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Riveiro-Barciela M, Carballal S, Díaz-González Á, Mañosa M, Gallgo-Plazas J, Cubiella J, Jiménez-Fonseca P, Varela M, Menchén L, Sangro B, Fernández-Montes A, Mesonero F, Rodríguez-Gandía MÁ, Rivera F, Londoño MC. Management of liver and gastrointestinal toxicity induced by immune checkpoint inhibitors: Position statement of the AEEH-AEG-SEPD-SEOM-GETECCU. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:83-113. [PMID: 38226597 DOI: 10.17235/reed.2024.10250/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
The development of the immune checkpoint inhibitors (ICI) is one of the most remarkable achievements in cancer therapy in recent years. However, their exponential use has led to an increase in immune-related adverse events (irAEs). Gastrointestinal and liver events encompass hepatitis, colitis and upper digestive tract symptoms accounting for the most common irAEs, with incidence rates varying from 2 % to 40 %, the latter in patients undergoing combined ICIs therapy. Based on the current scientific evidence derived from both randomized clinical trials and real-world studies, this statement document provides recommendations on the diagnosis, treatment and prognosis of the gastrointestinal and hepatic ICI-induced adverse events.
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Affiliation(s)
| | | | | | - Miriam Mañosa
- Gastroenterology, Hospital Universitari Germans Trias i Pujol
| | | | | | | | - María Varela
- Gastroenterology, Hospital Universitario Central de Asturias
| | - Luis Menchén
- Digestive Diseases, Instituto de Investigación Sanitaria Gregorio Marañón
| | | | | | | | | | - Fernando Rivera
- Hospital Universitario Marqués de Valdecilla, Medical Oncology
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Otsuka T, Hashii Y, Murayama S, Ishizuka Y, Kojitani Y, Nishio M, Kudo T. Checkpoint inhibitor-induced gastritis followed by delayed severe hepatitis in a patient with lung metastases of head and neck squamous cell carcinoma: a case report. Front Oncol 2023; 13:1164236. [PMID: 37251947 PMCID: PMC10213227 DOI: 10.3389/fonc.2023.1164236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 04/27/2023] [Indexed: 05/31/2023] Open
Abstract
Pembrolizumab, an anti-programmed death-1 (PD-1) receptor monoclonal antibody, is an effective first-line therapy for metastatic head and neck squamous cell carcinoma. Immune-related adverse events (irAEs) are well-described complications of PD-1 inhibitors, and multiorgan irAEs are known to occur occasionally. We report a patient with pulmonary metastases of oropharyngeal squamous cell carcinoma (SCC), who developed gastritis followed by delayed severe hepatitis and recovered with triple immunosuppressant therapy. A 58-year-old Japanese male with pulmonary metastases of oropharyngeal SCC who was treated with pembrolizumab, subsequently developed new-onset appetite loss and upper abdominal pain. Upper gastrointestinal endoscopy revealed gastritis and immunohistochemistry revealed pembrolizumab-induced gastritis. The patient developed delayed severe hepatitis at 15 months after initiating pembrolizumab treatment, presenting "Grade 4 aspartate aminotransferase increase" and "Grade 4 alanine aminotransferase increase." Impaired liver function persisted despite pulse corticosteroid therapy with intravenous methylprednisolone 1,000 mg/day, followed by oral prednisolone 2 mg/kg/day and oral mycophenolate mofetil 2,000 mg/day. Tacrolimus, which reached target serum trough concentrations of 8-10 ng/mL, gradually improved irAE grades from Grade 4 to Grade 1. The patient responded well to triple immunosuppressant therapy comprising prednisolone, mycophenolate mofetil, and tacrolimus. Therefore, this immunotherapeutic approach could be effective for multiorgan irAEs in patients with cancer.
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Affiliation(s)
- Tomoyuki Otsuka
- Department of Medical Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yoshiko Hashii
- Department of Pediatrics, Osaka International Cancer Institute, Osaka, Japan
| | - Sei Murayama
- Department of Medical Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yasunobu Ishizuka
- Department of Medical Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yoshiki Kojitani
- Department of Medical Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Minako Nishio
- Department of Medical Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Toshihiro Kudo
- Department of Medical Oncology, Osaka International Cancer Institute, Osaka, Japan
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Shroff GS, Strange CD, Ahuja J, Altan M, Sheshadri A, Unlu E, Truong MT, Vlahos I. Imaging of Immune Checkpoint Inhibitor Immunotherapy for Non-Small Cell Lung Cancer. Radiographics 2022; 42:1956-1974. [PMID: 36240075 DOI: 10.1148/rg.220108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The normal immune system identifies and eliminates precancerous and cancerous cells. However, tumors can develop immune resistance mechanisms, one of which involves the exploitation of pathways, termed immune checkpoints, that normally suppress T-cell function. The goal of immune checkpoint inhibitor (ICI) immunotherapy is to boost T-cell-mediated immunity to mount a more effective attack on cancer cells. ICIs have changed the treatment landscape of advanced non-small cell lung cancer (NSCLC), and numerous ICIs have now been approved as first-line treatments for NSCLC by the U.S. Food and Drug Administration. ICIs can cause atypical response patterns such as pseudoprogression, whereby the tumor burden initially increases but then decreases. Therefore, response criteria have been developed specifically for patients receiving immunotherapy. Because ICIs activate the immune system, they can lead to inflammatory side effects, termed immune-related adverse events (irAEs). Usually occurring within weeks to months after the start of therapy, irAEs range from asymptomatic abnormal laboratory results to life-threatening conditions such as encephalitis, pneumonitis, myocarditis, hepatitis, and colitis. It is important to be aware of the imaging appearances of the various irAEs to avoid misinterpreting them as metastatic disease, progressive disease, or infection. The basic principles of ICI therapy; indications for ICI therapy in the setting of NSCLC; response assessment and atypical response patterns of ICI therapy, as compared with conventional chemotherapy; and the spectrum of irAEs seen at imaging are reviewed. An invited commentary by Nishino is available online. ©RSNA, 2022.
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Affiliation(s)
- Girish S Shroff
- From the Departments of Thoracic Imaging (G.S.S., C.D.S., J.A., E.U., M.T.T., I.V.), Thoracic/Head and Neck Medical Oncology (M.A.), and Pulmonary Medicine (A.S.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Chad D Strange
- From the Departments of Thoracic Imaging (G.S.S., C.D.S., J.A., E.U., M.T.T., I.V.), Thoracic/Head and Neck Medical Oncology (M.A.), and Pulmonary Medicine (A.S.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Jitesh Ahuja
- From the Departments of Thoracic Imaging (G.S.S., C.D.S., J.A., E.U., M.T.T., I.V.), Thoracic/Head and Neck Medical Oncology (M.A.), and Pulmonary Medicine (A.S.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Mehmet Altan
- From the Departments of Thoracic Imaging (G.S.S., C.D.S., J.A., E.U., M.T.T., I.V.), Thoracic/Head and Neck Medical Oncology (M.A.), and Pulmonary Medicine (A.S.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Ajay Sheshadri
- From the Departments of Thoracic Imaging (G.S.S., C.D.S., J.A., E.U., M.T.T., I.V.), Thoracic/Head and Neck Medical Oncology (M.A.), and Pulmonary Medicine (A.S.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Ebru Unlu
- From the Departments of Thoracic Imaging (G.S.S., C.D.S., J.A., E.U., M.T.T., I.V.), Thoracic/Head and Neck Medical Oncology (M.A.), and Pulmonary Medicine (A.S.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Mylene T Truong
- From the Departments of Thoracic Imaging (G.S.S., C.D.S., J.A., E.U., M.T.T., I.V.), Thoracic/Head and Neck Medical Oncology (M.A.), and Pulmonary Medicine (A.S.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Ioannis Vlahos
- From the Departments of Thoracic Imaging (G.S.S., C.D.S., J.A., E.U., M.T.T., I.V.), Thoracic/Head and Neck Medical Oncology (M.A.), and Pulmonary Medicine (A.S.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
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Immunotherapy-induced Colitis: A Comprehensive Review of Epidemiology, Clinical Presentation, Diagnostic Workup, and Management Plan. J Clin Gastroenterol 2022; 56:555-564. [PMID: 35470301 DOI: 10.1097/mcg.0000000000001705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of a variety of malignancies including advanced melanoma, non-small cell lung cancer, renal cell carcinoma, head and neck cancers among others. Since their introduction, there has been significant improvement in survival and prognosis in patients with advanced malignancies. Unfortunately, improved outcomes have come at a price of significant immune-related adverse events, with those of the gastrointestinal tract being the most common. Gastrointestinal immune-related adverse events frequently present as diarrhea and colitis, the severity of which can range from mild diarrhea to fulminant colitis with intestinal perforation. Currently, management of ICI-induced colitis is primarily guided by retrospective studies and expert opinion. A significant number of ICI-induced colitis responds to high-dose corticosteroids; however, some patients require further therapy with biologics. There is limited information on the factors which may predispose patients to ICI-induced colitis. Future research elucidating these risk factors along with development of a scoring system could allow for risk-stratification of patients before initiation of ICI therapy. Such a system may help clinicians and patients keep a high index of suspicion regarding ICI-induced colitis and could hopefully reduce the incidence of severe cases. Similarly, future studies should investigate protective factors against ICI-induced colitis, which could potentially allow more patients to safely benefit from ICI therapy.
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Parente P, Maiorano BA, Ciardiello D, Cocomazzi F, Carparelli S, Guerra M, Ingravallo G, Cazzato G, Carosi I, Maiello E, Bossa F. Clinic, Endoscopic and Histological Features in Patients Treated with ICI Developing GI Toxicity: Some News and Reappraisal from a Mono-Institutional Experience. Diagnostics (Basel) 2022; 12:diagnostics12030685. [PMID: 35328239 PMCID: PMC8947154 DOI: 10.3390/diagnostics12030685] [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: 01/30/2022] [Revised: 03/05/2022] [Accepted: 03/09/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Immune checkpoint inhibitors (ICIs) have widened the therapeutic scenario of different solid tumors over the last ten years. Gastrointestinal (GI) adverse events (AEs), such as diarrhea and colitis, occur in up to 50% of patients treated with ICIs. Materials and methods: We conducted a single-center retrospective analysis in patients with solid tumors treated with ICIs in a 6-year period, from 2015 to 2021, developing GI AEs, for which an endoscopic analysis was performed, with available histological specimens or surgery. Results: Twenty-one patients developed GI AEs under ICIs. The median time from the start of ICIs to the onset of GI AEs was 5 months. Diarrhea was the most frequent symptom (57.2%), upper GI symptoms presented in four patients (19%), while three patients (14.3%) had no symptoms and were diagnosed occasionally. Two patients underwent surgical resection for acute abdomen. Histological findings observed in endoscopic sampling were eosinophilic-pattern gastro-enterocolitis, apoptotic damage, IBD-like features, and ischemic-like changes. Histological damage was also documented in patients with unremarkable endoscopy. Conclusions: Under ICI therapy, GI toxicity is an expected event. Since GIAEs can mimic a broad range of primary GI diseases, a multidisciplinary approach is advocated with upper and lower GI mucosal sampling to remodel therapy and avoid complications.
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Affiliation(s)
- Paola Parente
- Pathology Unit, Fondazione IRCCS Ospedale Casa Sollievo della Sofferenza, Viale Cappuccini 1, San Giovanni Rotondo, 71013 Foggia, Italy;
- Correspondence: (P.P.); (F.B.); Tel.: +390-8828-353910 (P.P. & F.B.); Fax: +390-8824-10411 (P.P. & F.B.)
| | - Brigida Anna Maiorano
- Oncology Unit, Fondazione IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (B.A.M.); (D.C.); (E.M.)
- Department of Translational Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Davide Ciardiello
- Oncology Unit, Fondazione IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (B.A.M.); (D.C.); (E.M.)
- Oncology Unit, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy
| | - Francesco Cocomazzi
- Division of Gastroenterology, Fondazione IRCCS Ospedale Casa Sollievo della Sofferenza, Viale Cappuccini 1, San Giovanni Rotondo, 71013 Foggia, Italy; (F.C.); (S.C.); (M.G.)
| | - Sonia Carparelli
- Division of Gastroenterology, Fondazione IRCCS Ospedale Casa Sollievo della Sofferenza, Viale Cappuccini 1, San Giovanni Rotondo, 71013 Foggia, Italy; (F.C.); (S.C.); (M.G.)
| | - Maria Guerra
- Division of Gastroenterology, Fondazione IRCCS Ospedale Casa Sollievo della Sofferenza, Viale Cappuccini 1, San Giovanni Rotondo, 71013 Foggia, Italy; (F.C.); (S.C.); (M.G.)
| | - Giuseppe Ingravallo
- Section of Molecular Pathology, Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, 70124 Bari, Italy; (G.I.); (G.C.)
| | - Gerardo Cazzato
- Section of Molecular Pathology, Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, 70124 Bari, Italy; (G.I.); (G.C.)
| | - Illuminato Carosi
- Pathology Unit, Fondazione IRCCS Ospedale Casa Sollievo della Sofferenza, Viale Cappuccini 1, San Giovanni Rotondo, 71013 Foggia, Italy;
| | - Evaristo Maiello
- Oncology Unit, Fondazione IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (B.A.M.); (D.C.); (E.M.)
| | - Fabrizio Bossa
- Division of Gastroenterology, Fondazione IRCCS Ospedale Casa Sollievo della Sofferenza, Viale Cappuccini 1, San Giovanni Rotondo, 71013 Foggia, Italy; (F.C.); (S.C.); (M.G.)
- Correspondence: (P.P.); (F.B.); Tel.: +390-8828-353910 (P.P. & F.B.); Fax: +390-8824-10411 (P.P. & F.B.)
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De Silva S, Trieu H, Rajan A, Liang Y, Lin JL, Kidambi TD. Flexible sigmoidoscopy may be sufficient for initial evaluation of suspected immunotherapy-mediated colitis: A cross-sectional study. J Gastroenterol Hepatol 2022; 37:284-290. [PMID: 34547818 DOI: 10.1111/jgh.15691] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/31/2021] [Accepted: 09/19/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Immune checkpoint inhibitors (ICIs) have shown promise in treating a variety of cancers. Their increased use coincides with increased incidence of immunotherapy-mediated colitis (IMC), a common adverse effect. Optimal strategy for endoscopic evaluation of IMC (full colonoscopy or flexible sigmoidoscopy) is not well-defined. METHODS Retrospective review of all patients at City of Hope referred to gastroenterology for evaluation of IMC due to gastrointestinal symptoms was performed. Patients with an existing histologic diagnosis of IMC established at an outside hospital or a diagnosis of infectious or chronic colitis were excluded. RESULTS We identified 51 symptomatic patients on ICIs prompting evaluation for IMC with colonoscopy (47/51) or flexible sigmoidoscopy (4/51). All distal rectosigmoid biopsies during flexible sigmoidoscopy demonstrated histologic evidence of IMC. In full colonoscopy, IMC was either present in all segments of colon simultaneously (35/47) or absent from all segments (12/47). No isolated proximal colonic biopsies demonstrated IMC. Endoscopically normal mucosa demonstrated histologic evidence of IMC up to 68.6% of the time. Endoscopically abnormal right, transverse, and left colon had low sensitivity (35.3%, 34.3%, and 41.7%, respectively) and high specificity (100.0%, 100.0%, and 91.7%, respectively) for histological presence of IMC. CONCLUSIONS Distal colon biopsies in patients on ICI therapy with diarrhea and suspected IMC were sufficient for diagnosing IMC in our cohort. Further, we found histologic evidence of IMC in biopsies taken from normal-appearing mucosa in a number of patients, suggesting that a normal endoscopic appearance does not preclude the presence of IMC and biopsies should be taken from both normal and abnormal-appearing mucosa.
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Affiliation(s)
- Sadie De Silva
- Division of Gastroenterology, Department of Medicine, City of Hope Medical Center, Duarte, California, USA.,Department of Medicine, Temecula Valley Hospital, Temecula, California, USA
| | - Harry Trieu
- Division of Gastroenterology, Department of Medicine, City of Hope Medical Center, Duarte, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Anand Rajan
- Division of Gastroenterology, Department of Medicine, City of Hope Medical Center, Duarte, California, USA.,Department of Medicine, Olive View Medical Center, Los Angeles, California, USA
| | - Yu Liang
- Department of Pathology, City of Hope Medical Center, Duarte, California, USA
| | - James L Lin
- Division of Gastroenterology, Department of Medicine, City of Hope Medical Center, Duarte, California, USA
| | - Trilokesh D Kidambi
- Division of Gastroenterology, Department of Medicine, City of Hope Medical Center, Duarte, California, USA
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Humbert O, Bauckneht M, Gal J, Paquet M, Chardin D, Rener D, Schiazza A, Genova C, Schiappa R, Zullo L, Rossi G, Martin N, Hugonnet F, Darcourt J, Morbelli S, Otto J. Prognostic value of immunotherapy-induced organ inflammation assessed on 18FDG PET in patients with metastatic non-small cell lung cancer. Eur J Nucl Med Mol Imaging 2022; 49:3878-3891. [PMID: 35562529 PMCID: PMC9399195 DOI: 10.1007/s00259-022-05788-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/30/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE We evaluated the prognostic value of immunotherapy-induced organ inflammation observed on 18FDG PET in patients with non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitors (ICPIs). METHODS Data from patients with IIIB/IV NSCLC included in two different prospective trials were analyzed. 18FDG PET/CT exams were performed at baseline (PETBaseline) and repeated after 7-8 weeks (PETInterim1) and 12-16 weeks (PETInterim2) of treatment, using iPERCIST for tumor response evaluation. The occurrence of abnormal organ 18FDG uptake, deemed to be due to ICPI-related organ inflammation, was collected. RESULTS Exploratory cohort (Nice, France): PETInterim1 and PETInterim2 revealed the occurrence of at least one ICPI-induced organ inflammation in 72.8% of patients, including midgut/hindgut inflammation (33.7%), gastritis (21.7%), thyroiditis (18.5%), pneumonitis (17.4%), and other organ inflammations (9.8%). iPERCIST tumor response was associated with improved progression-free survival (p < 0.001). iPERCIST tumor response and immuno-induced gastritis assessed on PET were both associated with improved overall survival (OS) (p < 0.001 and p = 0.032). Combining these two independent variables, we built a model predicting patients' 2-year OS with a sensitivity of 80.3% and a specificity of 69.2% (AUC = 72.7). Validation cohort (Genova, Italy): Immuno-induced gastritis (19.6% of patients) was associated with improved OS (p = 0.04). The model built previously predicted 2-year OS with a sensitivity and specificity of 72.0% and 63.6% (AUC = 70.7) and 3-year OS with a sensitivity and specificity of 69.2% and 80.0% (AUC = 78.2). CONCLUSION Immuno-induced gastritis revealed by early interim 18FDG PET in around 20% of patients with NSCLC treated with ICPI is a novel and reproducible imaging biomarker of improved OS.
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Affiliation(s)
- Olivier Humbert
- Department of Nuclear Medicine, Centre Antoine-Lacassagne, Université Côte d'Azur (UCA), 33 Avenue de Valombrose, 06189, Nice, France.
- TIRO-UMR E 4320, UCA/CEA, Nice, France.
| | - Matteo Bauckneht
- Nuclear Medicine Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Jocelyn Gal
- Department of Biostatistics, Centre Antoine-Lacassagne, Nice, France
| | - Marie Paquet
- Department of Nuclear Medicine, Centre Antoine-Lacassagne, Université Côte d'Azur (UCA), 33 Avenue de Valombrose, 06189, Nice, France
| | - David Chardin
- Department of Nuclear Medicine, Centre Antoine-Lacassagne, Université Côte d'Azur (UCA), 33 Avenue de Valombrose, 06189, Nice, France
- TIRO-UMR E 4320, UCA/CEA, Nice, France
| | - David Rener
- Department of Biostatistics, Centre Antoine-Lacassagne, Nice, France
| | - Aurelie Schiazza
- Department of Nuclear Medicine, Centre Antoine-Lacassagne, Université Côte d'Azur (UCA), 33 Avenue de Valombrose, 06189, Nice, France
| | - Carlo Genova
- UOC Clinica Di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Dipartimento Di Medicina Interna E Specialità Mediche (DiMI), Facoltà Di Medicina E Chirurgia, Università Degli Studi Di Genova, Genoa, Italy
| | - Renaud Schiappa
- Department of Biostatistics, Centre Antoine-Lacassagne, Nice, France
| | - Lodovica Zullo
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Giovanni Rossi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
- UO Oncologia Medica, Ospedale Padre Antero Micone, Genoa, Italy
| | - Nicolas Martin
- Department of Medical Oncology, Centre Antoine-Lacassagne, UCA, Nice, France
| | - Florent Hugonnet
- Department of Nuclear Medicine, Centre Hospitalier Princesse Grâce, Monaco, Monaco
| | - Jacques Darcourt
- Department of Nuclear Medicine, Centre Antoine-Lacassagne, Université Côte d'Azur (UCA), 33 Avenue de Valombrose, 06189, Nice, France
- TIRO-UMR E 4320, UCA/CEA, Nice, France
| | - Silvia Morbelli
- Nuclear Medicine Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Josiane Otto
- Department of Medical Oncology, Centre Antoine-Lacassagne, UCA, Nice, France
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