Cover Page
The handle http://hdl.handle.net/1887/51101 holds various files of this Leiden University dissertation
Author: Gent, M.D.J.M. van
Title: Tailoring therapy in endometrial and cervical cancer
Issue Date: 2017-06-20
IN ENDOMETRIAL AND CERVICAL CANCER
YROJHQVEHVOXLWYDQKHW&ROOHJHYRRU3URPRWLHV WHYHUGHGLJHQRSGLQVGDJMXQL
NORNNHXXU
*HERUHQWH9HJKHO LQ
&RYHU3ULQV&ODXVSOHLQE\$S6RN
,6%1
3ULQWHGE\,36.$03SULQWLQJ
/D\RXWE\$OH[:HVVHOLQN3HUVRRQOLMNSURHIVFKULIWQO
)LQDQFLDOVXSSRUWIRUWKHSULQWLQJRIWKLVWKHVLVZDVSURYLGHGE\&KLSVRIW%9
GHSDUWPHQWRIJ\QDHFRORJ\/HLGHQ8QLYHUVLW\0HGLFDO&HQWHU
k0LJQRQYDQ*HQW
$OOULJKWVUHVHUYHG1RSDUWRIWKLVWKHVLVPD\EHUHSURGXFHGRUWUDQVPLWWHGLQDQ\IRUPRU
E\DQ\PHDQVZLWKRXWSHUPLVVLRQRIWKHDXWKRU
IN ENDOMETRIAL AND CERVICAL CANCER
Proefschrift
Ter verkrijging van
de graad van Doctor aan de Universiteit Leiden, RSJH]DJYDQGHUHFWRU0DJQLƓFXVSURIPU&--06WRONHU
YROJHQVEHVOXLWYDQKHW&ROOHJHYRRU3URPRWLHV WHYHUGHGLJHQRSGLQVGDJMXQL
NORNNHXXU door
Mignon Dingena Johanna Maria van Gent
*HERUHQWH9HJKHO
LQ
&RYHU3ULQV&ODXVSOHLQE\$S6RN
,6%1
3ULQWHGE\,36.$03SULQWLQJ
/D\RXWE\$OH[:HVVHOLQN3HUVRRQOLMNSURHIVFKULIWQO
)LQDQFLDOVXSSRUWIRUWKHSULQWLQJRIWKLVWKHVLVZDVSURYLGHGE\&KLSVRIW%9
GHSDUWPHQWRIJ\QDHFRORJ\/HLGHQ8QLYHUVLW\0HGLFDO&HQWHU
k0LJQRQYDQ*HQW
$OOULJKWVUHVHUYHG1RSDUWRIWKLVWKHVLVPD\EHUHSURGXFHGRUWUDQVPLWWHGLQDQ\IRUPRU
E\DQ\PHDQVZLWKRXWSHUPLVVLRQRIWKHDXWKRU
&RSURPRWRUHV 'U0-.DJLH+DDJODQGHQ0HGLVFK&HQWUXP
'U&'GH.URRQ
/HGHQSURPRWLHFRPPLVVLH 3URI'U):-DQVHQ
3URI'U)$PDQW1HGHUODQGV.DQNHU,QVWLWXXW.8/HXYHQ
3URI'U0-(0RXULWV8QLYHUVLWHLW*URQLQJHQ
'U+0+D]HOEDJ+DDJODQGHQ0HGLVFK&HQWUXP
“Als je patiënten geen mogelijkheid tot vervullen kinderwens kan bieden moet je ze misschien iets anders te wensen bieden” - Michiel Krol, † 2012
&RSURPRWRUHV 'U0-.DJLH+DDJODQGHQ0HGLVFK&HQWUXP
'U&'GH.URRQ
/HGHQSURPRWLHFRPPLVVLH 3URI'U):-DQVHQ
3URI'U)$PDQW1HGHUODQGV.DQNHU,QVWLWXXW.8/HXYHQ
3URI'U0-(0RXULWV8QLYHUVLWHLW*URQLQJHQ
'U+0+D]HOEDJ+DDJODQGHQ0HGLVFK&HQWUXP
&+$37(5 1R6XUJHU\IRU/RZ*UDGH(QGRPHWULDO&DQFHULQ:RPHQ
ZLWKDGHVLUHWR3UHVHUYH)HUWLOLW\
&+$37(5 ([SORULQJPRUSKRORJLFDQGPROHFXODUDVSHFWVRI
HQGRPHWULDOFDQFHUXQGHUSURJHVWHURQHWUHDWPHQWLQWKH
FRQWH[WRIIHUWLOLW\SUHVHUYDWLRQ
&+$37(5 1HUYHVSDULQJUDGLFDOK\VWHUHFWRP\YHUVXVFRQYHQWLRQDO
UDGLFDOK\VWHUHFWRP\LQHDUO\VWDJHFHUYLFDOFDQFHU
$V\VWHPDWLFUHYLHZDQGPHWDDQDO\VLVRIVXUYLYDODQG
TXDOLW\RIOLIH
&+$37(5 /RQJWHUPRQFRORJLFDORXWFRPHDIWHUFRQYHQWLRQDOUDGLFDO
K\VWHUHFWRP\YHUVXVWZRQHUYHVSDULQJPRGDOLWLHVIRU
HDUO\VWDJHFHUYLFDOFDQFHU
&+$37(5 1HUYHVSDULQJUDGLFDODEGRPLQDOWUDFKHOHFWRP\YHUVXV
UDGLFDOK\VWHUHFWRP\LQHDUO\VWDJH),*2 ,$Ŋ,%FHUYLFDOFDQFHU$FRPSDUDWLYHVWXG\RQIHDVLELOLW\
DQGRXWFRPH
&+$37(5 *HQHUDOGLVFXVVLRQDQGUHFRPPHQGDWLRQV
&+$37(5 'XWFKVXPPDU\1HGHUODQGVHVDPHQYDWWLQJ
$33(1',&(6 %LEOLRJUDSK\
5HIHUHQFHV
$SSHQGL[)ORZFKDUW
$SSHQGL[&OLQLFDOGDWDDQGIROORZXSRI'XWFKFRKRUW
&XUULFXOXP9LWDH
$FNQRZOHGJHPHQWV
&+$37(5 ,QWURGXFWLRQ
&+$37(5 1R6XUJHU\IRU/RZ*UDGH(QGRPHWULDO&DQFHULQ:RPHQ
ZLWKDGHVLUHWR3UHVHUYH)HUWLOLW\
Journal of gynecol surg, 2012 Oct; volume 28 (issue 6):
398-398
&+$37(5 ([SORULQJPRUSKRORJLFDQGPROHFXODUDVSHFWVRI
HQGRPHWULDOFDQFHUXQGHUSURJHVWHURQHWUHDWPHQWLQWKH
FRQWH[WRIIHUWLOLW\SUHVHUYDWLRQ
Int J Gynecol Cancer. 2016 Mar; 26(3):483-90
&+$37(5 1HUYHVSDULQJUDGLFDOK\VWHUHFWRP\YHUVXVFRQYHQWLRQDO
UDGLFDOK\VWHUHFWRP\LQHDUO\VWDJHFHUYLFDOFDQFHU
$V\VWHPDWLFUHYLHZDQGPHWDDQDO\VLVRIVXUYLYDODQG
TXDOLW\RIOLIH
Maturitas. 2016 Dec;94.
&+$37(5 /RQJWHUPRQFRORJLFDORXWFRPHDIWHUFRQYHQWLRQDOUDGLFDO
K\VWHUHFWRP\YHUVXVWZRQHUYHVSDULQJPRGDOLWLHVIRU
HDUO\VWDJHFHUYLFDOFDQFHU
Int. J. Gynecol. Cancer. 2017. Accepted
&+$37(5 1HUYHVSDULQJUDGLFDODEGRPLQDOWUDFKHOHFWRP\YHUVXV
nerve sparing UDGLFDOK\VWHUHFWRP\LQHDUO\VWDJH),*2
,$Ŋ,%FHUYLFDOFDQFHU$FRPSDUDWLYHVWXG\RQIHDVLELOLW\
DQGRXWFRPH
Int J Gynecol Cancer. 2014 May; 24(4): 735-43
&+$37(5 *HQHUDOGLVFXVVLRQDQGUHFRPPHQGDWLRQV
&+$37(5 'XWFKVXPPDU\1HGHUODQGVHVDPHQYDWWLQJ
$33(1',&(6 %LEOLRJUDSK\
5HIHUHQFHV
$SSHQGL[)ORZFKDUW
$SSHQGL[&OLQLFDOGDWDDQGIROORZXSRI'XWFKFRKRUW
&XUULFXOXP9LWDH
$FNQRZOHGJHPHQWV
CHAPTER 1
Introduction
INTRODUCTION – TAILORING THERAPY IN GYNAECOLOGICAL CANCER
&DUHIRUSDWLHQWVZLWKFDQFHUKDVFKDQJHGRYHUWKHSDVWGHFDGHVIURPDPRUHSDWHUQDO
LVWLFPRGHOWRZDUGVDPRGHOLQZKLFKVKDUHGGHFLVLRQPDNLQJLVPRUHSURPLQHQW7KH
GRFWRUXVHGWRGHFLGHZKDWZDVEHVWIRUWKHSDWLHQWDQGVWDUWHGDWUHDWPHQWZLWKRXW
DOZD\VWDNLQJWKHSDWLHQWōVWKRXJKWVZLVKHVDQGYDOXHVLQWRFRQVLGHUDWLRQ,QVKDUHG
GHFLVLRQPDNLQJ WKH SDWLHQW DQG GRFWRU KDYH D GLDORJXH 4XDOLW\ RI OLIH DQG ZLVKHV
DQGYDOXHVRIWKHSDWLHQWSOD\DQLPSRUWDQWUROHLQGHWHUPLQLQJZKLFKZD\WRJR7KLV
GRHVQRWQHFHVVDULO\KDYHWREHWKHXVXDOJROGHQVWDQGDUGWUHDWPHQWRIZKLFKHIƓFDF\
DQGVDIHW\KDYHEHHQSURYHQLQZHOOSHUIRUPHGFRQWUROOHGWULDOV,WFDQDOVREHDQDG
DSWDWLRQRUDOWHUDWLRQRIWKHJROGHQVWDQGDUGWRDFFRPSOLVKPDLQWHQDQFHRIIHUWLOLW\LQ
HQGRPHWULDODQGFHUYLFDOFDQFHURUWRGHFLGHWREHPRUHRUOHVVDJJUHVVLYHLQUDGLFDO
K\VWHUHFWRP\VXUJHU\GHSHQGLQJRQWKHLQGLYLGXDOQHHGRIWKHSDWLHQW
,QWKLVWKHVLVWZRW\SHVRIJ\QDHFRORJLFDOFDQFHUVZLOOEHDGGUHVVHGQDPHO\ORZJUDGH
HDUO\VWDJHHQGRPHWULDOFDQFHUDQGHDUO\VWDJHFHUYLFDOFDQFHU6LQFHVXUYLYDOUDWHVRI
WKHVHSDWLHQWVDUHJRRGTXDOLW\RIOLIHDIWHUWUHDWPHQWLVRIJUHDWLPSRUWDQFH7KLVWKHVLV
SURYLGHVHYLGHQFHRIWKHWUHDWPHQWRSWLRQVDQGUHFRPPHQGDWLRQVDQGIXWXUHJRDOVWR
RSWLPLVH LQGLYLGXDOLVHG DQG WDLORUHG WKHUDS\ LQ HDUO\ VWDJH HQGRPHWULDO DQG FHUYLFDO
FDQFHU
ENDOMETRIAL CANCER
(QGRPHWULDOFDQFHULVWKHPRVWFRPPRQIRUPRIFDQFHURIWKHIHPDOHJHQLWDOWUDFWLQ
:HVWHUQFRXQWULHV,WLVWKHIRXUWKPRVWIUHTXHQWIRUPRIFDQFHUDIWHUEUHDVWOXQJDQG
FRORUHFWDOFDQFHU7KHLQFLGHQFHRIHQGRPHWULDOFDQFHULQWKH1HWKHUODQGVLVSHU
)RXUSHUFHQWRIWKHSDWLHQWVDUH\RXQJHUWKDQ\HDUVRIDJH7KLVPHDQV
DURXQGSDWLHQWVD\HDUDUHGLDJQRVHGZLWKHQGRPHWULDOFDQFHUZKRPD\QRWKDYH
FRPSOHWHGWKHLUIDPLO\+LJK%RG\0DVV,QGH[%0,DQGUHGXFHGSK\VLFDODFWLYLW\LQ
FUHDVHWKHULVNRIGHYHORSLQJHQGRPHWULDOFDQFHU2EHVLW\FDXVHVLQVXOLQUHVLVWDQFH
H[FHVVLYHDQGURJHQSURGXFWLRQE\WKHRYDULHVDQRYXODWLRQSRO\F\VWLFRYDU\V\QGURPH
DQGFKURQLFVKRUWDJHRISURJHVWHURQH:RPHQZLWKD%0,DERYHNJP2KDYHDGRX
EOHULVNRIJHWWLQJHQGRPHWULDOFDQFHUDQGZRPHQZLWKD%0,DERYHNJP2KDYHD
WULSOHULVNFRPSDUHGWRSDWLHQWVZLWKD%0,XQGHUNJP2%HFDXVHWKHPHDQ%0,ZLOO
ULVHGXULQJWKHFRPLQJ\HDUVWKHLQFLGHQFHRIHQGRPHWULDOFDQFHULQSUHPHQRSDXVDO
ZRPHQZLOODOVRULVH6LQFHSDWLHQWVZLWKWKHDERYHPHQWLRQHGIHDWXUHVKDYHDKLJKHU
FKDQFHRIKDYLQJIHUWLOLW\SUREOHPVWKH\KDYHDKLJKHUFKDQFHRIJHWWLQJSUHJQDQWUHO
DWLYHO\ODWH7KLVPDNHVWKHQHHGIRUUHVHDUFKLQWKLVƓHOGHYHQJUHDWHU0RVWSUHPHQR
SDXVDOZRPHQSUHVHQWZLWKDORZJUDGHHQGRPHWULRLGW\SHDGHQRFDUFLQRPDHPHUJHG
IURPWKHEDFNJURXQGRIHQGRPHWULDOK\SHUSODVLDDQGORQJODVWLQJHVWURJHQVWLPXODWLRQ
ZLWKRXWDGHTXDWHFRXQWHUDFWLRQE\SURJHVWHURQHV7KLVW\SHEHKDYHVOHVVDJJUHVVLYHO\
FRPSDUHGWRRWKHUW\SHVRIHQGRPHWULDOFDQFHU
7KHVWDQGDUGWUHDWPHQWRIVWDJH,HQGRPHWULDOFDQFHULVK\VWHUHFWRP\ZLWKELODWHUDOVDO
SLQJRRRSKRUHFWRP\&RQVHTXHQWO\WKLVPHDQVWKDWZRPHQZKRKDYHQRWFRPSOHWHG
WKHLUIDPLO\DUHFRQIURQWHGZLWKLQIHUWLOLW\DVDUHVXOWRIFDQFHUWKHUDS\
$QDOWHUQDWLYHIRUVXUJHU\FDQEHKRUPRQDOWUHDWPHQWZLWKSURJHVWHURQHV:RUOGZLGH
H[SHULHQFHVZLWKWKLVNLQGRIWUHDWPHQWKDYHEHHQGHVFULEHGLQRUGHUWRHYDOXDWHHIIHF
WLYHQHVVDQGVDIHW\ RIWKLVWKHVLVDUHYLHZLVSUHVHQWHGRQWKHHIIHF
WLYHQHVVDQGVDIHW\RIIHUWLOLW\VSDULQJWUHDWPHQWRIHDUO\VWDJHORZJUDGHHQGRPHWULDO
FDQFHU
:KLOHZULWLQJLWEHFDPHFOHDUWKDWUHSRUWLQJRIGDWDLVKHWHURJHQHRXVDQGWKDWVLQFHWKH
LQFLGHQFHRIHQGRPHWULDOFDQFHULQSUHPHQRSDXVDOZRPHQLVVRUDUHDXQLIRUPSURWR
FROZDVJUHDWO\QHHGHG7KHUHYLHZIRUPHGWKHEDVLVRIWKH'XWFKSURWRFROIRUIHUWLOLW\
VSDULQJWUHDWPHQWLQHQGRPHWULDOFDQFHUDSSHQGL[6LQFHWKHLQWURGXFWLRQRIWKHSUR
WRFROGDWDRISDWLHQWVWUHDWHGDFFRUGLQJWRWKHSURWRFROKDYHEHHQFROOHFWHGLQDFOLQLFDO
GDWDEDVHSURYLGLQJDQRYHUYLHZRIWKHUHVXOWVLQWKH'XWFKSRSXODWLRQDSSHQGL[
7KHTXHVWLRQUHPDLQVKRZWRGHFLGHZKLFKSDWLHQWZLOOEHQHƓWIURPKRUPRQDOWKHUDS\
DQG ZKLFK SDWLHQW ZLOO QRW7R UHGXFH WKH ULVN RI UHFXUUHQFH DQG IDLOHG WKHUDS\ SUH
GLFWRUVRISHUVLVWHQWUHVSRQVHQHHGWREHLGHQWLƓHG,Q WKRURXJKPROHFXODU
DQDO\VHVKDYHEHHQSHUIRUPHGRQVHTXHQWLDOHQGRPHWULDOVDPSOHVRISUHPHQRSDXVDO
ZRPHQZLWKORZJUDGHHQGRPHWULDOFDQFHU7KHVHSDWLHQWVZHUHWUHDWHGLQRUGHUWRSHU
FHLYHIHUWLOLW\ZLWKSURJHVWHURQHV7KHVDPSOHVKDYHEHHQXVHGIRULPPXQRKLVWRFKHP
LFDODQGLQGHSWKPROHFXODUDQDO\VLV:HNQRZIURPDGYDQFHGHQGRPHWULDOFDQFHULQ
ZKLFKSURJHVWHURQHUHFHSWRUDQDO\VLVLVGRQHURXWLQHO\WKDWDSRVLWLYHSURJHVWHURQH
UHFHSWRUVWDWXVLVSRVLWLYHO\SUHGLFWLQJUHVSRQVHWRSURJHVWHURQHWKHUDS\'XHWR
WKHORZSUHYDOHQFHRIHQGRPHWULDOFDQFHULQSUHPHQRSDXVDOZRPHQZHGRQRWKDYH
VXEVWDQWLDOHYLGHQFHWKDWZHFDQH[WUDSRODWHWKLVWRWKHORZJUDGHHQGRPHWULDOFDQFHUV
LQZRPHQZKRZRXOGFRQVLGHUIHUWLOLW\SUHVHUYLQJWKHUDS\3UHYLRXVVWXGLHVKDYHVXJ
JHVWHGSURJHVWHURQHWRKDYHDQDQWLWXPRXUHIIHFWE\LQWHUDFWLQJZLWKWKH:LQJOHVV
:QWDQGRU3KRVSKDWLG\OLQRVLWRONLQDVH3,.$NWVLJQDOWUDQVGXFWLRQSDWKZD\V
7KHVHSDWKZD\VLQGXFHFHOOSUROLIHUDWLRQDQGDUHWXUQHGŏRQŐDQGŏRIIŐGXULQJDPHQ
VWUXDOF\FOHXQGHUWKHLQŴXHQFHRISURJHVWHURQHHVWURJHQFKDQJHV:QWVLJQDOLQJFDQ
EH FRQVWLWXWLYHO\ DFWLYDWHG E\ PXWDWLRQV LQ WKH JHQH ҀFDWHQLQ$3& JHQH
RUXQGHULQŴXHQFHHQGRJHQRXVHVWURJHQRIWKHHQGRPHWULRLGHQGRPHWULDO
FDQFHUVKDVQXFOHDUҀFDWHQLQVWDLQLQJ,QYLWURDQDO\VHVKDYHVKRZQSURJHVWHURQH
1
&DUHIRUSDWLHQWVZLWKFDQFHUKDVFKDQJHGRYHUWKHSDVWGHFDGHVIURPDPRUHSDWHUQDO
LVWLFPRGHOWRZDUGVDPRGHOLQZKLFKVKDUHGGHFLVLRQPDNLQJLVPRUHSURPLQHQW7KH
GRFWRUXVHGWRGHFLGHZKDWZDVEHVWIRUWKHSDWLHQWDQGVWDUWHGDWUHDWPHQWZLWKRXW
DOZD\VWDNLQJWKHSDWLHQWōVWKRXJKWVZLVKHVDQGYDOXHVLQWRFRQVLGHUDWLRQ,QVKDUHG
GHFLVLRQPDNLQJ WKH SDWLHQW DQG GRFWRU KDYH D GLDORJXH 4XDOLW\ RI OLIH DQG ZLVKHV
DQGYDOXHVRIWKHSDWLHQWSOD\DQLPSRUWDQWUROHLQGHWHUPLQLQJZKLFKZD\WRJR7KLV
GRHVQRWQHFHVVDULO\KDYHWREHWKHXVXDOJROGHQVWDQGDUGWUHDWPHQWRIZKLFKHIƓFDF\
DQGVDIHW\KDYHEHHQSURYHQLQZHOOSHUIRUPHGFRQWUROOHGWULDOV,WFDQDOVREHDQDG
DSWDWLRQRUDOWHUDWLRQRIWKHJROGHQVWDQGDUGWRDFFRPSOLVKPDLQWHQDQFHRIIHUWLOLW\LQ
HQGRPHWULDODQGFHUYLFDOFDQFHURUWRGHFLGHWREHPRUHRUOHVVDJJUHVVLYHLQUDGLFDO
K\VWHUHFWRP\VXUJHU\GHSHQGLQJRQWKHLQGLYLGXDOQHHGRIWKHSDWLHQW
,QWKLVWKHVLVWZRW\SHVRIJ\QDHFRORJLFDOFDQFHUVZLOOEHDGGUHVVHGQDPHO\ORZJUDGH
HDUO\VWDJHHQGRPHWULDOFDQFHUDQGHDUO\VWDJHFHUYLFDOFDQFHU6LQFHVXUYLYDOUDWHVRI
WKHVHSDWLHQWVDUHJRRGTXDOLW\RIOLIHDIWHUWUHDWPHQWLVRIJUHDWLPSRUWDQFH7KLVWKHVLV
SURYLGHVHYLGHQFHRIWKHWUHDWPHQWRSWLRQVDQGUHFRPPHQGDWLRQVDQGIXWXUHJRDOVWR
RSWLPLVH LQGLYLGXDOLVHG DQG WDLORUHG WKHUDS\ LQ HDUO\ VWDJH HQGRPHWULDO DQG FHUYLFDO
FDQFHU
(QGRPHWULDOFDQFHULVWKHPRVWFRPPRQIRUPRIFDQFHURIWKHIHPDOHJHQLWDOWUDFWLQ
:HVWHUQFRXQWULHV,WLVWKHIRXUWKPRVWIUHTXHQWIRUPRIFDQFHUDIWHUEUHDVWOXQJDQG
FRORUHFWDOFDQFHU7KHLQFLGHQFHRIHQGRPHWULDOFDQFHULQWKH1HWKHUODQGVLVSHU
)RXUSHUFHQWRIWKHSDWLHQWVDUH\RXQJHUWKDQ\HDUVRIDJH7KLVPHDQV
DURXQGSDWLHQWVD\HDUDUHGLDJQRVHGZLWKHQGRPHWULDOFDQFHUZKRPD\QRWKDYH
FRPSOHWHGWKHLUIDPLO\+LJK%RG\0DVV,QGH[%0,DQGUHGXFHGSK\VLFDODFWLYLW\LQ
FUHDVHWKHULVNRIGHYHORSLQJHQGRPHWULDOFDQFHU2EHVLW\FDXVHVLQVXOLQUHVLVWDQFH
H[FHVVLYHDQGURJHQSURGXFWLRQE\WKHRYDULHVDQRYXODWLRQSRO\F\VWLFRYDU\V\QGURPH
DQGFKURQLFVKRUWDJHRISURJHVWHURQH:RPHQZLWKD%0,DERYHNJP KDYHDGRX
EOHULVNRIJHWWLQJHQGRPHWULDOFDQFHUDQGZRPHQZLWKD%0,DERYHNJP KDYHD
WULSOHULVNFRPSDUHGWRSDWLHQWVZLWKD%0,XQGHUNJP %HFDXVHWKHPHDQ%0,ZLOO
ULVHGXULQJWKHFRPLQJ\HDUVWKHLQFLGHQFHRIHQGRPHWULDOFDQFHULQSUHPHQRSDXVDO
ZRPHQZLOODOVRULVH6LQFHSDWLHQWVZLWKWKHDERYHPHQWLRQHGIHDWXUHVKDYHDKLJKHU
FKDQFHRIKDYLQJIHUWLOLW\SUREOHPVWKH\KDYHDKLJKHUFKDQFHRIJHWWLQJSUHJQDQWUHO
DWLYHO\ODWH7KLVPDNHVWKHQHHGIRUUHVHDUFKLQWKLVƓHOGHYHQJUHDWHU0RVWSUHPHQR
SDXVDOZRPHQSUHVHQWZLWKDORZJUDGHHQGRPHWULRLGW\SHDGHQRFDUFLQRPDHPHUJHG
IURPWKHEDFNJURXQGRIHQGRPHWULDOK\SHUSODVLDDQGORQJODVWLQJHVWURJHQVWLPXODWLRQ
ZLWKRXWDGHTXDWHFRXQWHUDFWLRQE\SURJHVWHURQHV7KLVW\SHEHKDYHVOHVVDJJUHVVLYHO\
FRPSDUHGWRRWKHUW\SHVRIHQGRPHWULDOFDQFHU
7KHVWDQGDUGWUHDWPHQWRIVWDJH,HQGRPHWULDOFDQFHULVK\VWHUHFWRP\ZLWKELODWHUDOVDO
SLQJRRRSKRUHFWRP\&RQVHTXHQWO\WKLVPHDQVWKDWZRPHQZKRKDYHQRWFRPSOHWHG
WKHLUIDPLO\DUHFRQIURQWHGZLWKLQIHUWLOLW\DVDUHVXOWRIFDQFHUWKHUDS\
Fertility-sparing treatment options
$QDOWHUQDWLYHIRUVXUJHU\FDQEHKRUPRQDOWUHDWPHQWZLWKSURJHVWHURQHV:RUOGZLGH
H[SHULHQFHVZLWKWKLVNLQGRIWUHDWPHQWKDYHEHHQGHVFULEHGLQRUGHUWRHYDOXDWHHIIHF
WLYHQHVVDQGVDIHW\ In chapter 2RIWKLVWKHVLVDUHYLHZLVSUHVHQWHGRQWKHHIIHF
WLYHQHVVDQGVDIHW\RIIHUWLOLW\VSDULQJWUHDWPHQWRIHDUO\VWDJHORZJUDGHHQGRPHWULDO
FDQFHU
:KLOHZULWLQJLWEHFDPHFOHDUWKDWUHSRUWLQJRIGDWDLVKHWHURJHQHRXVDQGWKDWVLQFHWKH
LQFLGHQFHRIHQGRPHWULDOFDQFHULQSUHPHQRSDXVDOZRPHQLVVRUDUHDXQLIRUPSURWR
FROZDVJUHDWO\QHHGHG7KHUHYLHZIRUPHGWKHEDVLVRIWKH'XWFKSURWRFROIRUIHUWLOLW\
VSDULQJWUHDWPHQWLQHQGRPHWULDOFDQFHUDSSHQGL[6LQFHWKHLQWURGXFWLRQRIWKHSUR
WRFROGDWDRISDWLHQWVWUHDWHGDFFRUGLQJWRWKHSURWRFROKDYHEHHQFROOHFWHGLQDFOLQLFDO
GDWDEDVHSURYLGLQJDQRYHUYLHZRIWKHUHVXOWVLQWKH'XWFKSRSXODWLRQDSSHQGL[
Pre-treatment patient selection
7KHTXHVWLRQUHPDLQVKRZWRGHFLGHZKLFKSDWLHQWZLOOEHQHƓWIURPKRUPRQDOWKHUDS\
DQG ZKLFK SDWLHQW ZLOO QRW7R UHGXFH WKH ULVN RI UHFXUUHQFH DQG IDLOHG WKHUDS\ SUH
GLFWRUVRISHUVLVWHQWUHVSRQVHQHHGWREHLGHQWLƓHG,Qchapter 3WKRURXJKPROHFXODU
DQDO\VHVKDYHEHHQSHUIRUPHGRQVHTXHQWLDOHQGRPHWULDOVDPSOHVRISUHPHQRSDXVDO
ZRPHQZLWKORZJUDGHHQGRPHWULDOFDQFHU7KHVHSDWLHQWVZHUHWUHDWHGLQRUGHUWRSHU
FHLYHIHUWLOLW\ZLWKSURJHVWHURQHV7KHVDPSOHVKDYHEHHQXVHGIRULPPXQRKLVWRFKHP
LFDODQGLQGHSWKPROHFXODUDQDO\VLV:HNQRZIURPDGYDQFHGHQGRPHWULDOFDQFHULQ
ZKLFKSURJHVWHURQHUHFHSWRUDQDO\VLVLVGRQHURXWLQHO\WKDWDSRVLWLYHSURJHVWHURQH
UHFHSWRUVWDWXVLVSRVLWLYHO\SUHGLFWLQJUHVSRQVHWRSURJHVWHURQHWKHUDS\'XHWR
WKHORZSUHYDOHQFHRIHQGRPHWULDOFDQFHULQSUHPHQRSDXVDOZRPHQZHGRQRWKDYH
VXEVWDQWLDOHYLGHQFHWKDWZHFDQH[WUDSRODWHWKLVWRWKHORZJUDGHHQGRPHWULDOFDQFHUV
LQZRPHQZKRZRXOGFRQVLGHUIHUWLOLW\SUHVHUYLQJWKHUDS\3UHYLRXVVWXGLHVKDYHVXJ
JHVWHGSURJHVWHURQHWRKDYHDQDQWLWXPRXUHIIHFWE\LQWHUDFWLQJZLWKWKH:LQJOHVV
:QWDQGRU3KRVSKDWLG\OLQRVLWRONLQDVH3,.$NWVLJQDOWUDQVGXFWLRQSDWKZD\V
7KHVHSDWKZD\VLQGXFHFHOOSUROLIHUDWLRQDQGDUHWXUQHGŏRQŐDQGŏRIIŐGXULQJDPHQ
VWUXDOF\FOHXQGHUWKHLQŴXHQFHRISURJHVWHURQHHVWURJHQFKDQJHV:QWVLJQDOLQJFDQ
EH FRQVWLWXWLYHO\ DFWLYDWHG E\ PXWDWLRQV LQ WKH CTNNB1 JHQH ҀFDWHQLQ$3& JHQH
RUXQGHULQŴXHQFHHQGRJHQRXVHVWURJHQRIWKHHQGRPHWULRLGHQGRPHWULDO
FDQFHUVKDVQXFOHDUҀFDWHQLQVWDLQLQJ,QYLWURDQDO\VHVKDYHVKRZQSURJHVWHURQH
WRLQKLELW:QWVLJQDOLQJE\XSUHJXODWLRQRI)2;2DQG'..VXJJHVWLQJWKHDQ
WLWXPRXUHIIHFWRISURJHVWHURQH3,.$NWLVDFWLYDWHGE\KRWVSRWPXWDWLRQVLQPIK3CA DQGRUKRASRULQDFWLYDWLRQRIWXPRXUVXSSUHVVRUJHQH37(1)LIW\WRHLJKW\SHUFHQW
RIWKHHQGRPHWULDOFDQFHUVLVNQRZQWRVKRZPTENORVVDQGUHVSHFWLYHO\DQG
RIWKHWXPRXUVKDYHPIK3CA and KRASPXWDWHG In chapter 3 VHTXHQWLDOHQGR
PHWULDOVDPSOHVRIZRPHQEHIRUHDQGZKLOHRQSURJHVWHURQHWKHUDS\DUHDQDO\VHGWR
LQYHVWLJDWHZKHWKHUJHQHWLFDOWHUDWLRQVLQWKHVHSDWKZD\VOHDGWRQRQUHVSRQVLYHQHVV
WRSURJHVWHURQHV7KHWKRXJKWZDVWKDWLIRQHSHUIRUPVWKHVHDQDO\VHVRQWKHWLVVXHDW
GLDJQRVLVLWPLJKWEHSRVVLEOHWRGLVWLQJXLVKUHVSRQGHUVIURPQRQUHVSRQGHUVEHIRUH
WUHDWPHQWLVLQLWLDWHG7KLVNQRZOHGJHZLOOUHVXOWLQLPSRUWDQWDGGLWLRQDOLQIRUPDWLRQDQG
LPSURYHVKDUHGGHFLVLRQPDNLQJLQUHVSHFWLYHZRPHQ
CERVICAL CANCER
7KHVHFRQGSDUWRIWKLVWKHVLVLVDERXWHDUO\VWDJHFHUYLFDOFDQFHU&HUYLFDOFDQFHULVWKH
VHFRQGPRVWIUHTXHQWW\SHRIFDQFHULQIHPDOHVZRUOGZLGH,WLVWKHIRXUWKPRVWOHWKDO
W\SHRIFDQFHUDIWHUEUHDVWOXQJDQGERZHOFDQFHU,QZRUOGZLGHQHZ
SDWLHQWVZHUHGLDJQRVHGZLWKFHUYLFDOFDQFHUDQGSHUFHQWRIWKHVHZRPHQZHUHOHVV
WKDQ\HDUVRIDJH7KHWUHDWPHQWRIFHUYLFDOFDQFHUGHSHQGVHQWLUHO\RQWKHVWDJHRI
GLVHDVHZKLFKLVGHWHUPLQHGE\FOLQLFDOH[DPLQDWLRQ0LFURVFRSLFGLVHDVH),*2,$LV
PRVWO\WUHDWHGE\FRQLVDWLRQRUVLPSOHK\VWHUHFWRP\7KHVRFDOOHGHDUO\VWDJHFHUYLFDO
FDQFHU),*2,$,%DQG,,$LVPRVWO\WUHDWHGZLWKDUDGLFDOK\VWHUHFWRP\LQFRPELQD
WLRQZLWKSHOYLFO\PSKDGHQHFWRP\$GMXYDQWFKHPRUDGLDWLRQFDQEHDGPLQLVWHUHG
LQFDVHRISRVLWLYHO\PSKQRGHVH[WUDFHUYLFDOJURZWKDQGXQIDYRXUDEOHWXPRXUFKDU
DFWHULVWLFV7KHSURJQRVLVRIFHUYLFDOFDQFHUDIWHUDUDGLFDOK\VWHUHFWRP\ZLWKSHOYLF
O\PSKDGHQHFWRP\GHSHQGVRQWKHDVSHFWVPHQWLRQHGDERYH<HDUVXUYLYDOUDWHVYDU\
EHWZHHQDQG$ZD\WRLPSURYHTXDOLW\RIOLIHDIWHUWUHDWPHQWLVWRUHGXFH
WKHUDS\LQGXFHGPRUELGLW\8SWRRIWKHSDWLHQWVWUHDWHGZLWKUDGLFDOK\VWHUHFWR
P\KDYHEODGGHUERZHORUVH[XDOG\VIXQFWLRQSUREOHPV,WLVWKRXJKWWKDWSDUWRI
WKLVPRUELGLW\LVGXHWRSHURSHUDWLYHGDPDJLQJRIWKHDXWRQRPLFQHUYHVLQWKHSHOYLV
0DDVHWDOVKRZHGWKDWWKHFRQYHQWLRQDOUDGLFDOK\VWHUHFWRP\3,9(5,,,GDPDJHVWKH
K\SRJDVWULFDQGVSODQFKQLFQHUYHVE\GLVVHFWLQJWKHVDFURXWHULQHOLJDPHQWVDQGWKH
SDUDPHWULXPXQGHUQHDWKWKHOHYHORIWKHGHHSXWHULQHYHLQUHVSHFWLYHO\7KHVHDX
WRQRPLFQHUYHVLQQHUYDWHWKHEODGGHUDQGERZHODQGUHJXODWHWKHOXEULFDWLRQVZHOOLQJ
UHVSRQVHRIWKHIHPDOHJHQLWDOVGXULQJVH[XDODURXVDO6LQFHJHQHUDODFFHSWDQFH
RIWKHQHUYHVSDULQJUDGLFDOK\VWHUHFWRP\DVDVWDQGDUGRIFDUHIRUWKHVXUJLFDOWUHDW
PHQWRIHDUO\VWDJHFHUYLFDOFDQFHULVULVLQJ+RZHYHUWKHWHFKQLTXHUHPDLQVVXEMHFW
RIGLVFXVVLRQLQWKHZRUOGRIJ\QDHFRORJLFRQFRORJ\3URSRQHQWVVWDWHWKHWHFKQLTXH
LVVDIHLWLPSURYHVTXDOLW\RIOLIHDIWHUVXUJHU\DQGVXUYLYDORXWFRPHVDUHQRWLPSDLUHG
2SSRQHQWVVD\WKHOLWHUDWXUHLVWRRKHWHURJHQHRXVWRGUDZWKHVHFRQFOXVLRQV
,Q7KH1HWKHUODQGVQHUYHVSDULQJVXUJHU\ZDVLQLWLDWHGDWWKHGHSDUWPHQWRIJ\QDHFR
ORJLFRQFRORJ\RIWKH/HLGHQ8QLYHUVLW\0HGLFDO&HQWHU/80&DQGWKHWHFKQLTXHKDV
HYROYHGRYHUWLPH)LUVWWKHUHZDVWKH/HLGHQ1HUYH6SDULQJ5DGLFDO+\VWHUHFWRP\
/165+ZKLFKZDVODWHUDGDSWHGWRWKH6ZLIWSURFHGXUHUHVHPEOLQJWKHWRWDOPHVRPH
WULDOUHVHFWLRQ7005DVGHYHORSHGDQGDGYRFDWHGE\+¸FNHOHWDO7KH6ZLIWSUR
FHGXUHLVDOVRDQHUYHVSDULQJWHFKQLTXHIRUUDGLFDOK\VWHUHFWRP\EHLQJPRUHUDGLFDO
WKDQWKH/165+EXWVSDULQJWKHVDPHQHUYHV7RHYDOXDWHWKHVDIHW\RIQHUYHVSDULQJ
WHFKQLTXHVIRUHDUO\VWDJHFHUYLFDOFDQFHUDV\VWHPDWLFUHYLHZDQGPHWDDQDO\VLVKDV
EHHQSHUIRUPHG ,WUHYLHZVVWXGLHVFRPSDULQJQHUYHVSDULQJUDGLFDOK\VWHU
HFWRPLHVZLWKQRQQHUYHVSDULQJUDGLFDOK\VWHUHFWRPLHVIRUHDUO\VWDJHFHUYLFDOFDQFHU
7KHUHYLHZIRFXVHVRQVXUYLYDODQGTXDOLW\RIOLIH,WZDVDOVRSHUIRUPHGWRFRPSDUHLW
ZLWKWKHƓQGLQJVRIWKHREVHUYDWLRQDOVWXG\SHUIRUPHGDWWKH/80& 7KLV
VLQJOHFHQWUHREVHUYDWLRQDOVWXG\HYDOXDWHVWKHUHVXOWVRIW\SHVRIUDGLFDOK\VWHUHF
WRPLHVQDPHO\WKHFRQYHQWLRQDOUDGLFDOK\VWHUHFWRP\:HUWKHLP0HLJV3,9(5,,,WKH
/HLGHQ1HUYH6SDULQJ5DGLFDO+\VWHUHFWRP\DQGWKH6ZLIWSURFHGXUH,WFODULƓHVZKDW
HIIHFWWKHLQWURGXFWLRQRIQHUYHVSDULQJWHFKQLTXHVLQUDGLFDOK\VWHUHFWRPLHVKDVRQWKH
RQFRORJLFDORXWFRPHV
)HUWLOLW\SUHVHUYDWLRQLVDQLPSRUWDQWLVVXHLQWDLORULQJWKHUDS\LQSDWLHQWVZLWKFHUYLFDO
FDQFHUDVZHOO$WWKH/80&DUDGLFDODEGRPLQDOWUDFKHOHFWRP\5$7ZLWKRUZLWKRXW
SUHRSHUDWLYHFKHPRWKHUDS\KDVEHHQSHUIRUPHGLQZRPHQZLWKVWDJH,$,%FHUYLFDO
FDQFHU3DUDOOHOWRWKHLQWURGXFWLRQRIWKHQHUYHVSDULQJWHFKQLTXHIRUWKHUDGLFDOK\VWHU
HFWRP\WKHSULQFLSOHRISUHVHUYDWLRQRIWKHDXWRQRPLFQHUYHVKDVEHHQWUDQVIHUUHGWR
WKH5$7HQVXULQJWKHVDPHIHUWLOLW\PDLQWDLQLQJVXUJHU\EXWDOVRSUHVHUYLQJWKHK\SR
JDVWULFDQGVSODQFKQLFQHUYHVQHUYHVSDULQJUDGLFDODEGRPLQDOWUDFKHOHFWRP\165$7
GHVFULEHVDFRPSDUDWLYHVWXG\HYDOXDWLQJRQFRORJLFDORXWFRPHVRIWKH16
5$7YHUVXVWKH165+FRQFXUUHQWO\GHVFULELQJWKHSUHJQDQF\RXWFRPHVRIWKH165$7
FRKRUW KROGVWKHJHQHUDOGLVFXVVLRQDQGUHFRPPHQGDWLRQVRQ
IHUWLOLW\VSDULQJWUHDWPHQWRIHQGRPHWULDOFDQFHUDQGQHUYHVSDULQJVXUJHU\DQGIHUWLOL
W\VSDULQJVXUJHU\IRUFHUYLFDOFDQFHU
1
WRLQKLELW:QWVLJQDOLQJE\XSUHJXODWLRQRI)2;2DQG'..VXJJHVWLQJWKHDQ
WLWXPRXUHIIHFWRISURJHVWHURQH3,.$NWLVDFWLYDWHGE\KRWVSRWPXWDWLRQVLQ
DQGRU RULQDFWLYDWLRQRIWXPRXUVXSSUHVVRUJHQH37(1)LIW\WRHLJKW\SHUFHQW
RIWKHHQGRPHWULDOFDQFHUVLVNQRZQWRVKRZ ORVVDQGUHVSHFWLYHO\DQG
RIWKHWXPRXUVKDYH PXWDWHG VHTXHQWLDOHQGR
PHWULDOVDPSOHVRIZRPHQEHIRUHDQGZKLOHRQSURJHVWHURQHWKHUDS\DUHDQDO\VHGWR
LQYHVWLJDWHZKHWKHUJHQHWLFDOWHUDWLRQVLQWKHVHSDWKZD\VOHDGWRQRQUHVSRQVLYHQHVV
WRSURJHVWHURQHV7KHWKRXJKWZDVWKDWLIRQHSHUIRUPVWKHVHDQDO\VHVRQWKHWLVVXHDW
GLDJQRVLVLWPLJKWEHSRVVLEOHWRGLVWLQJXLVKUHVSRQGHUVIURPQRQUHVSRQGHUVEHIRUH
WUHDWPHQWLVLQLWLDWHG7KLVNQRZOHGJHZLOOUHVXOWLQLPSRUWDQWDGGLWLRQDOLQIRUPDWLRQDQG
LPSURYHVKDUHGGHFLVLRQPDNLQJLQUHVSHFWLYHZRPHQ
7KHVHFRQGSDUWRIWKLVWKHVLVLVDERXWHDUO\VWDJHFHUYLFDOFDQFHU&HUYLFDOFDQFHULVWKH
VHFRQGPRVWIUHTXHQWW\SHRIFDQFHULQIHPDOHVZRUOGZLGH,WLVWKHIRXUWKPRVWOHWKDO
W\SHRIFDQFHUDIWHUEUHDVWOXQJDQGERZHOFDQFHU,QZRUOGZLGHQHZ
SDWLHQWVZHUHGLDJQRVHGZLWKFHUYLFDOFDQFHUDQGSHUFHQWRIWKHVHZRPHQZHUHOHVV
WKDQ\HDUVRIDJH7KHWUHDWPHQWRIFHUYLFDOFDQFHUGHSHQGVHQWLUHO\RQWKHVWDJHRI
GLVHDVHZKLFKLVGHWHUPLQHGE\FOLQLFDOH[DPLQDWLRQ0LFURVFRSLFGLVHDVH),*2,$LV
PRVWO\WUHDWHGE\FRQLVDWLRQRUVLPSOHK\VWHUHFWRP\7KHVRFDOOHGHDUO\VWDJHFHUYLFDO
FDQFHU),*2,$,%DQG,,$LVPRVWO\WUHDWHGZLWKDUDGLFDOK\VWHUHFWRP\LQFRPELQD
WLRQZLWKSHOYLFO\PSKDGHQHFWRP\$GMXYDQWFKHPRUDGLDWLRQFDQEHDGPLQLVWHUHG
LQFDVHRISRVLWLYHO\PSKQRGHVH[WUDFHUYLFDOJURZWKDQGXQIDYRXUDEOHWXPRXUFKDU
DFWHULVWLFV7KHSURJQRVLVRIFHUYLFDOFDQFHUDIWHUDUDGLFDOK\VWHUHFWRP\ZLWKSHOYLF
O\PSKDGHQHFWRP\GHSHQGVRQWKHDVSHFWVPHQWLRQHGDERYH<HDUVXUYLYDOUDWHVYDU\
EHWZHHQDQG$ZD\WRLPSURYHTXDOLW\RIOLIHDIWHUWUHDWPHQWLVWRUHGXFH
WKHUDS\LQGXFHGPRUELGLW\8SWRRIWKHSDWLHQWVWUHDWHGZLWKUDGLFDOK\VWHUHFWR
P\KDYHEODGGHUERZHORUVH[XDOG\VIXQFWLRQSUREOHPV,WLVWKRXJKWWKDWSDUWRI
WKLVPRUELGLW\LVGXHWRSHURSHUDWLYHGDPDJLQJRIWKHDXWRQRPLFQHUYHVLQWKHSHOYLV
0DDVHWDOVKRZHGWKDWWKHFRQYHQWLRQDOUDGLFDOK\VWHUHFWRP\3,9(5,,,GDPDJHVWKH
K\SRJDVWULFDQGVSODQFKQLFQHUYHVE\GLVVHFWLQJWKHVDFURXWHULQHOLJDPHQWVDQGWKH
SDUDPHWULXPXQGHUQHDWKWKHOHYHORIWKHGHHSXWHULQHYHLQUHVSHFWLYHO\7KHVHDX
WRQRPLFQHUYHVLQQHUYDWHWKHEODGGHUDQGERZHODQGUHJXODWHWKHOXEULFDWLRQVZHOOLQJ
UHVSRQVHRIWKHIHPDOHJHQLWDOVGXULQJVH[XDODURXVDO6LQFHJHQHUDODFFHSWDQFH
RIWKHQHUYHVSDULQJUDGLFDOK\VWHUHFWRP\DVDVWDQGDUGRIFDUHIRUWKHVXUJLFDOWUHDW
PHQWRIHDUO\VWDJHFHUYLFDOFDQFHULVULVLQJ+RZHYHUWKHWHFKQLTXHUHPDLQVVXEMHFW
RIGLVFXVVLRQLQWKHZRUOGRIJ\QDHFRORJLFRQFRORJ\3URSRQHQWVVWDWHWKHWHFKQLTXH
LVVDIHLWLPSURYHVTXDOLW\RIOLIHDIWHUVXUJHU\DQGVXUYLYDORXWFRPHVDUHQRWLPSDLUHG
2SSRQHQWVVD\WKHOLWHUDWXUHLVWRRKHWHURJHQHRXVWRGUDZWKHVHFRQFOXVLRQV
,Q7KH1HWKHUODQGVQHUYHVSDULQJVXUJHU\ZDVLQLWLDWHGDWWKHGHSDUWPHQWRIJ\QDHFR
ORJLFRQFRORJ\RIWKH/HLGHQ8QLYHUVLW\0HGLFDO&HQWHU/80&DQGWKHWHFKQLTXHKDV
HYROYHGRYHUWLPH)LUVWWKHUHZDVWKH/HLGHQ1HUYH6SDULQJ5DGLFDO+\VWHUHFWRP\
/165+ZKLFKZDVODWHUDGDSWHGWRWKH6ZLIWSURFHGXUHUHVHPEOLQJWKHWRWDOPHVRPH
WULDOUHVHFWLRQ7005DVGHYHORSHGDQGDGYRFDWHGE\+¸FNHOHWDO7KH6ZLIWSUR
FHGXUHLVDOVRDQHUYHVSDULQJWHFKQLTXHIRUUDGLFDOK\VWHUHFWRP\EHLQJPRUHUDGLFDO
WKDQWKH/165+EXWVSDULQJWKHVDPHQHUYHV7RHYDOXDWHWKHVDIHW\RIQHUYHVSDULQJ
WHFKQLTXHVIRUHDUO\VWDJHFHUYLFDOFDQFHUDV\VWHPDWLFUHYLHZDQGPHWDDQDO\VLVKDV
EHHQSHUIRUPHGchapter 4,WUHYLHZVVWXGLHVFRPSDULQJQHUYHVSDULQJUDGLFDOK\VWHU
HFWRPLHVZLWKQRQQHUYHVSDULQJUDGLFDOK\VWHUHFWRPLHVIRUHDUO\VWDJHFHUYLFDOFDQFHU
7KHUHYLHZIRFXVHVRQVXUYLYDODQGTXDOLW\RIOLIH,WZDVDOVRSHUIRUPHGWRFRPSDUHLW
ZLWKWKHƓQGLQJVRIWKHREVHUYDWLRQDOVWXG\SHUIRUPHGDWWKH/80&chapter 57KLV
VLQJOHFHQWUHREVHUYDWLRQDOVWXG\HYDOXDWHVWKHUHVXOWVRIW\SHVRIUDGLFDOK\VWHUHF
WRPLHVQDPHO\WKHFRQYHQWLRQDOUDGLFDOK\VWHUHFWRP\:HUWKHLP0HLJV3,9(5,,,WKH
/HLGHQ1HUYH6SDULQJ5DGLFDO+\VWHUHFWRP\DQGWKH6ZLIWSURFHGXUH,WFODULƓHVZKDW
HIIHFWWKHLQWURGXFWLRQRIQHUYHVSDULQJWHFKQLTXHVLQUDGLFDOK\VWHUHFWRPLHVKDVRQWKH
RQFRORJLFDORXWFRPHV
)HUWLOLW\SUHVHUYDWLRQLVDQLPSRUWDQWLVVXHLQWDLORULQJWKHUDS\LQSDWLHQWVZLWKFHUYLFDO
FDQFHUDVZHOO$WWKH/80&DUDGLFDODEGRPLQDOWUDFKHOHFWRP\5$7ZLWKRUZLWKRXW
SUHRSHUDWLYHFKHPRWKHUDS\KDVEHHQSHUIRUPHGLQZRPHQZLWKVWDJH,$,%FHUYLFDO
FDQFHU3DUDOOHOWRWKHLQWURGXFWLRQRIWKHQHUYHVSDULQJWHFKQLTXHIRUWKHUDGLFDOK\VWHU
HFWRP\WKHSULQFLSOHRISUHVHUYDWLRQRIWKHDXWRQRPLFQHUYHVKDVEHHQWUDQVIHUUHGWR
WKH5$7HQVXULQJWKHVDPHIHUWLOLW\PDLQWDLQLQJVXUJHU\EXWDOVRSUHVHUYLQJWKHK\SR
JDVWULFDQGVSODQFKQLFQHUYHVQHUYHVSDULQJUDGLFDODEGRPLQDOWUDFKHOHFWRP\165$7 Chapter 5GHVFULEHVDFRPSDUDWLYHVWXG\HYDOXDWLQJRQFRORJLFDORXWFRPHVRIWKH16
5$7YHUVXVWKH165+FRQFXUUHQWO\GHVFULELQJWKHSUHJQDQF\RXWFRPHVRIWKH165$7
FRKRUWchapter 6Chapter 7KROGVWKHJHQHUDOGLVFXVVLRQDQGUHFRPPHQGDWLRQVRQ
IHUWLOLW\VSDULQJWUHDWPHQWRIHQGRPHWULDOFDQFHUDQGQHUYHVSDULQJVXUJHU\DQGIHUWLOL
W\VSDULQJVXUJHU\IRUFHUYLFDOFDQFHU
REFERENCES
6FKDLQ:63DWLHQWVōULJKWVLQGHFLVLRQPDNLQJWKHFDVHIRUSHUVRQDOLVPYHUVXVSDWHUQDOLVPLQ
KHDOWKFDUH&DQFHU6XSSO
6LHJHO50D-=RX=-HPDO$&DQFHUVWDWLVWLFV&$&DQFHU-&OLQ
3DUNLQ '0 %UD\ ) )HUOD\ - 3LVDQL 3 *OREDO FDQFHU VWDWLVWLFV &$ &DQFHU - &OLQ
/HH1.&KHXQJ0.6KLQ-<+XVDLQ$7HQJ11%HUHN-6HWDO3URJQRVWLFIDFWRUVIRUXWHULQH
FDQFHULQUHSURGXFWLYHDJHGZRPHQ2EVWHW*\QHFRO
7UHIIHUV2EVWHWULHHQJ\QDHFRORJLHHKHU]LHQHGUXNHGS
6FKRXWHQ /- *ROGERKP 5$ YDQ GHQ %UDQGW 3$ $QWKURSRPHWU\ SK\VLFDO DFWLYLW\ DQG
HQGRPHWULDO FDQFHU ULVN UHVXOWV IURP WKH 1HWKHUODQGV FRKRUW VWXG\ ,QW - *\QHFRO &DQFHU
6XSSO
$PDQW)0RHUPDQ31HYHQ37LPPHUPDQ'9DQ/(9HUJRWH,(QGRPHWULDOFDQFHU/DQFHW
5HQHKDQ $* 6RHUMRPDWDUDP , /HLW]PDQQ 0) ,QWHUSUHWLQJ WKH HSLGHPLRORJLFDO HYLGHQFH
OLQNLQJREHVLW\DQGFDQFHU$IUDPHZRUNIRUSRSXODWLRQDWWULEXWDEOHULVNHVWLPDWLRQVLQ(XURSH
(XU-&DQFHU
%RNKPDQ -9 7ZR SDWKRJHQHWLF W\SHV RI HQGRPHWULDO FDUFLQRPD *\QHFRO 2QFRO
&DQFHU*HQRPH$WODV5HVHDUFK1.DQGRWK&6FKXOW]1&KHUQLDFN$'$NEDQL5/LX<HWDO
,QWHJUDWHGJHQRPLFFKDUDFWHUL]DWLRQRIHQGRPHWULDOFDUFLQRPD1DWXUH
&KXUFK '1 6WHOORR ( 1RXW 5$ 9DOWFKHYD 1 'HSUHHXZ - WHU +DDU 1 HW DO 3URJQRVWLF
VLJQLƓFDQFHRI32/(SURRIUHDGLQJPXWDWLRQVLQHQGRPHWULDOFDQFHU-RXUQDORIWKH1DWLRQDO
&DQFHU,QVWLWXWH
&RORPER1&UHXW]EHUJ&$PDQW)%RVVH7*RQ]DOH]0DUWLQ$/HGHUPDQQ-HWDO(602
(6*2(6752 &RQVHQVXV &RQIHUHQFH RQ (QGRPHWULDO &DQFHU 'LDJQRVLV 7UHDWPHQW DQG
)ROORZXS,QW-*\QHFRO&DQFHU
5DPLUH] 37 )UXPRYLW] 0 %RGXUND '& 6XQ && /HYHQEDFN & +RUPRQDO WKHUDS\ IRU WKH
PDQDJHPHQWRIJUDGHHQGRPHWULDODGHQRFDUFLQRPDDOLWHUDWXUHUHYLHZ*\QHFRO2QFRO
1LZD.7DJDPL./LDQ=2QRJL.0RUL+7DPD\D72XWFRPHRIIHUWLOLW\SUHVHUYLQJWUHDWPHQW
LQ\RXQJZRPHQZLWKHQGRPHWULDOFDUFLQRPDV%-2*
*DOORV,'<DS-5DMNKRZD0/XHVOH\'0&RRPDUDVDP\$*XSWD-.5HJUHVVLRQUHODSVH
DQGOLYHELUWKUDWHVZLWKIHUWLOLW\VSDULQJWKHUDS\IRUHQGRPHWULDOFDQFHUDQGDW\SLFDOFRPSOH[
HQGRPHWULDO K\SHUSODVLD D V\VWHPDWLF UHYLHZ DQG PHWDDQDO\VLV $P - 2EVWHW *\QHFRO
<DPD]DZD . +LUDL 0 )XMLWR $ 1LVKL + 7HUDXFKL ) ,VKLNXUD + HW DO )HUWLOLW\SUHVHUYLQJ
WUHDWPHQWZLWKSURJHVWLQDQGSDWKRORJLFDOFULWHULDWRSUHGLFWUHVSRQVHVLQ\RXQJZRPHQZLWK
HQGRPHWULDOFDQFHU+XP5HSURG
6LPSVRQ$1)HLJHQEHUJ7&ODUNH%$*LHQ/7,VPLLO1/DIUDPERLVH6HWDO)HUWLOLW\VSDULQJ
WUHDWPHQW RI FRPSOH[ DW\SLFDO K\SHUSODVLD DQG ORZJUDGH HQGRPHWULDO FDQFHU XVLQJ RUDO
SURJHVWLQ*\QHFRO2QFRO
*RWOLHE:+%HLQHU0(6KDOPRQ%.RUDFK<6HJDO<=PLUD1HWDO2XWFRPHRIIHUWLOLW\
VSDULQJWUHDWPHQWZLWKSURJHVWLQVLQ\RXQJSDWLHQWVZLWKHQGRPHWULDOFDQFHU2EVWHW*\QHFRO
2WD 7 <RVKLGD 0 .LPXUD 0 .LQRVKLWD . &OLQLFRSDWKRORJLF VWXG\ RI XWHULQH HQGRPHWULDO
FDUFLQRPDLQ\RXQJZRPHQDJHG\HDUVDQG\RXQJHU,QW-*\QHFRO&DQFHU
8VKLMLPD.<DKDWD+<RVKLNDZD+.RQLVKL,<DVXJL76DLWR7HWDO0XOWLFHQWHUSKDVH,,VWXG\
RIIHUWLOLW\VSDULQJWUHDWPHQWZLWKPHGUR[\SURJHVWHURQHDFHWDWHIRUHQGRPHWULDOFDUFLQRPD
DQGDW\SLFDOK\SHUSODVLDLQ\RXQJZRPHQ-RXUQDORIFOLQLFDORQFRORJ\RIƓFLDOMRXUQDORIWKH
$PHULFDQ6RFLHW\RI&OLQLFDO2QFRORJ\
YDQ *HQW 0'-0 .DJLH 0-7ULPERV-% 1R VXUJHU\ IRU /RZ*UDGH (QGRPHWULDO &DQFHU LQ
:RPHQZLWKD'HVLUHWR3UHVHUYH)HUWLOLW\-RXUQDORIJ\QHFRORJLF6XUJHU\
.DXSSLOD $ 2HVWURJHQ DQG SURJHVWLQ UHFHSWRUV DV SURJQRVWLF LQGLFDWRUV LQ HQGRPHWULDO
FDQFHU$UHYLHZRIWKHOLWHUDWXUH$FWD2QFRO
7KLJSHQ -7 %UDG\ 0) $OYDUH] 5' $GHOVRQ 0' +RPHVOH\ +' 0DQHWWD $ HW DO 2UDO
PHGUR[\SURJHVWHURQH DFHWDWH LQ WKH WUHDWPHQW RI DGYDQFHG RU UHFXUUHQW HQGRPHWULDO
FDUFLQRPDDGRVHUHVSRQVHVWXG\E\WKH*\QHFRORJLF2QFRORJ\*URXS-RXUQDORIFOLQLFDO
RQFRORJ\RIƓFLDOMRXUQDORIWKH$PHULFDQ6RFLHW\RI&OLQLFDO2QFRORJ\
:DQJ<YDQGHU=HH0)RGGH5%ORN/-:QW%HWDFDWHQLQDQGVH[KRUPRQHVLJQDOLQJLQ
HQGRPHWULDOKRPHRVWDVLVDQGFDQFHU2QFRWDUJHW
:DQJ < +DQLƓ0RJKDGGDP 3 +DQHNDPS (( .ORRVWHUERHU +- )UDQNHQ 3 9HOGVFKROWH -
HW DO 3URJHVWHURQH LQKLELWLRQ RI :QWEHWDFDWHQLQ VLJQDOLQJ LQ QRUPDO HQGRPHWULXP DQG
HQGRPHWULDOFDQFHU&OLQ&DQFHU5HV
6FKROWHQ$1&UHXW]EHUJ&/YDQGHQ%URHN/-1RRUGLMN(06PLW971XFOHDUEHWDFDWHQLQLV
DPROHFXODUIHDWXUHRIW\SH,HQGRPHWULDOFDUFLQRPD-3DWKRO
1
6FKDLQ:63DWLHQWVōULJKWVLQGHFLVLRQPDNLQJWKHFDVHIRUSHUVRQDOLVPYHUVXVSDWHUQDOLVPLQ
KHDOWKFDUH&DQFHU6XSSO
6LHJHO50D-=RX=-HPDO$&DQFHUVWDWLVWLFV&$&DQFHU-&OLQ
3DUNLQ '0 %UD\ ) )HUOD\ - 3LVDQL 3 *OREDO FDQFHU VWDWLVWLFV &$ &DQFHU - &OLQ
/HH1.&KHXQJ0.6KLQ-<+XVDLQ$7HQJ11%HUHN-6HWDO3URJQRVWLFIDFWRUVIRUXWHULQH
FDQFHULQUHSURGXFWLYHDJHGZRPHQ2EVWHW*\QHFRO
7UHIIHUV2EVWHWULHHQJ\QDHFRORJLHHKHU]LHQHGUXNHGS
6FKRXWHQ /- *ROGERKP 5$ YDQ GHQ %UDQGW 3$ $QWKURSRPHWU\ SK\VLFDO DFWLYLW\ DQG
HQGRPHWULDO FDQFHU ULVN UHVXOWV IURP WKH 1HWKHUODQGV FRKRUW VWXG\ ,QW - *\QHFRO &DQFHU
6XSSO
$PDQW)0RHUPDQ31HYHQ37LPPHUPDQ'9DQ/(9HUJRWH,(QGRPHWULDOFDQFHU/DQFHW
5HQHKDQ $* 6RHUMRPDWDUDP , /HLW]PDQQ 0) ,QWHUSUHWLQJ WKH HSLGHPLRORJLFDO HYLGHQFH
OLQNLQJREHVLW\DQGFDQFHU$IUDPHZRUNIRUSRSXODWLRQDWWULEXWDEOHULVNHVWLPDWLRQVLQ(XURSH
(XU-&DQFHU
%RNKPDQ -9 7ZR SDWKRJHQHWLF W\SHV RI HQGRPHWULDO FDUFLQRPD *\QHFRO 2QFRO
&DQFHU*HQRPH$WODV5HVHDUFK1.DQGRWK&6FKXOW]1&KHUQLDFN$'$NEDQL5/LX<HWDO
,QWHJUDWHGJHQRPLFFKDUDFWHUL]DWLRQRIHQGRPHWULDOFDUFLQRPD1DWXUH
&KXUFK '1 6WHOORR ( 1RXW 5$ 9DOWFKHYD 1 'HSUHHXZ - WHU +DDU 1 HW DO 3URJQRVWLF
VLJQLƓFDQFHRI32/(SURRIUHDGLQJPXWDWLRQVLQHQGRPHWULDOFDQFHU-RXUQDORIWKH1DWLRQDO
&DQFHU,QVWLWXWH
&RORPER1&UHXW]EHUJ&$PDQW)%RVVH7*RQ]DOH]0DUWLQ$/HGHUPDQQ-HWDO(602
(6*2(6752 &RQVHQVXV &RQIHUHQFH RQ (QGRPHWULDO &DQFHU 'LDJQRVLV 7UHDWPHQW DQG
)ROORZXS,QW-*\QHFRO&DQFHU
5DPLUH] 37 )UXPRYLW] 0 %RGXUND '& 6XQ && /HYHQEDFN & +RUPRQDO WKHUDS\ IRU WKH
PDQDJHPHQWRIJUDGHHQGRPHWULDODGHQRFDUFLQRPDDOLWHUDWXUHUHYLHZ*\QHFRO2QFRO
1LZD.7DJDPL./LDQ=2QRJL.0RUL+7DPD\D72XWFRPHRIIHUWLOLW\SUHVHUYLQJWUHDWPHQW
LQ\RXQJZRPHQZLWKHQGRPHWULDOFDUFLQRPDV%-2*
*DOORV,'<DS-5DMNKRZD0/XHVOH\'0&RRPDUDVDP\$*XSWD-.5HJUHVVLRQUHODSVH
DQGOLYHELUWKUDWHVZLWKIHUWLOLW\VSDULQJWKHUDS\IRUHQGRPHWULDOFDQFHUDQGDW\SLFDOFRPSOH[
HQGRPHWULDO K\SHUSODVLD D V\VWHPDWLF UHYLHZ DQG PHWDDQDO\VLV $P - 2EVWHW *\QHFRO
<DPD]DZD . +LUDL 0 )XMLWR $ 1LVKL + 7HUDXFKL ) ,VKLNXUD + HW DO )HUWLOLW\SUHVHUYLQJ
WUHDWPHQWZLWKSURJHVWLQDQGSDWKRORJLFDOFULWHULDWRSUHGLFWUHVSRQVHVLQ\RXQJZRPHQZLWK
HQGRPHWULDOFDQFHU+XP5HSURG
6LPSVRQ$1)HLJHQEHUJ7&ODUNH%$*LHQ/7,VPLLO1/DIUDPERLVH6HWDO)HUWLOLW\VSDULQJ
WUHDWPHQW RI FRPSOH[ DW\SLFDO K\SHUSODVLD DQG ORZJUDGH HQGRPHWULDO FDQFHU XVLQJ RUDO
SURJHVWLQ*\QHFRO2QFRO
*RWOLHE:+%HLQHU0(6KDOPRQ%.RUDFK<6HJDO<=PLUD1HWDO2XWFRPHRIIHUWLOLW\
VSDULQJWUHDWPHQWZLWKSURJHVWLQVLQ\RXQJSDWLHQWVZLWKHQGRPHWULDOFDQFHU2EVWHW*\QHFRO
2WD 7 <RVKLGD 0 .LPXUD 0 .LQRVKLWD . &OLQLFRSDWKRORJLF VWXG\ RI XWHULQH HQGRPHWULDO
FDUFLQRPDLQ\RXQJZRPHQDJHG\HDUVDQG\RXQJHU,QW-*\QHFRO&DQFHU
8VKLMLPD.<DKDWD+<RVKLNDZD+.RQLVKL,<DVXJL76DLWR7HWDO0XOWLFHQWHUSKDVH,,VWXG\
RIIHUWLOLW\VSDULQJWUHDWPHQWZLWKPHGUR[\SURJHVWHURQHDFHWDWHIRUHQGRPHWULDOFDUFLQRPD
DQGDW\SLFDOK\SHUSODVLDLQ\RXQJZRPHQ-RXUQDORIFOLQLFDORQFRORJ\RIƓFLDOMRXUQDORIWKH
$PHULFDQ6RFLHW\RI&OLQLFDO2QFRORJ\
YDQ *HQW 0'-0 .DJLH 0-7ULPERV-% 1R VXUJHU\ IRU /RZ*UDGH (QGRPHWULDO &DQFHU LQ
:RPHQZLWKD'HVLUHWR3UHVHUYH)HUWLOLW\-RXUQDORIJ\QHFRORJLF6XUJHU\
.DXSSLOD $ 2HVWURJHQ DQG SURJHVWLQ UHFHSWRUV DV SURJQRVWLF LQGLFDWRUV LQ HQGRPHWULDO
FDQFHU$UHYLHZRIWKHOLWHUDWXUH$FWD2QFRO
7KLJSHQ -7 %UDG\ 0) $OYDUH] 5' $GHOVRQ 0' +RPHVOH\ +' 0DQHWWD $ HW DO 2UDO
PHGUR[\SURJHVWHURQH DFHWDWH LQ WKH WUHDWPHQW RI DGYDQFHG RU UHFXUUHQW HQGRPHWULDO
FDUFLQRPDDGRVHUHVSRQVHVWXG\E\WKH*\QHFRORJLF2QFRORJ\*URXS-RXUQDORIFOLQLFDO
RQFRORJ\RIƓFLDOMRXUQDORIWKH$PHULFDQ6RFLHW\RI&OLQLFDO2QFRORJ\
:DQJ<YDQGHU=HH0)RGGH5%ORN/-:QW%HWDFDWHQLQDQGVH[KRUPRQHVLJQDOLQJLQ
HQGRPHWULDOKRPHRVWDVLVDQGFDQFHU2QFRWDUJHW
:DQJ < +DQLƓ0RJKDGGDP 3 +DQHNDPS (( .ORRVWHUERHU +- )UDQNHQ 3 9HOGVFKROWH -
HW DO 3URJHVWHURQH LQKLELWLRQ RI :QWEHWDFDWHQLQ VLJQDOLQJ LQ QRUPDO HQGRPHWULXP DQG
HQGRPHWULDOFDQFHU&OLQ&DQFHU5HV
6FKROWHQ$1&UHXW]EHUJ&/YDQGHQ%URHN/-1RRUGLMN(06PLW971XFOHDUEHWDFDWHQLQLV
DPROHFXODUIHDWXUHRIW\SH,HQGRPHWULDOFDUFLQRPD-3DWKRO
6DHJXVD02ND\DVX,)UHTXHQWQXFOHDUEHWDFDWHQLQDFFXPXODWLRQDQGDVVRFLDWHGPXWDWLRQV
LQHQGRPHWULRLGW\SHHQGRPHWULDODQGRYDULDQFDUFLQRPDVZLWKVTXDPRXVGLIIHUHQWLDWLRQ-
3DWKRO
0XWWHU*//LQ0&)LW]JHUDOG-7.XP-%%DDN-3/HHV-$HWDO$OWHUHG37(1H[SUHVVLRQDVD
GLDJQRVWLFPDUNHUIRUWKHHDUOLHVWHQGRPHWULDOSUHFDQFHUV-1DWO&DQFHU,QVW
/HH,,.LP--,QŴXHQFHRI$.7RQ3URJHVWHURQH$FWLRQLQ(QGRPHWULDO'LVHDVHV%LRO5HSURG
6SDDQV907ULHWVFK0'&UREDFK66WHOORR(.UHPHU'2VVH(0HWDO'HVLJQLQJDKLJK
WKURXJKSXW VRPDWLF PXWDWLRQ SURƓOLQJ SDQHO VSHFLƓFDOO\ IRU J\QDHFRORJLFDO FDQFHUV 3/R6
2QHH
$UE\Q0&DVWHOOVDJXH;GH66%UXQL/6DUDL\D0%UD\)HWDO:RUOGZLGHEXUGHQRIFHUYLFDO
FDQFHULQ$QQ2QFRO
3HWHUV :$ UG /LX 3< %DUUHWW 5- QG 6WRFN 5- 0RQN %- %HUHN -6 HW DO &RQFXUUHQW
FKHPRWKHUDS\ DQG SHOYLF UDGLDWLRQ WKHUDS\ FRPSDUHG ZLWK SHOYLF UDGLDWLRQ WKHUDS\ DORQH
DV DGMXYDQW WKHUDS\ DIWHU UDGLFDO VXUJHU\ LQ KLJKULVN HDUO\VWDJH FDQFHU RI WKH FHUYL[
-RXUQDORIFOLQLFDORQFRORJ\RIƓFLDOMRXUQDORIWKH$PHULFDQ6RFLHW\RI&OLQLFDO2QFRORJ\
5RWPDQ 0 6HGOLV $ 3LHGPRQWH 05 %XQG\ % /HQW] 66 0XGHUVSDFK /, HW DO $ SKDVH ,,,
UDQGRPL]HGWULDORISRVWRSHUDWLYHSHOYLFLUUDGLDWLRQLQ6WDJH,%FHUYLFDOFDUFLQRPDZLWKSRRU
SURJQRVWLFIHDWXUHVIROORZXSRIDJ\QHFRORJLFRQFRORJ\JURXSVWXG\,QW-5DGLDW2QFRO%LRO
3K\V
6HGOLV$%XQG\%15RWPDQ0=/HQW]660XGHUVSDFK/,=DLQR5-$UDQGRPL]HGWULDORISHOYLF
UDGLDWLRQWKHUDS\YHUVXVQRIXUWKHUWKHUDS\LQVHOHFWHGSDWLHQWVZLWKVWDJH,%FDUFLQRPDRI
WKHFHUYL[DIWHUUDGLFDOK\VWHUHFWRP\DQGSHOYLFO\PSKDGHQHFWRP\$*\QHFRORJLF2QFRORJ\
*URXS6WXG\*\QHFRO2QFRO
5RE / +DODVND 0 5RERYD + 1HUYHVSDULQJ DQG LQGLYLGXDOO\ WDLORUHG VXUJHU\ IRU FHUYLFDO
FDQFHU/DQFHW2QFRO
/RQJ<<DR'63DQ;:2X7<&OLQLFDOHIƓFDF\DQGVDIHW\RIQHUYHVSDULQJUDGLFDOK\VWHUHFWRP\
IRUFHUYLFDOFDQFHUDV\VWHPDWLFUHYLHZDQGPHWDDQDO\VLV3/R62QHH
3LHWHUVH4'.HQWHU**0DDV&3GH.URRQ&'&UHXW]EHUJ&/7ULPERV-%HWDO6HOIUHSRUWHG
VH[XDOERZHODQGEODGGHUIXQFWLRQLQFHUYLFDOFDQFHUSDWLHQWVIROORZLQJGLIIHUHQWWUHDWPHQW
PRGDOLWLHVORQJLWXGLQDOSURVSHFWLYHFRKRUWVWXG\,QW-*\QHFRO&DQFHU
%HUJPDUN.$YDOO/XQGTYLVW('LFNPDQ3:+HQQLQJVRKQ/6WHLQHFN*9DJLQDOFKDQJHVDQG
VH[XDOLW\LQZRPHQZLWKDKLVWRU\RIFHUYLFDOFDQFHU7KH1HZ(QJODQGMRXUQDORIPHGLFLQH
3LHWHUVH 4' 0DDV &3 7HU .XLOH 00 /RZLN 0 YDQ (LMNHUHQ 0$ 7ULPERV -% HW DO $Q
REVHUYDWLRQDO ORQJLWXGLQDO VWXG\ WR HYDOXDWH PLFWLRQ GHIHFDWLRQ DQG VH[XDO IXQFWLRQ
DIWHU UDGLFDO K\VWHUHFWRP\ ZLWK SHOYLF O\PSKDGHQHFWRP\ IRU HDUO\VWDJH FHUYLFDO FDQFHU
,QW-*\QHFRO&DQFHU
0DDV &3 7ULPERV -% 'HUXLWHU 0& YDQ GH 9HOGH &- .HQWHU ** 1HUYH VSDULQJ UDGLFDO
K\VWHUHFWRP\ ODWHVW GHYHORSPHQWV DQG KLVWRULFDO SHUVSHFWLYH &ULW 5HY 2QFRO +HPDWRO
7ULPERV-%0DDV&3'HUXLWHU0&3HWHUV$$.HQWHU**$QHUYHVSDULQJUDGLFDOK\VWHUHFWRP\
JXLGHOLQHVDQGIHDVLELOLW\LQ:HVWHUQSDWLHQWV,QW-*\QHFRO&DQFHU
0DDV &3 .HQWHU **7ULPERV -% 'HUXLWHU 0&$QDWRPLFDO EDVLV IRU QHUYHVSDULQJ UDGLFDO
K\VWHUHFWRP\ LPPXQRKLVWRFKHPLFDO VWXG\ RI WKH SHOYLF DXWRQRPLF QHUYHV $FWD 2EVWHW
*\QHFRO6FDQG
GH.URRQ&'*DDUHQVWURRP.1YDQ3RHOJHHVW0,3HWHUV$$7ULPERV-%1HUYHVSDULQJLQ
UDGLFDOVXUJHU\IRUHDUO\VWDJHFHUYLFDOFDQFHU\HVZHVKRXOG,QW-*\QHFRO&DQFHU
6XSSO66
7ULPERV-%0DDV&3'HUXLWHU0&.HQWHU**>1HUYHVSDULQJUDGLFDOK\VWHUHFWRP\LQWKHFDVH
RIFHUYLFDOFDQFHU@1HG7LMGVFKU*HQHHVNG
7ULPERV-%9DQ'HQ7LOODDUW6$+00DDV&33HWHUV$$:*DDUHQVWURRP.1'HUXLWHU0&
HWDO7KH6ZLIWRSHUDWLRQ$PRGLƓFDWLRQRIWKH/HLGHQQHUYHVSDULQJUDGLFDOK\VWHUHFWRP\
*\QHFRORJLFDO6XUJHU\
+RFNHO0+RUQ/&+HQWVFKHO%+RFNHO61DXPDQQ*7RWDOPHVRPHWULDOUHVHFWLRQKLJK
UHVROXWLRQ QHUYHVSDULQJ UDGLFDO K\VWHUHFWRP\ EDVHG RQ GHYHORSPHQWDOO\ GHƓQHG VXUJLFDO
DQDWRP\,QW-*\QHFRO&DQFHU
1
6DHJXVD02ND\DVX,)UHTXHQWQXFOHDUEHWDFDWHQLQDFFXPXODWLRQDQGDVVRFLDWHGPXWDWLRQV
LQHQGRPHWULRLGW\SHHQGRPHWULDODQGRYDULDQFDUFLQRPDVZLWKVTXDPRXVGLIIHUHQWLDWLRQ-
3DWKRO
0XWWHU*//LQ0&)LW]JHUDOG-7.XP-%%DDN-3/HHV-$HWDO$OWHUHG37(1H[SUHVVLRQDVD
GLDJQRVWLFPDUNHUIRUWKHHDUOLHVWHQGRPHWULDOSUHFDQFHUV-1DWO&DQFHU,QVW
/HH,,.LP--,QŴXHQFHRI$.7RQ3URJHVWHURQH$FWLRQLQ(QGRPHWULDO'LVHDVHV%LRO5HSURG
6SDDQV907ULHWVFK0'&UREDFK66WHOORR(.UHPHU'2VVH(0HWDO'HVLJQLQJDKLJK
WKURXJKSXW VRPDWLF PXWDWLRQ SURƓOLQJ SDQHO VSHFLƓFDOO\ IRU J\QDHFRORJLFDO FDQFHUV 3/R6
2QHH
$UE\Q0&DVWHOOVDJXH;GH66%UXQL/6DUDL\D0%UD\)HWDO:RUOGZLGHEXUGHQRIFHUYLFDO
FDQFHULQ$QQ2QFRO
3HWHUV :$ UG /LX 3< %DUUHWW 5- QG 6WRFN 5- 0RQN %- %HUHN -6 HW DO &RQFXUUHQW
FKHPRWKHUDS\ DQG SHOYLF UDGLDWLRQ WKHUDS\ FRPSDUHG ZLWK SHOYLF UDGLDWLRQ WKHUDS\ DORQH
DV DGMXYDQW WKHUDS\ DIWHU UDGLFDO VXUJHU\ LQ KLJKULVN HDUO\VWDJH FDQFHU RI WKH FHUYL[
-RXUQDORIFOLQLFDORQFRORJ\RIƓFLDOMRXUQDORIWKH$PHULFDQ6RFLHW\RI&OLQLFDO2QFRORJ\
5RWPDQ 0 6HGOLV $ 3LHGPRQWH 05 %XQG\ % /HQW] 66 0XGHUVSDFK /, HW DO $ SKDVH ,,,
UDQGRPL]HGWULDORISRVWRSHUDWLYHSHOYLFLUUDGLDWLRQLQ6WDJH,%FHUYLFDOFDUFLQRPDZLWKSRRU
SURJQRVWLFIHDWXUHVIROORZXSRIDJ\QHFRORJLFRQFRORJ\JURXSVWXG\,QW-5DGLDW2QFRO%LRO
3K\V
6HGOLV$%XQG\%15RWPDQ0=/HQW]660XGHUVSDFK/,=DLQR5-$UDQGRPL]HGWULDORISHOYLF
UDGLDWLRQWKHUDS\YHUVXVQRIXUWKHUWKHUDS\LQVHOHFWHGSDWLHQWVZLWKVWDJH,%FDUFLQRPDRI
WKHFHUYL[DIWHUUDGLFDOK\VWHUHFWRP\DQGSHOYLFO\PSKDGHQHFWRP\$*\QHFRORJLF2QFRORJ\
*URXS6WXG\*\QHFRO2QFRO
5RE / +DODVND 0 5RERYD + 1HUYHVSDULQJ DQG LQGLYLGXDOO\ WDLORUHG VXUJHU\ IRU FHUYLFDO
FDQFHU/DQFHW2QFRO
/RQJ<<DR'63DQ;:2X7<&OLQLFDOHIƓFDF\DQGVDIHW\RIQHUYHVSDULQJUDGLFDOK\VWHUHFWRP\
IRUFHUYLFDOFDQFHUDV\VWHPDWLFUHYLHZDQGPHWDDQDO\VLV3/R62QHH
3LHWHUVH4'.HQWHU**0DDV&3GH.URRQ&'&UHXW]EHUJ&/7ULPERV-%HWDO6HOIUHSRUWHG
VH[XDOERZHODQGEODGGHUIXQFWLRQLQFHUYLFDOFDQFHUSDWLHQWVIROORZLQJGLIIHUHQWWUHDWPHQW
PRGDOLWLHVORQJLWXGLQDOSURVSHFWLYHFRKRUWVWXG\,QW-*\QHFRO&DQFHU
%HUJPDUN.$YDOO/XQGTYLVW('LFNPDQ3:+HQQLQJVRKQ/6WHLQHFN*9DJLQDOFKDQJHVDQG
VH[XDOLW\LQZRPHQZLWKDKLVWRU\RIFHUYLFDOFDQFHU7KH1HZ(QJODQGMRXUQDORIPHGLFLQH
3LHWHUVH 4' 0DDV &3 7HU .XLOH 00 /RZLN 0 YDQ (LMNHUHQ 0$ 7ULPERV -% HW DO $Q
REVHUYDWLRQDO ORQJLWXGLQDO VWXG\ WR HYDOXDWH PLFWLRQ GHIHFDWLRQ DQG VH[XDO IXQFWLRQ
DIWHU UDGLFDO K\VWHUHFWRP\ ZLWK SHOYLF O\PSKDGHQHFWRP\ IRU HDUO\VWDJH FHUYLFDO FDQFHU
,QW-*\QHFRO&DQFHU
0DDV &3 7ULPERV -% 'HUXLWHU 0& YDQ GH 9HOGH &- .HQWHU ** 1HUYH VSDULQJ UDGLFDO
K\VWHUHFWRP\ ODWHVW GHYHORSPHQWV DQG KLVWRULFDO SHUVSHFWLYH &ULW 5HY 2QFRO +HPDWRO
7ULPERV-%0DDV&3'HUXLWHU0&3HWHUV$$.HQWHU**$QHUYHVSDULQJUDGLFDOK\VWHUHFWRP\
JXLGHOLQHVDQGIHDVLELOLW\LQ:HVWHUQSDWLHQWV,QW-*\QHFRO&DQFHU
0DDV &3 .HQWHU **7ULPERV -% 'HUXLWHU 0&$QDWRPLFDO EDVLV IRU QHUYHVSDULQJ UDGLFDO
K\VWHUHFWRP\ LPPXQRKLVWRFKHPLFDO VWXG\ RI WKH SHOYLF DXWRQRPLF QHUYHV $FWD 2EVWHW
*\QHFRO6FDQG
GH.URRQ&'*DDUHQVWURRP.1YDQ3RHOJHHVW0,3HWHUV$$7ULPERV-%1HUYHVSDULQJLQ
UDGLFDOVXUJHU\IRUHDUO\VWDJHFHUYLFDOFDQFHU\HVZHVKRXOG,QW-*\QHFRO&DQFHU
6XSSO66
7ULPERV-%0DDV&3'HUXLWHU0&.HQWHU**>1HUYHVSDULQJUDGLFDOK\VWHUHFWRP\LQWKHFDVH
RIFHUYLFDOFDQFHU@1HG7LMGVFKU*HQHHVNG
7ULPERV-%9DQ'HQ7LOODDUW6$+00DDV&33HWHUV$$:*DDUHQVWURRP.1'HUXLWHU0&
HWDO7KH6ZLIWRSHUDWLRQ$PRGLƓFDWLRQRIWKH/HLGHQQHUYHVSDULQJUDGLFDOK\VWHUHFWRP\
*\QHFRORJLFDO6XUJHU\
+RFNHO0+RUQ/&+HQWVFKHO%+RFNHO61DXPDQQ*7RWDOPHVRPHWULDOUHVHFWLRQKLJK
UHVROXWLRQ QHUYHVSDULQJ UDGLFDO K\VWHUHFWRP\ EDVHG RQ GHYHORSPHQWDOO\ GHƓQHG VXUJLFDO
DQDWRP\,QW-*\QHFRO&DQFHU
%DSWLVW7ULPERV
CHAPTER 2
No Surgery for Low-Grade Endometrial Cancer in Women with a desire to Preserve Fertility
Mignon van Gent 0DUMROHLQ.DJLH
%DSWLVW7ULPERV
Journal of gynecological surgery 2012 Oct; volume 28 (issue 6): 398-398
CHAPTER 2
No Surgery for Low-Grade Endometrial Cancer in Women with a desire to Preserve Fertility
$EVWUDFW
,QWURGXFWLRQ
2EMHFWLYHV
0DWHULDOVDQGPHWKRGV
5HVXOWV
'LVFXVVLRQ
$XWKRUVōFRQFOXVLRQV
5HIHUHQFHV
7KHWUHDWPHQWRIHQGRPHWULDOFDQFHULVWRWDOK\VWHUHFWRP\LQFOXGLQJELODWHUDOVDOSLQ
JRRRSKRUHFWRP\6WDQGDUGWUHDWPHQWWDNHVDZD\WKHSRVVLELOLW\IRUIHUWLOHZRPHQWR
FRQFHLYH 7KLV UHYLHZ VWXGLHV WKH HIIHFWLYHQHVV DQG VDIHW\ RI FRQVHUYDWLYHKRUPRQDO
WKHUDS\IRUVWDJH,JUDGHDQGHQGRPHWULDOFDQFHU
:HVHDUFKHG3XEPHGIRUSXEOLFDWLRQVIURP-DQXDU\WR1RYHPEHU3XEOL
FDWLRQVLQFOXGHGUHWURVSHFWLYHVWXGLHVFDVHUHSRUWVPXOWLFHQWHU3KDVH,,VWXG\DQGOLW
HUDWXUHUHYLHZVGHVFULELQJFRQVHUYDWLYHWUHDWPHQWIRUZRPHQZLWKW\SH,HQGRPHWULDO
FDQFHU
)LIW\ƓYHVWXGLHVGHVFULEHGSDWLHQWVZLWKVWDJH,HQGRPHWULDOFDQFHU7KHPHGLDQ
DJHRIWKHSDWLHQWVZDV\HDUV7ZRKXQGUHGDQGWKLUW\WZRSDWLHQWVKDGJUDGHGLV
HDVHDQGKDGJUDGHRUPRUH*UDGLQJZDVXQNQRZQIRUƓYHSDWLHQWV3DWLHQWVZHUH
WUHDWHGZLWKGLIIHUHQWSURJHVWDWLYHV7KUHHRXWRISDWLHQWVGLGQRWUHFHLYHDQ\WUHDW
PHQWIRUWKHLUGLVHDVH7KHPHDQQXPEHURIPRQWKVRIWUHDWPHQWZDVPRQWKV2QH
KXQGUHGDQGQLQHW\WKUHHRIWKHSDWLHQWVUHVSRQGHGLQLWLDOO\WRWKHUDS\3URJHVWHU
RQHUHFHSWRUVWDWXVZDVNQRZQLQRISDWLHQWV6HYHQW\VHYHQSDWLHQWVZHUH
SURJHVWHURQHUHFHSWRUSRVLWLYH7KHPHDQIROORZXSZDVPRQWKV1RSDWLHQWGLHGRI
HQGRPHWULDOFDQFHU2QHKXQGUHGDQGWZHQW\VHYHQSUHJQDQFLHVDQGOLYLQJELUWKV
ZHUHGHVFULEHG
&RQVHUYDWLYHWUHDWPHQWRIHQGRPHWULDOFDQFHUPD\EHFRQVLGHUHGLQDZHOOVHOHFWHG
JURXSRISDWLHQWVVWDJH,JUDGHDQGHQGRPHWULDOFDQFHULQZRPHQZKRZDQWWR
SUHVHUYHWKHLUIHUWLOLW\7KHSDWLHQWVKDYHWREHWUHDWHGDFFRUGLQJWRDZHOOGHƓQHGSUH
VHWSURWRFRO7KHSURFHVVVKRXOGEHZHOOGRFXPHQWHGWRLPSURYHWKHVDIHW\DQGHIIHF
WLYHQHVVRIWKHFRQVHUYDWLYHWUHDWPHQW
2
$EVWUDFW
,QWURGXFWLRQ
2EMHFWLYHV
0DWHULDOVDQGPHWKRGV
5HVXOWV
'LVFXVVLRQ
$XWKRUVōFRQFOXVLRQV
5HIHUHQFHV
2.1 ABSTRACT
Objective
7KHWUHDWPHQWRIHQGRPHWULDOFDQFHULVWRWDOK\VWHUHFWRP\LQFOXGLQJELODWHUDOVDOSLQ
JRRRSKRUHFWRP\6WDQGDUGWUHDWPHQWWDNHVDZD\WKHSRVVLELOLW\IRUIHUWLOHZRPHQWR
FRQFHLYH 7KLV UHYLHZ VWXGLHV WKH HIIHFWLYHQHVV DQG VDIHW\ RI FRQVHUYDWLYHKRUPRQDO
WKHUDS\IRUVWDJH,JUDGHDQGHQGRPHWULDOFDQFHU
Materials and Methods
:HVHDUFKHG3XEPHGIRUSXEOLFDWLRQVIURP-DQXDU\WR1RYHPEHU3XEOL
FDWLRQVLQFOXGHGUHWURVSHFWLYHVWXGLHVFDVHUHSRUWVPXOWLFHQWHU3KDVH,,VWXG\DQGOLW
HUDWXUHUHYLHZVGHVFULELQJFRQVHUYDWLYHWUHDWPHQWIRUZRPHQZLWKW\SH,HQGRPHWULDO
FDQFHU
Results
)LIW\ƓYHVWXGLHVGHVFULEHGSDWLHQWVZLWKVWDJH,HQGRPHWULDOFDQFHU7KHPHGLDQ
DJHRIWKHSDWLHQWVZDV\HDUV7ZRKXQGUHGDQGWKLUW\WZRSDWLHQWVKDGJUDGHGLV
HDVHDQGKDGJUDGHRUPRUH*UDGLQJZDVXQNQRZQIRUƓYHSDWLHQWV3DWLHQWVZHUH
WUHDWHGZLWKGLIIHUHQWSURJHVWDWLYHV7KUHHRXWRISDWLHQWVGLGQRWUHFHLYHDQ\WUHDW
PHQWIRUWKHLUGLVHDVH7KHPHDQQXPEHURIPRQWKVRIWUHDWPHQWZDVPRQWKV2QH
KXQGUHGDQGQLQHW\WKUHHRIWKHSDWLHQWVUHVSRQGHGLQLWLDOO\WRWKHUDS\3URJHVWHU
RQHUHFHSWRUVWDWXVZDVNQRZQLQRISDWLHQWV6HYHQW\VHYHQSDWLHQWVZHUH
SURJHVWHURQHUHFHSWRUSRVLWLYH7KHPHDQIROORZXSZDVPRQWKV1RSDWLHQWGLHGRI
HQGRPHWULDOFDQFHU2QHKXQGUHGDQGWZHQW\VHYHQSUHJQDQFLHVDQGOLYLQJELUWKV
ZHUHGHVFULEHG
Conclusions
&RQVHUYDWLYHWUHDWPHQWRIHQGRPHWULDOFDQFHUPD\EHFRQVLGHUHGLQDZHOOVHOHFWHG
JURXSRISDWLHQWVVWDJH,JUDGHDQGHQGRPHWULDOFDQFHULQZRPHQZKRZDQWWR
SUHVHUYHWKHLUIHUWLOLW\7KHSDWLHQWVKDYHWREHWUHDWHGDFFRUGLQJWRDZHOOGHƓQHGSUH
VHWSURWRFRO7KHSURFHVVVKRXOGEHZHOOGRFXPHQWHGWRLPSURYHWKHVDIHW\DQGHIIHF
WLYHQHVVRIWKHFRQVHUYDWLYHWUHDWPHQW
2.2 INTRODUCTION
7KHVWDQGDUGWUHDWPHQWIRUSDWLHQWVZLWKHQGRPHWULDOFDQFHULVWRWDOK\VWHUHFWRP\LQ
FOXGLQJELODWHUDOVDOSLQJRRRSKRUHFWRP\+RZHYHUWKLVVWDQGDUGDSSURDFKWDNHVDZD\
WKHSRVVLELOLW\IRUIHUWLOHZRPHQWRFRQFHLYH:HXQGHUWRRNWKLVUHYLHZWRGHWHUPLQH
WKHHIIHFWLYHQHVVDQGVDIHW\RIFRQVHUYDWLYHKRUPRQDOWKHUDS\IRUVWDJH,JUDGHDQG
HQGRPHWULDOFDQFHU
2.3 OBJECTIVES
&RQVHUYDWLYHKRUPRQDOWUHDWPHQWRIHDUO\VWDJHHQGRPHWULDOFDQFHUKDVEHHQDGYR
FDWHGDVDQDOWHUQDWLYHPHWKRGRIWUHDWPHQWLQH[FHSWLRQDOFDVHVIRU\RXQJZRPHQZKR
ZLVKWRSUHVHUYHWKHLUIHUWLOLW\7KHREMHFWLYHVRIWKLVUHYLHZDUHWRGHWHUPLQHWKH
HIIHFWLYHQHVVDQGVDIHW\RIFRQVHUYDWLYHWKHUDS\IRUVWDJH,JUDGHDQGHQGRPHWULDO
FDQFHUDQGWRIRUPXODWHDSURWRFROWRVDYHIHUWLOLW\LQ\RXQJSDWLHQWVZLWKHQGRPH
WULDOFDQFHU
2.4 MATERIALS AND METHODS
:HVHDUFKHG3XEPHGIRUSXEOLFDWLRQVIURP-DQXDU\WR1RYHPEHU3XEOL
FDWLRQVLQFOXGHGUHWURVSHFWLYHVWXGLHVFDVHUHSRUWVPXOWLFHQWHU3KDVH,,VWXG\DQGOLW
HUDWXUHUHYLHZVGHVFULELQJFRQVHUYDWLYHWUHDWPHQWIRUZRPHQZLWKW\SH,HQGRPHWULDO
FDQFHU%HFDXVHRIDODFNRISURVSHFWLYHVWXGLHVZHFROOHFWHGDOOGDWDDYDLODEOHRQWKH
VXEMHFW7ZRLQYHVWLJDWRUVDEVWUDFWHGWKHGDWD6WXGLHVWKDWZHUHQRWDYDLODEOHRQOLQH
ZHUHKDQGVHDUFKHG
2.5 RESULTS
/LWHUDWXUHRQFRQVHUYDWLYHWUHDWPHQWRIHQGRPHWULDOFDQFHULQZRPHQZKRZDQWWRSUH
VHUYHIHUWLOLW\LVLQFRQFOXVLYHZLWKUHJDUGWRWKHEHVWWUHDWPHQWPRGDOLW\7KHUHDUHPDQ\
FDVHUHSRUWVUHWURVSHFWLYHREVHUYDWLRQDOVWXGLHVVRPHSURVSHFWLYHVWXGLHVDQGPDQ\
UHYLHZV-DGRXOUHSRUWHGSDWLHQWVEHLQJWUHDWHGZLWKSURJHVWDJHQV5DFNRZ2VWXG
LHGSDWLHQWV*RWOLHE5DPLUH]DQG%RLQJKDYHZULWWHQWKHPRVWFRPSOHWH
DQGFOHDUUHYLHZV&KLYDKDVXVHGPRVWRIWKLVLQIRUPDWLRQDQGFRPSOHWHGLWZLWKWKH
ODVWDYDLODEOHGDWDDQGGHVFULEHGSDWLHQWV:HRIIHUWKHPRVWUHFHQWDQGFRPSOHWH
UHYLHZRIWKHDYDLODEOHOLWHUDWXUH5HFHSWRUVWDWXVDQGPHWKRGVRIWKHUDS\ZHUHSUHYL
RXVO\QRWGHVFULEHGDVFOHDUO\DVWKH\DUHLQWKLVUHYLHZ7DEOHVKRZVDOOFDVHUHSRUWV
DQGSURVSHFWLYHREVHUYDWLRQDOVWXGLHVSXEOLVKHGIURPWRWKHHQGRI
:H IRXQG VWXGLHV GHVFULELQJ FRQVHUYDWLYH WUHDWPHQW RI HQGRPHWULDO FDQFHU :H
FKHFNHGIRUGRXEOHUHJLVWUDWLRQDQGSDWLHQWVUHPDLQHG7KHPHGLDQDJHRIWKH
SDWLHQWVLV\HDUV
7ZRKXQGUHGDQGWKLUW\WZRSDWLHQWVZLWKVWDJH,HQGRPHWULDOFDQFHUKDGJUDGHGLV
HDVHDQGSDWLHQWVKDGJUDGHRUPRUH*UDGLQJZDVXQNQRZQIRUƓYHSDWLHQWV
3DWLHQWV ZHUH WUHDWHG ZLWK PHGUR[\SURJHVWHURQH DFHWDWH 03$ PHJHVWURO DFHWDWH
0$K\GUR[\SURJHVWHURQHFDSURDWH2+SURJQRUHWKLVWHURQHDFHWDWH1$GLK\GUR
VWHURQH'+DQGQRUHWKLQGURQH1(7KUHHRISDWLHQWVGLGQRWUHFHLYHDQ\WUHDW
PHQWIRUWKHLUGLVHDVH0RVWSDWLHQWVZHUHWUHDWHGZLWK03$YDU\LQJIURPWRPJ
SHUGD\7KHGXUDWLRQRIWKHWUHDWPHQWYDULHGEHWZHHQDQGPRQWKV7KHPHDQ
GXUDWLRQZDVPRQWKV2QHKXQGUHGDQGQLQHW\WKUHHRXWRISDWLHQWVUHVSRQGHG
WRWKHUDS\+LVWRORJ\UHVXOWVIRUSDWLHQWVZHUHJUDGHƓYHZHUHJUDGHRQHZDV
JUDGHDQGZHUHHLWKHUJUDGHRUQRWVSHFLƓHGE\WKHDXWKRUV
3URJHVWHURQHUHFHSWRUVWDWXVZDVRQO\NQRZQLQRISDWLHQWV6HYHQW\VHYHQ ZHUHSURJHVWHURQHUHFHSWRUSRVLWLYH1LQHSDWLHQWVZHUHUHFHSWRUQHJDWLYH5HFHSWRU
VWDWXVIRUDOORWKHUFDVHVZDVXQNQRZQ
7KHPHDQIROORZXSZDVPRQWKV2QHKXQGUHGDQGWZHQW\VHYHQSUHJQDQFLHVDQG
OLYLQJELUWKVZHUHGHVFULEHG6L[VWXGLHVGLGQRWPHQWLRQSUHJQDQF\UDWHVDQGWKH
UHVWRIWKHVWXGLHVZHUHLQFRPSOHWH,WZDVQRWVWDWHGLIDOOSDWLHQWVZLVKHGWRFRQFHLYH
1RW DOO RI WKH VWXGLHV UHSRUW DOO SUHJQDQFLHV LQFOXGLQJ PLVFDUULDJHV7KUHH SDWLHQWV
GLHGDIWHUEHLQJWUHDWHGFRQVHUYDWLYHO\WZRGLHGRIRYDULDQFDQFHUDQGRQHGLHGRI
OLYHUFLUUKRVLV$GHVFULSWLRQRIWKHPRUWDOLW\LVSURYLGHG
2
7KHVWDQGDUGWUHDWPHQWIRUSDWLHQWVZLWKHQGRPHWULDOFDQFHULVWRWDOK\VWHUHFWRP\LQ
FOXGLQJELODWHUDOVDOSLQJRRRSKRUHFWRP\+RZHYHUWKLVVWDQGDUGDSSURDFKWDNHVDZD\
WKHSRVVLELOLW\IRUIHUWLOHZRPHQWRFRQFHLYH:HXQGHUWRRNWKLVUHYLHZWRGHWHUPLQH
WKHHIIHFWLYHQHVVDQGVDIHW\RIFRQVHUYDWLYHKRUPRQDOWKHUDS\IRUVWDJH,JUDGHDQG
HQGRPHWULDOFDQFHU
&RQVHUYDWLYHKRUPRQDOWUHDWPHQWRIHDUO\VWDJHHQGRPHWULDOFDQFHUKDVEHHQDGYR
FDWHGDVDQDOWHUQDWLYHPHWKRGRIWUHDWPHQWLQH[FHSWLRQDOFDVHVIRU\RXQJZRPHQZKR
ZLVKWRSUHVHUYHWKHLUIHUWLOLW\7KHREMHFWLYHVRIWKLVUHYLHZDUHWRGHWHUPLQHWKH
HIIHFWLYHQHVVDQGVDIHW\RIFRQVHUYDWLYHWKHUDS\IRUVWDJH,JUDGHDQGHQGRPHWULDO
FDQFHUDQGWRIRUPXODWHDSURWRFROWRVDYHIHUWLOLW\LQ\RXQJSDWLHQWVZLWKHQGRPH
WULDOFDQFHU
:HVHDUFKHG3XEPHGIRUSXEOLFDWLRQVIURP-DQXDU\WR1RYHPEHU3XEOL
FDWLRQVLQFOXGHGUHWURVSHFWLYHVWXGLHVFDVHUHSRUWVPXOWLFHQWHU3KDVH,,VWXG\DQGOLW
HUDWXUHUHYLHZVGHVFULELQJFRQVHUYDWLYHWUHDWPHQWIRUZRPHQZLWKW\SH,HQGRPHWULDO
FDQFHU%HFDXVHRIDODFNRISURVSHFWLYHVWXGLHVZHFROOHFWHGDOOGDWDDYDLODEOHRQWKH
VXEMHFW7ZRLQYHVWLJDWRUVDEVWUDFWHGWKHGDWD6WXGLHVWKDWZHUHQRWDYDLODEOHRQOLQH
ZHUHKDQGVHDUFKHG
/LWHUDWXUHRQFRQVHUYDWLYHWUHDWPHQWRIHQGRPHWULDOFDQFHULQZRPHQZKRZDQWWRSUH
VHUYHIHUWLOLW\LVLQFRQFOXVLYHZLWKUHJDUGWRWKHEHVWWUHDWPHQWPRGDOLW\7KHUHDUHPDQ\
FDVHUHSRUWVUHWURVSHFWLYHREVHUYDWLRQDOVWXGLHVVRPHSURVSHFWLYHVWXGLHVDQGPDQ\
UHYLHZV-DGRXOUHSRUWHGSDWLHQWVEHLQJWUHDWHGZLWKSURJHVWDJHQV5DFNRZ VWXG
LHGSDWLHQWV*RWOLHE5DPLUH]DQG%RLQJKDYHZULWWHQWKHPRVWFRPSOHWH
DQGFOHDUUHYLHZV&KLYDKDVXVHGPRVWRIWKLVLQIRUPDWLRQDQGFRPSOHWHGLWZLWKWKH
ODVWDYDLODEOHGDWDDQGGHVFULEHGSDWLHQWV:HRIIHUWKHPRVWUHFHQWDQGFRPSOHWH
UHYLHZRIWKHDYDLODEOHOLWHUDWXUH5HFHSWRUVWDWXVDQGPHWKRGVRIWKHUDS\ZHUHSUHYL
RXVO\QRWGHVFULEHGDVFOHDUO\DVWKH\DUHLQWKLVUHYLHZ7DEOHVKRZVDOOFDVHUHSRUWV
DQGSURVSHFWLYHREVHUYDWLRQDOVWXGLHVSXEOLVKHGIURPWRWKHHQGRI
Number of patients
:H IRXQG VWXGLHV GHVFULELQJ FRQVHUYDWLYH WUHDWPHQW RI HQGRPHWULDO FDQFHU :H
FKHFNHGIRUGRXEOHUHJLVWUDWLRQDQGSDWLHQWVUHPDLQHG7KHPHGLDQDJHRIWKH
SDWLHQWVLV\HDUV
Grading
7ZRKXQGUHGDQGWKLUW\WZRSDWLHQWVZLWKVWDJH,HQGRPHWULDOFDQFHUKDGJUDGHGLV
HDVHDQGSDWLHQWVKDGJUDGHRUPRUH*UDGLQJZDVXQNQRZQIRUƓYHSDWLHQWV
Treatment
3DWLHQWV ZHUH WUHDWHG ZLWK PHGUR[\SURJHVWHURQH DFHWDWH 03$ PHJHVWURO DFHWDWH
0$K\GUR[\SURJHVWHURQHFDSURDWH2+SURJQRUHWKLVWHURQHDFHWDWH1$GLK\GUR
VWHURQH'+DQGQRUHWKLQGURQH1(7KUHHRISDWLHQWVGLGQRWUHFHLYHDQ\WUHDW
PHQWIRUWKHLUGLVHDVH0RVWSDWLHQWVZHUHWUHDWHGZLWK03$YDU\LQJIURPWRPJ
SHUGD\7KHGXUDWLRQRIWKHWUHDWPHQWYDULHGEHWZHHQDQGPRQWKV7KHPHDQ
GXUDWLRQZDVPRQWKV2QHKXQGUHGDQGQLQHW\WKUHHRXWRISDWLHQWVUHVSRQGHG
WRWKHUDS\+LVWRORJ\UHVXOWVIRUSDWLHQWVZHUHJUDGHƓYHZHUHJUDGHRQHZDV
JUDGHDQGZHUHHLWKHUJUDGHRUQRWVSHFLƓHGE\WKHDXWKRUV
Receptor status
3URJHVWHURQHUHFHSWRUVWDWXVZDVRQO\NQRZQLQRISDWLHQWV6HYHQW\VHYHQ ZHUHSURJHVWHURQHUHFHSWRUSRVLWLYH1LQHSDWLHQWVZHUHUHFHSWRUQHJDWLYH5HFHSWRU
VWDWXVIRUDOORWKHUFDVHVZDVXQNQRZQ
Follow-up
7KHPHDQIROORZXSZDVPRQWKV2QHKXQGUHGDQGWZHQW\VHYHQSUHJQDQFLHVDQG
OLYLQJELUWKVZHUHGHVFULEHG6L[VWXGLHVGLGQRWPHQWLRQSUHJQDQF\UDWHVDQGWKH
UHVWRIWKHVWXGLHVZHUHLQFRPSOHWH,WZDVQRWVWDWHGLIDOOSDWLHQWVZLVKHGWRFRQFHLYH
1RW DOO RI WKH VWXGLHV UHSRUW DOO SUHJQDQFLHV LQFOXGLQJ PLVFDUULDJHV7KUHH SDWLHQWV
GLHGDIWHUEHLQJWUHDWHGFRQVHUYDWLYHO\WZRGLHGRIRYDULDQFDQFHUDQGRQHGLHGRI
OLYHUFLUUKRVLV$GHVFULSWLRQRIWKHPRUWDOLW\LVSURYLGHG