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Nasir-Moin M, Wadiura LI, Sacalean V, Juros D, Movahed-Ezazi M, Lock EK, Smith A, Lee M, Weiss H, Müther M, Alber D, Ratna S, Fang C, Suero-Molina E, Hellwig S, Stummer W, Rössler K, Hainfellner JA, Widhalm G, Kiesel B, Reichert D, Mischkulnig M, Jain R, Straehle J, Neidert N, Schnell O, Beck J, Trautman J, Pastore S, Pacione D, Placantonakis D, Oermann EK, Golfinos JG, Hollon TC, Snuderl M, Freudiger CW, Heiland DH, Orringer DA. Localization of protoporphyrin IX during glioma-resection surgery via paired stimulated Raman histology and fluorescence microscopy. Nat Biomed Eng 2024:10.1038/s41551-024-01217-3. [PMID: 38987630 DOI: 10.1038/s41551-024-01217-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 04/20/2024] [Indexed: 07/12/2024]
Abstract
The most widely used fluorophore in glioma-resection surgery, 5-aminolevulinic acid (5-ALA), is thought to cause the selective accumulation of fluorescent protoporphyrin IX (PpIX) in tumour cells. Here we show that the clinical detection of PpIX can be improved via a microscope that performs paired stimulated Raman histology and two-photon excitation fluorescence microscopy (TPEF). We validated the technique in fresh tumour specimens from 115 patients with high-grade gliomas across four medical institutions. We found a weak negative correlation between tissue cellularity and the fluorescence intensity of PpIX across all imaged specimens. Semi-supervised clustering of the TPEF images revealed five distinct patterns of PpIX fluorescence, and spatial transcriptomic analyses of the imaged tissue showed that myeloid cells predominate in areas where PpIX accumulates in the intracellular space. Further analysis of external spatially resolved metabolomics, transcriptomics and RNA-sequencing datasets from glioblastoma specimens confirmed that myeloid cells preferentially accumulate and metabolize PpIX. Our findings question 5-ALA-induced fluorescence in glioma cells and show how 5-ALA and TPEF imaging can provide a window into the immune microenvironment of gliomas.
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Affiliation(s)
- Mustafa Nasir-Moin
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Vlad Sacalean
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Microenvironment and Immunology Research Laboratory, Medical Center - University of Freiburg, Freiburg, Germany
| | - Devin Juros
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Emily K Lock
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Andrew Smith
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Matthew Lee
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Hannah Weiss
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Michael Müther
- Department of Neurosurgery, Münster University Hospital, Münster, Germany
| | - Daniel Alber
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Camila Fang
- Department of Pathology, NYU Grossman School of Medicine, New York, NY, USA
| | - Eric Suero-Molina
- Department of Neurosurgery, Münster University Hospital, Münster, Germany
| | - Sönke Hellwig
- Department of Neurosurgery, Münster University Hospital, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, Münster University Hospital, Münster, Germany
| | - Karl Rössler
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Johannes A Hainfellner
- Division of Neuropathology and Neurochemistry (Obersteiner Institute), Department of Neurology, Medical University Vienna, Vienna, Austria
| | - Georg Widhalm
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Barbara Kiesel
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - David Reichert
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Mario Mischkulnig
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Rajan Jain
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Jakob Straehle
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Berta-Ottenstein Clinician Scientist Program, Faculty of Medicine, University Freiburg, Freiburg, Germany
| | - Nicolas Neidert
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Berta-Ottenstein Clinician Scientist Program, Faculty of Medicine, University Freiburg, Freiburg, Germany
| | - Oliver Schnell
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Translational NeuroOncology Research Group, Medical Center - University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for NeuroModulation (NeuroModul), University of Freiburg, Freiburg, Germany
| | | | | | - Donato Pacione
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Eric Karl Oermann
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
- Center for Data Science, New York University, New York, USA
| | - John G Golfinos
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Todd C Hollon
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Matija Snuderl
- Department of Pathology, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Dieter Henrik Heiland
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany.
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.
- Microenvironment and Immunology Research Laboratory, Medical Center - University of Freiburg, Freiburg, Germany.
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center - University of Freiburg, Freiburg, Germany.
- German Cancer Consortium (DKTK), partner site Freiburg, Freiburg, Germany.
| | - Daniel A Orringer
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA.
- Department of Pathology, NYU Grossman School of Medicine, New York, NY, USA.
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Pyrgidis N, Moschini M, Tzelves L, Somani BK, Juliebø-Jones P, Del Giudice F, Mertens LS, Pichler R, Volz Y, Ebner B, Eismann L, Semmler M, Pradere B, Soria F, Stief CG, Schulz GB. Perioperative Outcomes and Trends in Transurethral Resection of Bladder Tumors with Photodynamic Diagnosis: Results from the GeRmAn Nationwide Inpatient Data Study. J Clin Med 2024; 13:3531. [PMID: 38930060 PMCID: PMC11204857 DOI: 10.3390/jcm13123531] [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: 05/10/2024] [Revised: 05/30/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Photodynamic diagnosis (PDD) during transurethral resection of bladder tumor (TURBT) is guideline recommended, as it improves bladder cancer detection rates. However, the extent to which PDD is implemented in everyday clinical practice has not been thoroughly assessed. We aimed to evaluate the current trends and major perioperative outcomes of TURBT with PDD. Methods: The present study evaluated the GeRmAn Nationwide inpatient Data (GRAND) from 2010 (the year when PDD started to be coded separately in Germany) to 2021, which were made available from the Research Data Center of the German Bureau of Statistics. We undertook numerous patient-level and multivariable logistic regression analyses. Results: Overall, 972,208 TURBTs [228,207 (23%) with PDD and 744,001 (77%) with white light] were performed. Patients offered PDD during TURBT were younger (p < 0.001), presented fewer comorbidities (p < 0.001) and were discharged earlier from hospital (p < 0.001). PDD was associated with additional costs of about EUR 500 compared to white-light TURBT (p < 0.001). The yearly TURBT cases remained relatively stable from 2010 to 2021, whereas utilization of PDD underwent a 2-fold increase. After adjusting for major risk factors in the multivariate regression analysis, PDD was related to lower rates of transfusion (1.4% vs. 5.6%, OR: 0.29, 95% CI: 0.28 to 0.31, p < 0.001), intensive care unit admission (0.7% vs. 1.4%, OR: 0.56, 95% CI: 0.53 to 0.59, p < 0.001) and 30-day in-hospital mortality (0.1% vs. 0.7%, OR: 0.24, 95% CI: 0.22 to 0.27, p < 0.001) compared to white-light TURBT. On the contrary, PDD was related to clinically insignificant higher rates of bladder perforation (0.6% versus 0.5%, OR: 1.3, 95% CI: 1.2 to 1.4, p < 0.001), and reoperation (2.6% versus 2.3%, OR: 1.2, 95% CI: 1.1 to 1.2, p < 0.001). Conclusions: The utilization of PDD with TURBT is steadily increasing. Nevertheless, the road toward the establishment of PDD as the standard of care for TURBT is still long, despite of the advantages of PDD.
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Affiliation(s)
- Nikolaos Pyrgidis
- Department of Urology, University Hospital, Ludwig Maximilian University Munich, 81377 Munich, Germany; (Y.V.); (L.E.); (M.S.)
| | - Marco Moschini
- Department of Urology, Urological Research Institute, San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Lazaros Tzelves
- 2nd Department of Urology, Sismanoglio General Hospital of Athens, 15126 Athens, Greece
| | - Bhaskar K. Somani
- Department of Urology, University of Hospital Southampton NHS Trust, Southampton SO16 6YD, UK;
| | | | - Francesco Del Giudice
- Department of Urology, Sapienza Rome University, Policlinico Umberto I, 00161 Rome, Italy;
| | - Laura S. Mertens
- Department of Urology, Medical University Innsbruck, 6020 Innsbruck, Austria; (L.S.M.); (R.P.)
| | - Renate Pichler
- Department of Urology, Medical University Innsbruck, 6020 Innsbruck, Austria; (L.S.M.); (R.P.)
| | - Yannic Volz
- Department of Urology, University Hospital, Ludwig Maximilian University Munich, 81377 Munich, Germany; (Y.V.); (L.E.); (M.S.)
| | - Benedikt Ebner
- Department of Urology, University Hospital, Ludwig Maximilian University Munich, 81377 Munich, Germany; (Y.V.); (L.E.); (M.S.)
| | - Lennert Eismann
- Department of Urology, University Hospital, Ludwig Maximilian University Munich, 81377 Munich, Germany; (Y.V.); (L.E.); (M.S.)
| | - Marie Semmler
- Department of Urology, University Hospital, Ludwig Maximilian University Munich, 81377 Munich, Germany; (Y.V.); (L.E.); (M.S.)
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria
| | - Francesco Soria
- Department of Surgical Sciences, University of Turin, Città della Salute e della Scienza, 10126 Turin, Italy
| | - Christian G. Stief
- Department of Urology, University Hospital, Ludwig Maximilian University Munich, 81377 Munich, Germany; (Y.V.); (L.E.); (M.S.)
| | - Gerald B. Schulz
- Department of Urology, University Hospital, Ludwig Maximilian University Munich, 81377 Munich, Germany; (Y.V.); (L.E.); (M.S.)
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Sari Motlagh R, Ghoreifi A, Yanagisawa T, Kawada T, Ahyai S, Merseburger AS, Abufaraj M, Abern M, Djaladat H, Daneshmand S, Shariat SF. Surveillance of non-muscle-invasive bladder cancer with blue-light cystoscopy: a meta-analysis. BJU Int 2024. [PMID: 38658172 DOI: 10.1111/bju.16364] [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: 04/26/2024]
Abstract
OBJECTIVE To compare the value of flexible blue-light cystoscopy (BLC) vs flexible white-light cystoscopy (WLC) in the surveillance setting of non-muscle-invasive bladder cancer (NMIBC). METHODS All major databases were searched for articles published before May 2023 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The primary outcome was the accuracy of flexible BLC vs WLC in detecting bladder cancer recurrence among suspicious bladder lesions. RESULTS A total of 10 articles, comprising 1634 patients, were deemed eligible for the quantitative synthesis. In the meta-analysis focusing on the detection of disease recurrence, there was no difference between flexible BLC and WLC (odds ratio [OR] 1.08, 95% confidence interval [CI] 0.82-1.41)]; the risk difference (RD) showed 1% of flexible BLC, corresponding to a number needed to treat (NNT) of 100. In the subgroup meta-analysis of detection of carcinoma in situ (CIS) only, there was again no significant difference between flexible BLC and WLC (OR 1.19, 95% CI 0.82-1.69), BLC was associated with a RD of 2% (NNT = 50). The positive predictive values for flexible BLC and WLC in detecting all types of recurrence were 72% and 66%, respectively, and for CIS they were 39% and 29%, respectively. CONCLUSION Surveillance of NMIBC with flexible BLC could detect more suspicious lesions and consequently more tumour recurrences compared to flexible WLC, with a increase in the rate of false positives leading to overtreatment. A total of 100 and 50 flexible BLC procedures would need to be performed to find on additional tumor and CIS recurences, respectively. A risk-stratified strategy for patient selection could be considered when using flexible BLC for the surveillance of NMIBC patients.
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Affiliation(s)
- Reza Sari Motlagh
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Alireza Ghoreifi
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Takafumi Yanagisawa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Tatsushi Kawada
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Sascha Ahyai
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Axel S Merseburger
- Department of Urology, Campus Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Mohammad Abufaraj
- Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
- The National Center for Diabetes, Endocrinology and Genetics, The University of Jordan, Amman, Jordan
| | - Michael Abern
- Department of Urology, Duke University, Durham, NC, USA
| | - Hooman Djaladat
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Siamak Daneshmand
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
- Department of Urology, Weill Cornell Medical College, New York, NY, USA
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
- Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
- Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
- Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
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4
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Yanagisawa T, Kawada T, von Deimling M, Bekku K, Laukhtina E, Rajwa P, Chlosta M, Pradere B, D'Andrea D, Moschini M, Karakiewicz PI, Teoh JYC, Miki J, Kimura T, Shariat SF. Repeat Transurethral Resection for Non-muscle-invasive Bladder Cancer: An Updated Systematic Review and Meta-analysis in the Contemporary Era. Eur Urol Focus 2024; 10:41-56. [PMID: 37495458 DOI: 10.1016/j.euf.2023.07.002] [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: 05/06/2023] [Revised: 06/04/2023] [Accepted: 07/13/2023] [Indexed: 07/28/2023]
Abstract
CONTEXT Repeat transurethral resection (reTUR) is a guideline-recommended treatment strategy in high-risk non-muscle-invasive bladder cancer (NMIBC) patients treated with transurethral resection of bladder tumor (TURBT); however, the impact of recent procedural/technological developments on reTUR outcomes has not been assessed yet. OBJECTIVE To assess the outcomes of reTUR for NMIBC in the contemporary era, focusing on whether temporal differences and technical advancement, specifically, photodynamic diagnosis and en bloc resection of bladder tumor (ERBT), affect the outcomes. EVIDENCE ACQUISITION Multiple databases were queried in February 2023 for studies investigating reTUR outcomes, such as residual tumor and/or upstaging rates, its predictive factors, and oncologic outcomes, including recurrence-free (RFS), progression-free (PFS), cancer-specific (CSS), and overall (OS) survival. We synthesized comparative outcomes adjusting for the effect of possible confounders. EVIDENCE SYNTHESIS Overall, 81 studies were eligible for the meta-analysis. In T1 patients initially treated with conventional TURBT (cTURBT) in the 2010s, the pooled rates of any residual tumors and upstaging on reTUR were 31.4% (95% confidence interval [CI]: 26.0-37.2%) and 2.8% (95% CI: 2.0-3.8%), respectively. Despite a potential publication bias, these rates were significantly lower than those in patients treated in the 1990-2000s (both p < 0.001). ERBT and visual enhancement-guided cTURBT significantly improved any residual tumor rates on reTUR compared with cTURBT based on both matched-cohort and multivariable analyses. Among studies adjusting for the effect of possible confounders, patients who underwent reTUR had better RFS (hazard ratio [HR]: 0.78, 95% CI: 0.62-0.97) and OS (HR: 0.86, 95% CI: 0.81-0.93) than those who did not, while it did not lead to superior PFS (HR: 0.74, 95% CI: 0.47-1.15) and CSS (HR: 0.94, 95% CI: 0.86-1.03). CONCLUSIONS reTUR is currently recommended for high-risk NMIBC based on the persistent high rates of residual tumors after primary resection. Improvement of resection quality based on checklist applications and recent technical/procedural advancements hold the promise to omit reTUR. PATIENT SUMMARY Recent endoscopic/procedural developments improve the outcomes of repeat resection for high-risk non-muscle-invasive bladder cancer. Further investigations are urgently needed to clarify the potential impact of the use of these techniques on the need for repeat transurethral resection in the contemporary era.
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Affiliation(s)
- Takafumi Yanagisawa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Tatsushi Kawada
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Markus von Deimling
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kensuke Bekku
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Pawel Rajwa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Medical University of Silesia, Zabrze, Poland
| | - Marcin Chlosta
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Clinic of Urology and Urological Oncology, Jagiellonian University, Krakow, Poland
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, La Croix Du Sud Hospital, Quint Fonsegrives, France
| | - David D'Andrea
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Marco Moschini
- Department of Urology, IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Canada
| | - Jeremy Yuen-Chun Teoh
- S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Jun Miki
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Kimura
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia; Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria.
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5
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Miyake M, Nishimura N, Fujii T, Fujimoto K. Recent advancements in the diagnosis and treatment of non-muscle invasive bladder cancer: Evidence update of surgical concept, risk stratification, and BCG-treated disease. Int J Urol 2023; 30:944-957. [PMID: 37522629 DOI: 10.1111/iju.15263] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/13/2023] [Indexed: 08/01/2023]
Abstract
In the management of non-muscle invasive bladder cancer (NMIBC), disease progression and long-term control are determined by the intensity of delivered treatment and surveillance and the cancer cells' biological nature. This requires risk stratification-based postoperative management, such as intravesical instillation of chemotherapy drugs, Bacillus Calmette-Guérin (BCG), and radical cystectomy. Advancements in mechanical engineering, molecular biology, and surgical skills have evolved the clinical management of NMIBC. In this review, we describe the updated evidence and perspectives regarding the following aspects: (1) advancements in surgical concepts, techniques, and devices for transurethral resection of the bladder tumor; (2) advancements in risk stratification tools for NMIBC; and (3) advancements in treatment strategies for BCG-treated NMIBC. Repeat transurethral resection, en-bloc transurethral resection, and enhanced tumor visualization, including photodynamic diagnosis and narrow-band imaging, help reduce residual cancer cells, provide accurate diagnosis and staging, and sensitive detection, which are the first essential steps for cancer cure. Risk stratification should always be updated and improved because the treatment strategy changes over time. The BCG-treated disease concept has recently diversified to include BCG failure, resistance, refractory, unresponsiveness, exposure, and intolerance. A BCG-unresponsive disease is an extremely aggressive subset unlikely to respond to a rechallenge with BCG. Numerous ongoing clinical trials aim to develop a future bladder-sparing approach for very high-risk BCG-naïve NMIBC and BCG-unresponsive NMIBC. The key to improving the quality of patient care lies in the continuous efforts to overcome the clinical limitations of bedside management.
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Affiliation(s)
- Makito Miyake
- Department of Urology, Nara Medical University, Nara, Japan
| | | | - Tomomi Fujii
- Department of Diagnostic Pathology, Nara Medical University, Nara, Japan
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6
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Creswell ML, Sholklapper TN, Markel MJ, Mason JB, Pianka MA, Dall CP, Ulu C, Stamatakis L. Economic Outcomes of Hexaminolevulinate Blue-Light Cystoscopy in Non-Muscle Invasive Bladder Cancer: A 5-Year, Medicare-Based Model. Bladder Cancer 2023; 9:87-96. [PMID: 38994485 PMCID: PMC11181828 DOI: 10.3233/blc-220027] [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: 04/11/2022] [Accepted: 02/28/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Bladder cancer is the most expensive cancer to treat on a per-patient basis. Blue light cystoscopy with hexaminolevulinate (BLC) has demonstrated improved diagnostic accuracy compared with white light cystoscopy (WLC) in non-muscle invasive bladder cancer (NMIBC). With higher upfront costs, questions remain about long-term BLC cost outcomes. OBJECTIVE This study seeks to investigate the 5-year cost comparison of BLC and WLC from the Medicare payer perspective. METHODS A representative 5-year NMIBC management model was constructed and Medicare reimbursement values were overlaid. The primary outcome was mean year-over-year cumulative cost discounted to present value at a 3% annual percentage rate. The secondary outcome was the rate of clinical events. RESULTS Patients in the BLC cohort experienced fewer recurrences. On a cumulative present value cost basis, BLC was more expensive per patient in years 1, 2, and 3 than WLC, however, in years 4 and 5, BLC was economically favorable. Year 5 BLC mean cumulative cost savings was $1,172 per patient. Overall, 31.6% of all patients in the BLC group generated cumulative cost savings compared to WLC at year 1 compared with 50.9% at the end of year 5. CONCLUSIONS Despite a higher initial annual cost, a slight cumulative economic advantage of BLC is realized after surveillance year 3. Additionally, a greater proportion of patients who received BLC achieved cost savings at the end of year 5. As novel technology emerges, economic models can help health care systems predict associated costs and quality improvements.
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Affiliation(s)
- Michael L Creswell
- Georgetown University School of Medicine, Washington, DC, USA
- Georgetown University McDonough School of Business, Washington, DC, USA
| | | | | | - James B Mason
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Mark A Pianka
- Georgetown University School of Medicine, Washington, DC, USA
| | - Christopher P Dall
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Canan Ulu
- Georgetown University McDonough School of Business, Washington, DC, USA
| | - Lambros Stamatakis
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Urology, MedStar Washington Hospital Center, Washington, DC, USA
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7
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Zhao H, Liu K, Giannakopoulos S, Yuruk E, De Naeyer G, Álvarez-Maestro M, Ng CF, Laguna P, De La Rosette J, Yuen-Chun Teoh J. Impact of previous malignancy at diagnosis on oncological outcomes of upper tract urothelial carcinoma. BMC Urol 2023; 23:49. [PMID: 36991375 PMCID: PMC10061966 DOI: 10.1186/s12894-023-01206-9] [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: 11/09/2022] [Accepted: 03/07/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND The evidence of prognostic factors and individualized surveillance strategies for upper tract urothelial carcinoma are still weak. OBJECTIVES To evaluate whether the history of previous malignancy (HPM) affects the oncological outcomes of upper tract urothelial carcinoma (UTUC). METHODS The CROES-UTUC registry is an international, observational, multicenter cohort study on patients diagnosed with UTUC. Patient and disease characteristics from 2380 patients with UTUC were collected. The primary outcome of this study was recurrence-free survival. Kaplan-Meier and multivariate Cox regression analyses were performed by stratifying patients according to their HPM. RESULTS A total of 996 patients were included in this study. With a median recurrence-free survival time of 7.2 months and a median follow-up time of 9.2 months, 19.5% of patients had disease recurrence. The recurrence-free survival rate in the HPM group was 75.7%, which was significantly lower than non-HPM group (82.7%, P = 0.012). Kaplan-Meier analyses also showed that HPM could increase the risk of upper tract recurrence (P = 0.048). Furthermore, patients with a history of non-urothelial cancers had a higher risk of intravesical recurrence (P = 0.003), and patients with a history of urothelial cancers had a higher risk of upper tract recurrence (P = 0.015). Upon multivariate Cox regression analysis, the history of non-urothelial cancer was a risk factor for intravesical recurrence (P = 0.004), and the history of urothelial cancer was a risk factor for upper tract recurrence (P = 0.006). CONCLUSION Both previous non-urothelial and urothelial malignancy could increase the risk of tumor recurrence. But different cancer types may increase different sites' risk of tumor recurrence for patients with UTUC. According to present study, more personalized follow-up plans and active treatment strategies should be considered for UTUC patients.
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Affiliation(s)
- Hongda Zhao
- S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Kang Liu
- S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | | | - Emrah Yuruk
- Department of Urology, The Ministry of Health, University of Health Sciences, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Geert De Naeyer
- Department of Urology, Onze-Lieve-Vrouw Clinic, Aalst, Belgium
| | | | - Chi-Fai Ng
- S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Pilar Laguna
- Department of Urology, Medipol Mega Hospital, Istanbul Medipol University, Istanbul, Turkey
| | - Jean De La Rosette
- Department of Urology, Medipol Mega Hospital, Istanbul Medipol University, Istanbul, Turkey
| | - Jeremy Yuen-Chun Teoh
- S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China.
- Department of Surgery, Prince of Wales Hospital, 4/F LCW Clinical Sciences Building, Shatin, New Territories, Hong Kong, China.
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8
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Horňák J, Brisuda A, Babjuk M. Transurethral resection of bladder cancer with or without fluorescence. Curr Opin Urol 2023; 33:152-156. [PMID: 36630205 DOI: 10.1097/mou.0000000000001071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE OF REVIEW Transurethral resection of bladder cancer (TURBT) is in its standard form an inherently imperfect technique. Fluorescence-guided photodynamic diagnosis (PDD) represents one way to improve the outcome by enhancing tumour detection. Fluorescence has been used in connection with bladder cancer since the 1970s, with a number of studies being published since then. However, the method is still not recommended as a standard part of TURBT mainly because of the limited level of evidence of concerned studies, questionable cost-effectiveness and even contradictory results. The review lists the latest articles covering this topic. RECENT FINDINGS Several recently published meta-analyses reviewed a series of randomized controlled trials (RCTs) concerning PDD assisted TURBT. Results were generally supporting the positive effect on reduction of recurrence rate. However, the mentioned meta-analyses are overlapping in terms of reviewed RCT that provide only a low level of evidence according to a recent Cochrane review. Supposed limitations of PDD (timing of the procedure, low specificity) and possible solutions are also covered. SUMMARY Most of the published data confirmed reduced early recurrence rate after PDD assisted TURBT comparing to standard TURBT. Its impact on late recurrence rate, progression rate or cost-effectiveness has not been sufficiently demonstrated.
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Affiliation(s)
- Jakub Horňák
- Department of Urology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
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9
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Re: A Randomized Trial of PHOTOdynamic Surgery in Non-muscle-invasive Bladder Cancer. Eur Urol 2023; 83:477-478. [PMID: 36806362 DOI: 10.1016/j.eururo.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/16/2023] [Accepted: 02/01/2023] [Indexed: 02/18/2023]
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10
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Yang Y, Wang C, Li Z, Lu Q, Li Y. Precise diagnosis and treatment of non-muscle invasive bladder cancer - A clinical perspective. Front Oncol 2023; 13:1042552. [PMID: 36798814 PMCID: PMC9927396 DOI: 10.3389/fonc.2023.1042552] [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: 09/12/2022] [Accepted: 01/20/2023] [Indexed: 02/01/2023] Open
Abstract
According to the guidelines, transurethral resection of bladder tumor (TURBT) followed by intravesical therapy remains the standard strategy for the management of non-muscle invasive bladder cancer (NMIBC). However, even if patients receive standard strategy, the risk of postoperative recurrence and progression is high. From the clinical perspective, the standard strategy needs to be optimized and improved. Compared to conventional TURBT, the technique of en bloc resection of bladder tumor (ERBT) removes the tumor tissue in one piece, thus following the principles of cancer surgery. Meanwhile, the integrity and spatial orientation of tumor tissue is protected during the operation, which is helpful for pathologists to make accurate histopathological analysis. Then, urologists can make a postoperative individualized treatment plan based on the patient's clinical characteristics and histopathological results. To date, there is no strong evidence that NMIBC patients treated with ERBT achieve better oncological prognosis, which indicates that ERBT alone does not yet improve patient outcomes. With the development of enhanced imaging technology and proteogenomics technology, en bloc resection combined with these technologies will make it possible to achieve precise diagnosis and treatment of bladder cancer. In this review, the authors analyze the current existing shortcomings of en bloc resection and points out its future direction, in order to promote continuous optimization of the management strategy of bladder cancer.
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Affiliation(s)
| | | | | | - Qiang Lu
- *Correspondence: Qiang Lu, ; Yuanwei Li,
| | - Yuanwei Li
- *Correspondence: Qiang Lu, ; Yuanwei Li,
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11
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Hu X, Li G, Wu S. Advances in Diagnosis and Therapy for Bladder Cancer. Cancers (Basel) 2022; 14:cancers14133181. [PMID: 35804953 PMCID: PMC9265007 DOI: 10.3390/cancers14133181] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/19/2022] [Accepted: 06/24/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary The clinical management of bladder cancer has been developing in the past decade, including diagnostic tools and treatment options. Both monotherapy and combination therapy have been undoubtedly upgraded. Multiple diagnostic techniques and therapeutic strategies have been developed to meet the urgent clinical needs, resulting in the emergence of various explorations for cancer diagnosis and therapy. In this review, we mainly focus on the advances in the diagnosis and treatment of bladder cancer. Abstract Bladder cancer (BCa) is one of the most common and expensive urinary system malignancies for its high recurrence and progression rate. In recent years, immense amounts of studies have been carried out to bring a more comprehensive cognition and numerous promising clinic approaches for BCa therapy. The development of innovative enhanced cystoscopy techniques (optical techniques, imaging systems) and tumor biomarkers-based non-invasive urine screening (DNA methylation-based urine test) would dramatically improve the accuracy of tumor detection, reducing the risk of recurrence and progression of BCa. Moreover, intravesical instillation and systemic therapeutic strategies (cocktail therapy, immunotherapy, vaccine therapy, targeted therapy) also provide plentiful measures to break the predicament of BCa. Several exploratory clinical studies, including novel surgical approaches, pharmaceutical compositions, and bladder preservation techniques, emerged continually, which are supposed to be promising candidates for BCa clinical treatment. Here, recent advances and prospects of diagnosis, intravesical or systemic treatment, and novel drug delivery systems for BCa therapy are reviewed in this paper.
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Affiliation(s)
- Xinzi Hu
- Institute of Urology, The Affiliated Luohu Hospital of Shenzhen University, Shenzhen University, Shenzhen 518000, China; (X.H.); (G.L.)
- Department of Urology, South China Hospital, Health Science Center, Shenzhen University, Shenzhen 518116, China
| | - Guangzhi Li
- Institute of Urology, The Affiliated Luohu Hospital of Shenzhen University, Shenzhen University, Shenzhen 518000, China; (X.H.); (G.L.)
- Department of Urology, South China Hospital, Health Science Center, Shenzhen University, Shenzhen 518116, China
| | - Song Wu
- Institute of Urology, The Affiliated Luohu Hospital of Shenzhen University, Shenzhen University, Shenzhen 518000, China; (X.H.); (G.L.)
- Department of Urology, South China Hospital, Health Science Center, Shenzhen University, Shenzhen 518116, China
- Correspondence:
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12
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Lai LY, Tafuri SM, Ginier EC, Herrel LA, Dahm P, Maisch P, Lane GI. Narrow band imaging versus white light cystoscopy alone for transurethral resection of non-muscle invasive bladder cancer. Cochrane Database Syst Rev 2022; 4:CD014887. [PMID: 35393644 PMCID: PMC8990285 DOI: 10.1002/14651858.cd014887.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Disease recurrence and progression remain major challenges for the treatment of non-muscle invasive bladder cancer. Narrow band imaging (NBI) is an optical enhancement technique that may improve resection of non-muscle invasive bladder cancer and thereby lead to better outcomes for people undergoing the procedure. OBJECTIVES: To assess the effects of NBI- and white light cystoscopy (WLC)-guided transurethral resection of bladder tumor (TURBT) compared to WLC-guided TURBT in the treatment of non-muscle invasive bladder cancer. SEARCH METHODS We performed a comprehensive literature search of 10 databases, including the Cochrane Library, the Cochrane Database of Systematic Reviews, MEDLINE, Embase, several clinical trial registries, and grey literature for published and unpublished studies, irrespective of language. The search was performed per an a priori protocol on 3 December 2021. SELECTION CRITERIA We included randomized controlled trials of participants with suspected or confirmed non-muscle invasive bladder cancer. Participants in the control group must have received WLC-guided TURBT alone (hereinafter simply referred to as 'WLC TURBT'). Participants in the intervention group had to have received NBI- and WLC-guided TURBT (hereinafter simply referred to as 'NBI + WLC TURBT'). DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion/exclusion, performed data extraction, and assessed risk of bias. We conducted meta-analysis on time-to-event and dichotomous data using a random-effects model in RevMan, according to Cochrane methods. We rated the certainty of evidence for each outcome according to the GRADE approach. Primary outcomes were time to recurrence, time to progression, and the occurrence of a major adverse event, defined as a Clavien-Dindo III, IV, or V complication. Secondary outcomes included time to death from bladder cancer and the occurrence of a minor adverse event, defined as a Clavien-Dindo I or II complication. MAIN RESULTS: We included eight studies with a total of 2152 participants randomized to the standard WLC TURBT or to NBI + WLC TURBT. A total of 1847 participants were included for analysis. Based on limited confidence in the time-to-event data, we found that participants who underwent NBI + WLC TURBT had a lower risk of disease recurrence over time compared to participants who underwent WLC TURBT (hazard ratio 0.63, 95% CI 0.45 to 0.89; I2 = 53%; 6 studies, 1244 participants; low certainty of evidence). No studies examined disease progression as a time-to-event outcome or a dichotomous outcome. There was likely no difference in the risk of a major adverse event between participants who underwent NBI + WLC TURBT and those who underwent WLC TURBT (risk ratio 1.77, 95% CI 0.79 to 3.96; 4 studies, 1385 participants; low certainty of evidence). No studies examined death from bladder cancer as a time-to-event outcome or a dichotomous outcome. There was likely no difference in the risk of a minor adverse event between participants who underwent NBI + WLC TURBT and those who underwent WLC TURBT (risk ratio 0.88, 95% CI 0.49 to 1.56; I2 = 61%; 4 studies, 1385 participants; low certainty of evidence). AUTHORS' CONCLUSIONS: Compared to WLC TURBT alone, NBI + WLC TURBT may lower the risk of disease recurrence over time while having little or no effect on the risks of major or minor adverse events.
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Affiliation(s)
- Lillian Y Lai
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Sean M Tafuri
- College of Medicine, California Northstate University, Elk Grove, California, USA
| | - Emily C Ginier
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan, USA
| | - Lindsey A Herrel
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Philipp Maisch
- Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, Munich, Germany
- Department of Urology, University of Ulm, Ulm, Germany
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13
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Teoh JYC, Kamat AM, Black PC, Grivas P, Shariat SF, Babjuk M. Recurrence mechanisms of non-muscle-invasive bladder cancer - a clinical perspective. Nat Rev Urol 2022; 19:280-294. [PMID: 35361927 DOI: 10.1038/s41585-022-00578-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 12/24/2022]
Abstract
Non-muscle-invasive bladder cancer (NMIBC) is an early-stage cancer without invasion into the detrusor muscle layer. Transurethral resection of bladder tumour (TURBT) is a diagnostic and potentially curative procedure for NMIBC, but has some limitations, including difficulties in ascertaining complete tumour removal upon piecemeal resection and the possibility of tumour re-implantation after the procedure. The oncological control of NMIBC is far from satisfactory, with a 1-year recurrence rate of 15-61%, and a 5-year recurrence rate of 31-78%. Various recurrence mechanisms have been described for NMIBC, such as undetected tumours upon cystoscopy, incomplete resection during TURBT, tumour re-implantation after TURBT, drop metastasis from upper tract urothelial carcinoma and field change cancerization. Understanding the recurrence mechanisms from a clinical perspective has strong implications for the optimization of NMIBC oncological outcomes, as a cure for patients with NMIBC can only be achieved by tackling all possible recurrence mechanisms in a comprehensive manner.
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Affiliation(s)
- Jeremy Yuen-Chun Teoh
- S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China. .,European Association of Urology-Young Academic Urologists (EAU-YAU) Urothelial Cancer Working Group, Amsterdam, Netherlands.
| | - Ashish M Kamat
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Petros Grivas
- Division of Oncology, Department of Medicine, University of Washington, Washington, USA.,Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria.,Department of Urology, Weill Cornell Medical College, New York, NY, USA.,Department of Urology, University of Texas Southwestern, Dallas, TX, USA.,Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.,Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan.,Department of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic
| | - Marek Babjuk
- Department of Urology, Medical University of Vienna, Vienna, Austria.,Department of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic
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14
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Maisch P, Koziarz A, Vajgrt J, Narayan V, Kim MH, Dahm P. Blue versus white light for transurethral resection of non-muscle invasive bladder cancer. BJU Int 2022; 130:730-740. [PMID: 35238145 DOI: 10.1111/bju.15723] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/19/2022] [Accepted: 02/28/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To assess the effects of blue light-enhanced transurethral resection of bladder tumor (TURBT) compared to white light-based TURBT in the treatment of non-muscle invasive bladder cancer (NMIBC). METHODS Based on a published protocol we performed a systematic search of multiple databases from their inception to March 2021. We included randomized controlled trials (RCTs) comparing blue light (BL) TURBT to white light (WL) TURBT. Our meta-analysis is based on a random-effect model. We assessed the quality of evidence on a per-outcome basis according to the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. RESULTS We included 16 randomized controlled trials involving a total of 4325 participants in this review. BL TURBT may reduce the risk of disease recurrence over time (hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.54 to 0.81; low certainty evidence) depending on baseline risk. For participants with low-, intermediate-, and high-risk NMIBC, this corresponded to 48 (66 fewer to 27 fewer), 109 (152 fewer to 59 fewer), and 147 (211 fewer to 76 fewer) fewer recurrences per 1000 participants when compared to WL TURBT, respectively. BL TURBT may also reduce the risk of disease progression over time (HR 0.65, 95% CI 0.50 to 0.84; low-certainty evidence) depending on baseline risk. For participants with low-, intermediate-, and high-risk NMIBC, this corresponded to 1 (1 fewer to 0 fewer), 17 (25 fewer to 8 fewer), and 56 (81 fewer to 25 fewer) fewer progressions per 1000 participants when compared to WL TURBT, respectively. CONCLUSIONS Our findings suggest a favorable impact of BL TURBT on the risk of disease recurrence and progression; however, whether this risk reduction is clinically relevant greatly depends on the baseline risk of patients. We did not find an increase in severe surgical complications with BL cystoscopy, and we did not find any trial evidence on other, non-surgical adverse events.
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Affiliation(s)
- Philipp Maisch
- Department of Urology, University of Ulm, Ulm, Germany.,Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, Munich, Germany
| | - Alex Koziarz
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Jon Vajgrt
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Vikram Narayan
- Department of Urology, Emory University, Atlanta, Georgia, USA
| | - Myung Ha Kim
- Yonsei Wonju Medical Library, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
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15
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Mulawkar PM, Sharma G, Tamhankar A, Shah U, Raheem R. Role of Macroscopic Image Enhancement in Diagnosis of Non-Muscle-Invasive Bladder Cancer: An Analytical Review. Front Surg 2022; 9:762027. [PMID: 35265660 PMCID: PMC8898829 DOI: 10.3389/fsurg.2022.762027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/17/2022] [Indexed: 11/18/2022] Open
Abstract
Early diagnosis of non-muscle-invasive bladder cancer (NMIBC) is of paramount importance to prevent morbidity and mortality due to bladder cancer. Although white light imaging (WLI) cystoscopy has long been considered the gold standard in the diagnosis of bladder cancer, it can miss lesions in a substantial percentage of patients and is very likely to miss carcinoma in situ and dysplasia. Tumor margin detection by WLI can be inaccurate. Moreover, WLI could, sometimes, be inadequate in distinguishing inflammation and malignancy. To improve the diagnostic efficacy of cystoscopy, various optical image enhancement modalities have been studied. These image enhancement modalities have been classified as macroscopic, microscopic, or molecular. Photodynamic diagnosis (PDD), narrow band imaging (NBI), and Storz image 1 S enhancement (formerly known as SPIES) are macroscopic image enhancement modalities. A relevant search was performed for literature describing macroscopic image enhancement modalities like PDD, NBI, and image 1 S enhancement. The advantages, limitations, and usefulness of each of these in the diagnosis of bladder cancer were studied. Photodynamic diagnosis requires intravesical instillation of a photosensitizing agent and a special blue light cystoscope system. PDD has been shown to be more sensitive than WLI in the detection of bladder cancer. It is superior to WLI in the detection of flat lesions. Bladder tumor resection (TURBT) by PDD results in more complete resection and reduced recurrence rates. PDD-guided TURBT may have some role in reducing the risk of progression. Narrow band imaging provides increased contrast between normal and abnormal tissues based on neovascularization, thereby augmenting WLI. NBI requires a special light source. There is no need for intravesical contrast instillation. NBI is superior to WLI in the detection of bladder cancer. The addition of NBI to WLI improves the detection of flat lesions like carcinoma in situ. NBI is not useful in predicting invasive tumors or grades of tumors. NBI-directed TURBT reduces recurrence rates and recurrence free survival. But its efficacy in retarding progression is unproven. Image 1 S-enhancement utilizes software-based image enhancement modes without the need for a special light source or intravesical contrast instillation. This system provides high-quality images and identifies additional abnormal-looking areas. Another advantage of this system is simultaneous side-by-side visualization of WLI and enhanced image, providing WLI images as the control for comparison. As with PDD, S-enhancement produces a lower rate of a missed bladder cancer diagnosis. The system significantly improves the diagnosis of NMIBC. The sensitivity and negative predictive value of image 1 S enhancement increase with the increase in cancer grade. A negative test by S-enhancement effectively rules out NMIBC. All the image enhancement modalities have proven their utility in improving detection and short-term cancer control. But none of these modalities have proven their utility in delaying progression, or in long-term cancer control. Cancer progression and long-term control are governed by the biological nature of cancer cells. Early detection by optical enhancement may not be of utility in this regard. Well-designed studies are needed to establish the efficacy of these modalities in the evaluation of patients with bladder cancer. The last word, in this regard, is yet to be written.
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Affiliation(s)
- Prashant Motiram Mulawkar
- Department of Urology, Tirthankar Superspeciality Hospital, Akola, India
- Tutor in Urology, University of Edinburgh, Edinburgh, United Kingdom
- *Correspondence: Prashant Motiram Mulawkar
| | | | | | - Utsav Shah
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Rickaz Raheem
- Milton Keynes University Hospital, Eaglestone, United Kingdom
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16
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Maisch P, Koziarz A, Vajgrt J, Narayan V, Kim MH, Dahm P. Blue versus white light for transurethral resection of non-muscle invasive bladder cancer. Cochrane Database Syst Rev 2021; 12:CD013776. [PMID: 34850382 PMCID: PMC8632646 DOI: 10.1002/14651858.cd013776.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Disease recurrence and progression remain major challenges in the treatment of non-muscle invasive bladder cancer (NMIBC). Blue light-enhanced transurethral resection of bladder cancer (TURBT) is an approach to improve staging and achieve a complete resection of NMIBC. OBJECTIVES To assess the effects of blue light-enhanced TURBT compared to white light-based TURBT in the treatment of NMIBC. SEARCH METHODS We searched several medical literature databases, including the Cochrane Library, MEDLINE, and Embase, as well as trial registers, including ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We performed a comprehensive search with no restrictions on language of publication or publication status until March 2021. SELECTION CRITERIA We included randomized controlled trials using blue light versus white light TURBT. Included participants had a high level of suspicion based on imaging or 'visible diagnosis' for primary urothelial carcinoma of the bladder or recurrent urothelial carcinoma of the bladder upon cytoscopy. We excluded studies in which blue light was used in a surveillance setting. DATA COLLECTION AND ANALYSIS: Two review authors independently performed data extraction and risk of bias assessment. Our primary outcomes were time to disease recurrence, time to disease progression, and serious surgical complications. Secondary outcomes were time to death from bladder cancer, any adverse events, and non-serious complications. We rated the certainty of evidence using the GRADE approach. MAIN RESULTS We included 16 randomized controlled trials involving a total of 4325 participants in the review. The studies compared blue light versus white light TURBT for treatment of NMIBC. Primary outcomes Blue light TURBT may reduce the risk of disease recurrence over time (hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.54 to 0.81; low-certainty evidence) depending on baseline risk. For participants with low-, intermediate-, and high-risk NMIBC, this corresponded to 48 (66 fewer to 27 fewer), 109 (152 fewer to 59 fewer), and 147 (211 fewer to 76 fewer) fewer recurrences per 1000 participants when compared to white light TURBT, respectively. Blue light TURBT may also reduce the risk of disease progression over time (HR 0.65, 95% CI 0.50 to 0.84; low-certainty evidence) depending on baseline risk. For participants with low-, intermediate-, and high-risk NMIBC, this corresponded to 1 (1 fewer to 0 fewer), 17 (25 fewer to 8 fewer), and 56 (81 fewer to 25 fewer) fewer progressions per 1000 participants when compared to white light TURBT, respectively. Blue light TURBT may have little or no effect on serious surgical complications (risk ratio (RR) 0.54, 95% CI 0.14 to 2.14; low-certainty evidence). This corresponded to 10 fewer (19 fewer to 25 more) surgical complications per 1000 participants with blue light TURBT. Secondary outcomes Blue light TURBT may have little or no effect on the risk of death from bladder cancer over time (HR 0.55, 95% CI 0.19 to 1.61; low-certainty evidence). This corresponded to 22 deaths per 1000 participants with white light TURBT and 10 fewer (17 fewer to 13 more) deaths per 1000 participants with blue light TURBT. We are very uncertain how blue light TURBT affects the outcome adverse events of any grade (RR 1.09, 95% CI 0.88 to 1.33; low-certainty evidence). No analysis was possible for the outcome non-serious surgical complications, as it was not reported by any of the included studies. AUTHORS' CONCLUSIONS Blue light-enhanced TURBT for the treatment of non-muscle invasive bladder cancer compared to white light-based TURBT may reduce the risk of disease recurrence and disease progression over time depending on baseline risk. There may be little or no effect on serious surgical complications. The certainty of evidence for our findings was low, meaning that future studies are likely change to the reported estimates of effect. Frequent issues that led to downgrading of the certainty of the evidence were study limitations, inconsistency, and imprecision.
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Affiliation(s)
- Philipp Maisch
- Department of Urology, University of Ulm, Ulm, Germany
- Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, Munich, Germany
| | - Alex Koziarz
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Jon Vajgrt
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Vikram Narayan
- Department of Urology, Emory University, Atlanta, Georgia, USA
| | - Myung Ha Kim
- Yonsei Wonju Medical Library, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
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17
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Sari Motlagh R, Rajwa P, Mori K, Laukhtina E, Aydh A, Katayama S, Yanagisawa T, König F, Grossmann NC, Pradere B, Mostafai H, Quhal F, Karakiewicz PI, Babjuk M, Shariat SF. Comparison of Clinicopathologic and Oncological Outcomes Between Transurethral En Bloc Resection and Conventional Transurethral Resection of Bladder Tumor: A Systematic Review, Meta-Analysis and Network Meta-Analysis with Focus on Different Energy Sources. J Endourol 2021; 36:535-547. [PMID: 34693740 DOI: 10.1089/end.2021.0688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Introduction: It has been hypothesized that transurethral en bloc (TUEB) of bladder tumor offers benefits over conventional transurethral resection of bladder tumor (cTURBT). This study aimed to compare disease outcomes of TUEB and cTURBT with focus on the different energy sources. Methods: A systematic search was performed using PubMed and Web of Science databases in June 2021. Studies that compared the pathological (detrusor muscle presence), oncological (recurrence rates) efficacy, and safety (serious adverse events [SAEs]) of TUEB and cTURBT were included. Random- and fixed-effects meta-analytic models and Bayesian approach in the network meta-analysis was used. Results: Seven randomized clinical trials (RCTs) and seven non-RCTs (NRCT), with a total of 2092 patients. The pooled 3- and 12-month recurrence risk ratios (RR) of five and four NRCTs were 0.46 (95% CI 0.29-0.73) and 0.56 (95% CI 0.33-0.96), respectively. The pooled 3- and 12-month recurrence RRs of four and seven RCTs were 0.57 (95% CI 0.25-1.27) and 0.89 (95% CI 0.69-1.15), respectively. The pooled RR for SAEs such as prolonged hematuria and bladder perforation of seven RCTs was 0.16 (95% CI 0.06-0.41) in benefit of TUEB. Seven RCTs (n = 1077) met our eligibility criteria for network meta-analysis. There was no difference in 12-month recurrence rates between hybridknife, laser, and bipolar TUEB compared with cTURBT. Contrary, laser TUEB was significantly associated with lower SAEs compared with cTURBT. Surface under the cumulative ranking curve ranking analyses showed with high certainty that laser TUEB was the best treatment option to access all endpoints. Conclusion: While NRCTs suggested a recurrence-free benefit to TUEB compared with cTURBT, RCTs failed to confirm this. Conversely, SAEs were consistently and clinically significantly better for TUEB. Network meta-analyses suggested laser TUEB has the best performance compared with other energy sources. These early findings need to be confirmed and expanded upon.
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Affiliation(s)
- Reza Sari Motlagh
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Men's Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pawel Rajwa
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Department of Urology, Medical University of Silesia, Zabrze, Poland
| | - Keiichiro Mori
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Abdulmajeed Aydh
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Department of Urology, King Faisal Medical City, Abha, Saudi Arabia
| | - Satoshi Katayama
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takafumi Yanagisawa
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Frederik König
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nico C Grossmann
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Hadi Mostafai
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Research Center for Evidence Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fahad Quhal
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada
| | - Marek Babjuk
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Department of Urology, Motol University Hospital, 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.,Department of Urology, Weill Cornell Medical College, New York, New York, USA.,Department of Urology, University of Texas Southwestern, Dallas, Texas, USA.,Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic.,Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
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18
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Labeit B, Ahring S, Boehmer M, Sporns P, Sauer S, Claus I, Roderigo M, Suntrup-Krueger S, Dziewas R, Warnecke T, Muhle P. Comparison of Simultaneous Swallowing Endoscopy and Videofluoroscopy in Neurogenic Dysphagia. J Am Med Dir Assoc 2021; 23:1360-1366. [PMID: 34678269 DOI: 10.1016/j.jamda.2021.09.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE In the evaluation of oropharyngeal dysphagia, instrumental procedures, for example, flexible endoscopic evaluation of swallowing or videofluoroscopic swallowing study, are essential to improve diagnostic accuracy for salient findings such as penetration, aspiration, or pharyngeal residue. To date, it is unclear which of the 2 methods represents the diagnostic gold standard. The aim of this study, therefore, was to compare videofluoroscopy and swallowing endoscopy during a simultaneous swallowing examination in a large cohort of patients with oropharyngeal dysphagia. DESIGNS Prospective observational study. SETTING AND PARTICIPANTS In this study, 49 patients with oropharyngeal dysphagia (mean age 70.0 ± 10.8 years) were evaluated using simultaneous swallowing endoscopy and videofluoroscopy. Furthermore, the effect of narrow-band imaging in swallowing endoscopy on the assessment of penetration and aspiration was investigated in a subgroup of 19 patients. MEASURES The Penetration-Aspiration Scale and the Yale Pharyngeal Residue Severity Rating Scale were rated independently based on both modalities. RESULTS Both modalities showed a high correlation between penetration, aspiration, and pharyngeal residue. Causes for a higher score on the Penetration-Aspiration Scale in videofluoroscopy were intradeglutitive events that were not visible in swallowing endoscopy or false-positive events because of the loss of the lateral dimension in videofluoroscopy. A typical reason for a higher score on this scale in swallowing endoscopy was the better visualization of the anatomical structures. Narrow-band imaging in swallowing endoscopy resulted in a higher score on the Penetration-Aspiration Scale for liquids and semisolids in individual cases, although overall there was no statistically significant difference between scores using white light or narrow-band imaging. CONCLUSIONS AND IMPLICATIONS Videofluoroscopy and swallowing endoscopy may equally be considered as a diagnostic gold standard for oropharyngeal dysphagia regarding penetration, aspiration, and pharyngeal residue. Narrow-band imaging may increase the sensitivity for penetration and aspiration in individual cases.
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Affiliation(s)
- Bendix Labeit
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Muenster, North Rhine-Westphalia, Germany; Institute for Biomagnetism and Biosignalanalysis, University of Muenster, Muenster, North Rhine-Westphalia, Germany.
| | - Sigrid Ahring
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Muenster, North Rhine-Westphalia, Germany
| | - Maik Boehmer
- Department of Clinical Radiology, University Hospital Muenster, Muenster, North Rhine-Westphalia, Germany
| | - Peter Sporns
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sonja Sauer
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Muenster, North Rhine-Westphalia, Germany
| | - Inga Claus
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Muenster, North Rhine-Westphalia, Germany
| | - Malte Roderigo
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Muenster, North Rhine-Westphalia, Germany
| | - Sonja Suntrup-Krueger
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Muenster, North Rhine-Westphalia, Germany; Institute for Biomagnetism and Biosignalanalysis, University of Muenster, Muenster, North Rhine-Westphalia, Germany
| | - Rainer Dziewas
- Department of Neurology and Neurorehabilitation, Hospital Osnabrueck, Osnabrueck, North Rhine-Westphalia, Germany
| | - Tobias Warnecke
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Muenster, North Rhine-Westphalia, Germany
| | - Paul Muhle
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Muenster, North Rhine-Westphalia, Germany; Institute for Biomagnetism and Biosignalanalysis, University of Muenster, Muenster, North Rhine-Westphalia, Germany
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