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Moquist PN, Zhang X, Leiske CI, Eng-Duncan NML, Zeng W, Bindman NA, Wo SW, Wong A, Henderson CM, Crowder K, Lyon R, Doronina SO, Senter PD, Neff-LaFord HD, Sussman D, Gardai SJ, Levengood MR. Reversible Chemical Modification of Antibody Effector Function Mitigates Unwanted Systemic Immune Activation. Bioconjug Chem 2024; 35:855-866. [PMID: 38789102 PMCID: PMC11191404 DOI: 10.1021/acs.bioconjchem.4c00212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 05/13/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024]
Abstract
Antibody effector functions including antibody-dependent cellular cytotoxicity (ADCC) and phagocytosis (ADCP) are mediated through the interaction of the antibody Fc region with Fcγ receptors present on immune cells. Several approaches have been used to modulate antibody Fc-Fcγ interactions with the goal of driving an effective antitumor immune response, including Fc point mutations and glycan modifications. However, robust antibody-Fcγ engagement and immune cell binding of Fc-enhanced antibodies in the periphery can lead to the unwanted induction of systemic cytokine release and other dose-limiting infusion-related reactions. Creating a balance between effective engagement of Fcγ receptors that can induce antitumor activity without incurring systemic immune activation is an ongoing challenge in the field of antibody and immuno-oncology therapeutics. Herein, we describe a method for the reversible chemical modulation of antibody-Fcγ interactions using simple poly(ethylene glycol) (PEG) linkers conjugated to antibody interchain disulfides with maleimide attachments. This method enables dosing of a therapeutic with muted Fcγ engagement that is restored in vivo in a time-dependent manner. The technology was applied to an effector function enhanced agonist CD40 antibody, SEA-CD40, and experiments demonstrate significant reductions in Fc-induced immune activation in vitro and in mice and nonhuman primates despite showing retained efficacy and improved pharmacokinetics compared to the parent antibody. We foresee that this simple, modular system can be rapidly applied to antibodies that suffer from systemic immune activation due to peripheral FcγR binding immediately upon infusion.
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Affiliation(s)
- Philip N. Moquist
- ADC
Chemistry, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United states
| | - Xinqun Zhang
- ADC
Antibody Engineering, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Chris I. Leiske
- ADC
Antibody Engineering, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | | | - Weiping Zeng
- ADC
In Vivo Pharmacology, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Noah A. Bindman
- ADC
Antibody Engineering, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Serena W. Wo
- ADC
Antibody Engineering, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Abbie Wong
- ADC
Translational Sciences, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Clark M. Henderson
- ADC
Translational Sciences, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Karalyne Crowder
- Non-Clinical
Sciences, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Robert Lyon
- ADC
Antibody Engineering, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Svetlana O. Doronina
- ADC
Chemistry, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United states
| | - Peter D. Senter
- ADC
Chemistry, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United states
| | - Haley D. Neff-LaFord
- Non-Clinical
Sciences, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Django Sussman
- ADC
Antibody Engineering, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Shyra J. Gardai
- Immunology, Pfizer,
Inc., 21823 30th Dr.
SE, Bothell, Washington 98021, United States
| | - Matthew R. Levengood
- ADC
Antibody Engineering, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
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2
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Wu Y, Zhu M, Sun B, Chen Y, Huang Y, Gai J, Li G, Li Y, Wan Y, Ma L. A humanized trivalent Nectin-4-targeting nanobody drug conjugate displays potent antitumor activity in gastric cancer. J Nanobiotechnology 2024; 22:256. [PMID: 38755613 PMCID: PMC11097425 DOI: 10.1186/s12951-024-02521-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/01/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Gastric cancer represents a highly lethal malignancy with an elevated mortality rate among cancer patients, coupled with a suboptimal postoperative survival prognosis. Nectin-4, an overexpressed oncological target for various cancers, has been exploited to create antibody-drug conjugates (ADCs) to treat solid tumors. However, there is limited research on Nectin-4 ADCs specifically for gastric cancer, and conventional immunoglobulin G (IgG)-based ADCs frequently encounter binding site barriers. Based on the excellent tumor penetration capabilities inherent in nanobodies (Nbs), we developed Nectin-4-targeting Nb drug conjugates (NDCs) for the treatment of gastric cancer. RESULTS An immunized phage display library was established and employed for the selection of Nectin-4-specific Nbs using phage display technology. Subsequently, these Nbs were engineered into homodimers to enhance Nb affinity. To prolong in vivo half-life and reduce immunogenicity, we fused an Nb targeting human serum albumin (HSA), resulting in the development of trivalent humanized Nbs. Further, we site-specifically conjugated a monomethyl auristatin E (MMAE) at the C-terminus of the trivalent Nbs, creating Nectin-4 NDC (huNb26/Nb26-Nbh-MMAE) with a drug-to-antibody ratio (DAR) of 1. Nectin-4 NDC demonstrated excellent in vitro cell-binding activities and cytotoxic efficacy against cells with high Nectin-4 expression. Subsequent administration of Nectin-4 NDC to mice bearing NCI-N87 human gastric cancer xenografts demonstrated rapid tissue penetration and high tumor uptake through in vivo imaging. Moreover, Nectin-4 NDC exhibited noteworthy dose-dependent anti-tumor efficacy in in vivo studies. CONCLUSION We have engineered a Nectin-4 NDC with elevated affinity and effective tumor uptake, further establishing its potential as a therapeutic agent for gastric cancer.
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Affiliation(s)
- Yue Wu
- Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Min Zhu
- Shanghai Novamab Biopharmaceuticals Co., Ltd., Shanghai, China
| | - Baihe Sun
- Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Yongting Chen
- Graduate School of Xinxiang Medical University, Henan, China
| | - Yuping Huang
- Shanghai Novamab Biopharmaceuticals Co., Ltd., Shanghai, China
| | - Junwei Gai
- Shanghai Novamab Biopharmaceuticals Co., Ltd., Shanghai, China
| | - Guanghui Li
- Shanghai Novamab Biopharmaceuticals Co., Ltd., Shanghai, China
| | - Yanfei Li
- Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, China.
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China.
| | - Yakun Wan
- Shanghai Novamab Biopharmaceuticals Co., Ltd., Shanghai, China.
| | - Linlin Ma
- Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, China.
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China.
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3
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Liu X, Cheng Y, Mu Y, Zhang Z, Tian D, Liu Y, Hu X, Wen T. Diverse drug delivery systems for the enhancement of cancer immunotherapy: an overview. Front Immunol 2024; 15:1328145. [PMID: 38298192 PMCID: PMC10828056 DOI: 10.3389/fimmu.2024.1328145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/03/2024] [Indexed: 02/02/2024] Open
Abstract
Despite the clear benefits demonstrated by immunotherapy, there is still an inevitable off-target effect resulting in serious adverse immune reactions. In recent years, the research and development of Drug Delivery System (DDS) has received increased prominence. In decades of development, DDS has demonstrated the ability to deliver drugs in a precisely targeted manner to mitigate side effects and has the advantages of flexible control of drug release, improved pharmacokinetics, and drug distribution. Therefore, we consider that combining cancer immunotherapy with DDS can enhance the anti-tumor ability. In this paper, we provide an overview of the latest drug delivery strategies in cancer immunotherapy and briefly introduce the characteristics of DDS based on nano-carriers (liposomes, polymer nano-micelles, mesoporous silica, extracellular vesicles, etc.) and coupling technology (ADCs, PDCs and targeted protein degradation). Our aim is to show readers a variety of drug delivery platforms under different immune mechanisms, and analyze their advantages and limitations, to provide more superior and accurate targeting strategies for cancer immunotherapy.
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Affiliation(s)
- Xu Liu
- Department of Respiratory and Infectious Disease of Geriatrics, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yang Cheng
- Department of Respiratory and Infectious Disease of Geriatrics, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yao Mu
- Department of Respiratory and Infectious Disease of Geriatrics, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | | | - Dan Tian
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yunpeng Liu
- Key Laboratory of Anticancer Drugs and Biotherapy of Liaoning Province, The First Hospital of China Medical University, Shenyang, Liaoning, China
- Department of Medical Oncology, The First Hospital of China Medical University, Shenyang, Liaoning, China
- Liaoning Province Clinical Research Center for Cancer, The First Hospital of China Medical University, Shenyang, Liaoning, China
- Clinical Cancer Treatment and Research Center of Shenyang, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xuejun Hu
- Department of Respiratory and Infectious Disease of Geriatrics, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Ti Wen
- Key Laboratory of Anticancer Drugs and Biotherapy of Liaoning Province, The First Hospital of China Medical University, Shenyang, Liaoning, China
- Department of Medical Oncology, The First Hospital of China Medical University, Shenyang, Liaoning, China
- Liaoning Province Clinical Research Center for Cancer, The First Hospital of China Medical University, Shenyang, Liaoning, China
- Clinical Cancer Treatment and Research Center of Shenyang, The First Hospital of China Medical University, Shenyang, Liaoning, China
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4
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Guo X, Wu Y, Xue Y, Xie N, Shen G. Revolutionizing cancer immunotherapy: unleashing the potential of bispecific antibodies for targeted treatment. Front Immunol 2023; 14:1291836. [PMID: 38106416 PMCID: PMC10722299 DOI: 10.3389/fimmu.2023.1291836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/08/2023] [Indexed: 12/19/2023] Open
Abstract
Recent progressions in immunotherapy have transformed cancer treatment, providing a promising strategy that activates the immune system of the patient to find and eliminate cancerous cells. Bispecific antibodies, which engage two separate antigens or one antigen with two distinct epitopes, are of tremendous concern in immunotherapy. The bi-targeting idea enabled by bispecific antibodies (BsAbs) is especially attractive from a medical standpoint since most diseases are complex, involving several receptors, ligands, and signaling pathways. Several research look into the processes in which BsAbs identify different cancer targets such angiogenesis, reproduction, metastasis, and immune regulation. By rerouting cells or altering other pathways, the bispecific proteins perform effector activities in addition to those of natural antibodies. This opens up a wide range of clinical applications and helps patients with resistant tumors respond better to medication. Yet, further study is necessary to identify the best conditions where to use these medications for treating tumor, their appropriate combination partners, and methods to reduce toxicity. In this review, we provide insights into the BsAb format classification based on their composition and symmetry, as well as the delivery mode, focus on the action mechanism of the molecule, and discuss the challenges and future perspectives in BsAb development.
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Affiliation(s)
- Xiaohan Guo
- West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, China
| | - Yi Wu
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, China
| | - Ying Xue
- West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, China
| | - Na Xie
- West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, China
| | - Guobo Shen
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, China
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5
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Schoenfeld K, Harwardt J, Habermann J, Elter A, Kolmar H. Conditional activation of an anti-IgM antibody-drug conjugate for precise B cell lymphoma targeting. Front Immunol 2023; 14:1258700. [PMID: 37841262 PMCID: PMC10569071 DOI: 10.3389/fimmu.2023.1258700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/07/2023] [Indexed: 10/17/2023] Open
Abstract
Cancerous B cells are almost indistinguishable from their non-malignant counterparts regarding their surface antigen expression. Accordingly, the challenge to be faced consists in elimination of the malignant B cell population while maintaining a functional adaptive immune system. Here, we present an IgM-specific antibody-drug conjugate masked by fusion of the epitope-bearing IgM constant domain. Antibody masking impaired interaction with soluble pentameric as well as cell surface-expressed IgM molecules rendering the antibody cytotoxically inactive. Binding capacity of the anti-IgM antibody drug conjugate was restored upon conditional protease-mediated demasking which consequently enabled target-dependent antibody internalization and subsequent induction of apoptosis in malignant B cells. This easily adaptable approach potentially provides a novel mechanism of clonal B cell lymphoma eradication to the arsenal available for non-Hodgkin's lymphoma treatment.
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Affiliation(s)
- Katrin Schoenfeld
- Institute for Organic Chemistry and Biochemistry, Technical University of Darmstadt, Darmstadt, Germany
| | - Julia Harwardt
- Institute for Organic Chemistry and Biochemistry, Technical University of Darmstadt, Darmstadt, Germany
| | - Jan Habermann
- Institute for Organic Chemistry and Biochemistry, Technical University of Darmstadt, Darmstadt, Germany
| | - Adrian Elter
- Institute for Organic Chemistry and Biochemistry, Technical University of Darmstadt, Darmstadt, Germany
| | - Harald Kolmar
- Institute for Organic Chemistry and Biochemistry, Technical University of Darmstadt, Darmstadt, Germany
- Centre for Synthetic Biology, Technical University of Darmstadt, Darmstadt, Germany
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6
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Qian L, Lin X, Gao X, Khan RU, Liao JY, Du S, Ge J, Zeng S, Yao SQ. The Dawn of a New Era: Targeting the "Undruggables" with Antibody-Based Therapeutics. Chem Rev 2023. [PMID: 37186942 DOI: 10.1021/acs.chemrev.2c00915] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
The high selectivity and affinity of antibodies toward their antigens have made them a highly valuable tool in disease therapy, diagnosis, and basic research. A plethora of chemical and genetic approaches have been devised to make antibodies accessible to more "undruggable" targets and equipped with new functions of illustrating or regulating biological processes more precisely. In this Review, in addition to introducing how naked antibodies and various antibody conjugates (such as antibody-drug conjugates, antibody-oligonucleotide conjugates, antibody-enzyme conjugates, etc.) work in therapeutic applications, special attention has been paid to how chemistry tools have helped to optimize the therapeutic outcome (i.e., with enhanced efficacy and reduced side effects) or facilitate the multifunctionalization of antibodies, with a focus on emerging fields such as targeted protein degradation, real-time live-cell imaging, catalytic labeling or decaging with spatiotemporal control as well as the engagement of antibodies inside cells. With advances in modern chemistry and biotechnology, well-designed antibodies and their derivatives via size miniaturization or multifunctionalization together with efficient delivery systems have emerged, which have gradually improved our understanding of important biological processes and paved the way to pursue novel targets for potential treatments of various diseases.
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Affiliation(s)
- Linghui Qian
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Cancer Center, & Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310058, China
| | - Xuefen Lin
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Cancer Center, & Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310058, China
| | - Xue Gao
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Cancer Center, & Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310058, China
| | - Rizwan Ullah Khan
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Cancer Center, & Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310058, China
| | - Jia-Yu Liao
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Cancer Center, & Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310058, China
| | - Shubo Du
- School of Bioengineering, Dalian University of Technology, Dalian 116024, China
| | - Jingyan Ge
- Key Laboratory of Bioorganic Synthesis of Zhejiang Province, College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou 310014, China
| | - Su Zeng
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Cancer Center, & Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310058, China
| | - Shao Q Yao
- Department of Chemistry, National University of Singapore, 4 Science Drive 2, Singapore, 117544
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7
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Advances in antibody-based therapy in oncology. NATURE CANCER 2023; 4:165-180. [PMID: 36806801 DOI: 10.1038/s43018-023-00516-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 01/10/2023] [Indexed: 02/22/2023]
Abstract
Monoclonal antibodies are a growing class of targeted cancer therapeutics, characterized by exquisite specificity, long serum half-life, high affinity and immune effector functions. In this review, we outline key advances in the field with a particular focus on recent and emerging classes of engineered antibody therapeutic candidates, discuss molecular structure and mechanisms of action and provide updates on clinical development and practice.
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8
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Gout DY, Groen LS, van Egmond M. The present and future of immunocytokines for cancer treatment. Cell Mol Life Sci 2022; 79:509. [PMID: 36066630 PMCID: PMC9448690 DOI: 10.1007/s00018-022-04514-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/12/2022] [Accepted: 08/02/2022] [Indexed: 12/04/2022]
Abstract
Monoclonal antibody (mAb) therapy has successfully been introduced as treatment of several lymphomas and leukemias. However, solid tumors reduce the efficacy of mAb therapy because of an immune-suppressive tumor micro-environment (TME), which hampers activation of effector immune cells. Pro-inflammatory cytokine therapy may counteract immune suppression in the TME and increase mAb efficacy, but untargeted pro-inflammatory cytokine therapy is limited by severe off-target toxicity and a short half-life of cytokines. Antibody-cytokine fusion proteins, also referred to as immunocytokines, provide a solution to either issue, as the antibody both acts as local delivery platform and increases half-life. The antibody can furthermore bridge local cytotoxic immune cells, like macrophages and natural killer cells with tumor cells, which can be eliminated after effector cells are activated via the cytokine. Currently, a variety of different antibody formats as well as a handful of cytokine payloads are used to generate immunocytokines. However, many potential formats and payloads are still left unexplored. In this review, we describe current antibody formats and cytokine moieties that are used for the development of immunocytokines, and highlight several immunocytokines in (pre-)clinical studies. Furthermore, potential future routes of development are proposed.
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Affiliation(s)
- Dennis Y Gout
- Department of Molecular Cell Biology and Immunology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1108, Amsterdam, The Netherlands.,Cancer Biology and Immunology Program, Cancer Center Amsterdam, Amsterdam, The Netherlands.,Cancer Immunology Program, Amsterdam Institute for Infection and Immunity, Amsterdam, The Netherlands
| | - Lotte S Groen
- Department of Molecular Cell Biology and Immunology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1108, Amsterdam, The Netherlands.,LUMICKS, Paalbergweg 3, 1105 AG, Amsterdam, The Netherlands
| | - Marjolein van Egmond
- Department of Molecular Cell Biology and Immunology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1108, Amsterdam, The Netherlands. .,Cancer Biology and Immunology Program, Cancer Center Amsterdam, Amsterdam, The Netherlands. .,Cancer Immunology Program, Amsterdam Institute for Infection and Immunity, Amsterdam, The Netherlands. .,Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands.
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