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Gontero P, Birtle A, Capoun O, Compérat E, Dominguez-Escrig JL, Liedberg F, Mariappan P, Masson-Lecomte A, Mostafid HA, Pradere B, Rai BP, van Rhijn BWG, Seisen T, Shariat SF, Soria F, Soukup V, Wood R, Xylinas EN. European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and Carcinoma In Situ)-A Summary of the 2024 Guidelines Update. Eur Urol 2024:S0302-2838(24)02514-4. [PMID: 39155194 DOI: 10.1016/j.eururo.2024.07.027] [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: 07/11/2024] [Accepted: 07/29/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND AND OBJECTIVE This publication represents a summary of the updated 2024 European Association of Urology (EAU) guidelines for non-muscle-invasive bladder cancer (NMIBC), TaT1, and carcinoma in situ. The information presented herein is limited to urothelial carcinoma, unless specified otherwise. The aim is to provide practical recommendations on the clinical management of NMIBC with a focus on clinical presentation. METHODS For the 2024 guidelines on NMIBC, new and relevant evidence was identified, collated, and appraised via a structured assessment of the literature. Databases searched included Medline, EMBASE, and the Cochrane Libraries. Recommendations within the guidelines were developed by the panel to prioritise clinically important care decisions. The strength of each recommendation was determined according to a balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including the certainty of estimates), and the nature and variability of patient values and preferences. KEY FINDINGS AND LIMITATIONS Key recommendations emphasise the importance of thorough diagnosis, treatment, and follow-up for patients with NMIBC. The guidelines stress the importance of defining patients' risk stratification and treating them appropriately. CONCLUSIONS AND CLINICAL IMPLICATIONS This overview of the 2024 EAU guidelines offers valuable insights into risk factors, diagnosis, classification, prognostic factors, treatment, and follow-up of NMIBC. These guidelines are designed for effective integration into clinical practice.
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Affiliation(s)
- Paolo Gontero
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy.
| | - Alison Birtle
- Rosemere Cancer Centre, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Otakar Capoun
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Eva Compérat
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | | | - Fredrik Liedberg
- Institute of Translational Medicine, Lund University, Malmö, Sweden; Department of Urology, Skåne University Hospital, Malmö, Sweden
| | - Paramananthan Mariappan
- Edinburgh Bladder Cancer Surgery (EBCS), Western General Hospital, The University of Edinburgh, Edinburgh, UK
| | | | - Hugh A Mostafid
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Benjamin Pradere
- Department of Urology, La Croix Du Sud Hospital, Quint Fonsegrives, France
| | - Bhavan P Rai
- Department of Urology, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Bas W G van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Thomas Seisen
- Urology, GRC 5 Predictive Onco-Uro, AP-HP, Pitie-Salpetriere Hospital, Sorbonne University, Paris, France
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University Vienna, Vienna, Austria
| | - Francesco Soria
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Viktor Soukup
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Robert Wood
- EAU Guidelines Office, Arnhem, The Netherlands
| | - Evanguelos N Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, AP-HP, Université de Paris, Paris, France
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Remmelink MJ, Rip Y, Nieuwenhuijzen JA, Ket JCF, Oddens JR, de Reijke TM, de Bruin DM. Advanced optical imaging techniques for bladder cancer detection and diagnosis: a systematic review. BJU Int 2024. [PMID: 39015996 DOI: 10.1111/bju.16471] [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: 07/18/2024]
Abstract
OBJECTIVES To systematically assess the current available literature concerning advanced optical imaging methods for the detection and diagnosis of bladder cancer (BCa), focusing particularly on the sensitivity and specificity of these techniques. METHODS First a scoping search was performed to identify all available optical techniques for BCa detection and diagnosis. The optical imaging techniques used for detecting BCa are: the Storz professional image enhancement system (IMAGE1 S), narrow-band imaging (NBI), photoacoustic imaging (PAI), autofluorescence imaging (AFI), photodynamic diagnosis (PDD), and scanning fibre endoscopy (SFE). The staging and grading techniques for BCa are: optical coherence tomography (OCT), confocal laser endomicroscopy (CLE), Raman spectroscopy, endocytoscopy, and non-linear optical microscopy (NLO). Then a systematic literature search was conducted using MEDLINE, EMBASE and Web of Science from inception to 21 November 2023. Articles were screened and selected by two independent reviewers. Inclusion criteria were: reporting on both the sensitivity and specificity of a particular technique and comparison to histopathology, and in the case of a detection technique comparison to white light cystoscopy (WLC). RESULTS Out of 6707 articles, 189 underwent full-text review, resulting in 52 inclusions. No articles met criteria for IMAGE1 S, PAI, SFE, Raman spectroscopy, and endocytoscopy. All detection techniques showed higher sensitivity than WLC, with NBI leading (87.8-100%). Overall, detection technique specificity was comparable to WLC, with PDD being most specific (23.3-100%). CLE and OCT varied in sensitivity and specificity, with OCT showing higher specificity for BCa diagnosis, notably for carcinoma in situ (97-99%) compared to CLE (62.5-81.3%). NLO demonstrated high sensitivity and specificity (90-97% and 77-100%, respectively) based on limited data from two small ex vivo studies. CONCLUSIONS Optical techniques with the most potential are PDD for detecting and OCT for staging and grading BCa. Further research is crucial to validate their integration into routine practice and explore the value of other imaging techniques.
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Affiliation(s)
- Marinka J Remmelink
- Department of Urology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Yael Rip
- Department of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Jakko A Nieuwenhuijzen
- Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Urology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Johannes C F Ket
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jorg R Oddens
- Department of Urology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Theo M de Reijke
- Department of Urology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Daniel M de Bruin
- Department of Urology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and biomarkers, Amsterdam, The Netherlands
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Blichert-Refsgaard L, Graugaard-Jensen C, Nørgaard M, Jensen JB. Use of Bladder-Related Medication in Non-Muscle Invasive Bladder Cancer Patients. Cancers (Basel) 2024; 16:1936. [PMID: 38792014 PMCID: PMC11119777 DOI: 10.3390/cancers16101936] [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: 03/17/2024] [Revised: 04/16/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Repeated transurethral bladder resections (TURBs) and instillation treatments in non-muscle invasive bladder cancer (NMIBC) might influence bladder function and, therefore, quality of life. Bladder-related medication is a surrogate marker of compromised bladder function. The objective was to investigate whether TURBs and adjuvant instillation therapy are associated with the use of anticholinergics, β3-agonists, and cystitis-relevant antibiotics. We divided all Danish patients diagnosed with primary NMIBC during 2002-2017 registered in the Danish National Patient Registry (DNPR) based on TURB-load within the first five years from diagnosis (1 TURB, 2-4 TURBs, ≥5 TURBs). Instillation therapy with either mitomycin C (MMC) or bacillus Calmette-Guerin vaccine (BCG) was independent exposure (yes or no). We included 17,774 patients; 76% men, median age: 70 years (IQR: 63, 77). Patients exposed to ≥5 TURBs had a higher risk of using bladder-relaxing medication than patients exposed to 1 TURB, HR = 4.01 [3.33; 4.83], and higher risk of cystitis, HR = 2.27 [2.05; 2.51]. BCG-exposed patients had a higher risk of bladder-relaxing medication use compared to non-exposed, HR = 1.92 [1.69; 2.18], and a higher risk of cystitis, HR = 1.39 [1.31; 1.48]. Repeated TURBs have the highest impact on bladder function. Adjuvant instillation therapy is also associated with the use of bladder-related medication.
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Affiliation(s)
- Linea Blichert-Refsgaard
- Department of Urology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, 8200 Aarhus N, Denmark; (C.G.-J.); (J.B.J.)
| | - Charlotte Graugaard-Jensen
- Department of Urology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, 8200 Aarhus N, Denmark; (C.G.-J.); (J.B.J.)
| | - Mette Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Alle 43-45, 8200 Aarhus N, Denmark;
| | - Jørgen Bjerggaard Jensen
- Department of Urology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, 8200 Aarhus N, Denmark; (C.G.-J.); (J.B.J.)
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Laukhtina E, Shariat SF. Re: DaBlaCa-13 Study: Oncological Outcome of Short-term, Intensive Chemoresection with Mitomycin in Nonmuscle Invasive Bladder Cancer: Primary Outcome of a Randomized Controlled Trial. Eur Urol 2023; 84:512-513. [PMID: 37270391 DOI: 10.1016/j.eururo.2023.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/22/2023] [Indexed: 06/04/2023]
Affiliation(s)
- Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - 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; 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; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czechia; Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan.
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Tan WS, Hall E, Kamat AM, Kelly JD. Clinical trial design for non-muscle-invasive bladder cancer. Nat Rev Urol 2023; 20:575-576. [PMID: 37328547 DOI: 10.1038/s41585-023-00789-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Affiliation(s)
- Wei Shen Tan
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Division of Surgery & Interventional Science, University College London, London, UK.
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John D Kelly
- Division of Surgery & Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospital, London, UK
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Basile G, Pradere B, Bellmunt J, Rouprêt M, Kamat AM, Seisen T. A Plea for the Use of Video-recorded Cystoscopy for Blinded Independent Central Review of Tumor Response in Open-label Non-muscle invasive Bladder Cancer Trials. Eur Urol Oncol 2023; 6:453-455. [PMID: 37604762 DOI: 10.1016/j.euo.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/07/2023] [Indexed: 08/23/2023]
Abstract
Given that most of non-muscle invasive bladder cancer trials available in the literature share the same limitation of an open-label design, they are likely prone to detection bias. Indeed, tumor response is currently assessed by unblinded investigators, mainly via follow-up cystoscopy, which has well-known intraobserver and interobserver variability. Thus, we believe that the use of video-recorded cystoscopy for blinded independent central review of tumor response could help to minimize detection bias in open-label NMIBC trials.
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Affiliation(s)
- Giuseppe Basile
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Benjamin Pradere
- Department of Urology UROSUD, La Croix Du Sud Hospital, Quint Fonsegrives, France; Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Joaquim Bellmunt
- Department of Medical Oncology, Dana-Farber Cancer Center and IMIM Research Lab, Harvard Medical School, Boston, MA, USA
| | - Morgan Rouprêt
- Department of Urology, Pitié-Salpêtrière Hospital, AP-HP, GRC 5 Predictive Onco-Urology, Sorbonne University, Paris, France
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas Seisen
- Department of Urology, Pitié-Salpêtrière Hospital, AP-HP, GRC 5 Predictive Onco-Urology, Sorbonne University, Paris, France.
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Grabe-Heyne K, Henne C, Mariappan P, Geiges G, Pöhlmann J, Pollock RF. Intermediate and high-risk non-muscle-invasive bladder cancer: an overview of epidemiology, burden, and unmet needs. Front Oncol 2023; 13:1170124. [PMID: 37333804 PMCID: PMC10272547 DOI: 10.3389/fonc.2023.1170124] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/19/2023] [Indexed: 06/20/2023] Open
Abstract
Bladder cancer ranks among the most common cancers globally. At diagnosis, 75% of patients have non-muscle-invasive bladder cancer (NMIBC). Patients with low-risk NMIBC have a good prognosis, but recurrence and progression rates remain high in intermediate- and high-risk NMIBC, despite the decades-long availability of effective treatments for NMIBC such as intravesical Bacillus Calmette-Guérin (BCG). The present review provides an overview of NMIBC, including its burden and treatment options, and then reviews aspects that counteract the successful treatment of NMIBC, referred to as unmet treatment needs. The scale and reasons for each unmet need are described based on a comprehensive review of the literature, including insufficient adherence to treatment guidelines by physicians because of insufficient knowledge, training, or access to certain therapy options. Low rates of lifestyle changes and treatment completion by patients, due to BCG shortages or toxicities and adverse events as well as their impact on social activities, represent additional areas of potential improvement. Highly heterogeneous evidence for the effectiveness and safety of some treatments limits the comparability of results across studies. As a result, efforts are underway to standardize treatment schedules for BCG, but intravesical chemotherapy schedules remain unstandardized. In addition, risk-scoring models often perform unsatisfactorily due to significant differences between derivation and real-world cohorts. Reporting in clinical trials suffers from a lack of consistent outcomes reporting in bladder cancer clinical trials, paired with an under-representation of racial and ethnic minorities in many trials.
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Affiliation(s)
| | | | - Paramananthan Mariappan
- Edinburgh Bladder Cancer Surgery (EBCS), Department of Urology, Western General Hospital, Edinburgh, United Kingdom
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8
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Contieri R, Lazzeri M, Hurle R. When and How To Perform Active Surveillance for Low-risk Non-muscle-invasive Bladder Cancer. Eur Urol Focus 2023:S2405-4569(23)00095-0. [PMID: 37059619 DOI: 10.1016/j.euf.2023.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/15/2023] [Accepted: 03/30/2023] [Indexed: 04/16/2023]
Abstract
Active surveillance (AS) has been proposed as a possible management option for patients with recurrent low-grade non-muscle-invasive bladder cancer. Recent studies suggest that AS is a safe and effective management strategy. Nevertheless, a consensus statement is needed to standardize inclusion criteria and follow-up schedules.
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Affiliation(s)
- Roberto Contieri
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Department of Urology, IRCCS Humanitas Research Hospital, Rozzano, Italy.
| | - Massimo Lazzeri
- Department of Urology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Rodolfo Hurle
- Department of Urology, IRCCS Humanitas Research Hospital, Rozzano, Italy
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Pradere B, Basile G, Seisen T. Re: Maria S. Lindgren, Eric Hansen, Nessn Azawi, Anna M. Nielsen, Lars Dyrskjøt, Jørgen B. Jensen. DaBlaCa-13 Study: Oncological Outcome of Short-term, Intensive Chemoresection with Mitomycin in Nonmuscle Invasive Bladder Cancer: Primary Outcome of a Randomized Controlled Trial. J Clin Oncol. In press. https://doi.org/ 10.1200/JCO.22.00470. Eur Urol 2023; 83:e105-e106. [PMID: 36717285 DOI: 10.1016/j.eururo.2022.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 12/21/2022] [Indexed: 01/29/2023]
Affiliation(s)
- Benjamin Pradere
- Department of Urology UROSUD, La Croix Du Sud Hospital, Quint Fonsegrives, France; Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Giuseppe Basile
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Thomas Seisen
- Department of Urology, Pitié-Salpêtrière Hospital, APHP, Sorbonne University, GRC 5, Predictive Onco-Urology, Paris, France.
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Lindgren MS, Jensen JB. Reply to Benjamin Pradere, Giuseppe Basile, and Thomas Seisen's Letter to the Editor re: Maria S. Lindgren, Eric Hansen, Nessn Azawi, Anna M. Nielsen, Lars Dyrskjøt, Jørgen B. Jensen. DaBlaCa-13 Study: Oncological Outcome of Short-term, Intensive Chemoresection with Mitomycin in Nonmuscle Invasive Bladder Cancer: Primary Outcome of a Randomized Controlled Trial. J Clin Oncol 2023;41:2,206-11. Eur Urol 2023; 83:e107-e108. [PMID: 36710202 DOI: 10.1016/j.eururo.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 01/11/2023] [Indexed: 01/30/2023]
Affiliation(s)
- Maria S Lindgren
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark.
| | - Jørgen B Jensen
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark; Department of Urology, Regional Hospital West Jutland, Holstebro, Denmark; Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
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Lenfant L, Pinar U, Rouprêt M, Seisen T. First-line Intravesical Chemotherapy for Non-muscle-invasive Bladder Cancer: Chimera or "Ne Plus Ultra"? Eur Urol 2023:S0302-2838(23)02637-4. [PMID: 36941147 DOI: 10.1016/j.eururo.2023.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 02/03/2023] [Indexed: 03/23/2023]
Abstract
The efficacy of first-line intravesical chemotherapy for non-muscle-invasive bladder cancer has been tested in the neoadjuvant and chemoresection settings. However, the data available are highly heterogeneous and further high-quality studies are needed before its use can be embraced in either setting.
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Affiliation(s)
- Louis Lenfant
- Sorbonne University, GRC 5, Predictive Onco-urology, Department of Urology, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France.
| | - Ugo Pinar
- Sorbonne University, GRC 5, Predictive Onco-urology, Department of Urology, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Morgan Rouprêt
- Sorbonne University, GRC 5, Predictive Onco-urology, Department of Urology, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Thomas Seisen
- Sorbonne University, GRC 5, Predictive Onco-urology, Department of Urology, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
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Yanagisawa T, Quhal F, Kawada T, Mostafaei H, Motlagh RS, Laukhtina E, Rajwa P, Deimling MV, Bianchi A, Pallauf M, Majdoub M, Pradere B, Moschini M, Karakiewicz PI, Teoh JYC, Miki J, Kimura T, Shariat SF. A Systematic Review and Meta-analysis of Chemoablation for Non–muscle-invasive Bladder Cancer. Eur Urol Focus 2022:S2405-4569(22)00287-5. [DOI: 10.1016/j.euf.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/22/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022]
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