectively analyzed. Imatinib C min and NDI C min were tested, and adverse reactions were recorded. The association between imatinib C min , NDI C min , and serious adverse reactions was evaluated. RESULTS The C min range of imatinib was 209.5-4950.0 ng/mL, with the mean value and SD of 1491.8 ± 731.4 ng/mL. The C min range of NDI was 80.0-2390.0 ng/mL with the mean value and SD of 610.8 ± 281.5 ng/mL. NDI C min was positively correlated with imatinib C min , whereas the ratio of NDI C min to imatinib C min (NDI C min /imatinib C min ) was negatively correlated with imatinib C min . Univariate logistic regression analysis demonstrated that the treatment objective, daily dose, imatinib C min , NDI C min , and imatinib C min + NDI C min were significantly associated with serious adverse reactions. Multivariate logistic regression analysis showed that NDI C min was an independent risk factor for serious adverse reactions, with a threshold of 665 ng/mL. CONCLUSIONS NDI C min was an independent risk factor for serious adverse reactions, with a threshold of 665 ng/mL. Monitoring NDI C min was beneficial for the rational application of imatinib and individualized treatment of patients with gastrointestinal stromal tumors.
Collapse
Affiliation(s)
- Mingfeng Liu
- Department of Pharmacy, the Fourth Hospital of Hebei Medical University, Hebei Key Laboratory of Clinical Pharmacy, Shijiazhuang City, Hebei Province, China; and
| | - Teng Guo
- Department of Pharmacy, the Fourth Hospital of Hebei Medical University, Hebei Key Laboratory of Clinical Pharmacy, Shijiazhuang City, Hebei Province, China; and
| | - Zhixue Ma
- Third Department of Surgery, the Fourth Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province, China
| | - Liying Du
- Department of Pharmacy, the Fourth Hospital of Hebei Medical University, Hebei Key Laboratory of Clinical Pharmacy, Shijiazhuang City, Hebei Province, China; and
| | - Juan Hou
- Department of Pharmacy, the Fourth Hospital of Hebei Medical University, Hebei Key Laboratory of Clinical Pharmacy, Shijiazhuang City, Hebei Province, China; and
| | - Yuan Tian
- Third Department of Surgery, the Fourth Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province, China
| | - Meng Meng
- Department of Pharmacy, the Fourth Hospital of Hebei Medical University, Hebei Key Laboratory of Clinical Pharmacy, Shijiazhuang City, Hebei Province, China; and
| | - Xinran Chen
- Department of Pharmacy, the Fourth Hospital of Hebei Medical University, Hebei Key Laboratory of Clinical Pharmacy, Shijiazhuang City, Hebei Province, China; and
| |
Collapse
|
2
|
Cheng F, Cui Z, Li Q, Chen S, Li W, Zhang Y. Influence of genetic polymorphisms on imatinib concentration and therapeutic response in patients with chronic-phase chronic myeloid leukemia. Int Immunopharmacol 2024; 133:112090. [PMID: 38640718 DOI: 10.1016/j.intimp.2024.112090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 04/11/2024] [Accepted: 04/11/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Diminished bioavailability of imatinib in leukemic cells contributes to poor clinical response. We examined the impact of genetic polymorphisms of imatinib on the pharmacokinetics and clinical response in 190 patients with chronic myeloid leukaemia (CML). METHODS Single nucleotide polymorphisms were genotyped using pyrophosphate sequencing. Plasma trough levels of imatinib were measured using liquid chromatography-tandem mass spectrometry. RESULTS Patients carrying the TT genotype for ABCB1 (rs1045642, rs2032582, and rs1128503), GG genotype for CYP3A5-rs776746 and AA genotype for ABCG2-rs2231142 polymorphisms showed higher concentration of imatinib. Patients with T allele for ABCB1 (rs1045642, rs2032582, and rs1128503), A allele for ABCG2-rs2231142, and G allele for CYP3A5-rs776746 polymorphisms showed better cytogenetic response and molecular response. In multivariate analysis, carriers of the CYP3A5-rs776746 G allele exhibited higher rates of complete cytogenetic response (CCyR) and major molecular response (MMR). Similarly, patients with the T allele of ABCB1-rs1045642 and rs1128503 demonstrated significantly increased CCyR rates. Patients with the A allele of ABCG2-rs2231142 were associated with higher MMR rates. The AA genotype for CYP3A5-rs776746, and the CC genotype for ABCB1-rs104562, and rs1128503 polymorphisms were associated with a higher risk of imatinib failure. Patients with the G allele for CYP3A5-rs776746 exhibited a higher incidence of anemia, and T allele for ABCB1-rs2032582 demonstrated an increased incidence of diarrhea. CONCLUSIONS Genotyping of ABCB1, ABCG2, and CYP3A5 genes may be considered in the management of patients with CML to tailor therapy and optimize clinical outcomes.
Collapse
Affiliation(s)
- Fang Cheng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Zheng Cui
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Qiang Li
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Shi Chen
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China.
| | - Weiming Li
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - Yu Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China.
| |
Collapse
|
3
|
Chen L, Zhang Y, Zhang YX, Wang WL, Sun DM, Li PY, Feng XS, Tan Y. Pretreatment and analysis techniques development of TKIs in biological samples for pharmacokinetic studies and therapeutic drug monitoring. J Pharm Anal 2024; 14:100899. [PMID: 38634061 PMCID: PMC11022103 DOI: 10.1016/j.jpha.2023.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 10/26/2023] [Accepted: 11/15/2023] [Indexed: 04/19/2024] Open
Abstract
Tyrosine kinase inhibitors (TKIs) have emerged as the first-line small molecule drugs in many cancer therapies, exerting their effects by impeding aberrant cell growth and proliferation through the modulation of tyrosine kinase-mediated signaling pathways. However, there exists a substantial inter-individual variability in the concentrations of certain TKIs and their metabolites, which may render patients with compromised immune function susceptible to diverse infections despite receiving theoretically efficacious anticancer treatments, alongside other potential side effects or adverse reactions. Therefore, an urgent need exists for an up-to-date review concerning the biological matrices relevant to bioanalysis and the sampling methods, clinical pharmacokinetics, and therapeutic drug monitoring of different TKIs. This paper provides a comprehensive overview of the advancements in pretreatment methods, such as protein precipitation (PPT), liquid-liquid extraction (LLE), solid-phase extraction (SPE), micro-SPE (μ-SPE), magnetic SPE (MSPE), and vortex-assisted dispersive SPE (VA-DSPE) achieved since 2017. It also highlights the latest analysis techniques such as newly developed high performance liquid chromatography (HPLC) and high-resolution mass spectrometry (HRMS) methods, capillary electrophoresis (CE), gas chromatography (GC), supercritical fluid chromatography (SFC) procedures, surface plasmon resonance (SPR) assays as well as novel nanoprobes-based biosensing techniques. In addition, a comparison is made between the advantages and disadvantages of different approaches while presenting critical challenges and prospects in pharmacokinetic studies and therapeutic drug monitoring.
Collapse
Affiliation(s)
- Lan Chen
- School of Pharmacy, China Medical University, Shenyang, 110122, China
| | - Yuan Zhang
- School of Pharmacy, China Medical University, Shenyang, 110122, China
| | - Yi-Xin Zhang
- School of Pharmacy, China Medical University, Shenyang, 110122, China
| | - Wei-Lai Wang
- School of Pharmacy, China Medical University, Shenyang, 110122, China
| | - De-Mei Sun
- School of Pharmacy, China Medical University, Shenyang, 110122, China
| | - Peng-Yun Li
- Institute of Pharmacology and Toxicology Institution, National Engineering Research Center for Strategic Drugs, Beijing, 100850, China
| | - Xue-Song Feng
- School of Pharmacy, China Medical University, Shenyang, 110122, China
| | - Yue Tan
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, 110022, China
| |
Collapse
|
4
|
Shao X, Wu H, Huang C, Yin H, Wang P, Wu X. The correlation of sarcopenia and adverse events of imatinib therapy postoperatively in gastrointestinal stromal tumor through computed tomography quantitative body composition. J Gastrointest Surg 2024; 28:375-380. [PMID: 38583886 DOI: 10.1016/j.gassur.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/22/2023] [Accepted: 01/19/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE This study aimed to investigate the correlation between sarcopenia and adverse events (AEs) of postoperative imatinib therapy through computed tomography (CT) quantitative body composition for intermediate- and high-risk gastrointestinal stromal tumors (GISTs). METHODS The study retrospectively analyzed the clinical data of 208 patients with intermediate- and high-risk GIST treated surgically and treated with imatinib afterward at the First Affiliated Hospital of Wenzhou Medical University between October 2011 and October 2021. Images of preoperative CT scans within 1 month were used to determine the body composition of the patients. On the basis of the L3 skeletal muscle index, patients were classified into sarcopenia and nonsarcopenia groups. In 2 groups, AEs related to imatinib were analyzed. RESULTS The proportion of AEs related to imatinib in the sarcopenia group was higher, and this disparity had a significant statistical significance (P = .013). Sarcopenia was significantly associated with hemoglobin reduction compared with nonsarcopenia (P = .015). There was a significant difference between the sarcopenia group and the nonsarcopenia group in the ratio of severe AEs (grades 3-4). Hemoglobin content (odds ratio [OR], 0.981; 95% CI, 0.963-1.000; P = .045), sex (OR, 0.416; 95% CI, 0.192-0.904; P = .027), and sarcopenia (OR, 5.631; 95% CI, 2.262-14.014; P < .001) were the influential factors of imatinib severe AEs in patients with intermediate- and high-risk GIST within 1 year after imatinib treatment. CONCLUSION Patients with preoperative sarcopenia have a higher incidence and severity of AEs during adjuvant imatinib therapy.
Collapse
Affiliation(s)
- Xinyi Shao
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Hao Wu
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Chen Huang
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Hanyu Yin
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Pengfei Wang
- Department of General Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xiaoli Wu
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.
| |
Collapse
|
5
|
Ran P, Tan T, Li J, Yang H, Li J, Zhang J. Advanced gastrointestinal stromal tumor: reliable classification of imatinib plasma trough concentration via machine learning. BMC Cancer 2024; 24:264. [PMID: 38402382 PMCID: PMC10894477 DOI: 10.1186/s12885-024-11930-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/29/2024] [Indexed: 02/26/2024] Open
Abstract
AIM Patients with advanced gastrointestinal stromal tumors (GISTs) exhibiting an imatinib plasma trough concentration (IM Cmin) under 1100 ng/ml may show a reduced drug response rate, leading to the suggestion of monitoring for IM Cmin. Consequently, the objective of this research was to create a customized IM Cmin classification model for patients with advanced GISTs from China. METHODS Initial data and laboratory indicators from patients with advanced GISTs were gathered, and the above information was segmented into a training set, validation set, and testing set in a 6:2:2 ratio. Key variables associated with IM Cmin were identified to construct the classification model using the least absolute shrinkage and selection operator (LASSO) regression and forward stepwise binary logistic regression. Within the training and validation sets, nine ML classification models were constructed via the resampling method and underwent comparison through the Brier scores, the areas under the receiver-operating characteristic curve (AUROC), the decision curve, and the precision-recall (AUPR) curve to determine the most suitable model for this dataset. Two methods of internal validation were used to assess the most suitable model's classification performance: tenfold cross-validation and random split-sample validation (test set), and the value of the test set AUROC was used to evaluate the model's classification performance. RESULTS Six key variables (gender, daily IM dose, metastatic site, red blood cell count, platelet count, and percentage of neutrophils) were ultimately selected to construct the classification model. In the validation set, it is found by comparison that the Extreme Gradient Boosting (XGBoost) model has the largest AUROC, the lowest Brier score, the largest area under the decision curve, and the largest AUPR value. Furthermore, as evaluated via internal verification, it also performed well in the test set (AUROC = 0.725). CONCLUSION For patients with advanced GISTs who receive IM, initial data and laboratory indicators could be used to accurately estimate whether the IM Cmin is below 1100 ng/ml. The XGBoost model may stand a chance to assist clinicians in directing the administration of IM.
Collapse
Affiliation(s)
- Pan Ran
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Tao Tan
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Jinjin Li
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Hao Yang
- Department of Internal Medicine, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Juan Li
- Department of Pharmacy, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
| | - Jun Zhang
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
| |
Collapse
|
6
|
Teranishi R, Takahashi T, Nishida T, Kurokawa Y, Nakajima K, Koh M, Nishigaki T, Saito T, Yamamoto K, Yamashita K, Tanaka K, Makino T, Motoori M, Omori T, Hirota S, Hayashi Y, Takehara T, Eguchi H, Doki Y. Plasma trough concentration of imatinib and its effect on therapeutic efficacy and adverse events in Japanese patients with GIST. Int J Clin Oncol 2023; 28:680-687. [PMID: 36971916 DOI: 10.1007/s10147-023-02325-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/01/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Imatinib mesylate (IM) is the standard chemotherapy for patients with gastrointestinal stromal tumors (GISTs) and has a favorable safety profile. Pharmacokinetics (PK), such as plasma trough concentration (Cmin), varies among patients, requiring the need for therapeutic drug monitoring (TDM) during IM administration. Despite some reports from overseas, the relationship between Cmin, adverse events (AEs), and treatment efficacy in Japanese patients with GIST has still been lacking. This study aimed to investigate the relationship between IM plasma concentration and AEs in Japanese patients with GISTs. METHODS This retrospective study analyzed the data of 83 patients who underwent IM treatment for GISTs at our institution between May 2002 and September 2021. RESULTS The IM Cmin was associated with any grade of AEs (with AEs vs. without AEs = 1294 (260-4075) vs. 857 (163-1886) ng/mL, P < 0.001), edema (with edema vs. without edema = 1278 (634-4075) vs. 1036 (163-4069) ng/mL, P = 0.017), and fatigue (with fatigue vs. without fatigue = 1373 (634-4069) vs. 1046 (163-4075) ng/mL, P = 0.044). Moreover, a Cmin ≥ 1283 ng/mL was a risk factor for severe AEs. The median progression-free survival (PFS) was 3.04 years in the lowest Cmin tertile (T1, < 917 ng/mL) compared with 5.90 years for T2 and T3 (P = 0.010). CONCLUSION Edema and fatigue are potentially associated with IM plasma trough concentrations of ≥ 1283 ng/mL in Japanese patients with GISTs. Further, maintaining an IM plasma trough concentration above 917 ng/mL may improve PFS.
Collapse
|
7
|
Huang S, Liu X, Guo X, Wu H, Lu H, Pan Z, Cai S, Wu X, Zhang X. Sunitinib versus imatinib dose escalation after failure of imatinib standard dose in patients with advanced Gastrointestinal stromal tumors - a real-world multi-center study. Transl Oncol 2023; 30:101641. [PMID: 36791510 PMCID: PMC9950928 DOI: 10.1016/j.tranon.2023.101641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 01/28/2023] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Whether to escalate imatinib dosage or directly switch to sunitinib in gastrointestinal stromal tumors (GISTs) failing on standard dose 400 mg/d of imatinib is still controversial. METHODS We evaluated progression-free survival (PFS), overall survival (OS), and time to sunitinib failure (TTSF) of patients selecting imatinib dose escalation or directly switching to sunitinib after the failure of imatinib 400 mg/d therapy from 3 tertery referring centers between January 2008 to December 2016. RESULTS A total of 240 patients receiving sunitinib (37.5 mg continuous daily dose or 50 mg 4 weeks on with 2 weeks off) for at least 8 weeks were examined. After failure on imatinib 400 mg/d, 100 (49.3%) patients had dose escalation to 600 mg or 800 mg per day (IM group, imatinib group), and 103 (50.7%) directly switched to sunitinib (SU group, sunitinib group). The PFS in the SU and IM groups was 12 months and 5.0 months (P < 0.001), respectively. TTSF or OS in both groups was not statistically significantly different. CONCLUSIONS After the progression of imatinib standard-dose treatment in recurrent/metastatic GISTs, the PFS of patients directly switching to sunitinib was significantly longer compared with the PFS of patients with imatinib dose escalation. However, when the patients continued with sunitinib therapy after the failure of IM dose escalation, TTSF and OS in the IM group were similar to those in the SU group. Further exploration of the characteristics of the population benefiting from imatinib dose escalation are warranted.
Collapse
Affiliation(s)
- Shaoqing Huang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xing Liu
- Department of Gastric Surgery, Affiliated Union Hospital, Fujian Medical University, Fuzhou China
| | - Xiaodan Guo
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hui Wu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Huishan Lu
- Department of Colorectal Surgery, Affiliated Union Hospital, Fujian Medical University, Fuzhou China
| | - Zhizhong Pan
- Department of Colorectal Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Shirong Cai
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaojun Wu
- Department of Colorectal Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, China.
| | - Xinhua Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| |
Collapse
|
8
|
The Application of Virtual Therapeutic Drug Monitoring to Assess the Pharmacokinetics of Imatinib in a Chinese Cancer Population Group. J Pharm Sci 2023; 112:599-609. [PMID: 36202248 DOI: 10.1016/j.xphs.2022.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/28/2022] [Accepted: 09/28/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Imatinib is used in gastrointestinal stromal tumours (GIST) and chronic myeloid leukaemia (CML). Oncology patients demonstrate altered physiology compared to healthy adults, e.g. reduced haematocrit, increased α-1 acid glycoprotein, decreased albumin and reduced glomerular filtration rate (GFR), which may influence imatinib pharmacokinetics. Given that Chinese cancer patients often report raised imatinib plasma concentrations and wider inter-individual variability reported in trough concentration when compared to Caucasian cancer patients, therapeutic drug monitoring (TDM) has been advocated. METHOD This study utilised a previously validated a Chinese cancer population and assessed the impact of imatinib virtual-TDM in Chinese and Caucasian cancer populations across a dosing range from 200-800 mg daily. RESULTS Staged dose titration to 800 mg daily, resulted in recapitulation to within the target therapeutic range for 50 % (Chinese) and 42.1% (Caucasian) subjects possessing plasma concentration < 550 ng/mL when dosed at 400 mg daily. For subjects with plasma concentrations >1500 ng/mL when dosed at 400 mg daily, a dose reduction to 200 mg once daily was able to recover 67 % (Chinese) and 87.4 % (Caucasian) patients to the target therapeutic range. CONCLUSION Virtual TDM highlights the benefit of pharmacokinetic modelling to optimising treatments in challenging oncology population groups.
Collapse
|
9
|
Jiang X, Fu Q, Jing Y, Kong Y, Liu H, Peng H, Rexiti K, Wei X. Personalized Dose of Adjuvant Imatinib in Patients with Gastrointestinal Stromal Tumors: Results from a Population Pharmacokinetic Analysis. Drug Des Devel Ther 2023; 17:809-820. [PMID: 36942304 PMCID: PMC10024496 DOI: 10.2147/dddt.s400986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 03/06/2023] [Indexed: 03/15/2023] Open
Abstract
Purpose Imatinib is the first-line treatment for patients with gastrointestinal stromal tumors (GIST) after surgery. However, its pharmacokinetic profile varies remarkably between individuals and has not been well characterized in postoperative Chinese patients with GIST. Therefore, this study aimed to develop a population pharmacokinetic (PPK) model and recommend appropriate doses for different patients to achieve the target trough concentration in such a population. Patients and Methods A total of 110 surgically treated GIST patients were enrolled, of which 85 were applied to conduct a PPK analysis with a nonlinear mixed-effect model and 25 for external validation of the model. Demographic and biomedical covariates, as well as six single nucleotide polymorphisms were tested to explore the sources of variation in pharmacokinetic parameters of imatinib. Monte Carlo simulations were performed to establish the initial dosing regimens. Results A one-compartment model was established in postoperative GIST patients. The red blood cell count (RBC) and ABCG2 rs2231142 were observed to have a significant effect on the clearance of imatinib. The typical values estimated by the final model were 9.72 L/h for clearance (CL/F) and 229 L for volume of distribution (V/F). Different from the fixed dose regimen of 400 mg each day, patients carrying rs2231142 heterozygous type and with a lower level of RBC (2.9 × 1012/L), 300 mg imatinib daily is enough to achieve the target trough concentration. When RBC rises to 4.9 × 1012/L, 500 mg daily is recommended. For patients with rs2231142 GG genotype, 500 mg a day is required at RBCs of 3.9 × 1012/L and 4.9 × 1012/L. Conclusion RBC and rs2231142 contribute to the pharmacokinetic variation of imatinib and personalized dose recommendations based on patient characteristics may be necessary.
Collapse
Affiliation(s)
- Xuehui Jiang
- School of Pharmacy, Nanchang University, Nanchang, People’s Republic of China
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Qun Fu
- Jiangxi Provincial Drug Inspector Center, Jiangxi Provincial Drug Administration, Nanchang, People’s Republic of China
| | - Yan Jing
- Department of Pharmacy, Linyi Central Hospital, Linyi, People’s Republic of China
| | - Ying Kong
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Hong Liu
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Hongwei Peng
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Kaisaner Rexiti
- School of Pharmacy, Nanchang University, Nanchang, People’s Republic of China
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Xiaohua Wei
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
- Correspondence: Xiaohua Wei, Department of Pharmacy, The First Affiliated Hospital of Nanchang University, No. 17 Yong Wai Zheng Street, Nanchang, 330006, People’s Republic of China, Tel +86 13803523639, Email
| |
Collapse
|
10
|
Cheng F, Zeng F, Li Q, Cui Z, Chen Y, Li W, Zhang Y. Imatinib dose optimization based on therapeutic drug monitoring in Chinese patients with chronic-phase chronic myeloid leukemia. Cancer 2022; 128:3951-3958. [PMID: 36181667 DOI: 10.1002/cncr.34478] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/05/2022] [Accepted: 08/15/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Imatinib treatment often produces various adverse reactions in patients with chronic myeloid leukemia (CML), and increasing patients are pursuing dose optimization. In this study, the authors aimed to explore imatinib dose optimization based on therapeutic drug monitoring (TDM) in CML patients. METHODS The relationship between imatinib concentration and clinical response and adverse reactions was evaluated, then the dose-reduction data in 110 Chinese CML patients was also explored. RESULTS Patients with a major molecular response (MMR) had higher imatinib plasma concentration compared with those not achieving MMR (1473.70 ± 419.13 vs. 985.8 ± 213.32 ng/ml) when receiving 400 mg daily. Imatinib concentration >1000 ng/ml predicted improved event-free survival and failure-free survival. In addition, imatinib concentration was significantly correlated with leukopenia or neutropenia, diarrhea, edema, and rash. Patients receiving imatinib concentration >1685 ng/ml were more susceptible to diarrhea and those with levels >1575 ng/ml were more susceptible to periorbital and limb edema. Thirty-nine (35.5%) patients underwent low-dose therapy and seven (6.4%) patients received discontinuation therapy. Patients with a higher imatinib concentration were more likely to maintain MMR or deep molecular response after dose reduction. No significant difference in molecular relapse-free survival rate was observed between the low-dose and standard-dose groups over 1 year and 2 years. Furthermore, most adverse reactions significantly improved after dose reduction. CONCLUSIONS Imatinib concentration was closely associated with clinical response and adverse reactions, suggesting that dose optimization based on TDM might achieve beneficial clinical outcomes. Dose reduction based on TDM is feasible and safe for patients exhibiting optimal response, which could improve adverse reactions.
Collapse
Affiliation(s)
- Fang Cheng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Fang Zeng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Qiang Li
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Zheng Cui
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Yilin Chen
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weiming Li
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| |
Collapse
|
11
|
Elsbernd A, Boulouadnine B, Ahmed A, Farooqi M, Sandritter T, Shakhnovich V, Blanding D, Demoulin JB, Thompson J. Novel Oncogenic PDGFRB Variant in Severe Infantile Myofibromatosis With Response to Imatinib Using Therapeutic Drug Monitoring. JCO Precis Oncol 2022; 6:e2200250. [DOI: 10.1200/po.22.00250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Abbey Elsbernd
- Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, MO
| | | | - Atif Ahmed
- Department of Laboratory Medicine and Pathology, Seattle Children's Hospital, Seattle, WA
| | - Midhat Farooqi
- Department of Pathology & Laboratory Medicine, Children's Mercy Hospitals and Clinics, Kansas City, MO
- Department of Pathology, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Tracy Sandritter
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Hospitals and Clinics, Kansas City, MO
| | - Valentina Shakhnovich
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Hospitals and Clinics, Kansas City, MO
- Division of Gastroenterology, Hepatology & Nutrition, Children's Mercy Hospitals and Clinics, Kansas City, MO
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Darius Blanding
- Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, MO
| | | | - Joel Thompson
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
- Division of Pediatric Hematology/Oncology/BMT, Children's Mercy Hospitals and Clinics, Kansas City, MO
| |
Collapse
|
12
|
Zhao Z, Yin XN, Wang J, Chen X, Cai ZL, Zhang B. Prognostic significance of hemoglobin, albumin, lymphocyte, platelet in gastrointestinal stromal tumors: A propensity matched retrospective cohort study. World J Gastroenterol 2022; 28:3476-3487. [PMID: 36158264 PMCID: PMC9346454 DOI: 10.3748/wjg.v28.i27.3476] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/19/2022] [Accepted: 06/19/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The combined index of hemoglobin, albumin, lymphocyte, and platelet (HALP) can reflect systemic inflammation and nutritional status simultaneously, with some evidence revealing its prognostic value for some tumors. However, the effect of HALP on recurrence-free survival (RFS) in patients with gastrointestinal stromal tumors (GISTs) has not been reported.
AIM To investigate the prognostic value of HALP in GIST patients.
METHODS Data from 591 untreated patients who underwent R0 resection for primary and localized GISTs at West China Hospital between December 2008 and December 2016 were included. Clinicopathological data, preoperative albumin, blood routine information, postoperative treatment, and recurrence status were recorded. To eliminate baseline inequivalence, the propensity scores matching (PSM) method was introduced. Ultimately, the relationship between RFS and preoperative HALP was investigated.
RESULTS The optimal cutoff value for HALP was determined to be 31.5 by X-tile analysis. HALP was significantly associated with tumor site, tumor size, mitosis, Ki67, National Institutes of Health (NIH) risk category, and adjuvant therapy (all P < 0.001). Before PSM, GIST patients with an increased HALP had a significantly poor RFS (P < 0.001), and low HALP was an independent risk factor for poor RFS [hazard ratio (HR): 0.506, 95% confidence interval (95%CI): 0.291-0.879, P = 0.016]. In NIH high-risk GIST patients, GIST patients with low HALP had a worse RFS than patients with high HALP (P < 0.05). After PSM, 458 GIST patients were identified; those with an increased HALP still had significantly poor RFS after PSM (P < 0.001) and low HALP was still an independent risk factor for poor RFS (HR: 0.558, 95%CI: 0.319-0.976, P = 0.041).
CONCLUSION HALP was significantly correlated with postoperative pathology and postoperative treatment. Furthermore, HALP showed a strong ability to predict RFS in GIST patients who underwent radical resection.
Collapse
Affiliation(s)
- Zhou Zhao
- Department of Gastrointestinal Surgery, Sichuan University West China Hospital, Chengdu 610041, Sichuan Province, China
| | - Xiao-Nan Yin
- Department of Gastrointestinal Surgery, Sichuan University West China Hospital, Chengdu 610041, Sichuan Province, China
| | - Jian Wang
- Department of Gastrointestinal Surgery, Sichuan University West China Hospital, Chengdu 610041, Sichuan Province, China
| | - Xin Chen
- Department of Gastrointestinal Surgery, Sichuan University West China Hospital, Chengdu 610041, Sichuan Province, China
| | - Zhao-Lun Cai
- Department of Gastrointestinal Surgery, Sichuan University West China Hospital, Chengdu 610041, Sichuan Province, China
| | - Bo Zhang
- Department of Gastrointestinal Surgery, Sichuan University West China Hospital, Chengdu 610041, Sichuan Province, China
| |
Collapse
|
13
|
van de Wal D, Elie M, Le Cesne A, Fumagalli E, den Hollander D, Jones RL, Marquina G, Steeghs N, van der Graaf WTA, Husson O. Health-Related Quality of Life and Side Effects in Gastrointestinal Stromal Tumor (GIST) Patients Treated with Tyrosine Kinase Inhibitors: A Systematic Review of the Literature. Cancers (Basel) 2022; 14:cancers14071832. [PMID: 35406604 PMCID: PMC8997462 DOI: 10.3390/cancers14071832] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The introduction of tyrosine kinase inhibitors (TKIs) has revolutionized the treatment of gastrointestinal stromal tumors (GISTs), resulting in a substantial gain in median overall survival. Subsequently, health-related quality of life (HRQoL) has become more relevant. Here, we systematically review the available literature on HRQoL issues and side effects of different TKIs registered for the treatment of GIST. METHODS A search through five databases was performed. Full reports in English describing HRQoL outcomes and/or side effects in GIST patients on TKI therapy were included. RESULTS A total of 104 papers were included; 13 studies addressed HRQoL, and 96 studies investigated adverse events. HRQoL in patients treated with imatinib, regorafenib, and ripretinib remained stable, whereas most sunitinib-treated patients reported a decrease in HRQoL. Severe fatigue and fear of recurrence or progression were specifically assessed as HRQoL issues and had a negative impact on overall HRQoL as well as psychological and physical well-being. The majority of studies focused on physician-reported side effects. Nearly all GIST patients treated with a TKI experienced at least one adverse event, mostly mild to moderate. CONCLUSIONS Despite the fact that almost all patients treated with a TKI experienced side effects, this did not seem to affect overall HRQoL during TKI therapy. In daily practice, it are the side effects that hamper a patient's HRQoL resulting in treatment adjustments, suggesting that the reported side effects were underestimated by physicians, or the measures used to assess HRQoL do not capture all relevant issues that determine a GIST patient's HRQoL.
Collapse
Affiliation(s)
- Deborah van de Wal
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, 1066 CX Amsterdam, The Netherlands; (D.v.d.W.); (N.S.); (W.T.A.v.d.G.)
| | - Mai Elie
- Department of Medical Oncology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (M.E.); (D.d.H.)
| | - Axel Le Cesne
- Department of Medical Oncology, Gustave Roussy, 94805 Villejuif, France;
| | - Elena Fumagalli
- Department of Medical Oncology, IRCCS Foundation National Cancer Institute, 20133 Milan, Italy;
| | - Dide den Hollander
- Department of Medical Oncology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (M.E.); (D.d.H.)
| | - Robin L. Jones
- Department of Clinical Oncology, The Royal Marsden Hospital and Institute of Cancer Research, London SM2 5 NG, UK;
| | - Gloria Marquina
- Department of Medical Oncology, Hospital Clinico San Carlos, 28040 Madrid, Spain;
| | - Neeltje Steeghs
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, 1066 CX Amsterdam, The Netherlands; (D.v.d.W.); (N.S.); (W.T.A.v.d.G.)
- Department of Clinical Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, 1066 CX Amsterdam, The Netherlands
| | - Winette T. A. van der Graaf
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, 1066 CX Amsterdam, The Netherlands; (D.v.d.W.); (N.S.); (W.T.A.v.d.G.)
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Olga Husson
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, 1066 CX Amsterdam, The Netherlands; (D.v.d.W.); (N.S.); (W.T.A.v.d.G.)
- Department of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Division of Clinical Studies, Institute of Cancer Research, London SM2 5NG, UK
- Correspondence: ; Tel.: +31-614-549-755
| |
Collapse
|
14
|
Real-world data on the efficacy and safety of adjuvant chemotherapy in Japanese patients with a high-risk of gastrointestinal stromal tumor recurrence. Int J Clin Oncol 2022; 27:921-929. [DOI: 10.1007/s10147-022-02135-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 02/01/2022] [Indexed: 12/15/2022]
|
15
|
Zhang M, Liu X, Chen Z, Jiang S, Wang L, Tao M, Miao L. Method development and validation for simultaneous determination of six tyrosine kinase inhibitors and two active metabolites in human plasma/serum using UPLC–MS/MS for therapeutic drug monitoring. J Pharm Biomed Anal 2021; 211:114562. [DOI: 10.1016/j.jpba.2021.114562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 12/21/2021] [Accepted: 12/27/2021] [Indexed: 12/12/2022]
|
16
|
Corral Alaejos Á, Zarzuelo Castañeda A, Jiménez Cabrera S, Sánchez-Guijo F, Otero MJ, Pérez-Blanco JS. External evaluation of population pharmacokinetic models of imatinib in adults diagnosed with chronic myeloid leukaemia. Br J Clin Pharmacol 2021; 88:1913-1924. [PMID: 34705297 DOI: 10.1111/bcp.15122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/29/2021] [Accepted: 10/21/2021] [Indexed: 12/30/2022] Open
Abstract
AIMS Imatinib is considered the standard first-line treatment in newly diagnosed patients with chronic-phase myeloid leukaemia (CML). Several imatinib population pharmacokinetic (popPK) models have been developed. However, their predictive performance has not been well established when extrapolated to different populations. Therefore, this study aimed to perform an external evaluation of available imatinib popPK models developed mainly in adult patients, and to evaluate the improvement in individual model-based predictions through Bayesian forecasting computed by each model at different treatment occasions. METHODS A literature review was conducted through PubMed and Scopus to identify popPK models. Therapeutic drug monitoring data collected in adult CML patients treated with imatinib was used for external evaluation, including prediction- and simulated-based diagnostics together with Bayesian forecasting analysis. RESULTS Fourteen imatinib popPK studies were included for model-performance evaluation. A total of 99 imatinib samples were collected from 48 adult CML patients undergoing imatinib treatment with a minimum of one plasma concentration measured at steady-state between January 2016 and December 2020. The model proposed by Petain et al showed the best performance concerning prediction-based diagnostics in the studied population. Bayesian forecasting demonstrated a significant improvement in predictive performance at the second visit. Inter-occasion variability contributed to reducing bias and improving individual model-based predictions. CONCLUSIONS Imatinib popPK studies developed in Caucasian subjects including α1-acid glycoprotein showed the best model performance in terms of overall bias and precision. Moreover, two imatinib samples from different visits appear sufficient to reach an adequate model-based individual prediction performance trough Bayesian forecasting.
Collapse
Affiliation(s)
| | | | | | - Fermín Sánchez-Guijo
- Institute for Biomedical Research of Salamanca, Salamanca, Spain.,Haematology Department, University Hospital of Salamanca, Salamanca, Spain.,Department of Medicine, University of Salamanca, Salamanca, Spain
| | - María José Otero
- Pharmacy Service, University Hospital of Salamanca, Salamanca, Spain.,Institute for Biomedical Research of Salamanca, Salamanca, Spain
| | - Jonás Samuel Pérez-Blanco
- Department of Pharmaceutical Sciences, Pharmacy Faculty, University of Salamanca, Salamanca, Spain.,Institute for Biomedical Research of Salamanca, Salamanca, Spain
| |
Collapse
|
17
|
Xu H, Liu Q. Individualized Management of Blood Concentration in Patients with Gastrointestinal Stromal Tumors. Onco Targets Ther 2021; 13:13345-13355. [PMID: 33456310 PMCID: PMC7804055 DOI: 10.2147/ott.s279998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/18/2020] [Indexed: 01/29/2023] Open
Abstract
Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor, and surgical resection is the first choice for the treatment of the disease, but since the advent of tyrosine kinase inhibitors (TKIs) such as imatinib (IM), the prognosis of the disease has undergone revolutionary changes. According to the current version of the guidelines, most GIST patients receive a fixed dose without taking into account their own individual differences, resulting in a wide difference in blood concentration, adverse reactions and prognosis. With more studies on the relationship between blood drug concentrations and prognosis, the concept of individualized therapy has been paid more attention by researchers. Therapeutic drug monitoring (TDM) has also been made available for the research field of GIST targeted therapy. How to reduce the incidence of drug resistance and adverse reactions in patients with GISTs has become the focus of the current research. This article reviews the common monitoring methods and timing of TKIs blood concentration, the reasonable range of blood drug concentration, the toxic or adverse effects caused by high blood drug concentration, some possible factors affecting blood drug concentration and recent research progress, in order to discuss and summarize the treatment strategy of individual blood drug concentration, improve the prognosis of patients and reduce the adverse effects as much as possible.
Collapse
Affiliation(s)
- Hao Xu
- Department of Gastrointestinal Surgery, The First Hospital of China Medical University, Shenyang, People's Republic of China
| | - Qi Liu
- Trauma Center, The First Hospital of China Medical University, Shenyang, People's Republic of China
| |
Collapse
|