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Clift AK, Drymousis P, von Roon A, Humphries A, Goldin R, Bomanji J, Leaman S, Wasan H, Habib N, Frilling A. Management of Small Bowel Neuroendocrine Tumours: 10 Years' Experience at a Tertiary Referral Centre. Cancers (Basel) 2023; 15:4438. [PMID: 37760408 PMCID: PMC10526159 DOI: 10.3390/cancers15184438] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/24/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Neuroendocrine tumours (NET) arising from the small bowel are clinically challenging and are often diagnosed at advanced stages. Disease control with surgery alone can be demanding. Multimodal treatment concepts integrating surgery and non-surgical modalities could be of benefit. METHOD Retrospective review of consecutive adult patients with SB NET treated at Imperial College Healthcare NHS Trust between 1 January 2010 and 31 December 2019. Data regarding clinicopathological characteristics, treatments, and disease trajectory were extracted and summarised. Overall and progression/recurrence-free survival were estimated at 5 and 10 years. RESULTS 154 patients were identified, with a median age of 64 years (range 33-87); 135/154 (87.7%) had stage III/IV disease at diagnosis. Surgery was used in 125 individuals (81.2%), typically with either segmental small bowel resection (60.8%) or right hemicolectomy (33.6%) and mesenteric lymphadenectomy for the primary tumour. Systemic and/or liver-directed therapies were used in 126 (81.8%); 60 (47.6%) had more than one line of non-surgical treatment. Median follow-up was 67.2 months (range 3.1-310.4); overall survival at 5 and 10 years was 91.0% (95% CI: 84.9-94.7%) and 82.5% (95% CI: 72.9-88.9%), respectively. Imaging-based median progression-free survival was 42.7 months (95% CI: 24.7 to 72.4); 5-year progression-free survival was 63.4% (95% CI: 55.0-70.6%); 10-year progression-free survival was 18.7% (95% CI: 12.4-26.1). Nineteen patients (12.3%) reached 10 years follow-up without disease recurrence and therefore were considered cured. CONCLUSIONS Most patients with SB NET present in a metastasised stage. Multimodal treatment concepts may be associated with excellent clinical outcomes. Future work should explore optimal approaches to treatment sequencing and patient selection.
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Affiliation(s)
- Ashley K. Clift
- Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0HS, UK; (A.K.C.)
- CRUK Oxford Centre, Department of Oncology, University of Oxford, Oxford OX1 2JD, UK
| | - Panagiotis Drymousis
- Department of Surgery, Ealing Hospital, London North West University Healthcare NHS Trust, London HA1 3UJ, UK
| | - Alexander von Roon
- Department of Surgery, University College London Hospitals NHS Foundation Trust London, London NW1 2BU, UK
| | - Adam Humphries
- Department of Gastroenterology, St Mark’s Hospital, London North West University Health Care NHS Trust, London HA1 3UJ, UK
| | - Robert Goldin
- Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0HS, UK; (A.K.C.)
| | - Jamshed Bomanji
- Department of Nuclear Medicine, University College London Hospitals NHS Foundation Trust London, London NW1 2BU, UK
| | - Sydney Leaman
- MRC Centre for Neurodevelopmental Disorders, King’s College London, London SE1 8WA, UK
| | - Harpreet Wasan
- Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0HS, UK; (A.K.C.)
| | - Nagy Habib
- Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0HS, UK; (A.K.C.)
| | - Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0HS, UK; (A.K.C.)
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Nesti C, Bräutigam K, Benavent M, Bernal L, Boharoon H, Botling J, Bouroumeau A, Brcic I, Brunner M, Cadiot G, Camara M, Christ E, Clerici T, Clift AK, Clouston H, Cobianchi L, Ćwikła JB, Daskalakis K, Frilling A, Garcia-Carbonero R, Grozinsky-Glasberg S, Hernando J, Hervieu V, Hofland J, Holmager P, Inzani F, Jann H, Jimenez-Fonseca P, Kaçmaz E, Kaemmerer D, Kaltsas G, Klimacek B, Knigge U, Kolasińska-Ćwikła A, Kolb W, Kos-Kudła B, Kunze CA, Landolfi S, La Rosa S, López CL, Lorenz K, Matter M, Mazal P, Mestre-Alagarda C, Del Burgo PM, van Dijkum EJMN, Oleinikov K, Orci LA, Panzuto F, Pavel M, Perrier M, Reims HM, Rindi G, Rinke A, Rinzivillo M, Sagaert X, Satiroglu I, Selberherr A, Siebenhüner AR, Tesselaar MET, Thalhammer MJ, Thiis-Evensen E, Toumpanakis C, Vandamme T, van den Berg JG, Vanoli A, van Velthuysen MLF, Verslype C, Vorburger SA, Lugli A, Ramage J, Zwahlen M, Perren A, Kaderli RM. Hemicolectomy versus appendectomy for patients with appendiceal neuroendocrine tumours 1-2 cm in size: a retrospective, Europe-wide, pooled cohort study. Lancet Oncol 2023; 24:187-194. [PMID: 36640790 DOI: 10.1016/s1470-2045(22)00750-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/06/2022] [Accepted: 12/06/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Awareness of the potential global overtreatment of patients with appendiceal neuroendocrine tumours (NETs) of 1-2 cm in size by performing oncological resections is increasing, but the rarity of this tumour has impeded clear recommendations to date. We aimed to assess the malignant potential of appendiceal NETs of 1-2 cm in size in patients with or without right-sided hemicolectomy. METHODS In this retrospective cohort study, we pooled data from 40 hospitals in 15 European countries for patients of any age and Eastern Cooperative Oncology Group performance status with a histopathologically confirmed appendiceal NET of 1-2 cm in size who had a complete resection of the primary tumour between Jan 1, 2000, and Dec 31, 2010. Patients either had an appendectomy only or an appendectomy with oncological right-sided hemicolectomy or ileocecal resection. Predefined primary outcomes were the frequency of distant metastases and tumour-related mortality. Secondary outcomes included the frequency of regional lymph node metastases, the association between regional lymph node metastases and histopathological risk factors, and overall survival with or without right-sided hemicolectomy. Cox proportional hazards regression was used to estimate the relative all-cause mortality hazard associated with right-sided hemicolectomy compared with appendectomy alone. This study is registered with ClinicalTrials.gov, NCT03852693. FINDINGS 282 patients with suspected appendiceal tumours were identified, of whom 278 with an appendiceal NET of 1-2 cm in size were included. 163 (59%) had an appendectomy and 115 (41%) had a right-sided hemicolectomy, 110 (40%) were men, 168 (60%) were women, and mean age at initial surgery was 36·0 years (SD 18·2). Median follow-up was 13·0 years (IQR 11·0-15·6). After centralised histopathological review, appendiceal NETs were classified as a possible or probable primary tumour in two (1%) of 278 patients with distant peritoneal metastases and in two (1%) 278 patients with distant metastases in the liver. All metastases were diagnosed synchronously with no tumour-related deaths during follow-up. Regional lymph node metastases were found in 22 (20%) of 112 patients with right-sided hemicolectomy with available data. On the basis of histopathological risk factors, we estimated that 12·8% (95% CI 6·5 -21·1) of patients undergoing appendectomy probably had residual regional lymph node metastases. Overall survival was similar between patients with appendectomy and right-sided hemicolectomy (adjusted hazard ratio 0·88 [95% CI 0·36-2·17]; p=0·71). INTERPRETATION This study provides evidence that right-sided hemicolectomy is not indicated after complete resection of an appendiceal NET of 1-2 cm in size by appendectomy, that regional lymph node metastases of appendiceal NETs are clinically irrelevant, and that an additional postoperative exclusion of metastases and histopathological evaluation of risk factors is not supported by the presented results. These findings should inform consensus best practice guidelines for this patient cohort. FUNDING Swiss Cancer Research foundation.
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Affiliation(s)
- Cédric Nesti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Marta Benavent
- Department of Medical Oncology, University Hospital Virgen del Rocío, Instituto de Biomedicina De Sevilla, Seville, Spain
| | - Laura Bernal
- Department of Medical Oncology, University Hospital Virgen del Rocío, Instituto de Biomedicina De Sevilla, Seville, Spain
| | - Hessa Boharoon
- Neuroendocrine Tumour Unit-ENETS Centre of Excellence, Royal Free Hospital London, London, UK
| | - Johan Botling
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Antonin Bouroumeau
- Division of Clinical Pathology, Diagnostic Department, Geneva University Hospitals, Geneva, Switzerland
| | - Iva Brcic
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Maximilian Brunner
- Department of Surgery, University Hospital of Friedrich-Alexander University Erlangen-Nuernberg, Erlangen, Germany
| | - Guillaume Cadiot
- Service d'Hépato-gastroentérologie et d'Oncologie Digestive, Université Reims Champagne Ardenne, CHU de Reims, Reims, France
| | - Maria Camara
- Pathology Department, Hospital Universitario 12 de Octubre, Imas12, UCM, Madrid, Spain
| | - Emanuel Christ
- Department of Endocrinology, Diabetology and Metabolism, ENETS Center of Excellence, University Hospital of Basel, Basel, Switzerland
| | - Thomas Clerici
- Klinik für Allgemein-, Viszeral-, Endokrin- und Transplantationschirurgie, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Ashley K Clift
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Hamish Clouston
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - Lorenzo Cobianchi
- Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Department of General Surgery, IRCCS Policlinico San Matteo Fondazione, Pavia, Italy
| | | | - Kosmas Daskalakis
- 1st Department of Propaedeutic Internal Medicine, Endocrine Unit, National and Kapodistrian University of Athens, ENETS Center of Excellence, Athens, Greece
| | - Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Simona Grozinsky-Glasberg
- Neuroendocrine Tumor Unit, ENETS Center of Excellence, Department of Endocrinology and Metabolism, Hadassah Medical Organization and Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jorge Hernando
- Medical Oncology Department, Vall d'Hebron University Hospital-Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | | | - Johannes Hofland
- Department of Internal Medicine, Section of Endocrinology ENETS Center of Excellence and Erasmus Cancer Institute, Erasmus MC, Rotterdam, Netherlands
| | - Pernille Holmager
- ENETS Neuroendocrine Tumor Centre of Excellence, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Frediano Inzani
- General Pathology, Department of Woman and Child Health Science and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Roma European NeuroEndocrine Tumor Society Center of Excellence, Rome, Italy
| | - Henning Jann
- Hepatology and Gastroenterology, Charité University Medicine Berlin, Berlin, Germany
| | - Paula Jimenez-Fonseca
- Department of Medical Oncology, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | - Enes Kaçmaz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Daniel Kaemmerer
- Department of General and Visceral Surgery, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Gregory Kaltsas
- 1st Department of Propaedeutic Internal Medicine, Endocrine Unit, National and Kapodistrian University of Athens, ENETS Center of Excellence, Athens, Greece
| | - Branislav Klimacek
- Department of Surgery, Endocrine Surgical Unit, Uppsala University, Uppsala, Sweden
| | - Ulrich Knigge
- ENETS Neuroendocrine Tumor Centre of Excellence, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Walter Kolb
- Klinik für Allgemein-, Viszeral-, Endokrin- und Transplantationschirurgie, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Beata Kos-Kudła
- Department of Endocrinology and Neuroendocrine Neoplasms and Department of Endocrinology and Pathophysiology, Medical University of Silesia, Katowice, Poland
| | - Catarina Alisa Kunze
- Institute of Pathology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Stefania Landolfi
- Pathology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Stefano La Rosa
- Institute of Pathology, Department of Laboratory Medicine and Pathology, University of Lausanne, Lausanne, Switzerland; Unit of Pathology, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Carlos López López
- Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Kerstin Lorenz
- Department of Visceral, Vascular, and Endocrine Surgery, Martin-Luther University of Halle-Wittenberg, Halle, Germany
| | - Maurice Matter
- Department of Visceral Surgery, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Peter Mazal
- Department of Clinical Pathology, Medical University of Vienna, General Hospital Vienna, Vienna, Austria
| | | | | | | | - Kira Oleinikov
- Neuroendocrine Tumor Unit, ENETS Center of Excellence, Department of Endocrinology and Metabolism, Hadassah Medical Organization and Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Lorenzo A Orci
- Division of Abdominal Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Francesco Panzuto
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy; Digestive Disease Unit, Sant'Andrea University Hospital, ENETS Center of Excellence, Rome, Italy
| | - Marianne Pavel
- Department of Medicine 1, Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Marine Perrier
- Service d'Hépato-gastroentérologie et d'Oncologie Digestive, Université Reims Champagne Ardenne, CHU de Reims, Reims, France
| | - Henrik Mikael Reims
- Department of Pathology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Guido Rindi
- Unit of Head and Neck, Lung, and Endocrine Pathology, Department of Woman and Child Health Science and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Roma European NeuroEndocrine Tumor Society Center of Excellence, Rome, Italy; Section of Anatomic Pathology, Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anja Rinke
- Department of Gastroenterology and Endocrinology, UKGM, Marburg, Germany; Philipps University Marburg, Marburg, Germany
| | - Maria Rinzivillo
- Digestive Disease Unit, Sant'Andrea University Hospital, ENETS Center of Excellence, Rome, Italy
| | - Xavier Sagaert
- Translational Cell & Tissue Research, KU Leuven, Leuven, Belgium
| | - Ilker Satiroglu
- Department of Visceral, Vascular, and Endocrine Surgery, Martin-Luther University of Halle-Wittenberg, Halle, Germany
| | - Andreas Selberherr
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Alexander R Siebenhüner
- Klinik für Medizinische Onkologie und Hämatologie, Universitätsspital Zürich und Universität Zürich, Zurich, Switzerland; Departement Medizinische Onkologie, Kantonsspital Schaffhausen, Schaffhausen, Switzerland
| | - Margot E T Tesselaar
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Michael J Thalhammer
- Department of Surgery, Division of Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
| | - Espen Thiis-Evensen
- Department of Gastroenterology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Christos Toumpanakis
- Neuroendocrine Tumour Unit-ENETS Centre of Excellence, Royal Free Hospital London, London, UK
| | | | - José G van den Berg
- Department of Pathology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Alessandro Vanoli
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia, Pavia, Italy; Unit of Anatomic Pathology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | | | - Chris Verslype
- Clinical Digestive Oncology, University Hospitals Leuven, Belgium
| | | | | | - John Ramage
- University of Winchester, Winchester, UK; Hampshire Hospital, Basingstoke, UK
| | - Marcel Zwahlen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Aurel Perren
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Reto M Kaderli
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Gao M, Aveyard P, Lindson N, Hartmann-Boyce J, Watkinson P, Young D, Coupland C, Clift AK, Harrison D, Gould D, Pavord ID, Smith M, Hippisley-Cox J. Association between smoking, e-cigarette use and severe COVID-19: a cohort study. Int J Epidemiol 2022; 51:1062-1072. [PMID: 35179598 PMCID: PMC8903448 DOI: 10.1093/ije/dyac028] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/03/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Smoking is a risk factor for most respiratory infections, but it may protect against SARS-CoV-2 infection. The objective was to assess whether smoking and e-cigarette use were associated with severe COVID-19. METHODS This cohort ran from 24 January 2020 until 30 April 2020 at the height of the first wave of the SARS-CoV-2 epidemic in England. It comprised 7 869 534 people representative of the population of England with smoking status, demographic factors and diseases recorded by general practitioners in the medical records, which were linked to hospital and death data. The outcomes were COVID-19-associated hospitalization, intensive care unit (ICU) admission and death. The associations between smoking and the outcomes were assessed with Cox proportional hazards models, with sequential adjustment for confounding variables and indirect causal factors (body mass index and smoking-related disease). RESULTS Compared with never smokers, people currently smoking were at lower risk of COVID-19 hospitalization, adjusted hazard ratios (HRs) were 0.64 (95% confidence intervals 0.60 to 0.69) for <10 cigarettes/day, 0.49 (0.41 to 0.59) for 10-19 cigarettes/day, and 0.61 (0.49 to 0.74) for ≥20 cigarettes/day. For ICU admission, the corresponding HRs were 0.31 (0.24 to 0.40), 0.15 (0.06 to 0.36), and 0.35 (0.17 to 0.74) and death were: 0.79 (0.70 to 0.89), 0.66 (0.48 to 0.90), and 0.77 (0.54 to 1.09) respectively. Former smokers were at higher risk of severe COVID-19: HRs: 1.07 (1.03 to 1.11) for hospitalization, 1.17 (1.04 to 1.31) for ICU admission, and 1.17 (1.10 to 1.24) for death. All-cause mortality was higher for current smoking than never smoking, HR 1.42 (1.36 to 1.48). Among e-cigarette users, the adjusted HR for e-cigarette use and hospitalization with COVID-19 was 1.06 (0.88 to 1.28), for ICU admission was 1.04 (0.57 to 1.89, and for death was 1.12 (0.81 to 1.55). CONCLUSIONS Current smoking was associated with a reduced risk of severe COVID-19 but the association with e-cigarette use was unclear. All-cause mortality remained higher despite this possible reduction in death from COVID-19 during an epidemic of SARS-CoV-2. Findings support investigating possible protective mechanisms of smoking for SARS-CoV-2 infection, including the ongoing trials of nicotine to treat COVID-19.
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Affiliation(s)
- Min Gao
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- School of Public Health, Peking University Health Science Centre, Beijing, China
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
| | - Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Peter Watkinson
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Duncan Young
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Carol Coupland
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - Ashley K Clift
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
| | - David Harrison
- Intensive Care National Audit & Research Centre (ICNARC), Napier House, London, UK
| | - Doug Gould
- Intensive Care National Audit & Research Centre (ICNARC), Napier House, London, UK
| | - Ian D Pavord
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Margaret Smith
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Julia Hippisley-Cox
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
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Clift AK, von Ende A, Tan PS, Sallis HM, Lindson N, Coupland CAC, Munafò MR, Aveyard P, Hippisley-Cox J, Hopewell JC. Smoking and COVID-19 outcomes: an observational and Mendelian randomisation study using the UK Biobank cohort. Thorax 2022; 77:65-73. [PMID: 34580193 PMCID: PMC8483921 DOI: 10.1136/thoraxjnl-2021-217080] [Citation(s) in RCA: 92] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/14/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Conflicting evidence has emerged regarding the relevance of smoking on risk of COVID-19 and its severity. METHODS We undertook large-scale observational and Mendelian randomisation (MR) analyses using UK Biobank. Most recent smoking status was determined from primary care records (70.8%) and UK Biobank questionnaire data (29.2%). COVID-19 outcomes were derived from Public Health England SARS-CoV-2 testing data, hospital admissions data, and death certificates (until 18 August 2020). Logistic regression was used to estimate associations between smoking status and confirmed SARS-CoV-2 infection, COVID-19-related hospitalisation, and COVID-19-related death. Inverse variance-weighted MR analyses using established genetic instruments for smoking initiation and smoking heaviness were undertaken (reported per SD increase). RESULTS There were 421 469 eligible participants, 1649 confirmed infections, 968 COVID-19-related hospitalisations and 444 COVID-19-related deaths. Compared with never-smokers, current smokers had higher risks of hospitalisation (OR 1.80, 95% CI 1.26 to 2.29) and mortality (smoking 1-9/day: OR 2.14, 95% CI 0.87 to 5.24; 10-19/day: OR 5.91, 95% CI 3.66 to 9.54; 20+/day: OR 6.11, 95% CI 3.59 to 10.42). In MR analyses of 281 105 White British participants, genetically predicted propensity to initiate smoking was associated with higher risks of infection (OR 1.45, 95% CI 1.10 to 1.91) and hospitalisation (OR 1.60, 95% CI 1.13 to 2.27). Genetically predicted higher number of cigarettes smoked per day was associated with higher risks of all outcomes (infection OR 2.51, 95% CI 1.20 to 5.24; hospitalisation OR 5.08, 95% CI 2.04 to 12.66; and death OR 10.02, 95% CI 2.53 to 39.72). INTERPRETATION Congruent results from two analytical approaches support a causal effect of smoking on risk of severe COVID-19.
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Affiliation(s)
- Ashley K Clift
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Cancer Research UK Oxford Centre, Department of Oncology, University of Oxford, Oxford, UK
| | - Adam von Ende
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Pui San Tan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hannah M Sallis
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- School of Psychological Science, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Carol A C Coupland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Marcus R Munafò
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- School of Psychological Science, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Julia Hippisley-Cox
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jemma C Hopewell
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Aveyard P, Gao M, Lindson N, Hartmann-Boyce J, Watkinson P, Young D, Coupland CAC, Tan PS, Clift AK, Harrison D, Gould DW, Pavord ID, Hippisley-Cox J. Association between pre-existing respiratory disease and its treatment, and severe COVID-19: a population cohort study. Lancet Respir Med 2021; 9:909-923. [PMID: 33812494 PMCID: PMC8016404 DOI: 10.1016/s2213-2600(21)00095-3] [Citation(s) in RCA: 155] [Impact Index Per Article: 51.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Previous studies suggested that the prevalence of chronic respiratory disease in patients hospitalised with COVID-19 was lower than its prevalence in the general population. The aim of this study was to assess whether chronic lung disease or use of inhaled corticosteroids (ICS) affects the risk of contracting severe COVID-19. METHODS In this population cohort study, records from 1205 general practices in England that contribute to the QResearch database were linked to Public Health England's database of SARS-CoV-2 testing and English hospital admissions, intensive care unit (ICU) admissions, and deaths for COVID-19. All patients aged 20 years and older who were registered with one of the 1205 general practices on Jan 24, 2020, were included in this study. With Cox regression, we examined the risks of COVID-19-related hospitalisation, admission to ICU, and death in relation to respiratory disease and use of ICS, adjusting for demographic and socioeconomic status and comorbidities associated with severe COVID-19. FINDINGS Between Jan 24 and April 30, 2020, 8 256 161 people were included in the cohort and observed, of whom 14 479 (0·2%) were admitted to hospital with COVID-19, 1542 (<0·1%) were admitted to ICU, and 5956 (0·1%) died. People with some respiratory diseases were at an increased risk of hospitalisation (chronic obstructive pulmonary disease [COPD] hazard ratio [HR] 1·54 [95% CI 1·45-1·63], asthma 1·18 [1·13-1·24], severe asthma 1·29 [1·22-1·37; people on three or more current asthma medications], bronchiectasis 1·34 [1·20-1·50], sarcoidosis 1·36 [1·10-1·68], extrinsic allergic alveolitis 1·35 [0·82-2·21], idiopathic pulmonary fibrosis 1·59 [1·30-1·95], other interstitial lung disease 1·66 [1·30-2·12], and lung cancer 2·24 [1·89-2·65]) and death (COPD 1·54 [1·42-1·67], asthma 0·99 [0·91-1·07], severe asthma 1·08 [0·98-1·19], bronchiectasis 1·12 [0·94-1·33], sarcoidosis 1·41 [0·99-1·99), extrinsic allergic alveolitis 1·56 [0·78-3·13], idiopathic pulmonary fibrosis 1·47 [1·12-1·92], other interstitial lung disease 2·05 [1·49-2·81], and lung cancer 1·77 [1·37-2·29]) due to COVID-19 compared with those without these diseases. Admission to ICU was rare, but the HR for people with asthma was 1·08 (0·93-1·25) and severe asthma was 1·30 (1·08-1·58). In a post-hoc analysis, relative risks of severe COVID-19 in people with respiratory disease were similar before and after shielding was introduced on March 23, 2020. In another post-hoc analysis, people with two or more prescriptions for ICS in the 150 days before study start were at a slightly higher risk of severe COVID-19 compared with all other individuals (ie, no or one ICS prescription): HR 1·13 (1·03-1·23) for hospitalisation, 1·63 (1·18-2·24) for ICU admission, and 1·15 (1·01-1·31) for death. INTERPRETATION The risk of severe COVID-19 in people with asthma is relatively small. People with COPD and interstitial lung disease appear to have a modestly increased risk of severe disease, but their risk of death from COVID-19 at the height of the epidemic was mostly far lower than the ordinary risk of death from any cause. Use of inhaled steroids might be associated with a modestly increased risk of severe COVID-19. FUNDING National Institute for Health Research Oxford Biomedical Research Centre and the Wellcome Trust.
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Affiliation(s)
- Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK.
| | - Min Gao
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK; School of Public Health, Peking University Health Science Centre, Beijing, China
| | - Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK
| | - Peter Watkinson
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK
| | - Duncan Young
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Carol A C Coupland
- University of Nottingham, Division of Primary Care, Faculty of Medicine & Health Sciences, University Park, Nottingham, UK
| | - Pui San Tan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ashley K Clift
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Harrison
- Intensive Care National Audit & Research Centre, London, UK
| | - Doug W Gould
- Intensive Care National Audit & Research Centre, London, UK
| | - Ian D Pavord
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK
| | - Julia Hippisley-Cox
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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6
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Malczewska A, Frampton AE, Mato Prado M, Ameri S, Dabrowska AF, Zagorac S, Clift AK, Kos-Kudła B, Faiz O, Stebbing J, Castellano L, Frilling A. Circulating MicroRNAs in Small-bowel Neuroendocrine Tumors: A Potential Tool for Diagnosis and Assessment of Effectiveness of Surgical Resection. Ann Surg 2021; 274:e1-e9. [PMID: 31373926 DOI: 10.1097/sla.0000000000003502] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To discover serum-based microRNA (miRNA) biomarkers for small-bowel neuroendocrine tumors (SBNET) to help guide clinical decisions. BACKGROUND MiRNAs are small noncoding RNA molecules implicated in the initiation and progression of many cancers. MiRNAs are remarkably stable in bodily fluids, and can potentially be translated into clinically useful biomarkers. Novel biomarkers are needed in SBNET to determine disease aggressiveness, select patients for treatment, detect early recurrence, and monitor response. METHODS This study was performed in 3 stages (discovery, validation, and a prospective, longitudinal assessment). Discovery comprised of global profiling of 376 miRNA in sera from SBNET patients (n = 11) versus healthy controls (HCs; n = 3). Up-regulated miRNAs were subsequently validated in additional SBNET (n = 33) and HC sera (n = 14); and then longitudinally after SBNET resection (n = 12), with serial serum sampling (preoperatively day 0; postoperatively at 1 week, 1 month, and 12 months). RESULTS Four serum miRNAs (miR-125b-5p, -362-5p, -425-5p and -500a-5p) were significantly up-regulated in SBNET (P < 0.05; fold-change >2) based on multiple normalization strategies, and were validated by RT-qPCR. This combination was able to differentiate SBNET from HC with an area under the curve of 0.951. Longitudinal assessment revealed that miR-125b-5p returned towards HC levels at 1 month postoperatively in patients without disease, whereas remaining up-regulated in those with residual disease (RSD). This was also true at 12 months postoperatively. In addition, miR-362-5p appeared up-regulated at 12 months in RSD and recurrent disease (RCD). CONCLUSIONS Our study represents the largest global profiling of serum miRNAs in SBNET patients, and the first to evaluate ongoing serum miRNA expression changes after surgical resection. Serum miR-125b-5p and miR-362-5p have potential to be used to detect RSD/RCD.
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Affiliation(s)
- Anna Malczewska
- Department of Surgery & Cancer, Imperial College, Hammersmith Hospital campus, Du Cane Road, London, UK
- Department of Endocrinology and Neuroendocrine Tumors, Medical University of Silesia, Katowice, Poland
| | - Adam E Frampton
- Department of Surgery & Cancer, Imperial College, Hammersmith Hospital campus, Du Cane Road, London, UK
| | - Mireia Mato Prado
- Department of Surgery & Cancer, Imperial College, Hammersmith Hospital campus, Du Cane Road, London, UK
| | - Shima Ameri
- Department of Surgery & Cancer, Imperial College, Hammersmith Hospital campus, Du Cane Road, London, UK
| | - Aleksandra F Dabrowska
- Department of Surgery & Cancer, Imperial College, Hammersmith Hospital campus, Du Cane Road, London, UK
| | - Sladjana Zagorac
- Department of Surgery & Cancer, Imperial College, Hammersmith Hospital campus, Du Cane Road, London, UK
| | - Ashley K Clift
- Department of Surgery & Cancer, Imperial College, Hammersmith Hospital campus, Du Cane Road, London, UK
| | - Beata Kos-Kudła
- Department of Endocrinology and Neuroendocrine Tumors, Medical University of Silesia, Katowice, Poland
| | - Omar Faiz
- St. Mark's Hospital, Harrow, Middlesex, UK
| | - Justin Stebbing
- Department of Surgery & Cancer, Imperial College, Hammersmith Hospital campus, Du Cane Road, London, UK
| | - Leandro Castellano
- Department of Surgery & Cancer, Imperial College, Hammersmith Hospital campus, Du Cane Road, London, UK
- University of Sussex, School of Life Sciences, John Maynard Smith Building, Falmer, Brighton, UK
| | - Andrea Frilling
- Department of Surgery & Cancer, Imperial College, Hammersmith Hospital campus, Du Cane Road, London, UK
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7
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Steinkraus K, Andresen JR, Clift AK, Liedke MO, Frilling A. Multifocal neuroendocrine tumour of the small bowel presenting as an incarcerated incisional hernia: a surgical challenge in a high-risk patient. J Surg Case Rep 2021; 2021:rjab219. [PMID: 34150191 PMCID: PMC8208802 DOI: 10.1093/jscr/rjab219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 11/25/2022] Open
Abstract
Neuroendocrine tumours (NET) of the small bowel present significant clinical challenges, such as their rate of metastasis at initial presentation, common multifocality and understaging even with gold standard imaging. Here, we present a case of a high-risk surgical patient with a complex medical history initially presenting as an acute abdomen due to an incarcerated incisional hernia. He was found at emergency laparotomy to have three small NET deposits in a 30-cm segment of incarcerated ileum which was resected. Postoperative morphological and functional imaging and biochemical markers were unremarkable, but due to clinical suspicion for undetected residual tumour bulk given the non-systematic palpation of the entire small bowel at initial operation, underwent re-operation where a further 70 cm of ileum was found to harbour multiple tumour deposits (n = 25) and was resected. There was no surgical morbidity and the patient remains tumour-free at 9-month follow-up.
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Affiliation(s)
| | | | - Ashley K Clift
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Marc O Liedke
- Department of Visceral, Thoracic, and Vascular Surgery, Westkuestenkliniken, Heide Germany
| | - Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, London, UK
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8
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Frilling A, Clift AK, Frampton AE, Bomanji J, Kaemmerer D, Al-Nahhas A, Alsafi A, Kidd M, Modlin IM, Hoersch D, Baum RP. A combination of surgery, theranostics, and liquid biopsy - a personalised oncologic approach to treatment of patients with advanced metastatic neuroendocrine neoplasms. Int J Med Sci 2021; 18:2166-2175. [PMID: 33859524 PMCID: PMC8040427 DOI: 10.7150/ijms.51740] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 01/14/2021] [Indexed: 01/29/2023] Open
Abstract
Rationale: Neuroendocrine neoplasia (NEN) of small bowel (SBNEN) frequently present with metastatic disease. Theranostics (molecular imaging followed by targeting therapy) allow for personalised medicine. Liquid biopsies enable precise identification of residual disease and real-time monitoring of therapeutic response. Our aim was to determine the clinical utility of a combination of surgery, theranostics, and a multigene blood measurement in metastasised SBNEN. Methods: Inclusion criteria were SBNEN, G1/G2 NEN, initial tumour diagnosis, stage IV NEN, positivity on 68Ga somatostatin analogue PET/CT, eligible for surgery, and 177Lu peptide receptor radionuclide therapy (PRRT). Blood samples for NETest were collected longitudinally. Progression-free survival (PFS) and overall survival (OS) were calculated. NETest results were assessed prior to surgery and during clinical follow-up. Results: A surgical cohort of 39 SBNEN patients met eligibility criteria. Thirty-two patients underwent ileal resection and 7 right hemicolectomy. The mean number of 177Lu PRRT cycles was 4. Mortality was nil. Surgical morbidity was 10.3%. Transient grade 1/2 toxicity occurred in 41% (PRRT). NETest scores (n=9 patients) decreased in 100% following treatment and correlated with diminished tumour volume and disease stabilization following surgery and PRRT. Median follow-up: 78 months. Median PFS and OS: 42.7 and 110 months, respectively. Progression-free survival at 1-, 3-, and 5-years was 79.4%, 57.1% and 40.5%, respectively. Overall survival at 1-, 3-, and 5-years was 97.4%, 97.4%, and 94.1%, respectively. Conclusions: Surgery combined with 177Lu PRRT is safe and provides favourable PFS and OS in selected patients with advanced SBNEN. Liquid biopsy (NETest) has the potential to accurately delineate disease status.
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Affiliation(s)
- Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ashley K. Clift
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Adam E. Frampton
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jamshed Bomanji
- Department of Nuclear Medicine, University College London Hospitals, London, UK
| | - Daniel Kaemmerer
- Department of General and Visceral Surgery, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Adil Al-Nahhas
- Department of Imaging and Nuclear Medicine, Imperial College London, London, UK
| | - Ali Alsafi
- Department of Imaging and Nuclear Medicine, Imperial College London, London, UK
| | | | - Irvin M. Modlin
- Gastroenterological and Endoscopic Surgery, Yale University School of Medicine, New Haven, USA
| | - Dieter Hoersch
- Department of Gastroenterology/Endocrinology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Richard P. Baum
- CURANOSTICUM Wiesbaden-Frankfurt at DKD Helios Klinik, Wiesbaden, Germany
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9
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Dambha-Miller H, Griffin SJ, Young D, Watkinson P, Tan PS, Clift AK, Payne RA, Coupland C, Hopewell JC, Mant J, Martin RM, Hippisley-Cox J. The Use of Primary Care Big Data in Understanding the Pharmacoepidemiology of COVID-19: A Consensus Statement From the COVID-19 Primary Care Database Consortium. Ann Fam Med 2021; 19:135-140. [PMID: 33685875 PMCID: PMC7939714 DOI: 10.1370/afm.2658] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/07/2020] [Accepted: 08/31/2020] [Indexed: 01/12/2023] Open
Abstract
The use of big data containing millions of primary care medical records provides an opportunity for rapid research to help inform patient care and policy decisions during the first and subsequent waves of the coronavirus disease 2019 (COVID-19) pandemic. Routinely collected primary care data have previously been used for national pandemic surveillance, quantifying associations between exposures and outcomes, identifying high risk populations, and examining the effects of interventions at scale, but there is no consensus on how to effectively conduct or report these data for COVID-19 research. A COVID-19 primary care database consortium was established in April 2020 and its researchers have ongoing COVID-19 projects in overlapping data sets with over 40 million primary care records in the United Kingdom that are variously linked to public health, secondary care, and vital status records. This consensus agreement is aimed at facilitating transparency and rigor in methodological approaches, and consistency in defining and reporting cases, exposures, confounders, stratification variables, and outcomes in relation to the pharmacoepidemiology of COVID-19. This will facilitate comparison, validation, and meta-analyses of research during and after the pandemic.
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Affiliation(s)
- Hajira Dambha-Miller
- CORRESPONDING AUTHOR Hajira Dambha-Miller Primary Care and Population Health University of Southampton Southampton, SO16 5ST United Kingdom
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10
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Clift AK, Le Lannou E, Tighe CP, Shah SS, Beatty M, Hyvärinen A, Lane SJ, Strauss T, Dunn DD, Lu J, Aral M, Vahdat D, Ponzo S, Plans D. Development and Validation of Risk Scores for All-Cause Mortality for a Smartphone-Based "General Health Score" App: Prospective Cohort Study Using the UK Biobank. JMIR Mhealth Uhealth 2021; 9:e25655. [PMID: 33591285 PMCID: PMC7925156 DOI: 10.2196/25655] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/16/2020] [Accepted: 01/20/2021] [Indexed: 12/23/2022] Open
Abstract
Background Given the established links between an individual’s behaviors and lifestyle factors and potentially adverse health outcomes, univariate or simple multivariate health metrics and scores have been developed to quantify general health at a given point in time and estimate risk of negative future outcomes. However, these health metrics may be challenging for widespread use and are unlikely to be successful at capturing the broader determinants of health in the general population. Hence, there is a need for a multidimensional yet widely employable and accessible way to obtain a comprehensive health metric. Objective The objective of the study was to develop and validate a novel, easily interpretable, points-based health score (“C-Score”) derived from metrics measurable using smartphone components and iterations thereof that utilize statistical modeling and machine learning (ML) approaches. Methods A literature review was conducted to identify relevant predictor variables for inclusion in the first iteration of a points-based model. This was followed by a prospective cohort study in a UK Biobank population for the purposes of validating the C-Score and developing and comparatively validating variations of the score using statistical and ML models to assess the balance between expediency and ease of interpretability and model complexity. Primary and secondary outcome measures were discrimination of a points-based score for all-cause mortality within 10 years (Harrell c-statistic) and discrimination and calibration of Cox proportional hazards models and ML models that incorporate C-Score values (or raw data inputs) and other predictors to predict the risk of all-cause mortality within 10 years. Results The study cohort comprised 420,560 individuals. During a cohort follow-up of 4,526,452 person-years, there were 16,188 deaths from any cause (3.85%). The points-based model had good discrimination (c-statistic=0.66). There was a 31% relative reduction in risk of all-cause mortality per decile of increasing C-Score (hazard ratio of 0.69, 95% CI 0.663-0.675). A Cox model integrating age and C-Score had improved discrimination (8 percentage points; c-statistic=0.74) and good calibration. ML approaches did not offer improved discrimination over statistical modeling. Conclusions The novel health metric (“C-Score”) has good predictive capabilities for all-cause mortality within 10 years. Embedding the C-Score within a smartphone app may represent a useful tool for democratized, individualized health risk prediction. A simple Cox model using C-Score and age balances parsimony and accuracy of risk predictions and could be used to produce absolute risk estimations for app users.
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Affiliation(s)
- Ashley K Clift
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | | | - Christian P Tighe
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom.,Huma Therapeutics, London, United Kingdom
| | | | | | | | | | | | | | - Jiahe Lu
- Huma Therapeutics, London, United Kingdom
| | - Mert Aral
- Huma Therapeutics, London, United Kingdom
| | - Dan Vahdat
- Huma Therapeutics, London, United Kingdom
| | | | - David Plans
- Huma Therapeutics, London, United Kingdom.,Department of Science, Innovation, Technology, and Entrepreneurship, University of Exeter, Exeter, United Kingdom.,Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom
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11
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Abstract
Neuroendocrine neoplasms (NEN) are a class of tumours heterogeneous in terms of their anatomical sites of origin and clinical behaviour. Outdated perspectives of indolence have been superseded by appreciation for their myriad clinical challenges, such as the high rates of regional and distant metastases at initial diagnosis, lack of clarity on optimal treatment strategies/sequencing, and incompletely elucidated genetic/other pathophysiological drivers. The first randomised controlled trials in this arena were published approximately a decade ago - since then, increased understanding of the genetic drivers and signalling pathway perturbations in these tumours have suggested promise for precision therapy influenced by an individual tumour's molecular sub-type, but this is yet to be realised for manifold reasons. In this article, the authors review the genetic landscapes as currently understood for selected forms of NEN and discuss the current and developing evidence to support the use of genetic information to influence therapy. They provide a critical assessment of the potential limitations of using such approaches and also posit avenues for future developments in this arena.
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Affiliation(s)
- Ashley K Clift
- Department of Surgery and Cancer, Imperial College London, London, UK
- NHS Nightingale Hospital London, London, UK
| | - Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, London, UK
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12
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Clift AK. Population-level breast screening: how to salvage the concept? J R Soc Med 2020; 113:306-309. [PMID: 32780978 PMCID: PMC7539091 DOI: 10.1177/0141076820910317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Ashley K Clift
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London W12 0HS, UK
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13
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Linecker M, Kambakamba P, Raptis DA, Malagó M, Ratti F, Aldrighetti L, Robles-Campos R, Lehwald-Tywuschik N, Knoefel WT, Balci D, Ardiles V, De Santibañes E, Truant S, Pruvot FR, Stavrou GA, Oldhafer KJ, Voskanyan S, Mahadevappa B, Kozyrin I, Low JK, Ferrri V, Vicente E, Prachalias A, Pizanias M, Clift AK, Petrowsky H, Clavien PA, Frilling A. ALPPS in neuroendocrine liver metastases not amenable for conventional resection - lessons learned from an interim analysis of the International ALPPS Registry. HPB (Oxford) 2020; 22:537-544. [PMID: 31540885 DOI: 10.1016/j.hpb.2019.08.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 05/07/2019] [Revised: 07/10/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgery is the most effective treatment option for neuroendocrine liver metastases (NELM). This study investigated the role of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) as a novel strategy in treatment of NELM. METHODS The International ALPPS Registry was reviewed to study patients who underwent ALPPS for NELM. RESULTS From 2010 to 2017, 954 ALPPS procedures from 135 international centers were recorded in the International ALPPS Registry. Of them, 24 (2.5%) were performed for NELM. Twenty-one patients entered the final analysis. Overall grade ≥3b morbidity was 9% after stage 1 and 27% after stage 2. Ninety-day mortality was 5%. R0 resection was achieved in 19 cases (90%) at stage 2. Median follow-up was 28 (19-48) months. Median disease free survival (DFS) was 17.3 (95% CI: 7.1-27.4) months, 1-year and 2-year DFS was 73.2% and 41.8%, respectively. Median overall survival (OS) was not reached. One-year and 2-year OS was 95.2% and 95.2%, respectively. CONCLUSIONS ALPPS appears to be a suitable strategy for inclusion in the multimodal armamentarium of well-selected patients with neuroendocrine liver metastases. In light of the morbidity in this initial series and a high rate of disease-recurrence, the procedure should be taken with caution.
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Affiliation(s)
- Michael Linecker
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Switzerland
| | - Patryk Kambakamba
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Switzerland
| | - Dimitri A Raptis
- Department of HPB- and Liver Transplantation Surgery, University College London, Royal Free Hospitals, London, UK
| | - Massimo Malagó
- Department of HPB- and Liver Transplantation Surgery, University College London, Royal Free Hospitals, London, UK
| | - Francesca Ratti
- Hepatobiliary Surgery Division, Department of Surgery, IRCCS San Raffaele Hospital, School of Medicine, Milan, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, Department of Surgery, IRCCS San Raffaele Hospital, School of Medicine, Milan, Italy
| | - Ricardo Robles-Campos
- Department of Surgery and Liver and Pancreas Transplantation, Virgen de la Arrixaca Clinic and University Hospital, IMIB-Arrixaca, Murcia, Spain
| | | | - Wolfram T Knoefel
- Department of Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Deniz Balci
- Department of Surgery, Ankara University, Ankara, Turkey
| | - Victoria Ardiles
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital Buenos Aires, Argentina
| | - Eduardo De Santibañes
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital Buenos Aires, Argentina
| | - Stéphanie Truant
- Department of Digestive Surgery and Transplantation, University Hospital, Lille, France
| | - Francois-René Pruvot
- Department of Digestive Surgery and Transplantation, University Hospital, Lille, France
| | - Gregor A Stavrou
- Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany; Semmelweis University Budapest, Campus Hamburg, Germany
| | - Karl J Oldhafer
- Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany; Semmelweis University Budapest, Campus Hamburg, Germany
| | - Sergey Voskanyan
- Department of Surgery, A.I. Burnazyan FMBC Russian State Scientific Center of FMBA, Moscow, Russia
| | - Basant Mahadevappa
- Department of HPB and Liver Transplantation, HCG Hospitals, Bangalore, India
| | - Ivan Kozyrin
- Department of Thoracic and Abdominal Surgery and Oncology, Clinical Hospital #1 MEDSI, Moscow, Russia
| | - Jee K Low
- Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Valentina Ferrri
- General Surgery Department, Madrid Norte Sanchinarro San Pablo University Hospital, Madrid, Spain
| | - Emilio Vicente
- General Surgery Department, Madrid Norte Sanchinarro San Pablo University Hospital, Madrid, Spain
| | | | | | - Ashley K Clift
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Switzerland
| | - Pierre-Alain Clavien
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Switzerland
| | - Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, London, UK.
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14
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Frilling A, Clift AK, Braat AJAT, Alsafi A, Wasan HS, Al-Nahhas A, Thomas R, Drymousis P, Habib N, Tait PN. Radioembolisation with 90Y microspheres for neuroendocrine liver metastases: an institutional case series, systematic review and meta-analysis. HPB (Oxford) 2019; 21:773-783. [PMID: 30733049 DOI: 10.1016/j.hpb.2018.12.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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: 08/19/2018] [Revised: 12/03/2018] [Accepted: 12/11/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neuroendocrine liver metastases are clinically challenging due to their frequent disseminated distribution. This study aims to present a British experience with an emerging modality, radioembolisation with yttrium-90 labelled microspheres, and embed this within a meta-analysis of response and survival outcomes. METHODS A retrospective case series of patients treated with SIR-Spheres (radiolabelled resin microspheres) was performed. Results were included in a systematic review and meta-analysis of published results with glass or resin microspheres. Objective response rate (ORR) was defined as complete or partial response. Disease control rate (DCR) was defined as complete/partial response or stable disease. RESULTS Twenty-four patients were identified. ORR and DCR in the institutional series was 14/24 and 21/24 at 3 months. Overall survival and progression-free survival at 3-years was 77.6% and 50.4%, respectively. There were no grade 3/4 toxicities post-procedure. A fixed-effects pooled estimate of ORR of 51% (95% CI: 47%-54%) was identified from meta-analysis of 27 studies. The fixed-effects weighted average DCR was 88% (95% CI: 85%-90%, 27 studies). CONCLUSION Current data demonstrate evidence of the clinical effectiveness and safety of radioembolisation for neuroendocrine liver metastases. Prospective randomised studies to compare radioembolisation with other liver directed treatment modalities are needed.
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Affiliation(s)
- Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Ashley K Clift
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Arthur J A T Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, 3508, GA Utrecht, the Netherlands
| | - Ali Alsafi
- Department of Imaging, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Harpreet S Wasan
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Adil Al-Nahhas
- Department of Nuclear Medicine, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Robert Thomas
- Department of Imaging, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Panagiotis Drymousis
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Nagy Habib
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Paul N Tait
- Department of Imaging, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
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Affiliation(s)
- A K Clift
- Department of Surgery and Cancer, Imperial College London, United Kingdom
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16
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Clift AK, Kornasiewicz O, Drymousis P, Faiz O, Wasan HS, Kinross JM, Cecil T, Frilling A. Goblet cell carcinomas of the appendix: rare but aggressive neoplasms with challenging management. Endocr Connect 2018; 7:268-277. [PMID: 29335251 PMCID: PMC5801558 DOI: 10.1530/ec-17-0311] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/15/2018] [Indexed: 12/17/2022]
Abstract
Goblet cell carcinomas (GCC) are a rare, aggressive sub-type of appendiceal tumours with neuroendocrine features, and controversy exists with regards to therapeutic strategy. We undertook a retrospective review of GCC patients surgically treated at two tertiary referral centres. Clinical and histopathological data were extracted from a prospectively maintained database. Survival analyses utilised Kaplan-Meier methodology. Twenty-one patients were identified (9 females). Median age at diagnosis was 55 years (range 32-77). There were 3, 6 and 9 grade 1, 2 and 3 tumours, respectively. One, 10, 5 and 5 patients had stage I, II, III and IV disease at diagnosis, respectively. There were 8, 10 and 3 Tang class A, B and C tumours, respectively. Index operation was appendectomy (n = 12), right hemicolectomy (n = 6) or resections including appendix/right colon, omentum and the gynaecological system (n = 3). Eight patients underwent completion right hemicolectomy. Surgery for recurrence included small bowel resection (n = 2), debulking with peritonectomy and heated intraperitoneal chemotherapy, and hysterectomy and bilateral salpingo-oophorectomy (all n = 1). Median follow-up was 30 months (range 2.5-123). One-, 3- and 5-year OS was 79.4, 60 and 60%, respectively. Mean OS (1-, 3-, and 5-year OS) for Tang class A, B and C tumours were 73.1 months (85.7, 85.7, 51.4%), 83.7 months (all 66.7%) and 28.5 months (66.7, 66.7%, not reached), respectively. Chromogranin A/B and 68Ga-DOTATATE PET/CT were not useful in follow-up, but CEA, CA 19-9, CA 125 and 18F-FDG PET/CT identified tumour recurrence. GCC must be clearly discriminated from relatively indolent appendiceal neuroendocrine neoplasms. 18F-FDG PET/CT and CEA/CA19-9/CA 125 are useful in detecting recurrence of GCC.
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Affiliation(s)
- Ashley K Clift
- Department of Surgery and CancerImperial College London, London, UK
| | - Oskar Kornasiewicz
- Department of Surgery and CancerImperial College London, London, UK
- Department of SurgeryWarsaw Medical University, Warsaw, Poland
| | | | - Omar Faiz
- Department of SurgerySt Mark's Hospital, London, UK
| | - Harpreet S Wasan
- Department of Surgery and CancerImperial College London, London, UK
| | - James M Kinross
- Department of Surgery and CancerImperial College London, London, UK
| | - Thomas Cecil
- Peritoneal Malignancy UnitBasingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Andrea Frilling
- Department of Surgery and CancerImperial College London, London, UK
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Ronot M, Clift AK, Baum RP, Singh A, Kulkarni HR, Frilling A, Vilgrain V. Morphological and Functional Imaging for Detecting and Assessing the Resectability of Neuroendocrine Liver Metastases. Neuroendocrinology 2018; 106:74-88. [PMID: 28728155 DOI: 10.1159/000479293] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 07/07/2017] [Indexed: 12/17/2022]
Abstract
This review evaluates the diagnostic efficacy of different morphological and functional imaging modalities (ultrasound [US], computed tomography [CT], magnetic resonance [MR] imaging, scintigraphy, and positron emission tomography [PET]) in detecting neuroendocrine liver metastases (NELM), assessing vascular and biliary involvement, and the presence of extrahepatic disease. MR imaging is superior for depicting NELM compared to US, CT, and somatostatin receptor scintigraphy. Diffusion-weighted MR imaging is more sensitive for detecting NELM than both T2-weighted and dynamic gadolinium-enhanced MR sequences, and should be systematically performed. Similarly, gadoxetic acid-enhanced MR imaging is more sensitive for detecting liver metastases than conventional extracellular gadolinium chelate-enhanced MR sequences. Its role in detecting NELM remains investigational but appears promising. Somatostatin receptor-targeted PET/CT is a highly effective approach in assessing the resectability of well-differentiated NELM due to very high specificity (and high sensitivity) and its ability to detect small volume extrahepatic disease; this molecular imaging modality is becoming increasingly available in and outside Europe after the recent approval of 6868-DOTATATE in the US. In addition, the information from multiphase, contrast-enhanced CT with 3D reconstruction - obtained concurrently with the information on somatostatin receptor expression of the metastases - is very helpful in planning the extent and type of resection of NELM.
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Affiliation(s)
- Maxime Ronot
- Department of Radiology, University Hospitals of Beaujon, Clichy, France
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18
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Pawa N, Clift AK, Osmani H, Drymousis P, Cichocki A, Flora R, Goldin R, Patsouras D, Baird A, Malczewska A, Kinross J, Faiz O, Antoniou A, Wasan H, Kaltsas GA, Darzi A, Cwikla JB, Frilling A. Surgical Management of Patients with Neuroendocrine Neoplasms of the Appendix: Appendectomy or More. Neuroendocrinology 2018. [PMID: 28641291 DOI: 10.1159/000478742] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Appendiceal neuroendocrine neoplasms (ANEN) are mostly indolent tumours treated effectively with simple appendectomy. However, controversy exists regarding the necessity of oncologic right hemicolectomy (RH) in patients with histologic features suggestive of more aggressive disease. We assess the effects of current guidelines in selecting the surgical strategy (appendectomy or RH) for the management of ANEN. Methods/Aims: This is a retrospective review of all ANEN cases treated over a 14-year period at 3 referral centres and their management according to consensus guidelines of the European and the North American Neuroendocrine Tumor Societies (ENETS and NANETS, respectively). The operation performed, the tumour stage and grade, the extent of residual disease, and the follow-up outcomes were evaluated. RESULTS Of 14,850 patients who had appendectomies, 215 (1.45%) had histologically confirmed ANEN. Four patients had synchronous non-ANEN malignancies. One hundred and ninety-three patients had index appendectomy. Seventeen patients (7.9%) had lymph node metastases within the mesoappendix. Forty-nine patients underwent RH after appendectomy. The percentages of 30-day morbidity and mortality after RH were 2 and 0%, respectively. Twelve patients (24.5%) receiving completion RH were found to have lymph node metastases. Two patients had liver metastases, both of them synchronous. The median follow-up was 38.5 months (range 1-143). No patient developed disease recurrence. Five- and 10-year overall survival for all patients with ANEN as the only malignancy was both 99.05%. CONCLUSIONS The current guidelines appear effective in identifying ANEN patients at risk of harbouring nodal disease, but they question the oncological relevance of ANEN lymph node metastases. RH might present an overtreatment for a number of patients with ANEN.
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Clift AK, Giele H, Reddy S, Macedo R, Al-Nahhas A, Wasan HS, Gondolesi GE, Vianna RM, Friend P, Vaidya A, Frilling A. Neoadjuvant peptide receptor radionuclide therapy and modified multivisceral transplantation for an advanced small intestinal neuroendocrine neoplasm: an updated case report. Innov Surg Sci 2017; 2:247-253. [PMID: 31579758 PMCID: PMC6754026 DOI: 10.1515/iss-2017-0025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 04/09/2017] [Accepted: 08/02/2017] [Indexed: 01/12/2023] Open
Abstract
Small intestinal neuroendocrine neoplasms (SI-NEN) frequently metastasise to regional lymph nodes, and surgery is the mainstay of therapy for such patients. However, despite the possible use of advanced surgical techniques, the resection of both primary and locoregional diseases is not always attainable. Intestinal and multivisceral transplantation has been performed in a small number of patients with conventionally nonresectable, slow-growing tumours threatening the mesenteric root but has remained controversial. The use of donor skin in “sentinel flaps” in transplantation theoretically offers advantages in tailoring immunosuppression and monitoring for rejection. We represent (with extended follow-up) the first case of a patient with inoperable extensive mesenteric metastases from SI-NEN, who underwent neoadjuvant peptide receptor radionuclide therapy before a modified multivisceral transplant with a concomitant vascularised sentinel forearm flap. At 48 months after transplantation, our patient remained at full physical activity with no evidence of disease recurrence on either tumour biochemistry or radiological imaging.
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Affiliation(s)
- Ashley K Clift
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Henk Giele
- Department of Plastic and Reconstructive Surgery, Oxford University NHS Trust, Oxford, UK
| | - Srikanth Reddy
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, UK
| | - Rubens Macedo
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, UK
| | - Adil Al-Nahhas
- Department of Nuclear Medicine, Imperial College London, London, UK
| | - Harpreet S Wasan
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Gabriel E Gondolesi
- Instituto de Trasplante Multiorgano, Fundacion Favaloro, Buenos Aires, Argentina
| | - Rodrigo M Vianna
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Peter Friend
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, UK
| | - Anil Vaidya
- Department of Plastic and Reconstructive Surgery, Oxford University NHS Trust, Oxford, UK
| | - Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK,
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20
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Frilling A, Clift AK. Peritoneal Metastases from Gastroenteropancreatic Neuroendocrine Tumors. Ann Surg Oncol 2017; 24:3466-3468. [PMID: 28815440 DOI: 10.1245/s10434-017-6055-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Ashley K Clift
- Department of Surgery and Cancer, Imperial College London, London, UK
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21
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Frilling A, Kaemmerer D, Kidd MS, Clift AK, Stebbing J, Baum RP, Castellano L, Wasan HS, Modlin IM. Surgery in combination with peptide receptor radionuclide therapy is effective in metastatic neuroendocrine tumors and is definable by blood gene transcript analysis. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e15697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e15697 Background: Neuroendocrine tumours (NET) of the pancreas (PNET) or small bowel (SBNET) frequently present with metastases at initial diagnosis, undermining the efficacy of surgical treatment. Peptide receptor radionuclide therapy (PRRT) with radiolabelled somatostatin analogues, 90Y-DOTATOC and 177Lu-DOTATATE, has been shown to achieve prolonged progression-free survival (PFS) in a substantial number of non-surgical patients with advanced NET. Our aim was to prospectively determine the efficacy of a combination of radical loco-regional surgery and PRRT in patients with metastasised NET. Methods: A set of inclusion criteria was defined (e.g. G1/G2 NET, initial tumour diagnosis, treatment naïve patient, stage IV NET, positivity on 68Ga DOTA- PET/CT, eligibility for surgery and PRRT). Patients underwent PRRT within 3 months following surgery. Follow-up included biochemistry and imaging. In a sub-cohort, blood-based neuroendocrine gene transcript analysis of 51 genes (NETest) was used to define the effectiveness of treatment. Outcome measures included 5-year overall survival (OS) and PFS from initial diagnosis. Results: Twenty-five patients (5 PNET, 20 SBNET) met eligibility criteria and were included. There were 13 men (52%) and mean age was 57.1 years. All patients with SB NET underwent right hemicolectomy, terminal ileal resection and mesenteric lympadenectomy. In all PNET patients only limited pancreatic resection was required. The median number of PRRT cycles was 4 (range 2-6). Post-treatment mortality was 0%. Surgical morbidity was 12% (all Clavien-Dindo grade 1). Transient grade 1 toxicity occurred post-PRRT in 40%. NETest scores were increased in 8 patients (100%) pre-operatively and decreased in all following treatment. NETest decreases correlated with diminished tumour volume (R2=0.37, p=0.02). Median follow-up was 48 months (range 12-72months). Five-year OS was 90% and 5-year PFS was 84.3%. Conclusions: Radical loco-regional surgery for primary tumours combined with PRRT provides a novel, highly efficacious approach in metastasised NET. The NETest accurately measures the effectiveness of treatment.
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Affiliation(s)
| | | | | | | | - Justin Stebbing
- Imperial College Healthcare NHS Trust, London, United Kingdom
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22
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Clift AK, Frilling A. Neuroendocrine, goblet cell and mixed adeno-neuroendocrine tumours of the appendix: updates, clinical applications and the future. Expert Rev Gastroenterol Hepatol 2017; 11:237-247. [PMID: 28081662 DOI: 10.1080/17474124.2017.1282314] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Appendiceal neuroendocrine neoplasms are rare, clinically challenging tumours that are typically incidentally diagnosed, have a poorly understood biology and have controversy surrounding their management. Most are adequately treated with appendectomy, and although distant metastases are rare, the threat of disease dissemination remains and current guidelines possess poor accuracy in terms of selecting patients requiring more extensive surgery, i.e. oncological right-hemicolectomy. Areas covered: In this article, we discuss the presentation and diagnostic work-up of patients with appendiceal neuroendocrine neoplasms, and also examine the evidence base for existing management strategies. We highlight controversies within the management of these tumours, and anticipate avenues for further progress. Although no longer classified as neuroendocrine neoplasms, we also discuss two related forms of tumours with neuroendocrine features - goblet cell cancers and mixed adeno-neuroendocrine carcinomas. Expert commentary: Existing guidelines for the treatment of appendiceal neuroendocrine neoplasms are derived from a limited evidence base and are unable to accurately predict which patients require extensive attempts at surgical disease control. Future advances in the field of improved patient selection for more extensive surgery may be possible with multi-factorial tumour assessment integrating morphological and molecular analyses.
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Affiliation(s)
- Ashley K Clift
- a Department of Surgery and Cancer , Imperial College London , London , UK
| | - Andrea Frilling
- a Department of Surgery and Cancer , Imperial College London , London , UK
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Clift AK, Faiz O, Goldin R, Martin J, Wasan H, Liedke MO, Schloericke E, Malczewska A, Rindi G, Kidd M, Modlin IM, Frilling A. Predicting the survival of patients with small bowel neuroendocrine tumours: comparison of 3 systems. Endocr Connect 2017; 6:71-81. [PMID: 28104724 PMCID: PMC5424775 DOI: 10.1530/ec-16-0114] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 01/19/2017] [Indexed: 02/06/2023]
Abstract
Neuroendocrine tumours (NET) are clinically challenging due to their unpredictable behaviour. Nomograms, grading and staging systems are predictive tools with multiple roles in clinical practice, including patient prognostication. The NET nomogram allocates scores for various clinicopathological parameters, calculating percentage estimates for 5- and 10-year disease-specific survival of patients with small bowel (SB) NET. We evaluated the clinical utility of three prognostic systems in 70 SB NET patients: the NET nomogram, the World Health Organisation (WHO)/European Neuroendocrine Tumour Society (ENETS) grading system and the American Joint Commission on Cancer (AJCC)/Union Internationale Contre le Cancer (UICC) TNM staging method. Using Kaplan-Meier methodology, neither the WHO/ENETS grade (P = 0.6) nor the AJCC/UICC stage (P = 0.276) systems demonstrated significant differences in patient survival in the cohort. The NET nomogram was well calibrated to our data set, displaying favourable prediction accuracy. Harrel's C-index for the nomogram (a measure of predictive power) was 0.65, suggesting good prediction ability. On Kaplan-Meier analyses, there were significant differences in patient survival when stratified into nomogram score-based risk groups: low-, medium- and high-risk tumours were associated with median estimated survivals of 156, 129 and 112 months, respectively (P = 0.031). Our data suggest that a multivariable analysis-based NET nomogram may be clinically useful for patient survival prediction. This study identifies the limitations of the NET nomogram and the imperfections of other currently used single or binary parameter methodologies for assessing neuroendocrine disease prognosis. The future addition of other variables to the NET nomogram will likely amplify the accuracy of this personalised tool.
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Affiliation(s)
- Ashley K Clift
- Department of Surgery and CancerImperial College London, London, UK
| | - Omar Faiz
- Department of SurgerySt Mark's Hospital, London, UK
| | - Robert Goldin
- Centre for PathologyImperial College London, London, UK
| | - John Martin
- Department of GastroenterologyImperial College London, London, UK
| | - Harpreet Wasan
- Department of Surgery and CancerImperial College London, London, UK
| | | | | | - Anna Malczewska
- Department of Surgery and CancerImperial College London, London, UK
- Department of Pathophysiology and EndocrinologyMedical University of Silesia, Katowice, Poland
| | - Guido Rindi
- Institute of Anatomic PathologyUniversita Cattolica del Sacro Cuore, Rome, Italy
| | - Mark Kidd
- Wren LaboratoriesBranford, Connecticut, USA
| | - Irvin M Modlin
- Emeritus Professor Gastrointestinal SurgerySchool of Medicine, Yale University, New Haven, Connecticut, USA
| | - Andrea Frilling
- Department of Surgery and CancerImperial College London, London, UK
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Khan M, Clift AK, O'Cinneide C, Wilding J. Obesity as a disability: a weighty precedent? Clin Obes 2015; 5:163-4. [PMID: 26173751 DOI: 10.1111/cob.12102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- M Khan
- Department of Diabetes & Endocrinology, Clinical Sciences Centre, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - A K Clift
- Faculty of Medicine, Imperial College London, London, UK
| | - C O'Cinneide
- UCL Faculty of Laws, Bentham House, Endsleigh Gardens, London, UK
| | - J Wilding
- Department of Diabetes & Endocrinology, Clinical Sciences Centre, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
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Frilling A, Giele H, Vrakas G, Reddy S, Macedo R, Al-Nahhas A, Wasan H, Clift AK, Gondolesi GE, Vianna RM, Friend P, Vaidya A. Modified liver-free multivisceral transplantation for a metastatic small bowel neuroendocrine tumor: a case report. Transplant Proc 2015; 47:858-62. [PMID: 25689880 DOI: 10.1016/j.transproceed.2015.01.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 01/14/2015] [Indexed: 12/17/2022]
Abstract
Neuroendocrine tumors originating from the small bowel frequently metastasize to the lymph nodes and/or liver. Although surgical extirpation of the primary tumor and locoregional metastases epitomizes the management of patients with such tumors, this is not always possible with conventional surgical techniques. Nonresectable, slow-growing tumors involving the mesenteric root represent a generally accepted indication for deceased donor intestinal and multivisceral transplantation. Furthermore, vascularized sentinel forearm flaps offer opportunities for monitoring graft rejection and tailoring immunosuppression regimens. Here, we report the first documented case of modified liver-free multivisceral transplantation preceded by neoadjuvant 177-lutetium peptide receptor radionuclide therapy in a patient with a small bowel neuroendocrine tumor and extensive lymph node metastases in the mesenterium. At a follow-up of 21 months the patient is biochemically and radiologically disease-free.
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Affiliation(s)
- A Frilling
- Department of Surgery and Cancer, Imperial College London, United Kingdom.
| | - H Giele
- Department of Plastic and Reconstructive Surgery, Oxford University NHS Trust, Oxford, United Kingdom
| | - G Vrakas
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, United Kingdom
| | - S Reddy
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, United Kingdom
| | - R Macedo
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, United Kingdom
| | - A Al-Nahhas
- Department of Nuclear Medicine, Imperial College London, United Kingdom
| | - H Wasan
- Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - A K Clift
- School of Medicine, Imperial College London, United Kingdom
| | - G E Gondolesi
- Instituto de Trasplante Multiorgánico, Fundación Favaloro, Buenos Aires, Argentina
| | - R M Vianna
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Fla., United States
| | - P Friend
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, United Kingdom
| | - A Vaidya
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, United Kingdom
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Clift AK, Drymousis P, Al-Nahhas A, Wasan H, Martin J, Holm S, Frilling A. Incidence of Second Primary Malignancies in Patients with Neuroendocrine Tumours. Neuroendocrinology 2015; 102:26-32. [PMID: 25824138 DOI: 10.1159/000381716] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 03/16/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND An association between neuroendocrine tumours (NET) and increased risk of developing second primary malignancies (SPM) has been recognised. METHODS This was a retrospective review of our institutional prospectively maintained database of NET patients. We identified patients who had been diagnosed with both neuroendocrine and any additional malignancies via examination of patient notes. RESULTS Clinical data for 169 patients were analysed. After exclusion of patients known to have hereditary tumour predisposition syndromes, 29 SPM were identified in 26 patients (15.38%), the commonest being colorectal (n = 6), breast and renal carcinomas (both n = 5). SPM were classified as previous, synchronous or subsequent relative to NET diagnosis. Rates of SPM in pancreatic and small-bowel NET patients were comparable (15.7 vs. 19.6%, p = 0.78). A person-year methodology was used to compare observed numbers of SPM against expected values generated from age- and sex-specific incidence tables, with standardised incidence ratios (SIR) and 95% confidence intervals (CI) calculated. SPM incidence was significantly elevated in the synchronous subset (SIR 2.732, CI 1.177-5.382) whilst significantly fewer NET patients had a cancer history compared to the general population (SIR 0.4, CI 0.241-0.624). No overall differences were evident between observed and expected incidences of subsequent SPM (SIR 0.36, CI 0.044-1.051). The incidence of synchronous colorectal cancers was markedly elevated (SIR 13.079, CI 4.238-30.474). CONCLUSIONS Our data support the use of colonoscopy in the diagnostic work-up of NET patients in anticipation of a colorectal SPM. The mechanistic underpinnings of this clinical phenomenon require further genetic investigation, and consideration of this knowledge in patient management pathways is warranted.
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Frilling A, Clift AK. Therapeutic strategies for neuroendocrine liver metastases. Cancer 2014; 121:1172-86. [PMID: 25274401 DOI: 10.1002/cncr.28760] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [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: 01/20/2014] [Revised: 04/09/2014] [Accepted: 04/10/2014] [Indexed: 12/16/2022]
Abstract
Patients who have neuroendocrine tumors frequently present with liver metastases. A wide panel of treatment options exists for these patients. Liver resection with curative intent achieves the best long-term results. Highly selected patients may be considered for liver transplantation. Substantial recurrence rates reported after surgical approaches call for neoadjuvant and adjuvant concepts. Liver-directed, locally ablative procedures are recommended for patients with limited, nonresectable tumor burden. Angiographic liver-directed techniques, such as transarterial embolization, transarterial chemoembolization, and selective internal radiotherapy, offer excellent palliation for patients with liver-predominant disease. Peptide receptor radionuclide therapy is a promising palliative procedure for patients with hepatic and/or extrahepatic metastases. The efficacy of these treatment options needs to be evaluated in randomized trials. Somatostatin analogues have demonstrated effectiveness not only for symptomatic relief in patients with secreting tumors but also for the control of proliferation in small intestinal neuroendocrine tumors and most recently also in those originating from the pancreas. Chemotherapy is an option mainly for those with pancreatic neuroendocrine tumors and high-grade tumors irrespective of the origin. Novel drugs targeting specific pathways within the tumor cell have produced improved progression-free survival compared with placebo in patients with pancreatic neuroendocrine tumors. Despite such a diverse armamentarium, there is uncertainty with regard to the optimal treatment regimens. Newly introduced molecular-based markers, along with the conduction of clinical trials comparing the efficacy of treatment modalities, offer a chance to move the treatment of neuroendocrine tumor disease toward personalized patient care. In this report, the authors review the approaches for treatment of neuroendocrine liver metastases, identify shortcomings, and anticipate future perspectives. Furthermore, clinical practice recommendations are provided for currently available treatment options. Although multiple modalities are available for the treatment of neuroendocrine liver metastases, optimal management is unclear. The current knowledge pertaining to these treatment options is analyzed.
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Affiliation(s)
- Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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