1
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Toniutto P, Shalaby S, Mameli L, Morisco F, Gambato M, Cossiga V, Guarino M, Marra F, Brunetto MR, Burra P, Villa E. Role of sex in liver tumor occurrence and clinical outcomes: A comprehensive review. Hepatology 2024; 79:1141-1157. [PMID: 37013373 DOI: 10.1097/hep.0000000000000277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/06/2022] [Indexed: 04/05/2023]
Abstract
Clinical research on sex-based differences in the manifestations, pathophysiology, and prevalence of several diseases, including those affecting the liver, has expanded considerably in recent years. Increasing evidence suggests that liver diseases develop, progress, and respond to treatment differently depending on the sex. These observations support the concept that the liver is a sexually dimorphic organ in which estrogen and androgen receptors are present, which results in disparities between men and women in liver gene expression patterns, immune responses, and the progression of liver damage, including the propensity to develop liver malignancies. Sex hormones play protective or deleterious roles depending on the patient's sex, the severity of the underlying disease, and the nature of precipitating factors. Moreover, obesity, alcohol consumption, and active smoking, as well as social determinants of liver diseases leading to sex-related inequalities, may interact strongly with hormone-related mechanisms of liver damage. Drug-induced liver injury, viral hepatitis, and metabolic liver diseases are influenced by the status of sex hormones. Available data on the roles of sex hormones and gender differences in liver tumor occurrence and clinical outcomes are conflicting. Here, we critically review the main gender-based differences in the molecular mechanisms associated with liver carcinogenesis and the prevalence, prognosis, and treatment of primary and metastatic liver tumors.
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Affiliation(s)
- Pierluigi Toniutto
- Hepatology and Liver Transplantation Unit, Azienda Sanitaria Universitaria Integrata, Department of Medical Area, University of Udine, Udine, Italy
| | - Sarah Shalaby
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Laura Mameli
- Liver and Pancreas Transplant Center, Azienda Ospedaliera Brotzu Piazzale Ricchi 1, Cagliari, Italy
| | - Filomena Morisco
- Department of Clinical Medicine and Surgery, Departmental Program "Diseases of the Liver and Biliary System," University of Naples "Federico II," Napoli, Italy
| | - Martina Gambato
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Valentina Cossiga
- Department of Clinical Medicine and Surgery, Departmental Program "Diseases of the Liver and Biliary System," University of Naples "Federico II," Napoli, Italy
| | - Maria Guarino
- Department of Clinical Medicine and Surgery, Departmental Program "Diseases of the Liver and Biliary System," University of Naples "Federico II," Napoli, Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Erica Villa
- Gastroenterology Department, University of Modena and Reggio Emilia, Modena, Italy
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2
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Rizzo A, Salati M, Frega G, Merz V, Caputo F, Di Federico A, Palloni A, Carloni R, Ricci AD, Gadaleta-Caldarola G, Messina C, Spallanzani A, Gelsomino F, Benatti S, Luppi G, Melisi D, Dominici M, Brandi G. Second-Line Chemotherapy in Elderly Patients with Advanced Biliary Tract Cancer: A Multicenter Real-World Study. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58111543. [PMID: 36363500 PMCID: PMC9698581 DOI: 10.3390/medicina58111543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/14/2022] [Accepted: 10/26/2022] [Indexed: 11/07/2022]
Abstract
Objectives: The ABC-06 and the NIFTY trials recently established the role of second-line chemotherapy (2L) in patients with advanced biliary tract cancer (BTC). Our real-world study aimed to explore 2L in BTC patients aged ≥ 70 years old and to compare their outcomes with younger subjects. Methods: Institutional registries across three academic medical centers were retrospectively reviewed. The Kaplan−Meier methods were used to estimate survival, and the log-rank test was used to make comparisons. Results: A total of 190 BTC patients treated with 2L were identified and included in the analysis. Among them, 52 (27.3%) were aged ≥ 70 years (range 70−87 years). No statistically significant differences in both median overall survival (mOS) and median progression-free survival (mPFS) were recorded between the elderly and younger patients. Absolute lymphocyte count < 1000/mmc (p < 0.001) and albumin level < 3 g/dL (p < 0.001) were independently associated with worse prognoses. Conclusions: The results of this real-world study suggest that for patients aged ≥ 70 years, 2L could be equally effective for younger patients with survival outcomes aligned to those from the ABC-06 and NIFTY trials. The delivery of 2L should be carefully evaluated and monitored in this patient subset.
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Affiliation(s)
- Alessandro Rizzo
- Struttura Semplice Dipartimentale di Oncologia Medica per la Presa in Carico Globale del Paziente Oncologico “Don Tonino Bello”, I.R.C.C.S. Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy
| | - Massimiliano Salati
- PhD Program Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41121 Modena, Italy
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41125 Modena, Italy
| | - Giorgio Frega
- Osteoncology, Bone and Soft Tissue Sarcomas, and Innovative Therapies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Valeria Merz
- Department of Medical Oncology, Santa Chiara Hospital, 35127 Trento, Italy
- Digestive Molecular Clinical Oncology Research Unit, University of Verona, 37129 Verona, Italy
| | - Francesco Caputo
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41125 Modena, Italy
| | - Alessandro Di Federico
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni-15, 40138 Bologna, Italy
| | - Andrea Palloni
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni-15, 40138 Bologna, Italy
| | - Riccardo Carloni
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni-15, 40138 Bologna, Italy
| | - Angela Dalia Ricci
- Medical Oncology Unit, National Institute of Gastroenterology, “Saverio de Bellis” Research Hospital, 70013 Castellana Grotte, Italy
- Correspondence:
| | - Gennaro Gadaleta-Caldarola
- Medical Oncology Unit, ‘Mons. R. Dimiccoli’ Hospital, Barletta (BT), Azienda Sanitaria Locale Barletta, 76121 Barletta, Italy
| | - Carlo Messina
- Department of Medical Oncology, Santa Chiara Hospital, 35127 Trento, Italy
| | - Andrea Spallanzani
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41125 Modena, Italy
| | - Fabio Gelsomino
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41125 Modena, Italy
| | - Stefania Benatti
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41125 Modena, Italy
| | - Gabriele Luppi
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41125 Modena, Italy
| | - Davide Melisi
- Digestive Molecular Clinical Oncology Research Unit, University of Verona, 37129 Verona, Italy
| | - Massimo Dominici
- Division of Oncology, Department of Oncology and Hematology, University Hospital of Modena, 41125 Modena, Italy
| | - Giovanni Brandi
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni-15, 40138 Bologna, Italy
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3
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Khankhel ZS, Goring S, Bobiak S, Lamy FX, Nayak D, Garside J, Reese ES, Schoenherr N. Second-line treatments in advanced biliary tract cancer: systematic literature review of efficacy, effectiveness and safety. Future Oncol 2022; 18:2321-2338. [PMID: 35387496 DOI: 10.2217/fon-2021-1302] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: A systematic review was conducted to understand clinical, economic and health-related quality-of-life outcomes in second-line biliary tract cancer. Materials & methods: The review followed established recommendations. The feasibility of network meta-analysis revealed limited networks, thus synthesis was limited to a summary of reported ranges, percentiles and medians. Results: The review included 62 trials and observational studies highly variable with respect to key baseline characteristics. Commonly evaluated second-line treatments included fluoropyrimidine-, gemcitabine- and S-1-based regimens. Across active treatment arms, median overall survival ranged from 3.5 to 15.0 months (median: 6.9), median progression-free survival from 1.4 to 6.5 months (median: 2.9) and objective response from 0 to 36.4%. Outcomes were similar between study types, with a few notable outliers. Treatment-related/-emergent adverse events were infrequently reported; no studies reported economic or health-related quality-of-life outcomes. Conclusions: Biliary tract cancer is a difficult-to-treat disease with poor prognosis. Despite evolving treatment landscapes, more recent studies did not show clinical outcome improvement, highlighting an unmet need among advanced/metastatic patients.
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Affiliation(s)
| | - Sarah Goring
- SMG Outcomes Research, Vancouver, BC, V6T0C2, Canada
| | - Sarah Bobiak
- EMD Serono Research & Development Institute, Inc., Billerica, MA 01821, USA, an affiliate of Merck KGaA
| | | | | | | | - Emily S Reese
- EMD Serono Research & Development Institute, Inc., Billerica, MA 01821, USA, an affiliate of Merck KGaA
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4
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Massa A, Peraldo-Neia C, Vita F, Varamo C, Basiricò M, Raggi C, Bernabei P, Erriquez J, Sarotto I, Leone F, Marchiò S, Cavalloni G, Aglietta M. Paclitaxel Restores Sensitivity to Chemotherapy in Preclinical Models of Multidrug-Resistant Intrahepatic Cholangiocarcinoma. Front Oncol 2022; 12:771418. [PMID: 35251961 PMCID: PMC8891641 DOI: 10.3389/fonc.2022.771418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/24/2022] [Indexed: 12/30/2022] Open
Abstract
The treatment of unresectable cholangiocarcinoma (CCA) is limited by the development of resistance to conventional first-line chemotherapy based on gemcitabine (GEM). In addition, a prior treatment with GEM frequently induces cross-resistance to other drugs employed in the second-line. Paclitaxel (PTX) is now emerging as an alternative option for the management of advanced/metastatic CCA. In the present work, we evaluate the antitumor activity of PTX in preclinical models of multidrug-resistant intrahepatic cholangiocarcinoma (iCCA). In vitro, PTX decreases tumor cell viability by affecting the cell cycle and inducing apoptosis and impairs the stem cell compartment. In vivo, a therapeutic regimen containing albumin-bound nanoparticle (Nab)-PTX overcomes drug resistance resulting in delayed tumor growth, impaired organization of the tumor vasculature, and reduced glucose uptake. Together, our results provide a rationale to consider PTX-based regimens in patients with iCCA who became refractory to conventional therapies.
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Affiliation(s)
- Annamaria Massa
- Medical Oncology, Candiolo Cancer Institute, Fondazione del Piemonte per l'Oncologia (FPO)-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Torino, Italy
- Division of Oncology, University of Torino, Torino, Italy
- *Correspondence: Annamaria Massa,
| | | | - Francesca Vita
- Division of Oncology, University of Torino, Torino, Italy
| | - Chiara Varamo
- Division of Oncology, University of Torino, Torino, Italy
| | - Marco Basiricò
- Medical Oncology, Candiolo Cancer Institute, Fondazione del Piemonte per l'Oncologia (FPO)-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Torino, Italy
- Division of Oncology, University of Torino, Torino, Italy
| | - Chiara Raggi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
| | - Paola Bernabei
- Flow Cytometry Center, Candiolo Cancer Institute, Fondazione del Piemonte per l'Oncologia (FPO)-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Torino, Italy
| | - Jessica Erriquez
- Candiolo Cancer Institute, Fondazione del Piemonte per l'Oncologia (FPO)-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Torino, Italy
| | - Ivana Sarotto
- Unit of Pathology, Candiolo Cancer Institute, Fondazione del Piemonte per l'Oncologia (FPO)-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Torino, Italy
| | - Francesco Leone
- Department of Oncology, Azienda Sanitaria Locale (ASL) Biella (BI), Nuovo Ospedale degli Infermi, Biella, Italy
| | - Serena Marchiò
- Division of Oncology, University of Torino, Torino, Italy
- Candiolo Cancer Institute, Fondazione del Piemonte per l'Oncologia (FPO)-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Torino, Italy
| | - Giuliana Cavalloni
- Medical Oncology, Candiolo Cancer Institute, Fondazione del Piemonte per l'Oncologia (FPO)-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Torino, Italy
| | - Massimo Aglietta
- Medical Oncology, Candiolo Cancer Institute, Fondazione del Piemonte per l'Oncologia (FPO)-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Torino, Italy
- Division of Oncology, University of Torino, Torino, Italy
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5
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Filippi R, Montagnani F, Lombardi P, Fornaro L, Aprile G, Casadei-Gardini A, Faloppi L, Palloni A, Satolli MA, Scartozzi M, Citarella F, Lutrino SE, Vivaldi C, Silvestris N, Rovesti G, Rimini M, Aglietta M, Brandi G, Leone F. A prognostic model in patients with advanced biliary tract cancer receiving first-line chemotherapy. Acta Oncol 2021; 60:1317-1324. [PMID: 34282710 DOI: 10.1080/0284186x.2021.1953704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Standard treatment of advanced biliary tract cancer (aBTC) is represented by first-line chemotherapy (CT1). However, some patients do not gain any benefit from CT1, contributing to the overall dismal prognosis of aBTC. The present study aimed to devise a prognostic model in aBTC patients receiving CT1. METHODS A large panel of clinical, laboratory, and pathology variables, available before the start of CT1, were retrospectively assessed in a multi-centric cohort to determine their prognostic value on univariate and multivariate regression analysis. The variables that showed a significant correlation with overall survival (OS) were computed in a three-tier prognostic score. External validation of the prognostication performance was carried out. RESULTS Clinical histories of 935 patients (median OS 10.3 months), with diagnosis dates ranging from 2001 to 2017, were retrieved from 14 institutions. According to multivariate analysis, Eastern Cooperative Oncology Group performance status, carbohydrate antigen 19.9, albumin levels, and neutrophil/lymphocyte ratio were strongly associated with OS (p <0.01). The prognostic score could generate a highly significant stratification (all between-group p values ≤0.001) into groups of favorable (comprising 51.5% of the sample), intermediate (39.2%), and poor prognosis (9.3%): median OS was 12.7 (CI95% 11.0-14.4), 7.1 (CI95% 5.8-8.4), and 3.2 months (CI95% 1.7-4.7), respectively. This OS gradient was replicated in the validation set (129 patients), with median OS of 12.7 (CI95% 11.0-14.3), 7.5 (CI95% 6.1-8.9), and 1.4 months (CI95% 0.1-2.7), respectively (all between-group p values ≤0.05). CONCLUSION A prognostic score, derived from a limited set of easily-retrievable variables, efficiently stratified a large population of unselected aBTC patients undergoing CT1. This tool could be useful to clinicians, to ascertain the potential benefit from CT1 at the start of treatment.
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Affiliation(s)
- Roberto Filippi
- Department of Oncology, University of Turin, Torino, Italy
- Division of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
- Centro Oncologico Ematologico Subalpino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Francesco Montagnani
- Division of Medical Oncology, ASL BI, Nuovo Ospedale degli Infermi, Ponderano, Italy
| | - Pasquale Lombardi
- Department of Oncology, University of Turin, Torino, Italy
- Division of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Lorenzo Fornaro
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Giuseppe Aprile
- Department of Oncology, University Hospital of Udine, Udine, Italy
- Department of Oncology, San Bortolo General Hospital, AULSS8, Vicenza, Italy
| | - Andrea Casadei-Gardini
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, Meldola, Italy
- Department of Oncology and Haematology, University Hospital of Modena, Italy
| | - Luca Faloppi
- Medical Oncology Unit, Macerata General Hospital, Macerata, Italy
| | - Andrea Palloni
- Department of Experimental, Diagnostic and Specialty Medicine, University Hospital S. Orsola-Malpighi, Bologna, Italy
| | - Maria Antonietta Satolli
- Department of Oncology, University of Turin, Torino, Italy
- Centro Oncologico Ematologico Subalpino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Mario Scartozzi
- Department of Medical Oncology, University Hospital, Cagliari, Italy
| | - Fabrizio Citarella
- Department of Medical Oncology, Campus Bio-Medico University, Roma, Italy
| | | | - Caterina Vivaldi
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy
| | - Nicola Silvestris
- Medical Oncology Unit, IRCCS Cancer Institute “Giovanni Paolo II”, Bari, Italy
- Department of Biomedical Sciences and Human Oncology (DIMO), University of Bari, Italy
| | - Giulia Rovesti
- Department of Oncology and Haematology, University Hospital of Modena, Italy
| | - Margherita Rimini
- Department of Oncology and Haematology, University Hospital of Modena, Italy
| | - Massimo Aglietta
- Department of Oncology, University of Turin, Torino, Italy
- Division of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Giovanni Brandi
- Department of Experimental, Diagnostic and Specialty Medicine, University Hospital S. Orsola-Malpighi, Bologna, Italy
| | - Francesco Leone
- Division of Medical Oncology, ASL BI, Nuovo Ospedale degli Infermi, Ponderano, Italy
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6
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Filippi R, Leone F, Fornaro L, Aprile G, Casadei-Gardini A, Silvestris N, Palloni A, Satolli MA, Scartozzi M, Russano M, Lutrino SE, Lombardi P, Frega G, Garattini SK, Vivaldi C, Spadi R, Giulia O, Fenocchio E, Brunetti O, Aglietta M, Brandi G. Clinical insights and prognostic factors from an advanced biliary tract cancer case series: a real-world analysis. J Chemother 2021; 34:123-132. [PMID: 34313188 DOI: 10.1080/1120009x.2021.1953887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Advanced biliary tract cancer (aBTC) comprises a heterogeneous group of rare malignancies with dismal prognosis. Given the scarcity of prospective evidence, the aim of this study was to derive clinically useful insights and prognostic factors from a large, real-world series of aBTC. Clinicopathologic variables and treatment outcomes were retrospectively collected involving 940 patients diagnosed with aBTC between 2001 and 2017, and treated with first-line chemotherapy (CT1) at 14 Italian medical oncology institutions. Median overall survival (OS) was 10.3 months (CI95% 9.5-11.1). CT1 with gemcitabine-Platinum salts doublets achieved OS of 11.7 months vs 7.5 with gemcitabine alone (HR 0.67, p < 0.001). However, a clear temporal trend towards improved OS could not be demonstrated. Radical surgery of recurrent disease achieved a relapse-free survival of 5.9 months. A substantial minority (44.5%) of patients were able to receive a second-line chemotherapy, which achieved a response rate of 7.6%, and disease control in 30% of patients with no significant differences between combination regimens and monotherapies. In a large retrospective series of real-world aBTC, outcomes of standard CT1 closely resembled those of the registrational trials. A limited set of easily retrievable independent prognostic factors was defined. Further research is needed on second-line regimens.
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Affiliation(s)
- Roberto Filippi
- Department of Oncology, University of Turin, Torino, Italy.,Division of Medical Oncology, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, Italy.,Division of Medical Oncology 1, Centro Oncologico Ematologico Subalpino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Francesco Leone
- Division of Medical Oncology, ASL BI, Nuovo Ospedale degli Infermi, Ponderano, Italy
| | - Lorenzo Fornaro
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Giuseppe Aprile
- Department of Oncology, University Hospital of Udine, Udine, Italy.,Department of Oncology, San Bortolo General Hospital, Vicenza, Italy
| | - Andrea Casadei-Gardini
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, Meldola, Italy.,Department of Oncology and Haematology, University Hospital of Modena, Italy
| | - Nicola Silvestris
- Medical Oncology Unit, IRCCS Cancer Institute "Giovanni Paolo II", Bari, Italy
| | - Andrea Palloni
- Department of Experimental, Diagnostic and Speciality Medicine, University Hospital S. Orsola-Malpighi, Bologna, Italy
| | - Maria Antonietta Satolli
- Department of Oncology, University of Turin, Torino, Italy.,Division of Medical Oncology 1, Centro Oncologico Ematologico Subalpino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Mario Scartozzi
- Department of Medical Oncology, University Hospital, Cagliari, Italy
| | - Marco Russano
- Department of Medical Oncology, Campus Bio-Medico University, Roma, Italy
| | | | - Pasquale Lombardi
- Department of Oncology, University of Turin, Torino, Italy.,Division of Medical Oncology, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, Italy
| | - Giorgio Frega
- Department of Experimental, Diagnostic and Speciality Medicine, University Hospital S. Orsola-Malpighi, Bologna, Italy
| | | | - Caterina Vivaldi
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.,Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy
| | - Rosella Spadi
- Division of Medical Oncology 1, Centro Oncologico Ematologico Subalpino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Orsi Giulia
- Department of Oncology and Haematology, University Hospital of Modena, Italy
| | - Elisabetta Fenocchio
- Multidisciplinary Outpatient Oncology Clinic, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Oronzo Brunetti
- Medical Oncology Unit, IRCCS Cancer Institute "Giovanni Paolo II", Bari, Italy
| | - Massimo Aglietta
- Department of Oncology, University of Turin, Torino, Italy.,Division of Medical Oncology, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, Italy
| | - Giovanni Brandi
- Department of Experimental, Diagnostic and Speciality Medicine, University Hospital S. Orsola-Malpighi, Bologna, Italy
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7
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Sasaki T, Takeda T, Okamoto T, Ozaka M, Sasahira N. Chemotherapy for Biliary Tract Cancer in 2021. J Clin Med 2021; 10:3108. [PMID: 34300274 PMCID: PMC8305063 DOI: 10.3390/jcm10143108] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 01/02/2023] Open
Abstract
Biliary tract cancer refers to a group of malignancies including cholangiocarcinoma, gallbladder cancer, and ampullary cancer. While surgical resection is considered the only curative treatment, postoperative recurrence can sometimes occur. Adjuvant chemotherapy is used to prolong prognosis in some cases. Many unresectable cases are also treated with chemotherapy. Therefore, systemic chemotherapy is widely introduced for the treatment of biliary tract cancer. Evidence on chemotherapy for biliary tract cancer is recently on the increase. Combination chemotherapy with gemcitabine and cisplatin is currently the standard of care for first-line chemotherapy in advanced cases. Recently, FOLFOX also demonstrated efficacy as a second-line treatment. In addition, efficacies of isocitrate dehydrogenase inhibitors and fibroblast growth factor receptor inhibitors have been shown. In the adjuvant setting, capecitabine monotherapy has become the standard of care in Western countries. In addition to conventional cytotoxic agents, molecular-targeted agents and immunotherapy have been evaluated in multiple clinical trials. Genetic testing is used to check for genetic alterations and molecular-targeted agents and immunotherapy are introduced based on tumor characteristics. In this article, we review the latest evidence of chemotherapy for biliary tract cancer.
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Affiliation(s)
- Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo 135-8550, Japan; (T.T.); (T.O.); (M.O.); (N.S.)
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8
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Peraldo-Neia C, Massa A, Vita F, Basiricò M, Raggi C, Bernabei P, Ostano P, Casorzo L, Panero M, Leone F, Cavalloni G, Aglietta M. A Novel Multidrug-Resistant Cell Line from an Italian Intrahepatic Cholangiocarcinoma Patient. Cancers (Basel) 2021; 13:cancers13092051. [PMID: 33922695 PMCID: PMC8123022 DOI: 10.3390/cancers13092051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/20/2021] [Indexed: 12/21/2022] Open
Abstract
Simple Summary Intrahepatic cholangiocarcinoma (ICC) has limited prognosis and therapies. The first-line gemcitabine-based therapy provided poor benefits in terms of survival due to the development of resistance. Gemcitabine-resistance mechanisms were studied on pancreatic cancer models or cell lines derived from ICC patients of Eastern countries. Since ICC has different etiology and genetic/molecular characteristics depending on the ethnicity, appropriate preclinical models that recapitulate their biology are required. Thus, we aimed to establish and characterize an Italian ICC cell line, named 82.3. Cells were isolated from a patient-derived xenograft. After one year, immunophenotypical, biological, genetic, molecular features, and in vivo tumorigenicity in NOD/SCID mice were investigated. Furthermore, 82.3 cells displayed resistance to gemcitabine, 5-fluorouracil, carboplatin, and oxaliplatin. This model could be exploited either to investigate drug resistance mechanisms or to test alternative drugs through the identification of suitable targets to overcome drug resistance. Abstract Chemotherapy resistance is a relevant clinical issue in tumor treatment, in particular in biliary tract carcinoma (BTC), for which there are no effective therapies, neither in the first nor in the second line. The development of chemoresistant cell lines as experimental models to investigate the mechanisms of resistance and identify alternative druggable pathways is mandatory. In BTC, in which genetics and biological behavior depend on the etiology, ethnicity, and anatomical site of origin, the creation of models that better recapitulate these characteristics is even more crucial. Here we have established and characterized an intrahepatic cholangiocarcinoma (iCCA) cell line derived from an Italian patient, called 82.3. Cells were isolated from a patient-derived xenograft (PDX) and, after establishment, immunophenotypic, biological, genetic, molecular characteristics, and tumorigenicity in vivo in NOD/SCID mice were investigated. 82.3 cells exhibited epithelial morphology and cell markers (EPCAM, CK7, and CK19); they also expressed different cancer stem markers (CD44, CD133, CD49b, CD24, Stro1, PAX6, FOXA2, OCT3/4), α–fetoprotein and under anchorage-independent and serum-free conditions were capable of originating cholangiospheres. The population doubling time was approximately 53 h. In vitro, they demonstrated a poor ability to migrate; in vivo, 82.3 cells retained their tumorigenicity, with a long latency period (16 weeks). Genetic identity using DNA fingerprinting analysis revealed 16 different loci, and the cell line was characterized by a complex hyperdiploid karyotype. Furthermore, 82.3 cells showed cross-resistance to gemcitabine, 5-fluorouracil, carboplatin, and oxaliplatin; in fact, their genetic profile showed that 60% of genes (n = 168), specific for drug resistance and related to the epithelial-mesenchymal transition, were deregulated in 82.3 cells compared to a control iCCA cell line sensitive to chemotherapeutics. RNA sequencing analysis revealed the enrichment for genes associated with epithelial to mesenchymal transition (EMT), vasculature development, and extracellular matrix (ECM) remodeling, underlining an aggressive phenotype. In conclusion, we have created a new iCCA cell line of Caucasian origin: this could be exploited as a preclinical model to study drug resistance mechanisms and to identify alternative therapies to improve the prognosis of this tumor type.
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Affiliation(s)
- Caterina Peraldo-Neia
- Laboratory of Cancer Genomics, Fondazione Edo ed Elvo Tempia, 13900 Biella, Italy; (C.P.-N.); (P.O.)
| | - Annamaria Massa
- Division of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, 10060 Candiolo (Torino), Italy; (A.M.); (M.B.); (M.A.)
| | - Francesca Vita
- Department of Oncology, University of Torino, 10126 Torino, Italy;
| | - Marco Basiricò
- Division of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, 10060 Candiolo (Torino), Italy; (A.M.); (M.B.); (M.A.)
- Department of Oncology, University of Torino, 10126 Torino, Italy;
| | - Chiara Raggi
- Department of Experimental and Clinical Medicine, University of Firenze, 50134 Firenze, Italy;
| | - Paola Bernabei
- Flow Cytometry Center, Candiolo Cancer Institute, FPO-IRCCS, 10060 Candiolo (Torino), Italy;
| | - Paola Ostano
- Laboratory of Cancer Genomics, Fondazione Edo ed Elvo Tempia, 13900 Biella, Italy; (C.P.-N.); (P.O.)
| | - Laura Casorzo
- Unit of Pathology, Candiolo Cancer Institute, FPO-IRCCS, 10060 Candiolo (Torino), Italy; (L.C.); (M.P.)
| | - Mara Panero
- Unit of Pathology, Candiolo Cancer Institute, FPO-IRCCS, 10060 Candiolo (Torino), Italy; (L.C.); (M.P.)
| | - Francesco Leone
- Department of Oncology, Nuovo Ospedale degli Infermi, Azienda Sanitaria Locale Biella, 13875 Ponderano (Biella), Italy;
| | - Giuliana Cavalloni
- Division of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, 10060 Candiolo (Torino), Italy; (A.M.); (M.B.); (M.A.)
- Correspondence:
| | - Massimo Aglietta
- Division of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, 10060 Candiolo (Torino), Italy; (A.M.); (M.B.); (M.A.)
- Department of Oncology, University of Torino, 10126 Torino, Italy;
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9
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Takahara N, Nakai Y, Saito K, Sasaki T, Suzuki Y, Inokuma A, Oyama H, Kanai S, Suzuki T, Sato T, Hakuta R, Ishigaki K, Saito T, Hamada T, Mizuno S, Kogure H, Tada M, Isayama H, Koike K. The impact of age and comorbidity in advanced or recurrent biliary tract cancer receiving palliative chemotherapy. J Gastroenterol Hepatol 2020; 35:1828-1835. [PMID: 32267557 DOI: 10.1111/jgh.15066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 03/07/2020] [Accepted: 04/01/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Limited data are available on age and comorbidity assessment in patients with biliary tract cancer (BTC). This study aimed to evaluate the association of age and comorbidity burden with clinical outcomes of chemotherapy for BTC. METHODS Consecutive 197 BTC patients undergoing first-line chemotherapy between 2007 and 2017 were retrospectively studied. Patients were classified to three groups according to the age-adjusted Charlson comorbidity index (ACCI) excluding the score about BTC and progression-free survival, overall survival (OS), and safety were compared. RESULTS Fifty-one patients (26%) were elderly (≥ 75 years), and ACCI was 0-2 in 73 patients (37%), 3-4 in 98 (50%), and ≥ 5 in 26 (13%). ACCI was associated with the administration of first-line combination chemotherapy (89% in 0-2, 80% in 3-4, and 64% in ≥ 5, P < 0.01) and second-line chemotherapy (67% in 0-2, 51% in 3-4, and 35% in ≥ 5, P = 0.01). ACCI was prognostic for OS in addition to performance status, disease status, and CA19-9: The hazard ratios in ACCI of 3-4 and ≥ 5 were 1.39 and 1.79, compared with ACCI of 0-2 (P = 0.04). While overall safety profile did not differ by ACCI, higher ACCI score group developed Grade 3-4 neutropenia more frequently (26% in 0-2, 42% in 3-4, and 46% in ≥ 5, P = 0.04). CONCLUSION Age and comorbidity burden did affect OS and safety profile in BTC patients undergoing first-line palliative chemotherapy. ACCI can be a simple and useful tool to evaluate the age and comorbidity burden in these patients.
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Affiliation(s)
- Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kei Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takashi Sasaki
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yukari Suzuki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akiyuki Inokuma
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Oyama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sachiko Kanai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsunori Suzuki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazunaga Ishigaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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10
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Jansen H, Pape UF, Utku N. A review of systemic therapy in biliary tract carcinoma. J Gastrointest Oncol 2020; 11:770-789. [PMID: 32953160 PMCID: PMC7475338 DOI: 10.21037/jgo-20-203] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/13/2020] [Indexed: 12/11/2022] Open
Abstract
Biliary tract carcinoma (BTC) has a poor prognosis and is increasing in incidence. Although surgery, chemotherapy and other treatment modalities have improved, surgery remains the only potential curative treatment and is appropriate for only those few patients who present with localized, resectable disease. However, for the majority of patients, unresectable disease is evident at diagnosis and about 95% of patients die within 10 years, despite the majority receiving chemotherapy. Long-term survival is significantly greater for patients with resected BTC compared to those with unresectable disease. In unresected disease, life expectancy is limited, with first-line gemcitabine/cisplatin (GEM/CIS) accepted as standard of care. Currently no standard second-line regimen which provides significant improvement of clinical outcomes exists for those who present with refractory disease or who relapse after first-line treatment. Of particular importance is establishing the impact of best supportive care (BSC) as a benchmark for survival outcomes to which the impact of treatment modalities can be compared. Survival outcome often differs significantly for patients with different prognostic factor profiles even when receiving the same therapy so that it can be difficult to predict which patient subgroup might benefit most from which therapy. Therefore, the influence of prognostic factors on survival under different therapies as well as under BSC needs to be further assessed in order to arrive at truly evidence-based, best therapeutic decisions for individual patients. Encouraging new research into the genomic landscape of BTC may help to further subdivide the BTC population into molecular-genetic clusters likely to be sensitive to different targeted therapy approaches leading to further improvements in survival. Consequently, an unmet need exists not only to develop new and more effective therapies for this devastating disease, but also to integrate original research findings into a more complex, dynamic, individualized therapeutic decision model to aid clinicians in making evidence-based, best therapeutic decisions for individual patients.
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Affiliation(s)
- Holger Jansen
- Campus Virchow & Mitte Charité, Institute f. Med. Immunologie, Berlin, Germany
| | - Ulrich-Frank Pape
- Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Germany
- Internal Medicine and Gastroenterology, Asklepios Klinik St. Georg, Asklepios Tumor Zentrum Hamburg, Germany
| | - Nalân Utku
- Campus Virchow & Mitte Charité, Institute f. Med. Immunologie, Berlin, Germany
- CellAct Pharma GmbH, Dortmund, Germany
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11
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Wu CE, Chou WC, Hsieh CH, Chang JWC, Lin CY, Yeh CN, Chen JS. Prognostic and predictive factors for Taiwanese patients with advanced biliary tract cancer undergoing frontline chemotherapy with gemcitabine and cisplatin: a real-world experience. BMC Cancer 2020; 20:422. [PMID: 32410631 PMCID: PMC7227306 DOI: 10.1186/s12885-020-06914-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/30/2020] [Indexed: 12/15/2022] Open
Abstract
Background Chemotherapy with gemcitabine and cisplatin has been the standard of care in first-line chemotherapy for advanced biliary tract cancer (BTC) since the trial ABC-02 was published in 2010. We aimed to investigate the prognostic and predictive factors of this regimen in a cohort of Taiwanese patients with advanced BTC. Methods A total of 118 patients with histologically confirmed BTC treated at Chang Gung Memorial Hospital at Linkou from 2012 to 2017 were retrospectively reviewed. Results The median progression-free survival (PFS) and overall survival (OS) were 3.6 months and 8.4 months, respectively. In the multivariate analysis, neutrophil to lymphocyte ratio (NLR) > 7.45, biliary drainage requiring both percutaneous transhepatic cholangiography drainage (PTCD) and internal stenting, and tumor responses with progressive diseases and not assessed were independent poor prognostic factors for PFS. Male sex, NLR > 7.45, alkaline phosphatase> 94 U/L, biliary drainage requiring both PTCD and internal stenting, and tumor responses with stable disease, progressive diseases and not assessed were independent poor prognostic factors for OS. Monocyte to lymphocyte ratio (MLR) ≤ 0.28 was the only significant predictive factor for the tumor response. Patients with complete response/partial response had significantly lower MLR than patients with other tumor responses. Conclusion We identified three important prognostic factors, namely tumor response, NLR, and biliary drainage requiring both PTCD and internal stenting for both PFS and OS. MLR was the only significant predictive factor for the tumor response. These findings could provide physicians with more information to justify the clinical outcomes in patients with advanced BTC in real-world practice.
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Affiliation(s)
- Chiao-En Wu
- Division of Haematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, 5, Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - Wen-Chi Chou
- Division of Haematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, 5, Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - Chia-Hsun Hsieh
- Division of Haematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, 5, Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - John Wen-Cheng Chang
- Division of Haematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, 5, Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - Cheng-Yu Lin
- Department of Gastroenterology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, 5, Fu-Hsing Street, Taoyuan, Kwei-Shan, Taiwan
| | - Chun-Nan Yeh
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, 5, Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan.
| | - Jen-Shi Chen
- Division of Haematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, 5, Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan.
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12
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Filippi R, Lombardi P, Quarà V, Fenocchio E, Aimar G, Milanesio M, Leone F, Aglietta M. Pharmacotherapeutic options for biliary tract cancer: current standard of care and new perspectives. Expert Opin Pharmacother 2019; 20:2121-2137. [PMID: 31550186 DOI: 10.1080/14656566.2019.1667335] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Biliary tract cancer (BTC), which comprises gallbladder cancer, ampullary cancer, and cholangiocarcinoma, is a rare and heterogeneous entity, with limited approved therapeutic options. However, interest in this disease has grown exponentially in recent years, as a mounting body of evidence has shed light on the complex molecular and microenvironmental background of BTC, and clinical investigations have explored a variety of new agents and combinations, with promising results.Areas covered: This review describes the standard of care in advanced BTC and summarizes the most recent evidence available on the pharmacological treatment of resected and advanced disease, focusing on chemotherapy, targeted therapy, and immunotherapy.Expert opinion: The therapeutic armamentarium of BTC has made radical progress after almost a decade of very few positive results. Phase-III evidence now supports the use of adjuvant capecitabine after resection of localized disease, while investigations into improved regimens in the advanced setting are underway, exploring alternative options to the standard gemcitabine-cisplatin doublet. The first positive phase-III trial supports the use of the mFOLFOX6 regimen as a second-line chemotherapy. Targeted therapy against specific genomic alterations can combine with chemotherapy in specific subsets of patients. Despite recent advancements, conducting clinical trials for BTC is still a real challenge.
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Affiliation(s)
- Roberto Filippi
- Department of Oncology, University of Turin, Candiolo, Italy.,Department of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Pasquale Lombardi
- Department of Oncology, University of Turin, Candiolo, Italy.,Department of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Virginia Quarà
- Department of Oncology, University of Turin, Candiolo, Italy.,Department of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Elisabetta Fenocchio
- Multidisciplinary Outpatient Oncology Clinic, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Giacomo Aimar
- Department of Oncology, University of Turin, Candiolo, Italy.,Department of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Michela Milanesio
- Department of Oncology, University of Turin, Candiolo, Italy.,Department of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Francesco Leone
- Medical Oncology, Ospedale degli Infermi, Azienda Sanitaria Locale di Biella, Biella, Italy
| | - Massimo Aglietta
- Department of Oncology, University of Turin, Candiolo, Italy.,Department of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
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