I have heard there is a yeah, yesterday we discussed we’re discussing that if you give neoadjuvant chemotherapy EPP or whatever and before surgery the ctDNA is positive that some people say oh there is no need to do surgery that is based on an assumption so we don’t have data because if you if we review the data that was reported on ctDNA in the NILE trial, you see that before starting the neoadjuvant platinum gemcitabine atezolizumab, there are 50% of patients around 50% being positive...
I have heard there is a yeah, yesterday we discussed we’re discussing that if you give neoadjuvant chemotherapy EPP or whatever and before surgery the ctDNA is positive that some people say oh there is no need to do surgery that is based on an assumption so we don’t have data because if you if we review the data that was reported on ctDNA in the NILE trial, you see that before starting the neoadjuvant platinum gemcitabine atezolizumab, there are 50% of patients around 50% being positive. After neoadjuvant therapy, there is a decline on the positivity of ctDNA to 22%. And then these patients go to surgery. After surgery this 22% become 9% meaning the surgery is maybe removing the source of the spreading of the DNA. So I think that presently we cannot make decisions on the dynamics of ctDNA is helping. People is using ctDNA not only in this perioperative space we are using now in patients with metastatic disease. It’s the easiest way to say, okay, this to me is working. If you see the DNA going down and up, the best way to use the CT-DNA is in patients that have a single metastatic location that has been completely resected. And in addition to those scans, PET scans and so on, you can monitor with ctDNA. If this patient was having ctDNA before, there are tumors that are not shedding DNA, and this is something that we have seen. That is, for example, specific metastatic locations that are not shedding DNA. As mentioned, in the IMvigor211, we saw that there were 12% of patients that the disease recurred having negative ctDNA after a year, meaning that it’s not the perfect tool.
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