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Aredo JV, Hellyer JA, Neal JW, Wakelee HA. Consolidation Durvalumab Should Not Be Administered to Patients With Stage III EGFR-Mutant NSCLC. J Thorac Oncol 2021; 16:1994-1998. [PMID: 34809803 DOI: 10.1016/j.jtho.2021.07.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/26/2021] [Accepted: 07/29/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Jacqueline V Aredo
- Department of Medicine, University of California, San Francisco, California
| | - Jessica A Hellyer
- Division of Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joel W Neal
- Division of Oncology, Department of Medicine, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Heather A Wakelee
- Division of Oncology, Department of Medicine, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California.
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2
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Hellyer JA, White MN, Gardner RM, Cunanan K, Padda SK, Das M, Ramchandran K, Neal JW, Wakelee HA. Impact of Tumor Suppressor Gene Co-Mutations on Differential Response to EGFR TKI Therapy in EGFR L858R and Exon 19 Deletion Lung Cancer. Clin Lung Cancer 2021; 23:264-272. [PMID: 34838441 DOI: 10.1016/j.cllc.2021.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND In most studies, patients with EGFR L858R mutant non-small cell lung cancer (NSCLC) have a shorter duration of response to EGFR tyrosine kinase inhibitor (TKI) therapy than do patients with EGFR exon 19 deletion NSCLC. The role that co-mutations play in this observation is unknown. METHODS We performed a single-institution retrospective analysis of patients with EGFR-mutant NSCLC (exon 19 deletion or L858R mutation) who received frontline EGFR TKI for metastatic disease between 2014 and 2019, and who had STAMP next-generation sequencing (NGS), a 130-gene platform. Time to treatment failure (TTF) and overall survival were calculated using Cox models adjusted for age, race, and brain metastases. Co-mutations in key tumor suppressor genes (TP53, RB1, KEAP1, CDKN2A, or CTNNB1) were identified and their effects on outcomes were evaluated. Analyses were stratified according to receipt of osimertinib versus nonosimertinib as frontline EGFR TKI. RESULTS Of 137 patients, 72 (57%) had EGFR exon 19 deletions and 65 (43%) had EGFR L858R mutations. Median TTF and OS on frontline TKI was shorter for the L858R cohort versus the exon 19 deletion cohort in univariate analysis. In adjusted models, this difference persisted for TTF but was no longer significant for OS. The difference in TTF in L858R mutant tumors was driven by the presence of co-mutations in key tumor suppressor genes. CONCLUSION Patients with metastatic NSCLC with mutations in EGFR L858R had shorter TTF on frontline TKI compared to patients with EGFR exon 19 deletions. Co-mutations in tumor suppressor genes may play an important role in the differential response to TKI therapy.
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Affiliation(s)
- Jessica A Hellyer
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA
| | - Maya N White
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA
| | - Rebecca M Gardner
- Quantitative Sciences Unit, Stanford School of Medicine, Stanford, CA
| | - Kristen Cunanan
- Quantitative Sciences Unit, Stanford School of Medicine, Stanford, CA
| | - Sukhmani K Padda
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA
| | - Millie Das
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA
| | - Kavitha Ramchandran
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA
| | - Joel W Neal
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA
| | - Heather A Wakelee
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA.
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3
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Padda SK, Gökmen-Polar Y, Hellyer JA, Badve SS, Singh NK, Vasista SM, Basu K, Kumar A, Wakelee HA. Genomic clustering analysis identifies molecular subtypes of thymic epithelial tumors independent of World Health Organization histologic type. Oncotarget 2021; 12:1178-1186. [PMID: 34136086 PMCID: PMC8202771 DOI: 10.18632/oncotarget.27978] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/15/2021] [Indexed: 11/25/2022] Open
Abstract
Further characterization of thymic epithelial tumors (TETs) is needed. Genomic information from 102 evaluable TETs from The Cancer Genome Atlas (TCGA) dataset and from the IU-TAB-1 cell line (type AB thymoma) underwent clustering analysis to identify molecular subtypes of TETs. Six novel molecular subtypes (TH1-TH6) of TETs from the TCGA were identified, and there was no association with WHO histologic subtype. The IU-TAB-1 cell line clustered into the TH4 molecular subtype and in vitro testing of candidate therapeutics was performed. The IU-TAB-1 cell line was noted to be resistant to everolimus (mTORC1 inhibitor) and sensitive to nelfinavir (AKT1 inhibitor) across the endpoints measured. Sensitivity to nelfinavir was due to the IU-TAB-1 cell line’s gain-of function (GOF) mutation in PIK3CA and amplification of genes observed from array comparative genomic hybridization (aCGH), including AURKA, ERBB2, KIT, PDGFRA and PDGFB, that are known upregulate AKT, while resistance to everolimus was primarily driven by upregulation of downstream signaling of KIT, PDGFRA and PDGFB in the presence of mTORC1 inhibition. We present a novel molecular classification of TETs independent of WHO histologic subtype, which may be used for preclinical validation studies of potential candidate therapeutics of interest for this rare disease.
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Affiliation(s)
- Sukhmani K Padda
- Stanford University School of Medicine/Stanford Cancer Institute, Stanford, CA, USA
| | | | - Jessica A Hellyer
- Stanford University School of Medicine/Stanford Cancer Institute, Stanford, CA, USA
| | - Sunil S Badve
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | | | | | - Heather A Wakelee
- Stanford University School of Medicine/Stanford Cancer Institute, Stanford, CA, USA
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4
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Aredo JV, Mambetsariev I, Hellyer JA, Amini A, Neal JW, Padda SK, McCoach CE, Riess JW, Cabebe EC, Naidoo J, Abuali T, Salgia R, Loo BW, Diehn M, Han SS, Wakelee HA. Durvalumab for Stage III EGFR-Mutated NSCLC After Definitive Chemoradiotherapy. J Thorac Oncol 2021; 16:1030-1041. [DOI: 10.1016/j.jtho.2021.01.1628] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/26/2021] [Accepted: 01/29/2021] [Indexed: 12/25/2022]
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5
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Foggetti G, Li C, Cai H, Hellyer JA, Lin WY, Ayeni D, Hastings K, Choi J, Wurtz A, Andrejka L, Maghini DG, Rashleigh N, Levy S, Homer R, Gettinger SN, Diehn M, Wakelee HA, Petrov DA, Winslow MM, Politi K. Genetic Determinants of EGFR-Driven Lung Cancer Growth and Therapeutic Response In Vivo. Cancer Discov 2021; 11:1736-1753. [PMID: 33707235 PMCID: PMC8530463 DOI: 10.1158/2159-8290.cd-20-1385] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/23/2020] [Accepted: 02/11/2021] [Indexed: 11/16/2022]
Abstract
In lung adenocarcinoma, oncogenic EGFR mutations co-occur with many tumor suppressor gene alterations; however, the extent to which these contribute to tumor growth and response to therapy in vivo remains largely unknown. By quantifying the effects of inactivating 10 putative tumor suppressor genes in a mouse model of EGFR-driven Trp53-deficient lung adenocarcinoma, we found that Apc, Rb1, or Rbm10 inactivation strongly promoted tumor growth. Unexpectedly, inactivation of Lkb1 or Setd2-the strongest drivers of growth in a KRAS-driven model-reduced EGFR-driven tumor growth. These results are consistent with mutational frequencies in human EGFR- and KRAS-driven lung adenocarcinomas. Furthermore, KEAP1 inactivation reduced the sensitivity of EGFR-driven tumors to the EGFR inhibitor osimertinib, and mutations in genes in the KEAP1 pathway were associated with decreased time on tyrosine kinase inhibitor treatment in patients. Our study highlights how the impact of genetic alterations differs across oncogenic contexts and that the fitness landscape shifts upon treatment. SIGNIFICANCE: By modeling complex genotypes in vivo, this study reveals key tumor suppressors that constrain the growth of EGFR-mutant tumors. Furthermore, we uncovered that KEAP1 inactivation reduces the sensitivity of these tumors to tyrosine kinase inhibitors. Thus, our approach identifies genotypes of biological and therapeutic importance in this disease.This article is highlighted in the In This Issue feature, p. 1601.
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Affiliation(s)
- Giorgia Foggetti
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | - Chuan Li
- Department of Biology, Stanford University, Stanford, California
| | - Hongchen Cai
- Department of Genetics, Stanford University School of Medicine, Stanford, California
| | - Jessica A Hellyer
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Wen-Yang Lin
- Department of Genetics, Stanford University School of Medicine, Stanford, California
| | - Deborah Ayeni
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | | | - Jungmin Choi
- Department of Genetics, Yale School of Medicine, New Haven, Connecticut.,Department of Biomedical Sciences, Korea University College of Medicine, Seoul, Korea
| | - Anna Wurtz
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | - Laura Andrejka
- Department of Genetics, Stanford University School of Medicine, Stanford, California
| | - Dylan G Maghini
- Department of Genetics, Stanford University School of Medicine, Stanford, California
| | | | - Stellar Levy
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | - Robert Homer
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, Pathology and Laboratory Medicine Service, West Haven, Connecticut
| | - Scott N Gettinger
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut.,Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Maximilian Diehn
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, California.,Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California.,Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Heather A Wakelee
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California.,Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Dmitri A Petrov
- Department of Biology, Stanford University, Stanford, California
| | - Monte M Winslow
- Department of Genetics, Stanford University School of Medicine, Stanford, California. .,Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California.,Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Katerina Politi
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut. .,Department of Pathology, Yale School of Medicine, New Haven, Connecticut.,Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Hellyer JA, Padda SK, Diehn M, Wakelee HA. Clinical Implications of KEAP1-NFE2L2 Mutations in NSCLC. J Thorac Oncol 2020; 16:395-403. [PMID: 33307193 DOI: 10.1016/j.jtho.2020.11.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 11/10/2020] [Accepted: 11/12/2020] [Indexed: 12/16/2022]
Abstract
The KEAP1-NFE2L2 pathway is an important modulator of cell homeostasis. Mutations in this pathway are common in NSCLC and have been associated with enhanced tumor growth and aggressiveness. In addition, tumors with mutations in the KEAP1-NFE2L2 pathway have been reported in preclinical and clinical studies to convey refractoriness to cancer-directed therapy such as radiation, chemotherapy, and targeted therapy. The role of immunotherapy in this patient population is less clear, and there are conflicting studies on the efficacy of immune checkpoint inhibitors in KEAP1-NFE2L2-mutant NSCLC. Here, we review the current clinical evidence on several classes of anticancer therapeutics in KEAP1-NFE2L2-mutant tumors. Furthermore, we provide an overview of the landscape of the current clinical trials in this patient population, highlighting the work being done with mTORC1, mTORC2, and glutaminase inhibition.
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Affiliation(s)
- Jessica A Hellyer
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Sukhmani K Padda
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Maximilian Diehn
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California; Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, California; Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Heather A Wakelee
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California.
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Hellyer JA, Ouseph MM, Padda SK, Wakelee HA. Everolimus in the treatment of metastatic thymic epithelial tumors. Lung Cancer 2020; 149:97-102. [PMID: 33007678 DOI: 10.1016/j.lungcan.2020.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/05/2020] [Accepted: 09/09/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION There is emerging evidence to support the use of mTOR inhibitor everolimus in patients with advanced, relapsed-refractory thymic epithelial tumors (TETs). However, patient selection and identifying predictive biomarkers of response remains a challenge. Here, we describe a single-center experience with everolimus in patients with TETs and provide detailed molecular analysis of their thymic tumors. MATERIALS AND METHODS Data on all patients with advanced TETs who were prescribed everolimus at Stanford University were retrospectively assessed. Time to treatment failure (TTF) and overall survival (OS) were calculated. STAMP, a 130-gene targeted next generation sequencing (NGS) panel, was performed on each tumor sample. RESULTS Twelve patients with thymoma (T) and three with thymic carcinoma (TC) treated with everolimus were included. Patients had been heavily pre-treated with an average of three prior lines of therapy. Three patients discontinued treatment due to adverse events. The average TTF was 14.7 months in T and 2.6 months in TC with median OS of 27.6 months in the entire cohort (NR T and 5.3 months TC). Two patients with paraneoplastic autoimmune diseases had improvement in autoimmunity on everolimus. Pathogenic mutations were observed in 4/15 (27 %) of patients and includedTP53, KEAP1 and CDKN2A. Several variants of unknown significance in key genes responsible for modulating tumor response to mTOR inhibition were also found. CONCLUSION As previously reported in a prospective trial, patients with previously treated advanced TETs appear to benefit from everolimus in this single institution cohort. Moreover, there was a manageable toxicity profile and no cases of everolimus-induced pneumonitis. A targeted NGS panel revealed several pathogenic mutations but there was no association between detectable tumor mutations and time to treatment failure in this cohort.
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Affiliation(s)
- Jessica A Hellyer
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA, USA
| | - Madhu M Ouseph
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Sukhmani K Padda
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA, USA
| | - Heather A Wakelee
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA, USA.
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8
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Hellyer JA, Wakelee HA. Adjuvant Chemotherapy. Thorac Surg Clin 2020; 30:179-185. [PMID: 32327176 DOI: 10.1016/j.thorsurg.2020.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Five-year survival rates for patients with early-stage non-small cell lung cancer have room for improvement. Adjuvant chemotherapy results in a small but significant increase in overall survival at 5 years. Efforts to improve outcomes by intensifying adjuvant treatment, utilizing cancer-specific vaccines or tyrosine kinase inhibitors in unselected patients, have been unsuccessful. In addition to research with immune checkpoint inhibitors that are addressed in a separate article, ongoing studies to personalize adjuvant therapy either by selecting only patients with evidence of minimal residual disease or targeting tumor driver mutations are promising.
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Affiliation(s)
- Jessica A Hellyer
- Department of Medicine, Division of Oncology, Stanford Cancer Institute, Stanford University School of Medicine, 875 Blake Wilbur Drive, Stanford, CA 94305, USA
| | - Heather A Wakelee
- Department of Medicine, Division of Oncology, Stanford Cancer Institute, Stanford University School of Medicine, 875 Blake Wilbur Drive, Stanford, CA 94305, USA.
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9
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Jeong Y, Hellyer JA, Stehr H, Hoang NT, Niu X, Das M, Padda SK, Ramchandran K, Neal JW, Wakelee H, Diehn M. Role of KEAP1/NFE2L2 Mutations in the Chemotherapeutic Response of Patients with Non-Small Cell Lung Cancer. Clin Cancer Res 2019; 26:274-281. [PMID: 31548347 DOI: 10.1158/1078-0432.ccr-19-1237] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/12/2019] [Accepted: 09/16/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE Activation of NFE2L2 has been linked to chemoresistance in cell line models. Recently, somatic mutations that activate NFE2L2, including mutations in NFE2L2, KEAP1, or CUL3, have been found to be associated with poor outcomes in patients with non-small cell lung cancer (NSCLC). However, the impact of these mutations on chemoresistance remains incompletely explored. EXPERIMENTAL DESIGN We investigated the effect of Keap1 deletion on chemoresistance in cell lines from Trp53-based mouse models of lung squamous cell carcinoma (LSCC) and lung adenocarcinoma (LUAD). Separately, we identified 51 patients with stage IV NSCLC with KEAP1, NFE2L2, or CUL3 mutations and a matched cohort of 52 wild-type patients. Time to treatment failure after first-line platinum doublet chemotherapy and overall survival was compared between the two groups. RESULTS Deletion of Keap1 in Trp53-null murine LUAD and LSCC resulted in increased clonogenic survival upon treatment with diverse cytotoxic chemotherapies. In patients with NSCLC, median time to treatment failure (TTF) after first-line chemotherapy for the KEAP1/NFE2L2/CUL3-mutant cohort was 2.8 months compared with 8.3 months in the control group (P < 0.0001). Median overall survival (OS) was 11.2 months in the KEAP1/NFE2L2/CUL3-mutant group and 36.8 months in the control group (P = 0.006). CONCLUSIONS Keap1 deletion confers chemoresistance in murine lung cancer cells. Patients with metastatic NSCLC with mutations in KEAP1, NFE2L2, or CUL3 have shorter TTF and OS after first-line platinum doublet chemotherapy compared with matched controls. Novel approaches for improving outcomes in this subset of patients with NSCLC are therefore needed.
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Affiliation(s)
- Youngtae Jeong
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California.,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, California.,Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California.,Department of New Biology, DGIST, Daegu, Republic of Korea
| | - Jessica A Hellyer
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Henning Stehr
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Ngoc T Hoang
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California.,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, California.,Department of Biology, San Francisco State University, San Francisco, California
| | - Xiaomin Niu
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California.,Department of Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Millie Das
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California.,Department of Medicine, VA Palo Alto Health Care System, Palo Alto, California
| | - Sukhmani K Padda
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Kavitha Ramchandran
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Joel W Neal
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Heather Wakelee
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California.
| | - Maximilian Diehn
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California. .,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, California.,Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
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10
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Hellyer JA, Gubens MA, Cunanan KM, Padda SK, Burns M, Spittler AJ, Riess JW, San Pedro-Salcedo M, Ramchandran KJ, Neal JW, Wakelee HA, Loehrer PJ. Phase II trial of single agent amrubicin in patients with previously treated advanced thymic malignancies. Lung Cancer 2019; 137:71-75. [PMID: 31557562 DOI: 10.1016/j.lungcan.2019.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 09/04/2019] [Accepted: 09/17/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES There are limited treatment options for patients with thymic malignancies. Here we present data supporting treatment with single agent amrubicin, a third generation anthracycline and topoisomerase II inhibitor. MATERIALS AND METHODS This was a phase 2 open-label, single arm trial of amrubicin in patients with thymoma (T) or thymic carcinoma (TC), conducted at two academic institutions. Patients were included if they had received at least one prior chemotherapy regimen. The first 18 patients received amrubicin at 40 mg/m2 IV days 1-3 repeated every 3-weeks. Due to the high incidence of febrile neutropenia, dosing was subsequently amended to 35 mg/m2 for the final 15 patients. RESULTS A total of 33 patients (14 T/19 TC) were enrolled from 2011 to 2014. Median number of prior therapies was 2. Best response included 6 partial responses, 21 stable disease, and 6 progressive disease (all TC). Objective response rate was 18% (90% exact binomial CI 8.2%-32.8%; T = 4/14 (29%), TC = 2/19 (11%)). Median progression-free survival was 7.7 months (T: 8.3 months; TC: 7.3) and median overall survival was 29.7 months (T: 54.1 months; TC: 18 months). There was a high rate of febrile neutropenia (7 patients) that occurred despite a reduction in amrubicin dose and one related death. Five patients had reduction in LVEF below 50% during the course of treatment resulting in treatment discontinuation in one patient. CONCLUSION Amrubicin shows promise as a single agent in heavily pre-treated patients with thymic malignancies. Notable side effects include febrile neutropenia and the use of growth factor support is essential. Further investigation of this agent is warranted.
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Affiliation(s)
- Jessica A Hellyer
- Stanford University School of Medicine and Stanford Cancer Institute, 875 Blake Wilbur Driver, Stanford, CA, USA
| | - Matthew A Gubens
- Stanford University School of Medicine and Stanford Cancer Institute, 875 Blake Wilbur Driver, Stanford, CA, USA; University of California San Francisco, 1450 3rdSt, San Francisco, CA, USA
| | - Kristen M Cunanan
- Stanford University School of Medicine and Stanford Cancer Institute, 875 Blake Wilbur Driver, Stanford, CA, USA
| | - Sukhmani K Padda
- Stanford University School of Medicine and Stanford Cancer Institute, 875 Blake Wilbur Driver, Stanford, CA, USA
| | - Matthew Burns
- Indiana University Melvin and Bren Simon Cancer Center, 535 Barnhill Dr. Indianapolis, IN, USA
| | - A John Spittler
- Indiana University Melvin and Bren Simon Cancer Center, 535 Barnhill Dr. Indianapolis, IN, USA
| | - Jonathan W Riess
- Stanford University School of Medicine and Stanford Cancer Institute, 875 Blake Wilbur Driver, Stanford, CA, USA; UC Davis Comprehensive Cancer Center, 2279 45thSt, Sacramento, CA, USA
| | - Melanie San Pedro-Salcedo
- Stanford University School of Medicine and Stanford Cancer Institute, 875 Blake Wilbur Driver, Stanford, CA, USA
| | - Kavitha J Ramchandran
- Stanford University School of Medicine and Stanford Cancer Institute, 875 Blake Wilbur Driver, Stanford, CA, USA
| | - Joel W Neal
- Stanford University School of Medicine and Stanford Cancer Institute, 875 Blake Wilbur Driver, Stanford, CA, USA
| | - Heather A Wakelee
- Stanford University School of Medicine and Stanford Cancer Institute, 875 Blake Wilbur Driver, Stanford, CA, USA.
| | - Patrick J Loehrer
- Indiana University Melvin and Bren Simon Cancer Center, 535 Barnhill Dr. Indianapolis, IN, USA
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11
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Hellyer JA, Patel MI. Sex disparities in lung cancer incidence: validation of a long-observed trend. Transl Lung Cancer Res 2019; 8:543-545. [PMID: 31555528 PMCID: PMC6749120 DOI: 10.21037/tlcr.2019.04.06] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 04/08/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Jessica A. Hellyer
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Manali I. Patel
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Center for Health Policy/Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
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12
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Hann CL, Scherpereel A, Hellyer JA, Wakelee HA. Role of Immunotherapy in Small Cell Lung Cancer, Thymic Epithelial Tumors, and Mesothelioma. Am Soc Clin Oncol Educ Book 2019; 39:543-552. [PMID: 31099677 DOI: 10.1200/edbk_237847] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The introduction of programmed death receptor ligand-1 (PD-L1) and programmed death receptor-1 (PD-1) inhibitors into the field of non-small cell lung cancer (NSCLC) was practice changing. The pivotal trials consistently showed a clinically meaningful improvement in overall survival (OS) for patients with driver mutation-negative NSCLC, a field in which outcomes had been stagnant for decades. The success of immune checkpoint inhibitor (ICI) therapy in NSCLC has led to enthusiasm to expand the reach of these drugs into other thoracic malignancies such as thymic epithelial tumors (TETs), mesothelioma, and small cell lung cancer (SCLC). Unfortunately, the improvement in outcomes with ICI therapy in these rarer thoracic tumors has been somewhat modest, and in the case of thymoma, rates of adverse events are too high to routinely justify their use. Although the response rates seen in ICI therapy in these tumor types are similar to those seen with other available single-agent therapies for advanced disease, ICIs do present another option for clinicians treating patients with mesothelioma, small cell carcinoma, and thymic carcinoma (TC), diseases in which approved treatment options are limited. Here we review the latest trials of ICI therapy in mesothelioma, SCLC, and TETs.
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Affiliation(s)
- Christine L Hann
- 1 Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Arnaud Scherpereel
- 2 Pulmonary and Thoracic Oncology Department, University of Lille, CHU Lille, Lille, France.,3 French National Network of Clinical Expert Centers for Malignant Pleural Mesothelioma Management, Lille, France
| | - Jessica A Hellyer
- 4 Division of Oncology, Department of Medicine, Stanford University School of Medicine and Stanford Cancer Institute, Stanford, CA
| | - Heather A Wakelee
- 4 Division of Oncology, Department of Medicine, Stanford University School of Medicine and Stanford Cancer Institute, Stanford, CA
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Hellyer JA, Stehr H, Das M, Padda SK, Ramchandran K, Neal JW, Diehn M, Wakelee HA. Impact of KEAP1/NFE2L2/CUL3 mutations on duration of response to EGFR tyrosine kinase inhibitors in EGFR mutated non-small cell lung cancer. Lung Cancer 2019; 134:42-45. [PMID: 31319993 DOI: 10.1016/j.lungcan.2019.05.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/30/2019] [Accepted: 05/03/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVES For patients with Epidermal Growth Factor Receptor (EGFR)-mutated non-small cell lung cancer (NSCLC), frontline EGFR-tyrosine kinase inhibitor (TKI) therapy compared to chemotherapy improves outcomes. However, resistance to these agents uniformly develops. Recently, mutations in the KEAP1-NFE2L2 pathway have been implicated as a potential mechanism of acquired EGFR TKI resistance. MATERIALS AND METHODS We examined all patients with metastatic NSCLC with mutations in both EGFR and KEAP1/NFE2L2/CUL3 identified on next generation sequencing from 2015 - 2018. These patients were compared to a NSCLC control cohort with mutations in EGFR and wild type in KEAP1/NFE2L2/CUL3 matched on the basis of sex, smoking status, age and race. Time to treatment failure on EGFR TKI therapy and overall survival were examined. RESULTS Among 228 EGFR mutant NSCLCs, 17 (7%) also carried mutations in KEAP1, NFE2L2, or CUL3. The most common co-mutation in both the KEAP1/NFE2L2/CUL3 mutant and wild-type cohort was TP53. Patients with KEAP1/NFE2L2/CUL3 mutations had a shorter median time to treatment failure on EGFR TKI (4.7 months) compared with the wild-type matched cohort (13.0 months), p= 0.0014. There was no difference in overall survival. CONCLUSION For NSCLC patients with mutations in EGFR, co-mutations in KEAP1/NFE2L2/CUL3 are associated with significantly decreased time to treatment failure. Our results suggest that these mutations represent a mechanism of intrinsic resistance to TKI treatment.
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Affiliation(s)
- Jessica A Hellyer
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Henning Stehr
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Millie Das
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, 94305, USA; Department of Medicine, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Sukhmani K Padda
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Kavitha Ramchandran
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Joel W Neal
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Maximilian Diehn
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, 94305, USA; Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA; Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, 94305, USA.
| | - Heather A Wakelee
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, 94305, USA.
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Hellyer JA, Azarbal F, Than CT, Fan J, Schmitt SK, Yang F, Frayne SM, Phibbs CS, Yong C, Heidenreich PA, Turakhia MP. Impact of Baseline Stroke Risk and Bleeding Risk on Warfarin International Normalized Ratio Control in Atrial Fibrillation (from the TREAT-AF Study). Am J Cardiol 2017; 119:268-274. [PMID: 27836133 DOI: 10.1016/j.amjcard.2016.09.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 09/27/2016] [Accepted: 09/27/2016] [Indexed: 10/20/2022]
Abstract
Warfarin prevents stroke and prolongs survival in patients with atrial fibrillation and flutter (AF, collectively) but can cause hemorrhage. The time in international normalized ratio (INR) therapeutic range (TTR) mediates stroke reduction and bleeding risk. This study sought to determine the relation between baseline stroke, bleeding risk, and TTR. Using data from The Retrospective Evaluation and Assessment of Therapies in Atrial Fibrillation (TREAT-AF) retrospective cohort study, national Veterans Health Administration records were used to identify patients with newly diagnosed AF from 2003 to 2012 and subsequent initiation of warfarin. Baseline stroke and bleeding risk was determined by calculating CHA2DS2-VASc and HAS-BLED scores, respectively. Main outcomes were first-year and long-term TTR and INR monitoring rate. In 167,190 patients, the proportion of patients with TTR (>65%) decreased across increasing strata of CHA2DS2-VASc and HAS-BLED. After covariate adjustment, odds of achieving TTR >65% were significantly associated with high CHA2DS2-VASc or HAS-BLED score. INR monitoring rate was similar across risk strata. In conclusion, increased baseline stroke and bleeding risk is associated with poor INR control, despite similar rates of INR monitoring. These findings may paradoxically limit warfarin's efficacy and safety in high-risk patients and may explain observed increased bleeding and stroke rates in this cohort.
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Yang F, Hellyer JA, Than C, Ullal AJ, Kaiser DW, Heidenreich PA, Hoang DD, Winkelmayer WC, Schmitt S, Frayne SM, Phibbs CS, Turakhia MP. Warfarin utilisation and anticoagulation control in patients with atrial fibrillation and chronic kidney disease. Heart 2016; 103:818-826. [PMID: 27852694 DOI: 10.1136/heartjnl-2016-309266] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 10/11/2016] [Accepted: 10/14/2016] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate warfarin prescription, quality of international normalised ratio (INR) monitoring and of INR control in patients with atrial fibrillation (AF) and chronic kidney disease (CKD). METHODS We performed a retrospective cohort study of patients with newly diagnosed AF in the Veterans Administration (VA) healthcare system. We evaluated anticoagulation prescription, INR monitoring intensity and time in and outside INR therapeutic range (TTR) stratified by CKD. RESULTS Of 123 188 patients with newly diagnosed AF, use of warfarin decreased with increasing severity of CKD (57.2%-46.4%), although it was higher among patients on dialysis (62.3%). Although INR monitoring intensity was similar across CKD strata, the proportion with TTR≥60% decreased with CKD severity, with only 21% of patients on dialysis achieving TTR≥60%. After multivariate adjustment, the magnitude of TTR reduction increased with CKD severity. Patients on dialysis had the highest time markedly out of range with INR <1.5 or >3.5 (30%); 12% of INR time was >3.5, and low TTR persisted for up to 3 years. CONCLUSIONS There is a wide variation in anticoagulation prescription based on CKD severity. Patients with moderate-to-severe CKD, including dialysis, have substantially reduced TTR, despite comparable INR monitoring intensity. These findings have implications for more intensive warfarin management strategies in CKD or alternative therapies such as direct oral anticoagulants.
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Affiliation(s)
- Felix Yang
- Maimonides Medical Center, Brooklyn, New York, USA
| | - Jessica A Hellyer
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Claire Than
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Aditya J Ullal
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.,Stanford University School of Medicine, Stanford, California, USA
| | - Daniel W Kaiser
- Stanford University School of Medicine, Stanford, California, USA
| | - Paul A Heidenreich
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.,Stanford University School of Medicine, Stanford, California, USA
| | - Donald D Hoang
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Wolfgang C Winkelmayer
- Stanford University School of Medicine, Stanford, California, USA.,Baylor College of Medicine, Houston, Texas, USA
| | - Susan Schmitt
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Susan M Frayne
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.,Stanford University School of Medicine, Stanford, California, USA
| | - Ciaran S Phibbs
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.,Stanford University School of Medicine, Stanford, California, USA
| | - Mintu P Turakhia
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.,Stanford University School of Medicine, Stanford, California, USA
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Rhee KS, Hsueh CH, Hellyer JA, Park HW, Lee YS, Garlie J, Onkka P, Doytchinova AT, Garner JB, Patel J, Chen LS, Fishbein MC, Everett T, Lin SF, Chen PS. Cervical vagal nerve stimulation activates the stellate ganglion in ambulatory dogs. Korean Circ J 2015; 45:149-57. [PMID: 25810737 PMCID: PMC4372981 DOI: 10.4070/kcj.2015.45.2.149] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 11/12/2014] [Accepted: 01/08/2015] [Indexed: 12/04/2022] Open
Abstract
Background and Objectives Recent studies showed that, in addition to parasympathetic nerves, cervical vagal nerves contained significant sympathetic nerves. We hypothesized that cervical vagal nerve stimulation (VNS) may capture the sympathetic nerves within the vagal nerve and activate the stellate ganglion. Materials and Methods We recorded left stellate ganglion nerve activity (SGNA), left thoracic vagal nerve activity (VNA), and subcutaneous electrocardiogram in seven dogs during left cervical VNS with 30 seconds on-time and 30 seconds off time. We then compared the SGNA between VNS on and off times. Results Cervical VNS at moderate (0.75 mA) output induced large SGNA, elevated heart rate (HR), and reduced HR variability, suggesting sympathetic activation. Further increase of the VNS output to >1.5 mA increased SGNA but did not significantly increase the HR, suggesting simultaneous sympathetic and parasympathetic activation. The differences of integrated SGNA and integrated VNA between VNS on and off times (ΔSGNA) increased progressively from 5.2 mV-s {95% confidence interval (CI): 1.25-9.06, p=0.018, n=7} at 1.0 mA to 13.7 mV-s (CI: 5.97-21.43, p=0.005, n=7) at 1.5 mA. The difference in HR (ΔHR, bpm) between on and off times was 5.8 bpm (CI: 0.28-11.29, p=0.042, n=7) at 1.0 mA and 5.3 bpm (CI 1.92 to 12.61, p=0.122, n=7) at 1.5 mA. Conclusion Intermittent cervical VNS may selectively capture the sympathetic components of the vagal nerve and excite the stellate ganglion at moderate output. Increasing the output may result in simultaneously sympathetic and parasympathetic capture.
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Affiliation(s)
- Kyoung-Suk Rhee
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA. ; Department of Internal Medicine, Chonbuk National University School of Medicine, Jeonju, Korea
| | - Chia-Hsiang Hsueh
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jessica A Hellyer
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Hyung Wook Park
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA. ; Department of Cardiovascular Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Young Soo Lee
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA. ; Division of Cardiology, College of Medicine, Catholic University of Daegu, Daegu, Korea
| | - Jason Garlie
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Patrick Onkka
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Anisiia T Doytchinova
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John B Garner
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jheel Patel
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lan S Chen
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, The David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Thomas Everett
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shien-Fong Lin
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Peng-Sheng Chen
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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