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van Steenhoven JEC, van Maaren MC, Verreck EEF, Schipper RJ, Nieuwenhuijzen GAP, Kuijer A, Siesling S, van Dalen T. Inequalities in the omission of axillary dissection in sentinel lymph node positive patients in the Netherlands: Innovative hospitals are early adopters of a de-escalating approach. Int J Cancer 2023; 152:1378-1387. [PMID: 36522834 PMCID: PMC10108210 DOI: 10.1002/ijc.34400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/29/2022] [Accepted: 10/05/2022] [Indexed: 12/23/2022]
Abstract
During the last decade completion axillary lymph node dissection (cALND) was gradually omitted in sentinel lymph node positive (SLN+) breast cancer patients. However, adoption varies among hospitals. We analyzed factors associated with the omission of cALND in all Dutch SLN+ patients. As one of the focus hospital-related factors we defined "innovative" as the percentage of gene-expression profile (GEP) deployment within the indicated group of patients per hospital as a proxy for early adoption of innovations. cT1-2N0M0 SLN+ patients treated between 2011 and 2018 were selected from the Netherlands Cancer Registry. Hospitals were defined to be innovative based on their GEP use. Multivariable logistic regression (MLR) was performed to assess the relationship between innovative capacity, patient-, treatment- and hospital-related characteristics and cALND performance. 14 317 patients were included. Treatment in a hospital with high innovative capacity was associated with a lower probability of receiving cALND (OR 0.69, OR 0.46 and OR 0.35 in modestly, fairly and very innovative, respectively). Other factors associated with a lower probability of receiving a cALND were age 70 and 79 years and ≥79 years (ORs 0.59 [95% CI: 0.50-0.68] and 0.21 [95% CI: 0.17-0.26]) and treatment in an academic hospital (OR 0.41 [95% CI: 0.33-0.51]). Factors associated with an increased probability of undergoing cALND were HR-/HER2- tumors (OR 1.46 [95% CI: 1.19-1.80]), macrometastatic lymph node involvement (OR 6.37 [95% CI: 5.70-7.13]) and mastectomy (OR 4.57 [95% CI: 4.09-5.10]). Patients treated in a hospital that early adopted innovations were less likely to receive cALND. Our findings endorse the need for studies on barriers and facilitators of implementing innovations.
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Affiliation(s)
- Julia E C van Steenhoven
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands.,Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marissa C van Maaren
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands.,Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | | | - Robert J Schipper
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | | | - Anne Kuijer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands.,Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Thijs van Dalen
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands
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2
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Vliek SB, Hilbers FS, Jager A, Retèl VP, Bueno de Mesquita JM, Drukker CA, Veltkamp SC, Zeillemaker AM, Rutgers EJ, van Tinteren H, van Harten WH, van 't Veer LJ, van de Vijver MJ, Linn SC. Ten-year follow-up of the observational RASTER study, prospective evaluation of the 70-gene signature in ER-positive, HER2-negative, node-negative, early breast cancer. Eur J Cancer 2022; 175:169-179. [PMID: 36126477 DOI: 10.1016/j.ejca.2022.07.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/13/2022] [Accepted: 07/14/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Prognostic gene expression signatures can be used in combination with classical clinicopathological factors to guide adjuvant chemotherapy decisions in ER-positive, HER2-negative breast cancer. However, long-term outcome data after introduction of genomic testing in the treatment decision-making process are limited. METHODS In the prospective RASTER study, the tumours of 427 patients with cTanyN0M0 breast cancer were tested to assess the 70-gene signature (MammaPrint). The results were provided to their treating physician to be incorporated in the decision-making on adjuvant systemic therapy. Here, we report the long-term outcome of the 310 patients with ER-positive, HER2-negative tumours by clinical and genomic risk categories at a median follow-up of 10.3 years. RESULTS Among the clinically high-risk patients, 45 (49%) were classified as genomically low risk. In this subgroup, at 10 years, distant recurrence free interval (DRFI) was similar between patients treated with (95.7% [95% CI 87.7-100]) and without (95.5% [95% CI 87.1-100]) chemotherapy. Within the group of clinically low-risk patients, 56 (26%) were classified as genomically high risk. Within the clinically low-risk group, beyond 5 years, a difference emerged between the genomically high- and low-risk subgroup resulting in a 10-year DRFI of 84.3% (95% CI 74.8-95.0) and 93.4% (95% CI 89.5-97.5), respectively. Interestingly, genomic ultralow-risk patients have a 10-year DRFI of 96.7% (95% CI 90.5-100), largely (79%) without systemic therapy. CONCLUSIONS These data confirm that clinically high-risk, genomically low-risk tumours have an excellent outcome in the real-world setting of shared decision-making. Together with the updated results of the MINDACT trial, these data support the use of the MammaPrint, in ER-positive, HER2-negative, node-negative, clinically high-risk breast cancer patients. REGISTRY ISRCTN71917916.
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Affiliation(s)
- Sonja B Vliek
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Florentine S Hilbers
- Department of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Valesca P Retèl
- Departmentment of Psycosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Health Technology and Services Research, University of Twente, Enschede, the Netherlands
| | - Jolien M Bueno de Mesquita
- Department of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Addiction Medicin & Psychiatry, Brijder/Parnassia Group, The Hague, the Netherlands
| | - Caroline A Drukker
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Sanne C Veltkamp
- Department of Surgery, Amstelland Ziekenhuis, Amstelveen, the Netherlands
| | - Anneke M Zeillemaker
- Department of Surgical Oncology, Alrijne Ziekenhuis, Leiderdorp, the Netherlands
| | - Emiel J Rutgers
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Harm van Tinteren
- Department of Biometrics, The Netherlands Cancer Institute, Amsterdam, Netherlands; Trial and Data Center, Princes Maxima Centrum, Utrecht, the Netherlands
| | - Wim H van Harten
- Departmentment of Psycosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Health Technology and Services Research, University of Twente, Enschede, the Netherlands
| | - Laura J van 't Veer
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, USA
| | - Marc J van de Vijver
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Sabine C Linn
- Department of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands.
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Schipper RJ, de Bruijn A, Voogd AC, Bloemen JG, Van Riet YE, Vriens BEP, Smidt ML, Siesling S, van der Sangen MJC, Nieuwenhuijzen GAP. Rate and predictors of nodal pathological complete response following neoadjuvant endocrine treatment in clinically biopsy-proven node-positive breast cancer patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 47:1928-1933. [PMID: 34030918 DOI: 10.1016/j.ejso.2021.04.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/10/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Data on effectiveness and optimal use of neoadjuvant endocrine therapy (NET) in clinically biopsy-proven node-positive breast cancer is lacking. This study examined the incidence of axillary pathological complete response (pCR) on NET in clinically biopsy-proven node-positive breast cancer patients. Secondary, patient and tumour characteristics, as well as the optimal duration of NET in relation to the occurrence of axillary pCR were investigated. MATERIAL AND METHODS Patients diagnosed with primary hormone receptor positive, HER2 negative breast cancer between 2014 and 2019, with at least one positive axillary lymph node (pathologically proven), treated with NET were selected from the Netherlands Cancer Registry. The incidence of axillary pCR in combination with patient, tumour and treatment characteristics was analysed. RESULTS In a population of 561 patients, an axillary pCR of 7.3% on NET was observed. Median length of treatment was 8.1 months in the patients without vs. 8.8 months in those with axillary pCR, with no statistically significant difference. A p-value <0.30 was found for age, histologic type, clinical tumour status, hormone receptor status and the type of NET in univariable analysis. After multivariable logistic regression analyses, none of these variables were independently associated with the likelihood of an axillary pCR. CONCLUSION The rate of axillary pCR after NET in HR + HER2-clinically biopsy-proven node-positive breast cancer patients is low. Factors independently associated with the likelihood of an axillary pCR could not be identified. More research is warranted regarding optimizing the duration of NET and the prognostic value of residual disease in the axilla after NET.
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Affiliation(s)
| | - Anne de Bruijn
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | - Adri C Voogd
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands; GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | - Yvonne E Van Riet
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | - Birgit E P Vriens
- Department of Internal Medicine, Catharina Hospital Eindhoven, the Netherlands
| | - Marjolein L Smidt
- GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Center +, Maastricht, the Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands; Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, the Netherlands
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van Dooijeweert C, Baas IO, Deckers IAG, Siesling S, van Diest PJ, van der Wall E. The increasing importance of histologic grading in tailoring adjuvant systemic therapy in 30,843 breast cancer patients. Breast Cancer Res Treat 2021; 187:577-586. [PMID: 33517555 PMCID: PMC8189961 DOI: 10.1007/s10549-021-06098-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 01/06/2021] [Indexed: 12/21/2022]
Abstract
Purpose The large variation in histologic grading of invasive breast cancer (IBC) that has been reported likely influences tailoring adjuvant therapy. The role of grading in therapeutic decision-making in daily practice, was evaluated using the Dutch national guidelines for IBC-management. Methods Synoptic reports of IBC resection-specimens, obtained between 2013 and 2016, were extracted from the nationwide Dutch Pathology Registry, and linked to treatment-data from the Netherlands Cancer Registry. The relevance of grading for adjuvant chemotherapy (aCT) was quantified by identifying patients for whom grade was the determinative factor. In addition, the relation between grade and aCT-administration was evaluated by multivariate logistic regression for patients with a guideline-aCT-indication. Results 30,843 patients were included. Applying the guideline that was valid between 2013 and 2016, grade was the determinative factor for the aCT-indication in 7744 (25.1%) patients, a percentage that even increased according to the current guideline where grade would be decisive for aCT in 10,869 (35.2%) patients. Also in current practice, the indication for adjuvant endocrine therapy (aET) would be based on grade in 9173 (29.7%) patients. Finally, as patients with lower-grade tumors receive aCT significantly less often, grade was also decisive in tailoring aCT de-escalation. Conclusions In the largest study published so far we illustrate the increasing importance of histologic grade in tailoring adjuvant systemic breast cancer therapy. Next to playing a key-role in aCT-indication and de-escalation, the role of grading has expanded to the indication for aET. Optimizing histologic grading by pathologists is urgently needed to diminish the risk of worse patient outcome due to non-optimal treatment. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-021-06098-7.
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Affiliation(s)
- C van Dooijeweert
- Department of Pathology, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - I O Baas
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I A G Deckers
- Foundation PALGA (the Nationwide Network and Registry of Histo- and Cytopathology in the Netherlands), Houten, The Netherlands
| | - S Siesling
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands.,Department of Health Technology & Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - P J van Diest
- Department of Pathology, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - E van der Wall
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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5
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van der Meer DJ, Kramer I, van Maaren MC, van Diest PJ, C Linn S, Maduro JH, J A Strobbe L, Siesling S, Schmidt MK, Voogd AC. Comprehensive trends in incidence, treatment, survival and mortality of first primary invasive breast cancer stratified by age, stage and receptor subtype in the Netherlands between 1989 and 2017. Int J Cancer 2020; 148:2289-2303. [PMID: 33252836 PMCID: PMC8048677 DOI: 10.1002/ijc.33417] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/27/2020] [Accepted: 11/11/2020] [Indexed: 01/06/2023]
Abstract
Our study aimed to provide a comprehensive overview of trends in incidence, survival, mortality and treatment of first primary invasive breast cancer (BC), according to age, stage and receptor subtype in the Netherlands between 1989 and 2017. Data from all women diagnosed with first primary stage I to IV BC (N = 320 249) were obtained from the Netherlands Cancer Registry. BC mortality and general population data were retrieved from Statistics Netherlands. Age-standardised incidence and mortality rates were calculated with annual percentage change (APC) and average annual percentage change (AAPC) statistics. The relative survival (RS) was used as estimator for disease-specific survival. The BC incidence for all BC patients combined significantly increased until 2013 from 126 to 158 per 100 000 person-years, after which a declining trend was observed. Surgery became less extensive, but (neo-)adjuvant systemic treatments and their combinations were given more frequently. The RS improved for all age groups and for most stages and receptor subtypes, but remained stable for all subtypes since 2012 to 2013 and since 2000 to 2009 for Stage IV BC at 15 years of follow-up. Overall, the 5- and 10-year RS increased from 76.8% (95% confidence interval [CI]: 76.1, 77.4) and 55.9% (95% CI: 54.7, 57.1) in 1989 to 1999 to 91.0% (95% CI: 90.5, 91.5) and 82.9% (95% CI: 82.2, 83.5), respectively, in 2010 to 2016. BC mortality improved regardless of age and overall decreased from 57 to 35 per 100 000 person-years between 1989 and 2017. In conclusion, the BC incidence in the Netherlands has steadily increased since 1989, but the latest trends show promising declines. Survival improved markedly for most patients and the mortality decreased regardless of age.
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Affiliation(s)
- Daniël J van der Meer
- Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht
| | - Iris Kramer
- Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Marissa C van Maaren
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht.,Department of Health Technology and Services Research, Technical Medical Center, University of Twente, Enschede
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht
| | | | - John H Maduro
- Department of radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen
| | - Luc J A Strobbe
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht.,Department of Health Technology and Services Research, Technical Medical Center, University of Twente, Enschede
| | - Marjanka K Schmidt
- Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Adri C Voogd
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht.,Department of Epidemiology, Maastricht University, Maastricht
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6
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van Steenhoven JEC, den Dekker BM, Kuijer A, van Diest PJ, Nieboer P, Zuetenhorst JM, Imholz ALT, Siesling S, van Dalen T. Patients' perceptions of 70-gene signature testing: commonly changing the initial inclination to undergo or forego chemotherapy and reducing decisional conflict. Breast Cancer Res Treat 2020; 182:107-115. [PMID: 32430679 PMCID: PMC7275022 DOI: 10.1007/s10549-020-05683-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/11/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Little is known about the impact of 70-gene signature (70-GS) use on patients' chemotherapy decision-making. The primary aim of this study was to evaluate the impact of 70-GS use on patients' decisions to undergo chemotherapy. The perceived decision conflict during decision-making was a secondary objective of the study. METHODS Patients operated for estrogen receptor positive early breast cancer were asked to fill out a questionnaire probing their inclination to undergo chemotherapy before deployment of the 70-GS test. After disclosure of the 70-GS result patients were asked about their decision regarding chemotherapy. Patients' decisional conflict was measured using the 16-item decisional conflict scale (DCS); scores < 25 are associated with a persuaded decision while a score > 37.5 implies that one feels unsure about a choice. RESULTS Between January 1th 2017 and December 31th 2018, 106 patients completed both questionnaires. Before deployment of the 70-GS, 58% of patients (n = 62) formulated a clear treatment preference, of whom 21 patients (34%) changed their opinion on treatment with chemotherapy following the 70-GS. The final decision regarding chemotherapy was in line with the 70-GS result in 90% of patients. The percentage of patients who felt unsure about their preference to be treated with chemotherapy decreased from 42 to 5% after disclosure of the 70-GS. The mean total DCS significantly decreased from pre-test to post-test from 35 to 23, irrespective of the risk estimate (p < 0.001). CONCLUSION Deployment of the 70-GS changed patients' inclination to undergo adjuvant chemotherapy in one third of patients and decreased patients' decisional conflict.
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Affiliation(s)
- Julia E C van Steenhoven
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands.
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Bianca M den Dekker
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anne Kuijer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Peter Nieboer
- Department of Medical Oncology, Wilhelmina Hospital Assen, Assen, The Netherlands
| | - Johanna M Zuetenhorst
- Department of Medical Oncology, Franciscus Gasthuis Hospital, Rotterdam, The Netherlands
| | - Alex L Th Imholz
- Department of Medical Oncology, Deventer Hospital, Deventer, The Netherlands
| | - Sabine Siesling
- Department of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Thijs van Dalen
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
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van Steenhoven JEC, van Dalen T. ASO Author Reflections: The Changing Role of Gene Expression Profiling in ER+/HER2- Breast Cancer. Ann Surg Oncol 2019; 26:800-801. [PMID: 31650304 PMCID: PMC6901413 DOI: 10.1245/s10434-019-07955-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Julia E C van Steenhoven
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands.
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - T van Dalen
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
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