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Blažek T, Petráš M, Hurník P, Matoušek P, Knybel L, Čermáková ZZ, Štembírek J, Cvek J, Soumarová R. High PD-L1 expression on immune cells along with increased density of tumor-infiltrating lymphocytes predicts a favorable survival outcome for patients with loco-regionally advanced head and neck cancer: early results from a prospective study. Front Oncol 2024; 14:1346793. [PMID: 38638854 PMCID: PMC11024328 DOI: 10.3389/fonc.2024.1346793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/18/2024] [Indexed: 04/20/2024] Open
Abstract
Introduction In the era of personalized medicine and treatment optimization, use of immune biomarkers holds promise for estimating the prognosis of patients with head and neck squamous cell carcinoma (HNSCC) undergoing definitive treatment. Methods To evaluate the prognostic potential of immune biomarkers, we conducted a prospective monocentric cohort study with loco-regionally advanced HNSCC patients indicated for definitive radiotherapy/radiochemotherapy at the Department of Oncology, Ostrava University Hospital, Czech Republic, between June 2020 and August 2023. We focused on the expression of programmed death ligand 1 (PD-L1) and tumor-infiltrating lymphocytes (TILs) relative to overall survival (OS) and specific survival rates. Associations between biomarkers and survival rates were assessed by crude and adjusted hazard ratios (cHR, aHR, respectively) obtained from Cox proportional hazards regression. Results Among a total of 55 patients within a median follow-up of 19.7 months, there were 21 (38.2%) all-cause deaths and 15 (27.3%) cancer-related deaths. An overall survival (OS) rate of 61.8% and a disease-specific survival (DSS) rate of 72.7% were recorded. A significant association between survival rates and a ≥10% difference in PD-L1 expression on immune versus tumor cells (high PD-L1IC expression) was documented regardless of the type of analysis (univariate or multivariate). In addition, a stronger association was confirmed for OS and the composite biomarker high PD-L1IC expression along with either median-higher CD8+ TIL count or increased TIL density ≥30%, as indicated by an aHR of 0.08 (95% CI, 0.01 to 0.52) and 0.07 (95% CI, 0.01 to 0.46), respectively. Similar results were demonstrated for other specific survival rates. Discussion The early outcomes of the present study suggest the utility of a strong prognostic factor involving a composite biomarker high PD-L1IC expression along with increased TIL density in HNSCC patients undergoing definitive radiotherapy and radiochemotherapy. Trial registration The study is registered with Clinicaltrials.gov. - NCT05941676.
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Affiliation(s)
- Tomáš Blažek
- Department of Oncology, Ostrava University Hospital, Ostrava, Czechia
- Faculty of Medicine, University of Ostrava, Ostrava, Czechia
- Third Faculty of Medicine, Charles University, Prague, Czechia
| | - Marek Petráš
- Third Faculty of Medicine, Charles University, Prague, Czechia
| | - Pavel Hurník
- Faculty of Medicine, University of Ostrava, Ostrava, Czechia
- Department of Pathology, Ostrava University Hospital, Ostrava, Czechia
| | - Petr Matoušek
- Faculty of Medicine, University of Ostrava, Ostrava, Czechia
- Department of Otorhinolaryngology, Ostrava University Hospital, Ostrava, Czechia
| | - Lukáš Knybel
- Department of Oncology, Ostrava University Hospital, Ostrava, Czechia
- Faculty of Medicine, University of Ostrava, Ostrava, Czechia
| | - Zuzana Zděblová Čermáková
- Department of Oncology, Ostrava University Hospital, Ostrava, Czechia
- Faculty of Medicine, University of Ostrava, Ostrava, Czechia
| | - Jan Štembírek
- Faculty of Medicine, University of Ostrava, Ostrava, Czechia
- Department of Orofacial Surgery, Ostrava University Hospital, Ostrava, Czechia
| | - Jakub Cvek
- Department of Oncology, Ostrava University Hospital, Ostrava, Czechia
- Faculty of Medicine, University of Ostrava, Ostrava, Czechia
| | - Renata Soumarová
- Third Faculty of Medicine, Charles University, Prague, Czechia
- Department of Oncology, Královské Vinohrady University Hospital, Prague, Czechia
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Kakkar A, Thakur R, Roy D, Sood R, Sharma A, Malhotra RK, Thakar A. Tumour-infiltrating lymphocyte subsets and their individual prognostic impact in oral squamous cell carcinoma. J Clin Pathol 2023:jcp-2023-208918. [PMID: 37699696 DOI: 10.1136/jcp-2023-208918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 08/29/2023] [Indexed: 09/14/2023]
Abstract
AIMS Current understanding of oral squamous cell carcinoma (OSCC) is incomplete with regard to prognostic factors that lead to the considerable heterogeneity in treatment response and patient outcomes. We aimed to evaluate the impact of individual tumour-infiltrating lymphocyte (TIL) subsets on prognosis as a possible rationale for this, in a retrospective observational study. METHODS Immunohistochemistry was performed to quantitatively assess cell densities of CD3+, CD20+, CD4+, CD8+ and FOXP3+TIL subsets in 50 surgically treated OSCC cases. Results were correlated with disease-free survival (DFS) and overall survival (OS). Receiver operating characteristic curve analysis and Youden index were applied to determine prognostically significant cut-off values. RESULTS Mean counts for CD3+, CD4+, CD8+, CD20+ and FOXP3+TILs were 243, 52, 132, 53 and 116 cells per high power field, respectively. High CD8+ and low FOXP3+TIL counts, and high ratio of CD8:FOXP3 were significantly associated with longer DFS and OS, as well as with improved tumour-host interface parameters. CONCLUSIONS Host immune response and its interaction with cancer cells have a significant impact on OSCC outcomes, with some TIL subsets being more clinically relevant than others. High cytotoxic T-cell (CD8) and low Treg (FOXP3) counts, and high cytotoxic T-cell to Treg (CD8:FOXP3) ratio are significantly associated with favourable prognosis. These results may serve as a leading point in identifying novel therapeutic agents that can redesign the tumour immune microenvironment by reducing infiltrating FOXP3-lymphocytes, and modifying their signalling pathways.
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Affiliation(s)
- Aanchal Kakkar
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Rishikesh Thakur
- Department of Otorhinolaryngology & Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Diya Roy
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Ridhi Sood
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Sharma
- Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajeev Kumar Malhotra
- Delhi Cancer Registry, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Alok Thakar
- Department of Otorhinolaryngology & Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
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Chen L, Shi V, Wang S, Freeman R, Ruiz F, Jayachandran K, Zhang J, Cosper P, Sun L, Luke CJ, Spina C, Grigsby PW, Schwarz JK, Markovina S. SCCA1/SERPINB3 promotes suppressive immune environment via STAT-dependent chemokine production, blunting the therapy-induced T cell responses. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.02.01.526675. [PMID: 36778224 PMCID: PMC9915608 DOI: 10.1101/2023.02.01.526675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Radiotherapy is a commonly used cancer treatment; however, patients with high serum squamous cell carcinoma antigen (SCCA1/SERPINB3) are associated with resistance and poor prognosis. Despite being a strong clinical biomarker, the modulation of SERPINB3 in tumor immunity is poorly understood. We investigated the microenvironment of SERPINB3 high tumors through RNAseq of primary cervix tumors and found that SERPINB3 was positively correlated with CXCL1/8, S100A8/A9 and myeloid cell infiltration. Induction of SERPINB3 in vitro resulted in increased CXCL1/8 and S100A8/A9 production, and supernatants from SERPINB3-expressing cultures attracted monocytes and MDSCs. In murine tumors, the orthologue mSerpinB3a promoted MDSC, TAM, and M2 macrophage infiltration contributing to an immunosuppressive phenotype, which was further augmented upon radiation. Radiation-enhanced T cell response was muted in SERPINB3 tumors, whereas Treg expansion was observed. A STAT-dependent mechanism was implicated, whereby inhibiting STAT signaling with ruxolitinib abrogated suppressive chemokine production. Patients with elevated pre-treatment serum SCCA and high pSTAT3 had increased intratumoral CD11b+ myeloid cell compared to patients with low SCCA and pSTAT3 cohort that had overall improved cancer specific survival after radiotherapy. These findings provide a preclinical rationale for targeting STAT signaling in tumors with high SERPINB3 to counteract the immunosuppressive microenvironment and improve response to radiation.
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Jiang S, Li X, Huang L, Xu Z, Lin J. Prognostic value of PD-1, PD-L1 and PD-L2 deserves attention in head and neck cancer. Front Immunol 2022; 13:988416. [PMID: 36119046 PMCID: PMC9478105 DOI: 10.3389/fimmu.2022.988416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Head and neck cancer has high heterogeneity with poor prognosis, and emerging researches have been focusing on the prognostic markers of head and neck cancer. PD-L1 expression is an important basis for strategies of immunosuppressive treatment, but whether it has prognostic value is still controversial. Although meta-analysis on PD-L1 expression versus head and neck cancer prognosis has been performed, the conclusions are controversial. Since PD-L1 and PD-L2 are two receptors for PD-1, here we summarize and analyze the different prognostic values of PD-1, PD-L1, and PD-L2 in head and neck cancer in the context of different cell types, tissue localization and protein forms. We propose that for head and neck cancer, the risk warning value of PD-1/PD-L1 expression in precancerous lesions is worthy of attention, and the prognostic value of PD-L1 expression at different subcellular levels as well as the judgment convenience of prognostic value of PD-1, PD-L1, PD-L2 should be fully considered. The PD-L1 evaluation systems established based on immune checkpoint inhibitors (ICIs) are not fully suitable for the evaluation of PD-L1 prognosis in head and neck cancer. It is necessary to establish a new PD-L1 evaluation system based on the prognosis for further explorations. The prognostic value of PD-L1, PD-L2 expression in head and neck cancer may be different for early-stage and late-stage samples, and further stratification is required.
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Affiliation(s)
- Siqing Jiang
- Department of Comprehensive Chemotherapy/Head and Neck Cancer, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Xin Li
- Department of Pain Management and Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Lihua Huang
- Center for Experimental Medicine, Third Xiangya Hospital of Central South University, Changsha, China
| | - Zhensheng Xu
- Department of Oncologic Chemotheraphy, Affiliated Haikou Hospital of Xiangya Medical College, Central South University, Haikou, China
- *Correspondence: Zhensheng Xu, ; Jinguan Lin,
| | - Jinguan Lin
- Department of Comprehensive Chemotherapy/Head and Neck Cancer, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
- *Correspondence: Zhensheng Xu, ; Jinguan Lin,
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Gondhowiardjo SA, Adham M, Rachmadi L, Atmakusuma TD, Tobing DL, Auzan M, Hariyanto AD, Sulaeman D, Permata TBM, Handoko. Immune cells markers within local tumor microenvironment are associated with EBV oncoprotein in nasopharyngeal cancer. BMC Cancer 2022; 22:887. [PMID: 35963999 PMCID: PMC9375267 DOI: 10.1186/s12885-022-09948-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 07/29/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction EBV infection in nasopharyngeal cancer ensued in latent infection mode. In this latent infection various EBV oncoproteins such as EBNA1 and LMP1 was expressed. EBV oncoproteins could theoretically recruit immune cells, which might help to control cancer. Therefore, this study was aimed to elucidate the association with EBV oncoproteins (EBNA1 and LMP1), immune markers (CD4, CD8, and FOXP3) from nasopharyngeal cancer microenvironment with tumor progression. Method Nasopharyngeal biopsy was obtained from patients suspected to have nasopharyngeal cancer. Those samples with microscopically confirmed nasopharyngeal cancer were tested for EBNA1, LMP1, CD4, CD8, and FOXP3 concentration with ELISA, then verified with IHC. Each patient tumor volume was assessed for primary nasopharyngeal tumor volume (GTVp) and neck nodal metastases tumor volume (GTVn). Correlation test with Spearman correlation and scatterplot were carried out. Result Total 23 samples with nasopharyngeal cancer were analyzed. There was moderate correlation (ρ = 0.45; p value = 0.032) between LMP1 and GTVp. There was strong correlation (ρ = 0.81; p value < 0.001) between CD8 and GTVp. There was also moderate correlation (ρ = 0.6; p value = 0.002) between FOXP3 and GTVp. The CD8 concentration has moderate correlation with both EBNA1 (ρ = 0.46; p value = 0.026) and LMP1 (ρ = 0.47; p value = 0.023). While FOXP3 has moderate correlation with only LMP1 (ρ = 0.58; p value = 0.004). No correlation was found between all the markers tested here with GTVn. Discussion We found larger primary nasopharyngeal tumor was associated with higher CD8 marker. This was thought due to the presence of abundance CD8 T cells in the nasopharynx, but those abundance CD8 T cells were suspected to be dysfunctional. The nasopharyngeal cancer was also known to upregulate chemokines that could recruit T regulatory FOXP3 cells. Furthermore, T regulatory FOXP3 cells differentiation was induced through several pathways which was triggered by EBNA1. The correlation found in this study could guide further study to understand nasopharyngeal carcinogenesis and the relationship with our immune system.
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Affiliation(s)
- Soehartati A Gondhowiardjo
- Department of Radiation Oncology, Faculty of Medicine, Universitas Indonesia / Cipto Mangunkusumo National General Hospital, Jakarta - Indonesia, Jl. Salemba Raya No. 6, Jakarta, Indonesia, 10430
| | - Marlinda Adham
- Department of ENT, Faculty of Medicine, Universitas Indonesia / Cipto Mangunkusumo National General Hospital, Jakarta - Indonesia, Jl. Salemba Raya No. 6, Jakarta, Indonesia, 10430
| | - Lisnawati Rachmadi
- Department of Anatomical Pathology, Faculty of Medicine, Universitas Indonesia / Cipto Mangunkusumo National General Hospital, Jakarta - Indonesia, Jl. Salemba Raya No. 6, Jakarta, Indonesia, 10430
| | - Tubagus Djumhana Atmakusuma
- Department of Medical Oncology, Faculty of Medicine, Universitas Indonesia / Cipto Mangunkusumo National General Hospital, Jakarta - Indonesia, Jl. Salemba Raya No. 6, Jakarta, Indonesia, 10430
| | - Demak Lumban Tobing
- Department of Clinical Pathology, Dharmais National Cancer Hospital, Jakarta - Indonesia, Jl. Letjen S. Parman No. 84-86, Jakarta, Indonesia, 11420
| | - Mahesa Auzan
- Department of Radiation Oncology, Faculty of Medicine, Universitas Indonesia / Cipto Mangunkusumo National General Hospital, Jakarta - Indonesia, Jl. Salemba Raya No. 6, Jakarta, Indonesia, 10430
| | - Agustinus Darmadi Hariyanto
- Department of Radiation Oncology, Faculty of Medicine, Universitas Indonesia / Cipto Mangunkusumo National General Hospital, Jakarta - Indonesia, Jl. Salemba Raya No. 6, Jakarta, Indonesia, 10430
| | - Dede Sulaeman
- Department of Radiation Oncology, Faculty of Medicine, Universitas Indonesia / Cipto Mangunkusumo National General Hospital, Jakarta - Indonesia, Jl. Salemba Raya No. 6, Jakarta, Indonesia, 10430
| | - Tiara Bunga Mayang Permata
- Department of Radiation Oncology, Faculty of Medicine, Universitas Indonesia / Cipto Mangunkusumo National General Hospital, Jakarta - Indonesia, Jl. Salemba Raya No. 6, Jakarta, Indonesia, 10430
| | - Handoko
- Department of Radiation Oncology, Faculty of Medicine, Universitas Indonesia / Cipto Mangunkusumo National General Hospital, Jakarta - Indonesia, Jl. Salemba Raya No. 6, Jakarta, Indonesia, 10430.
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Monsrud AL, Avadhani V, Mosunjac MB, Flowers L, Krishnamurti U. Programmed Death Ligand-1 Expression Is Associated With Poorer Survival in Anal Squamous Cell Carcinoma. Arch Pathol Lab Med 2021; 146:1094-1101. [DOI: 10.5858/arpa.2021-0169-oa] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2021] [Indexed: 11/06/2022]
Abstract
Context.—
Upregulation of programmed death ligand-1 (PD-L1), an immunoregulatory protein, is associated with an adverse outcome in several malignancies. Very few studies have evaluated PD-L1 expression in invasive anal squamous cell carcinoma (ASCC).
Objective.—
To assess PD-L1 expression in patients with ASCC and correlate it with clinicopathologic factors and clinical outcomes.
Design.—
Fifty-one cases of ASCC were immunostained for PD-L1. PD-L1 expression by combined positive score and tumor proportion score was correlated with age, gender, HIV status, HIV viral load, CD4 count, stage, and outcomes. Kaplan-Meier curves for overall survival were plotted and compared using the log-rank test. Cox regression analysis was performed to identify significant prognostic factors (2-tailed P < .05 was considered statistically significant).
Results.—
PD-L1 was positive in 24 of 51 cases (47%) by combined positive score and in 18 of 51 (35%) by tumor proportion score. The median cancer-specific survival and 5-year overall survival were significantly lower in PD-L1+ patients. Age, gender, HIV status, HIV viral load, stage, and cancer progression were not significantly different between the two groups. CD4 count of more than 200/μL was significantly higher in PD-L1+ patients. PD-L1+ status remained statistically significant for worse overall survival on multivariate analysis.
Conclusions.—
PD-L1+ status is an independent adverse prognostic factor for overall survival in ASCC. This study highlights the potential of PD-L1 targeted therapy in better management of ASCC.
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Affiliation(s)
- Ashley L. Monsrud
- From the Department of Pathology & Laboratory Medicine (Monsrud, Avadhani, Mosunjac, Krishnamurti), Emory University, Atlanta, Georgia
| | - Vaidehi Avadhani
- From the Department of Pathology & Laboratory Medicine (Monsrud, Avadhani, Mosunjac, Krishnamurti), Emory University, Atlanta, Georgia
| | - Marina B. Mosunjac
- From the Department of Pathology & Laboratory Medicine (Monsrud, Avadhani, Mosunjac, Krishnamurti), Emory University, Atlanta, Georgia
| | - Lisa Flowers
- Department of Gynecology & Obstetrics (Flowers), Emory University, Atlanta, Georgia
| | - Uma Krishnamurti
- From the Department of Pathology & Laboratory Medicine (Monsrud, Avadhani, Mosunjac, Krishnamurti), Emory University, Atlanta, Georgia
- Krishnamurti is now with the Department of Pathology at Yale School of Medicine
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Rodrigo JP, Sánchez-Canteli M, López F, Wolf GT, Hernández-Prera JC, Williams MD, Willems SM, Franchi A, Coca-Pelaz A, Ferlito A. Tumor-Infiltrating Lymphocytes in the Tumor Microenvironment of Laryngeal Squamous Cell Carcinoma: Systematic Review and Meta-Analysis. Biomedicines 2021; 9:biomedicines9050486. [PMID: 33925205 PMCID: PMC8145951 DOI: 10.3390/biomedicines9050486] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/18/2021] [Accepted: 04/26/2021] [Indexed: 02/08/2023] Open
Abstract
The presence of tumor-infiltrating lymphocytes (TIL) in the tumor microenvironment has been demonstrated to be of prognostic value in various cancers. In this systematic review and meta-analysis, we investigated the prognostic value of TIL in laryngeal squamous cell carcinoma (LSCC). We performed a systematic search in PubMed for publications that investigated the prognostic value of TIL in LSCC. A meta-analysis was performed including all studies assessing the association between TIL counts in hematoxylin-eosin (HE)-stained sections, for CD8+ and/or CD3+/CD4+ TIL and overall survival (OS) or disease-free survival (DFS). The pooled meta-analysis showed a favorable prognostic role for stromal TIL in HE sections for OS (HR 0.57, 95% CI 0.36–0.91, p = 0.02), and for DFS (HR 0.56, 95% CI 0.34–0.94, p = 0.03). High CD8+ TIL were associated with a prolonged OS (HR 0.62, 95% CI 0.4–0.97, p = 0.04) and DFS (HR 0.73, 95% CI 0.34–0.94, p = 0.002). High CD3+/CD4+ TIL demonstrated improved OS (HR 0.32, 95% CI 0.16–0.9, p = 0.03) and DFS (HR 0.23, 95% CI 0.10–0.53, p = 0.0005). This meta-analysis confirmed the favorable prognostic significance of TIL in LSCC. High stromal TIL evaluated in HE sections and intra-tumoral and stromal CD3+, CD4+ and/or CD8+ TIL might predict a better clinical outcome.
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Affiliation(s)
- Juan P. Rodrigo
- Department of Otolaryngology, Hospital Universitario Central de Asturias-Instituto de Salud del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (M.S.-C.); (F.L.); (A.C.-P.)
- IUOPA-University of Oviedo, 33006 Oviedo, Spain
- CIBERONC, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence:
| | - Mario Sánchez-Canteli
- Department of Otolaryngology, Hospital Universitario Central de Asturias-Instituto de Salud del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (M.S.-C.); (F.L.); (A.C.-P.)
- IUOPA-University of Oviedo, 33006 Oviedo, Spain
- CIBERONC, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Fernando López
- Department of Otolaryngology, Hospital Universitario Central de Asturias-Instituto de Salud del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (M.S.-C.); (F.L.); (A.C.-P.)
- IUOPA-University of Oviedo, 33006 Oviedo, Spain
- CIBERONC, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Gregory T. Wolf
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, MI 48109, USA;
| | | | - Michelle D. Williams
- Department of Pathology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA;
| | - Stefan M. Willems
- Department of Pathology, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands;
| | - Alessandro Franchi
- Department of Translational Research, School of Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Andrés Coca-Pelaz
- Department of Otolaryngology, Hospital Universitario Central de Asturias-Instituto de Salud del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (M.S.-C.); (F.L.); (A.C.-P.)
- IUOPA-University of Oviedo, 33006 Oviedo, Spain
- CIBERONC, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, 35125 Padua, Italy;
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