1
|
Stögbauer F, Geß B, Brambs C, Lautizi M, Kacprowski T, Ourailidis I, Bronger H, Kiechle M, Noske A, Keller G, Jesinghaus M, Poremba C, Weichert W, Boxberg M. Independent Tissue-Based Biomarkers in Endometrioid Endometrial Cancer: Tumor Budding in Microsatellite Instability and WHO Grading in Copy-Number-Low Patients. Cancers (Basel) 2023; 15:3832. [PMID: 37568650 PMCID: PMC10416921 DOI: 10.3390/cancers15153832] [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: 05/30/2023] [Revised: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 08/13/2023] Open
Abstract
The molecular characterization of endometrial endometrioid adenocarcinomas has provided major advances in its prognostic stratification. However, risk assessment of microsatellite instability (MSI) and copy-number (CN)-low cases remains a challenge. Thus, we aimed to identify tissue-based morphologic biomarkers that might help in the prognostic stratification of these cases. Histomorphologic parameters (WHO grading, tumor budding (TB), tumor-stroma ratio (as a quantitative description of stromal desmoplasia), tumor-infiltrating lymphocytes (TIL), "microcystic, elongated, fragmented" (MELF) pattern) were analyzed in resection specimens of the TCGA-UCEC cohort (n = 228). For each quantitative parameter, a two-tiered system was developed utilizing systematically determined cutoffs. Associations with survival outcomes were calculated in univariate and multivariate analysis and validated in two independent cohorts. In MSI tumors, only TB remained an independent prognostic factor. TB (≥3 buds/high-power field) was associated with inferior outcomes and with lymph node metastases. The prognostic significance of TB was confirmed in two validation cohorts. For CN-low tumors, established grading defined by the WHO was independently prognostic with inferior outcomes for high-grade tumors. The evaluation of TB might help in identifying MSI-patients with unfavorable prognosis who, e.g., could benefit from lymphadenectomy. WHO-based grading facilitates independent prognostic stratification of CN-low endometrioid adenocarcinomas. Therefore, we propose the utilization of TB and WHO-based grading, two tissue-based and easy-to-assess biomarkers, in MSI/CN-low endometrial carcinomas for improved clinical management.
Collapse
Affiliation(s)
- Fabian Stögbauer
- Institute of Pathology, School of Medicine, Technical University of Munich (TUM), 81675 Munich, Germany; (F.S.); (M.L.); (A.N.); (G.K.); (W.W.)
| | - Barbara Geß
- Department of Obstetrics and Gynecology, Technical University of Munich, 81675 Munich, Germany; (B.G.); (H.B.)
| | - Christine Brambs
- Lucerne Cantonal Hospital, Department of Obstetrics & Gynecology, Division of Gynecologic Oncology, 6000 Lucerne, Switzerland;
| | - Manuela Lautizi
- Institute of Pathology, School of Medicine, Technical University of Munich (TUM), 81675 Munich, Germany; (F.S.); (M.L.); (A.N.); (G.K.); (W.W.)
- Chair of Experimental Bioinformatics, TUM School of Life Sciences Weihenstephan, Technical University of Munich, 85354 Freising, Germany
| | - Tim Kacprowski
- Division Data Science in Biomedicine, Peter L. Reichertz Institute for Medical Informatics, TU Braunschweig and Hannover Medical School, 38106 Brunswick, Germany;
- Braunschweig Integrated Centre of Systems Biology (BRICS), 38106 Brunswick, Germany
| | - Iordanis Ourailidis
- Institute of Pathology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
| | - Holger Bronger
- Department of Obstetrics and Gynecology, Technical University of Munich, 81675 Munich, Germany; (B.G.); (H.B.)
- German Cancer Consortium (DKTK) Partner Site Munich, 81675 Munich, Germany
| | - Marion Kiechle
- Department of Obstetrics and Gynecology, Technical University of Munich, 81675 Munich, Germany; (B.G.); (H.B.)
| | - Aurelia Noske
- Institute of Pathology, School of Medicine, Technical University of Munich (TUM), 81675 Munich, Germany; (F.S.); (M.L.); (A.N.); (G.K.); (W.W.)
| | - Gisela Keller
- Institute of Pathology, School of Medicine, Technical University of Munich (TUM), 81675 Munich, Germany; (F.S.); (M.L.); (A.N.); (G.K.); (W.W.)
| | - Moritz Jesinghaus
- Institute of Pathology, University Hospital Marburg, Baldingerstraße, 35043 Marburg, Germany;
| | | | - Wilko Weichert
- Institute of Pathology, School of Medicine, Technical University of Munich (TUM), 81675 Munich, Germany; (F.S.); (M.L.); (A.N.); (G.K.); (W.W.)
- German Cancer Consortium (DKTK) Partner Site Munich, 81675 Munich, Germany
| | - Melanie Boxberg
- Institute of Pathology, School of Medicine, Technical University of Munich (TUM), 81675 Munich, Germany; (F.S.); (M.L.); (A.N.); (G.K.); (W.W.)
- German Cancer Consortium (DKTK) Partner Site Munich, 81675 Munich, Germany
- Pathologie München-Nord, 80992 Munich, Germany;
| |
Collapse
|
2
|
Garzon S, Grassi T, Mariani A, Kollikonda S, Weaver AL, McGree ME, Petersen IA, Weroha SJ, Glaser GE, Langstraat CL, Amarnath SR, AlHilli MM. Not all stage I and II endometrial cancers are created equal: Recurrence-free survival and cause-specific survival after observation or vaginal brachytherapy alone in all subgroups of early-stage high-intermediate and high-risk endometrial cancer. Gynecol Oncol 2022; 167:444-451. [PMID: 36244826 DOI: 10.1016/j.ygyno.2022.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/14/2022] [Accepted: 10/03/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate recurrence-free survival (RFS) and cause-specific survival (CSS) after observation or vaginal brachytherapy (VB) alone in all subgroups of early-stage high-intermediate (HIR) and high-risk endometrial cancer (EC). METHODS We identified patients with stage I HIR (GOG-249 criteria) and stage II endometrioid EC, and stage I and II non-endometrioid EC who underwent surgery at Mayo Clinic and Cleveland Clinic between 1999 and 2016. Three-year RFS and CSS after observation or VB only were estimated in 16 subgroups defined by risk factors. RESULTS Among 4156 ECs, we identified 447 (10.8%) stage I endometrioid HIR, 52 (1.3%) stage II endometrioid, 350 (8.4%) stage I non-endometrioid, and 17 (0.4%) stage II non-endometrioid ECs; observation or VB alone was applied in 349 (78.1%), 24 (46.2%), 187 (53.4%), and 2 (11.8%) patients, respectively. After observation or VB, stage I HIR endometrioid EC subgroups with <2 factors among grade 3, LVSI, or stage IB had a 3-year CSS >95% (lower 95% confidence intervals limit: 89.8%), whereas subgroups with ≥2 factors had poorer outcomes. No EC-related deaths after 3 years were reported in 97 stage IA non-endometrioid ECs without myometrial invasion. Stage II ECs had poor outcomes regardless of histology. CONCLUSIONS Observation or VB only may be sufficient in stage I endometrioid HIR ECs with <2 factors among grade 3, LVSI, or IB and in stage IA non-endometrioid ECs without myometrial invasion. Stratification of early-stage HIR and high-risk ECs into risk subgroups potentially alleviates the overtreatment and undertreatment risk and should be considered in future research.
Collapse
Affiliation(s)
- Simone Garzon
- Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN, USA
| | - Tommaso Grassi
- Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN, USA
| | - Andrea Mariani
- Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN, USA
| | - Swapna Kollikonda
- Department of Gynecology and Obstetrics, Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy L Weaver
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Michaela E McGree
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - S John Weroha
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Gretchen E Glaser
- Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN, USA
| | | | - Sudha R Amarnath
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mariam M AlHilli
- Department of Subspecialty Care for Women's Health, Division of Gynecologic Oncology, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
3
|
Zammarrelli WA, Kim SH, Da Cruz Paula A, Rios-Doria EV, Ehmann S, Yeoshoua E, Hanlon EJ, Zhou Q, Iasonos A, Alektiar KM, Aghajanian C, Makker V, Leitao MM, Abu-Rustum NR, Ellenson LH, Weigelt B, Mueller JJ. Risk Stratification of Stage I Grade 3 Endometrioid Endometrial Carcinoma in the Era of Molecular Classification. JCO Precis Oncol 2022; 6:e2200194. [PMID: 36240474 PMCID: PMC9616646 DOI: 10.1200/po.22.00194] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/07/2022] [Accepted: 07/27/2022] [Indexed: 02/16/2023] Open
Abstract
PURPOSE The role of adjuvant therapy in stage I grade 3 endometrioid endometrial carcinoma (EEC) is debatable. We sought to define the agreement between Post Operative Radiation Therapy in Endometrial Carcinoma 1 (PORTEC-1) high-intermediate risk (HIR) and Gynecologic Oncology Group (GOG)-99 HIR criteria, assess their concordance with The Cancer Genome Atlas molecular subtypes, and evaluate oncologic outcomes in this population. METHODS We identified patients with stage I grade 3 EECs who underwent surgical staging at our institution from January 2014 to January 2020. Patients were stratified into PORTEC-1 HIR, GOG-99 HIR, and The Cancer Genome Atlas molecular subtypes. Adjuvant treatment, and progression-free survival (PFS), and overall survival (OS) were analyzed. RESULTS Seventy-five patients were included. The agreement between PORTEC-1 and GOG-99 HIR classification was 68% (95% CI, 56.2 to 78.3), with a kappa of 0.36 (P = .001). There was no agreement between PORTEC-1 or GOG-99 HIR classification and a dichotomized molecular classification (copy number-high [CN-H] v other subtypes), with a kappa of 0.03 (P = .39) and -0.03 (P = .601), respectively. There was no difference in PFS between PORTEC-1 HIR and non-HIR (HR, 10.9; 95% CI, 0.28 to 4.21) or between GOG-99 HIR and non-HIR (HR, 1.22; 95% CI, 0.32 to 4.6) stage I grade 3 EECs. Patients with CN-H compared with non-CN-H EEC had worse PFS (HR, 5.67; 95% CI, 1.73 to 18.63) and OS (HR, 5.05; 95% CI, 1.13 to 22.5). CONCLUSION In surgically staged patients with stage I grade 3 EEC, PORTEC-1 and GOG-99 HIR criteria were not prognostic and did not identify CN-H patients. Patients with CN-H EEC had worse PFS and OS compared with those with other molecular subtypes. The integration of the molecular classification with recognized clinicopathologic factors may identify patients with higher-risk stage I grade 3 EEC who benefit from additional therapy.
Collapse
Affiliation(s)
- William A. Zammarrelli
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sarah H. Kim
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Arnaud Da Cruz Paula
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eric V. Rios-Doria
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sarah Ehmann
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Effi Yeoshoua
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Etta J. Hanlon
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Qin Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexia Iasonos
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kaled M. Alektiar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Carol Aghajanian
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Vicky Makker
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Mario M. Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY
| | - Nadeem R. Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY
| | - Lora H. Ellenson
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Britta Weigelt
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jennifer J. Mueller
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY
| |
Collapse
|
4
|
Nasioudis D, Oh J, Ko EM, Haggerty AF, Cory L, Giuntoli Ii RL, Kim SH, Morgan MA, Latif NA. Adjuvant chemotherapy for stage I high-intermediate risk endometrial carcinoma with lymph-vascular invasion. Int J Gynecol Cancer 2022; 32:ijgc-2022-003496. [PMID: 35649658 DOI: 10.1136/ijgc-2022-003496] [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: 11/04/2022] Open
Abstract
OBJECTIVE The goal of this study was to evaluate if addition of adjuvant chemotherapy to radiation therapy improves overall survival in patients with high-intermediate risk stage I endometrial carcinoma with lymphovascular invasion. METHODS Patients diagnosed between January 2010 and December 2015 with FIGO (International Federation of Gynecology and Obstetrics) stage I endometrioid endometrial carcinoma with lymphovascular invasion who underwent hysterectomy with lymphadenectomy and met the GOG-99 criteria for high-intermediate risk were identified in the National Cancer Database. Patients who received adjuvant radiotherapy with or without adjuvant chemotherapy (administered within 6 months of surgery) and had at least 1 month of follow-up were selected for further analysis. Overall survival was compared with the log-rank test following stratification by type of radiation treatment. A Cox model was constructed to control for a priori selected confounders. RESULTS A total of 2881 patients who met the inclusion criteria were identified; 2417 (83.9%) patients received radiation therapy alone while 464 (16.1%) received chemoradiation. Rate of adjuvant chemotherapy administration was comparable between patients who received vaginal brachytherapy alone (16.2%), and external beam radiation therapy (with or without vaginal brachytherapy) (15.8%), p=0.78. Rate of chemoradiation was higher for patients with grade 3 (28.8%) tumors compared with those with grade 2 (9.9%) and grade 1 (8.3%) tumors, p<0.001. After controlling for confounders for patients receiving external beam radiation, addition of chemotherapy was not associated with improved overall survival (HR 0.90, 95% CI 0.56 to 1.46). For patients receiving vaginal brachytherapy addition of chemotherapy was associated with better overall survival (HR 0.644, 95% CI 0.45 to 0.92). Benefit was limited to patients with grade 3 tumors, p=0.026; 4-year overall survival rate was 81.1% versus 74.9%. CONCLUSIONS In patients with high-intermediate risk FIGO stage I endometrioid endometrial carcinoma and lymphovascular invasion, addition of chemotherapy to radiation therapy was associated with a survival benefit for patients with grade 3 tumors receiving vaginal brachytherapy.
Collapse
Affiliation(s)
- Dimitrios Nasioudis
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jinhee Oh
- Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
| | - Emily M Ko
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ashley F Haggerty
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lori Cory
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert L Giuntoli Ii
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah H Kim
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark A Morgan
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nawar A Latif
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
5
|
Coada CA, Dondi G, Ravegnini G, De Leo A, Santini D, De Crescenzo E, Tesei M, Bovicelli A, Giunchi S, Dormi A, Di Stanislao M, Morganti AG, De Biase D, De Iaco P, Perrone AM. Classification Systems of Endometrial Cancer: A Comparative Study about Old and New. Diagnostics (Basel) 2021; 12:33. [PMID: 35054199 PMCID: PMC8774791 DOI: 10.3390/diagnostics12010033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 02/05/2023] Open
Abstract
Endometrial cancer is the most common gynecological malignancy of the female reproductive organs. Historically it was divided into type I and type II, until 2013 when the Cancer Genome Atlas molecular classification was proposed. Here, we applied the different classification types on our endometrial cancer patient cohort in order to identify the most predictive one. We enrolled 117 endometrial cancer patients available for the study and collected the following parameters: age, body mass index, stage, menopause, Lynch syndrome status, parity, hypertension, type of localization of the lesion at hysteroscopy, type of surgery and complications, and presence of metachronous or synchronous tumors. The tumors were classified according to the European Society for Medical Oncology, Proactive Molecular Risk Classifier for Endometrial Cancer, Post-Operative Radiation Therapy in Endometrial Carcinoma, and Cancer Genome Atlas classification schemes. Our data confirmed that European Society for Medical Oncology risk was the strongest predictor of prognosis in our cohort. The parameters correlated with poor prognosis were the histotype, FIGO stage, and grade. Our study cohort shows that risk stratification should be based on the integration of histologic, clinical, and molecular parameters.
Collapse
Affiliation(s)
- Camelia Alexandra Coada
- Center for Applied Biomedical Research, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy
| | - Giulia Dondi
- Division of Oncologic Gynecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy
| | - Gloria Ravegnini
- Department of Pharmacy and Biotechnology (FABIT), University of Bologna, 40126 Bologna, Italy
| | - Antonio De Leo
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, 40138 Bologna, Italy
| | - Donatella Santini
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy
- Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Eugenia De Crescenzo
- Division of Oncologic Gynecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Marco Tesei
- Division of Oncologic Gynecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy
| | - Alessandro Bovicelli
- Division of Oncologic Gynecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Susanna Giunchi
- Division of Oncologic Gynecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Ada Dormi
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Marco Di Stanislao
- Division of Oncologic Gynecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Alessio G Morganti
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, 40138 Bologna, Italy
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Dario De Biase
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy
- Department of Pharmacy and Biotechnology (FABIT), University of Bologna, 40126 Bologna, Italy
| | - Pierandrea De Iaco
- Division of Oncologic Gynecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Anna Myriam Perrone
- Division of Oncologic Gynecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy
| |
Collapse
|
6
|
Eifel PJ. High intermediate risk endometrial cancer. What is it? Int J Gynecol Cancer 2020; 29:1084-1085. [PMID: 31474586 DOI: 10.1136/ijgc-2019-000776] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 07/18/2019] [Indexed: 11/04/2022] Open
Affiliation(s)
- Patricia J Eifel
- Radiation Oncology, MD Anderson Cancer Center, Houston, TX 77030, USA
| |
Collapse
|