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Zemp LW, Rudzinski JK, Pettaway CA, Nicholson S, Spiess PE. Management of Bulky Inguinal and Pelvic Lymph Nodes. Urol Clin North Am 2024; 51:335-345. [PMID: 38925736 DOI: 10.1016/j.ucl.2024.03.012] [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] [Indexed: 06/28/2024]
Abstract
Penile cancer with bulky inguinal metastasis has a high probability of harboring pathologically involved lymph nodes best managed in a multidisciplinary care setting. Appropriate staging with cross-sectional imaging and fine-needle aspirate cytology of suspicious nodes guide decision-making for the use of platinum-based neoadjuvant chemotherapy followed by inguinal lymph node dissection. Surgical resection plays an important diagnostic, therapeutic, and guiding role in disease management. Patients with adverse pathologic features, especially those with extranodal disease extension, may derive additional benefit from adjuvant radiotherapy.
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Affiliation(s)
- Logan W Zemp
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA.
| | - Jan K Rudzinski
- Catherine and Joseph Aresty Department of Urology, Institute of Urology, Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033, USA
| | - Curtis A Pettaway
- Division of Surgery, Department of Urology, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1373, Houston, TX 77030, USA
| | - Steve Nicholson
- Division of Medical Oncology, Mid- & South Essex NHS Foundation Trust, Court Road, Broomfield, Chelmsford CM1 7ET, UK
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive Office 12538, Tampa, FL 33612, USA
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2
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Ge S, Zheng L, Li Y, Gan L, Wang Z, Zeng Z, Meng C, Li K, Ma J, Wang D, Ren Y. Comparing the safety and effectiveness of minimally invasive surgery and open inguinal lymph node dissection in penile cancer: A systematic review and meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108553. [PMID: 39059191 DOI: 10.1016/j.ejso.2024.108553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 06/04/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVE To compare the safety and effectiveness of minimally invasive surgery (MIS) with open inguinal lymph node dissection (O-ILND) in penile cancer. METHODS We performed a systematic reviews and cumulative meta-analyses of primary results of interest according to PRISMA criteria, and quality assessment followed AMSTAR. The system searched five databases, including Zhiwang, Embase, PubMed, Cochrane Library and Web of Science. The search period ranged was from database creation until September 2023. The statistical analysis software used Stata16. RESULTS A total of 16 studies, including 898 patients. Compared to O-ILND, MIS is superior in length of stay (WMD = -2.96, 95%CI [-4.38, -1.54], P < 0.05), drainage time (WMD = -3.24, 95%CI [-4.70, -1.78], P < 0.05) and estimated blood loss (WMD = -35.70, 95%CI [-46.27, -25.14], P < 0.05), while operation time, recurrence rate and 5-year overall survival rate are the same. The number of lymph nodes dissection between the two groups are not statistically significant. Subgroup analyses found that there are more lymph nodes dissection in robotic-assisted inguinal lymph nodes dissection (WMD = 0.50, 95%CI [0.20, 0.80], P < 0.05). The overall complication rate of MIS was lower (OR = 0.26, 95%CI [0.09, 0.70], P < 0.05). CONCLUSION Minimally invasive inguinal lymph nodes dissection appears to be a better option for penile cancer cases. But more large samples and multicenter studies are needed to further confirm.
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Affiliation(s)
- Si Ge
- Department of Urology, Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College (University), Nanchong, 63700, Sichuan, China; Department of Urology, School of Clinical Medicine, Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Lei Zheng
- Department of Urology, Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College (University), Nanchong, 63700, Sichuan, China
| | - Yunxiang Li
- Department of Urology, Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College (University), Nanchong, 63700, Sichuan, China; Department of Urology, School of Clinical Medicine, Southwest Medical University, Luzhou, 646000, Sichuan, China.
| | - Lijian Gan
- Department of Urology, Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College (University), Nanchong, 63700, Sichuan, China
| | - Zuoping Wang
- Department of Urology, Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College (University), Nanchong, 63700, Sichuan, China
| | - Zhiqiang Zeng
- Department of Urology, School of Clinical Medicine, Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Chunyang Meng
- Department of Urology, School of Clinical Medicine, Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Kangsen Li
- Department of Urology, Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College (University), Nanchong, 63700, Sichuan, China
| | - Jiakai Ma
- Department of Urology, Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College (University), Nanchong, 63700, Sichuan, China
| | - Deyu Wang
- Department of Urology, Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College (University), Nanchong, 63700, Sichuan, China
| | - Yuan Ren
- Department of Urology, School of Clinical Medicine, Southwest Medical University, Luzhou, 646000, Sichuan, China
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Ozambela M, McCormick BZ, Rudzinski JK, Pieretti AC, González GMN, Meissner MA, Papadopoulos JN, Adibi M, Matin SF, Dahmen AS, Spiess PE, Pettaway CA. Robotic or open superficial inguinal lymph node dissection as staging procedures for clinically node negative high risk penile cancer. Urol Oncol 2024; 42:120.e1-120.e9. [PMID: 38388244 DOI: 10.1016/j.urolonc.2024.01.036] [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: 11/24/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE To evaluate perioperative and oncologic outcomes of a cohort of clinically node negative high-risk penile cancer patients undergoing robotic assisted inguinal lymph node dissection (RAIL) compared to patients undergoing open superficial inguinal lymph node dissection (OSILND). PATIENTS AND METHODS We retrospectively reviewed the clinical characteristics and outcomes of clinically node negative high-risk penile cancer patients undergoing RAIL at MDACC from 2013-2019. We sought to compare this to a contemporary open cohort of clinically node negative patients treated from 1999 to 2019 at MDACC and Moffit Cancer Center (MCC) with an OSILND. Descriptive statistics were used to characterize the study cohorts. Comparison analysis between operative variables was performed using Fisher's exact test and Wilcoxon's rank-sum test. The Kaplan-Meier method was used to estimate survival endpoints. RESULTS There were 24 patients in the RAIL cohort, and 35 in the OSILND cohort. Among the surgical variables, operative time (348.5 minutes vs. 239.0 minutes, P < 0.01) and the duration of operative drain (37 vs. 22 days P = 0.017) were both significantly longer in the RAIL cohort. Complication incidences were similar for both cohorts (34.3% for OSILND vs. 33.3% for RAIL), with wound complications making up 33% of all complications for RAIL and 31% of complications for OSILND. No inguinal recurrences were noted in either cohort. The median follow-up was 40 months for RAIL and 33 months for OSILND. CONCLUSIONS We observed similar complication rates and surgical variable outcomes in our analysis apart from operative time and operative drain duration. Oncological outcomes were similar between the two cohorts. RAIL was a reliable staging and potentially therapeutic procedure among clinically node negative patients with penile squamous cell carcinoma with comparable outcomes to an OSILND cohort.
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Affiliation(s)
- Manuel Ozambela
- Department of Urology at The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Barrett Z McCormick
- Department of Urology at The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jan K Rudzinski
- Department of Urology at The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Matthew A Meissner
- Department of Urology at The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John N Papadopoulos
- Department of Urology at The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mehrad Adibi
- Department of Urology at The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Surena F Matin
- Department of Urology at The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Aaron S Dahmen
- Department of Urology at University of Chicago, Chicago, IL
| | - Philippe E Spiess
- Department of Genitourinary Oncology at Moffit Cancer Center, Tampa, FL
| | - Curtis A Pettaway
- Department of Urology at The University of Texas MD Anderson Cancer Center, Houston, TX.
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Sachdeva A, McGuinness L, Zapala Ł, Greco I, Garcia-Perdomo HA, Kailavasan M, Antunes-Lopes T, Ayres B, Barreto L, Campi R, Crook J, Johnstone P, Kumar V, Manzie K, Marcus JD, Necchi A, Oliveira P, Osborne J, Pagliaro LC, Protzel C, Bryan Rumble R, Sánchez Martínez DF, Spiess PE, Tagawa ST, van der Heijden MS, Parnham AS, Pettaway CA, Albersen M, Sangar VK, Brouwer OR, Sakalis VI. Management of Lymph Node-positive Penile Cancer: A Systematic Review. Eur Urol 2024; 85:257-273. [PMID: 37208237 DOI: 10.1016/j.eururo.2023.04.018] [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: 11/20/2022] [Revised: 03/27/2023] [Accepted: 04/19/2023] [Indexed: 05/21/2023]
Abstract
CONTEXT Lymph node (LN) involvement in penile cancer is associated with poor survival. Early diagnosis and management significantly impact survival, with multimodal treatment approaches often considered in advanced disease. OBJECTIVE To assess the clinical effectiveness of treatment options available for the management of inguinal and pelvic lymphadenopathy in men with penile cancer. EVIDENCE ACQUISITION EMBASE, MEDLINE, the Cochrane Database of Systematic Reviews, and other databases were searched from 1990 to July 2022. Randomised controlled trials (RCTs), nonrandomised comparative studies (NRCSs), and case series (CSs) were included. EVIDENCE SYNTHESIS We identified 107 studies, involving 9582 patients from two RCTs, 28 NRCSs, and 77 CSs. The quality of evidence is considered poor. Surgery is the mainstay of LN disease management, with early inguinal LN dissection (ILND) associated with better outcomes. Videoendoscopic ILND may offer comparable survival outcomes to open ILND with lower wound-related morbidity. Ipsilateral pelvic LN dissection (PLND) in N2-3 cases improves overall survival in comparison to no pelvic surgery. Neoadjuvant chemotherapy in N2-3 disease showed a pathological complete response rate of 13% and an objective response rate of 51%. Adjuvant radiotherapy may benefit pN2-3 but not pN1 disease. Adjuvant chemoradiotherapy may provide a small survival benefit in N3 disease. Adjuvant radiotherapy and chemotherapy improve outcomes after PLND for pelvic LN metastases. CONCLUSIONS Early LND improves survival in nodal disease in penile cancer. Multimodal treatments may provide additional benefit in pN2-3 cases; however, data are limited. Therefore, individualised management of patients with nodal disease should be discussed in a multidisciplinary team setting. PATIENT SUMMARY Spread of penile cancer to the lymph nodes is best managed with surgery, which improves survival and has curative potential. Supplementary treatment, including the use of chemotherapy and/or radiotherapy, may further improve survival in advanced disease. Patients with penile cancer with lymph node involvement should be treated by a multidisciplinary team.
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Affiliation(s)
- Ashwin Sachdeva
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Department of Urology, The Christie NHS Foundation Trust, Manchester, UK.
| | - Luke McGuinness
- Department of Urology, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Łukasz Zapala
- Department of Urology, Medical University of Warsaw, Warsaw, Poland
| | - Isabella Greco
- Department of Urological Minimally Invasive and Robotic Surgery and Kidney Transplantation, Careggi Hospital, University of Florence, Florence, Italy
| | - Herney Andres Garcia-Perdomo
- Division of Urology/Uro-oncology, Department of Surgery, School of Medicine, Universidad Del Valle, Cali, Colombia
| | | | | | - Benjamin Ayres
- Department of Urology, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Lenka Barreto
- Department of Urology, University Hospital Nitra, Nitra, Slovakia
| | - Riccardo Campi
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi University Hospital, Florence, Italy
| | - Juanita Crook
- British Columbia Cancer Agency, University of British Columbia, Kelowna, Canada
| | - Peter Johnstone
- Departments of Radiation Oncology and Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA
| | - Vivek Kumar
- Department of Urology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | | | | | - Andrea Necchi
- Department of Urology and Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Pedro Oliveira
- Department of Pathology, The Christie NHS Foundation Trust, Manchester, UK; Centre for the Research and Technology of Agro-Environmental and Biological Sciences, University of Trásos-Montes and Alto Douro, Vila Real, Portugal; Veterinary Sciences Department, University of Trásos-Montes and Alto Douro, Vila Real, Portugal
| | | | | | | | - R Bryan Rumble
- American Society of Clinical Oncology, Alexandria, VA, USA
| | | | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Scott T Tagawa
- Division of Hematology and Medical Oncology, Weill Cornell Medical College, New York, NY, USA
| | | | - Arie S Parnham
- Department of Urology, The Christie NHS Foundation Trust, Manchester, UK
| | | | - Maarten Albersen
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Vijay K Sangar
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Department of Urology, The Christie NHS Foundation Trust, Manchester, UK
| | - Oscar R Brouwer
- The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Franco A, Ditonno F, Manfredi C, Johnson AD, Mamgain A, Feldman-Schultz O, Feng CL, Pellegrino AA, Mir MC, Porpiglia F, Crivellaro S, De Nunzio C, Chow AK, Autorino R. Robot-assisted Surgery in the Field of Urology: The Most Pioneering Approaches 2015-2023. Res Rep Urol 2023; 15:453-470. [PMID: 37842031 PMCID: PMC10575039 DOI: 10.2147/rru.s386025] [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: 07/27/2023] [Accepted: 09/30/2023] [Indexed: 10/17/2023] Open
Abstract
Robot-assisted surgery has emerged as a transformative technology, revolutionizing surgical approaches and techniques that decades ago could barely be imagined. The field of urology has taken charge in pioneering a new era of minimally invasive surgery with the ascent of robotic systems which offer enhanced visualization, precision, dexterity, and enabling surgeons to perform intricate maneuvers with improved accuracy. This has led to improved surgical outcomes, including reduced blood loss, lower complication rates, and faster patient recovery. The aim of our review is to present an evidence-based critical analysis on the most pioneering robotic urologic approaches described over the last eight years (2015-2023).
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Affiliation(s)
- Antonio Franco
- Department of Urology, Rush University, Chicago, IL, USA
- Department of Urology, Sant’Andrea Hospital, Sapienza University, Rome, Italy
| | - Francesco Ditonno
- Department of Urology, Rush University, Chicago, IL, USA
- Department of Urology, University of Verona, Verona, Italy
| | - Celeste Manfredi
- Department of Urology, Rush University, Chicago, IL, USA
- Urology Unit, “Luigi Vanvitelli” University, Naples, Italy
| | | | | | | | - Carol L Feng
- Department of Urology, Rush University, Chicago, IL, USA
| | - Antony A Pellegrino
- Department of Urology, University of Illinois at Chicago, Chicago, Illinois, USA
- Unit of Urology/Division of Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Carmen Mir
- Department of Urology, Hospital Universitario La Ribera, Valencia, Spain
| | - Francesco Porpiglia
- Department of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Simone Crivellaro
- Department of Urology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Cosimo De Nunzio
- Department of Urology, Sant’Andrea Hospital, Sapienza University, Rome, Italy
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European Association of Urology-American Society of Clinical Oncology Collaborative Guideline on Penile Cancer: 2023 Update. Eur Urol 2023; 83:548-560. [PMID: 36906413 DOI: 10.1016/j.eururo.2023.02.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/25/2023] [Indexed: 03/11/2023]
Abstract
CONTEXT Penile cancer is a rare disease but has a significant impact on quality of life. Its incidence is increasing, so it is important to include new and relevant evidence in clinical practice guidelines. OBJECTIVE To provide a collaborative guideline that offers worldwide physician and patient guidance for the management of penile cancer. EVIDENCE ACQUISITION Comprehensive literature searches were performed for each section topic. In addition, three systematic reviews were conducted. Levels of evidence were assessed, and a strength rating for each recommendation was assigned according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. EVIDENCE SYNTHESIS Penile cancer is a rare disease but its global incidence is increasing. Human papillomavirus (HPV) is the main risk factor for penile cancer and pathology should include an assessment of HPV status. The main aim of primary tumour treatment is complete tumour eradication, which has to be balanced against optimal organ preservation without compromising oncological control. Early detection and treatment of lymph node (LN) metastasis is the main determinant of survival. Surgical LN staging with sentinel node biopsy is recommended for patients with a high-risk (≥pT1b) tumour with cN0 status. While (inguinal) LN dissection remains the standard for node-positive disease, multimodal treatment is needed in patients with advanced disease. Owing to a lack of controlled trials and large series, the levels of evidence and grades of recommendation are low in comparison to those for more common diseases. CONCLUSIONS This collaborative penile cancer guideline provides updated information on the diagnosis and treatment of penile cancer for use in clinical practice. Organ-preserving surgery should be offered for treatment of the primary tumour when feasible. Adequate and timely LN management remains a challenge, especially in advanced disease stages. Referral to centres of expertise is recommended. PATIENT SUMMARY Penile cancer is a rare disease that significantly impacts quality of life. While the disease can be cured in most cases without lymph node involvement, management of advanced disease remains challenging. Many unmet needs and unanswered questions remain, underlining the importance of research collaborations and centralisation of penile cancer services.
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Sood A, Rudzinski JK, Spiess PE, Pettaway CA. The Acute Complications After Surgery for Penile Carcinoma and Strategies for Their Management: A Systematic Review of the Literature. Semin Oncol Nurs 2022; 38:151285. [PMID: 35597731 DOI: 10.1016/j.soncn.2022.151285] [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: 10/18/2022]
Abstract
OBJECTIVES To investigate the contemporary rates of 30-day complications after surgery for penile cancer and to discuss the currently used preventative and therapeutic practices aimed at mitigation of these postoperative adverse events. DATA SOURCES A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed, and studies reporting on the contemporary rates, nature, or management of acute complications following primary penile surgery or inguinal lymph node dissection for penile cancer were abstracted. Medline (PubMed) and EMBASE libraries were used to retrieve the articles published between January 1984 and December 2021 (n = 170 articles). Ultimately, 38 articles were included. The primary outcome of interest was 30-day (acute) postoperative complications, stratified by those associated with treatment of the primary penile lesion and those with inguinal lymph node dissection. Risk of bias assessment was undertaken. Special attention was paid to studies reporting management strategies for these complications. CONCLUSION This comprehensive review revealed that the quality of existing studies reporting on complications is poor and the risk of bias is high. Within these studies, the rates of acute complications following primary penile surgery and inguinal lymph node dissection ranged between 0% and 29.4% and 6% and 90%, respectively. More than 50% of these complications were wound related. Over the past two decades, several studies have reported on improved surgical techniques and protocolized postsurgical care pathways. Although the newer techniques have been associated with improved outcomes, the absolute rates of complications have remained high even in the most contemporary series. Therefore, there is an urgent need for health care providers and stakeholders to reach consensus regarding preoperative workup and medical optimization goals, stage appropriate therapies, and postoperative care pathways, as has been done for other malignancies associated with high morbidity. IMPLICATIONS FOR NURSING PRACTICE Penile cancer is a disease of the elderly, and surgical management of the primary lesion or the groins is associated with a high rate of complications. Most complications are wound related. Meticulous surgical technique and careful postoperative monitoring with early intervention are keys to mitigating surgery-related morbidity. However, equally important is dissemination and adoption of these principles by all health care workers universally.
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Affiliation(s)
- Akshay Sood
- Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Jan K Rudzinski
- Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Philippe E Spiess
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL
| | - Curtis A Pettaway
- Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, TX.
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Lee EWC, Issa A, Oliveira P, Lau M, Sangar V, Parnham A, Fankhauser CD. High diagnostic accuracy of inguinal ultrasonography and fine needle aspiration followed by dynamic sentinel lymph node biopsy in men with non‐palpable and palpable inguinal lymph nodes. BJU Int 2022; 130:331-336. [DOI: 10.1111/bju.15700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/15/2022] [Accepted: 01/21/2022] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | - Maurice Lau
- The Christie NHS Foundation Trusts Manchester UK
| | - Vijay Sangar
- The Christie NHS Foundation Trusts Manchester UK
| | - Arie Parnham
- The Christie NHS Foundation Trusts Manchester UK
| | - Christian D. Fankhauser
- The Christie NHS Foundation Trusts Manchester UK
- Luzerner Kantonsspital, Luzern Switzerland
- University of Zurich Zurich Switzerland
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