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Zhang J, Zou L, Tan F, Wang H, Wen Z, Wang H, Li L. Screening of co-expressed genes in hypopharyngeal carcinoma with esophageal carcinoma based on RNA sequencing and Clinical Research. Sci Rep 2024; 14:13796. [PMID: 38877096 PMCID: PMC11178892 DOI: 10.1038/s41598-024-64162-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 06/05/2024] [Indexed: 06/16/2024] Open
Abstract
To explore the hub comorbidity genes and potential pathogenic mechanisms of hypopharyngeal carcinoma with esophageal carcinoma, and evaluate their diagnostic value for hypopharyngeal carcinoma with co-morbid esophageal carcinoma. We performed gene sequencing on tumor tissues from 6 patients with hypopharyngeal squamous cell carcinoma with esophageal squamous cell carcinoma (hereafter referred to as "group A") and 6 patients with pure hypopharyngeal squamous cell carcinoma (hereafter referred to as "group B"). We analyzed the mechanism of hub genes in the development and progression of hypopharyngeal squamous cell carcinoma with esophageal squamous cell carcinoma through bioinformatics, and constructed an ROC curve and Nomogram prediction model to analyze the value of hub genes in clinical diagnosis and treatment. 44,876 genes were sequenced in 6 patients with group A and 6 patients with group B. Among them, 76 genes showed significant statistical differences between the group A and the group B.47 genes were expressed lower in the group A than in the group B, and 29 genes were expressed higher. The top five hub genes were GABRG2, CACNA1A, CNTNAP2, NOS1, and SCN4B. GABRG2, CNTNAP2, and SCN4B in the hub genes have high diagnostic value in determining whether hypopharyngeal carcinoma patients have combined esophageal carcinoma (AUC: 0.944, 0.944, 0.972). These genes could possibly be used as potential molecular markers for assessing the risk of co-morbidity of hypopharyngeal carcinoma combined with esophageal carcinoma.
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Affiliation(s)
- Jianing Zhang
- Department of Otorhinolaryngology Head and Neck Surgery, Central Hospital of Chaoyang, Liaoning, 122000, China
| | - Liangyu Zou
- Department of Otorhinolaryngology Head and Neck Surgery, Central Hospital of Chaoyang, Liaoning, 122000, China
| | - Fuxian Tan
- Department of Otorhinolaryngology Head and Neck Surgery, Central Hospital of Chaoyang, Liaoning, 122000, China
| | - Hongmin Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Central Hospital of Chaoyang, Liaoning, 122000, China
| | - Zhenlei Wen
- Department of Otorhinolaryngology Head and Neck Surgery, Central Hospital of Chaoyang, Liaoning, 122000, China
| | - Hongmei Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Central Hospital of Chaoyang, Liaoning, 122000, China
| | - Lianhe Li
- Department of Otorhinolaryngology Head and Neck Surgery, Central Hospital of Chaoyang, Liaoning, 122000, China.
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Katano A, Yamashita H. The role of upfront neck dissection in definitive radiotherapy for locally advanced hypopharyngeal squamous cell carcinoma: A single-center retrospective analysis. Head Neck 2024. [PMID: 38842032 DOI: 10.1002/hed.27839] [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: 02/07/2024] [Revised: 05/23/2024] [Accepted: 05/29/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Hypopharyngeal cancer, constituting 3%-5% of head and neck cancers, predominantly presents as squamous cell carcinoma, with a 5-year overall survival rate of approximately 40%. Treatment modalities for locally advanced cases include chemoradiotherapy; however, the role of upfront neck dissection (UND) remains controversial. This study aimed to investigate the effect of UND on definitive radiotherapy in locally advanced hypopharyngeal carcinoma. METHODS This retrospective analysis included consecutive patients with locally advanced hypopharyngeal squamous cell carcinoma who were treated in our department between January 2007 and June 2023. All patients underwent definitive radiotherapy (dRT) at a total dose of 70 Gy in 35 fractions. The patients were categorized into two groups: dRT (radiotherapy with or without chemotherapy) and UND-dRT (surgical neck dissection followed by radiotherapy). Univariate Cox models and multivariate analyses were conducted to investigate the independent prognostic factors for overall survival and locoregional control rate. RESULTS This study included 115 patients, predominantly male (109/115), with a median age of 66 years. Clinical stage and chemotherapy distribution differed significantly between the dRT and UND-dRT groups. The 3-year overall survival and locoregional control rates for all patients were 63.8% and was 63.3%, respectively. The UND-dRT group exhibited a trend toward improved locoregional control, although this difference was not statistically significant. The multivariate analysis revealed that UND was an independent factor significantly associated with improved overall survival and locoregional control. CONCLUSION This study provided evidence supporting the effectiveness of UND in conjunction with definitive radiotherapy for locally advanced hypopharyngeal carcinoma. Future research should focus on validating and refining these findings through well-designed prospective multicenter trials.
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Affiliation(s)
- Atsuto Katano
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Hideomi Yamashita
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
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Zhang D, Li L. Risk factors and prognostic models of lymph node metastatic hypopharyngeal squamous cell carcinoma. Eur Arch Otorhinolaryngol 2023; 280:5019-5029. [PMID: 37351665 DOI: 10.1007/s00405-023-08077-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/14/2023] [Indexed: 06/24/2023]
Abstract
PURPOSE To explore the risk factors for lymph node metastasis (LNM) and establish nomograms for predicting survival outcomes and assessing individual risk in patients with LNM and hypopharyngeal squamous carcinoma (HSCC). METHODS Clinical data of patients with HSCC were retrospectively reviewed. The study's primary endpoints were overall survival (OS) and disease-specific survival (DSS). Nomograms were established based on Cox regression analyses. The accuracy and calibration ability of the nomograms were evaluated using the C-index, area under the curve, calibration curves, and decision curve analysis. RESULTS Overall, 2888 patients were enrolled, and the LNM rate was 74.2%. Age ≤ 60 years, male sex, unmarried status, pyriform sinus location, grade III-IV, tumor larger than 4 cm, and advanced T stage increased the risk of LNM. In addition, LNM was a negative prognostic factor for OS and DSS. Ten variables were identified and incorporated into nomograms to estimate OS and DSS. Our nomograms outperformed the traditional staging system in training and validation cohorts. Patients were stratified into risk subgroups based on the OS- and DSS-nomogram scores. Patients in the high-risk subgroup had a higher risk of death and disease-specific mortality than those in the low- and intermediate-risk subgroups. CONCLUSIONS LNM worsens the prognosis of HSCC. This study identified the independent prognostic factors for HSCC with LNM and developed satisfactory OS- and DSS-monogram to provide individual prediction and risk classification for patients with this diagnosis.
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Affiliation(s)
- Di Zhang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Chaoyang District, Pan jia yuan nan Road 17, Beijing, 100021, China
| | - Lixi Li
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Chaoyang District, Pan jia yuan nan Road 17, Beijing, 100021, China.
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Agarwal P, Bloom J, Zhou Y, Zhao R, Huang S, Yajima M, Devaiah AK. Socioeconomic disparities in treatment and survival in patients with hypopharyngeal malignancy. Head Neck 2023; 45:2670-2679. [PMID: 37638612 DOI: 10.1002/hed.27492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/26/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND This retrospective study utilizes The Surveillance, Epidemiology, and End Results database to investigate socioeconomic factors leading to treatment disparities in hypopharyngeal malignancy. METHODS Treatment was compared to National Cancer Care Network guidelines. Novel analyses, including logistic modeling, allowed survival analysis and identification of socioeconomic variables not previously considered in staging and management guidelines. RESULTS Black and older patients, and residence in low-income areas predict lower likelihood of standard therapy (p < 0.05). Early-stage disease and standard therapy correlate with improved survival (p < 0.001). Medicaid, advanced age, advanced disease, and treatment outside of consensus guidelines correlated with lower survival (p < 0.0001). CONCLUSIONS There are clear socioeconomic factors impacting treatment and survival in hypopharyngeal malignancies. Standard therapy affords superior survival rate. Black, low socioeconomic status, and older patients are less likely to receive standard therapy. Education and language isolation do not predict treatment or survival. Understanding these discrepancies is paramount to palliating disparities in healthcare.
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Affiliation(s)
- Pratima Agarwal
- Department of Otolaryngology - Head and Neck Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jacob Bloom
- Department of Otolaryngology - Head and Neck Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
| | | | - Runqi Zhao
- Boston University, Boston, Massachusetts, USA
| | - Simu Huang
- Boston University, Boston, Massachusetts, USA
| | | | - Anand K Devaiah
- Department of Otolaryngology - Head and Neck Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
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Li R, Yan L, Tian S, Zhao Y, Zhu Y, Wang X. Increased response to TPF chemotherapy promotes immune escape in hypopharyngeal squamous cell carcinoma. Front Pharmacol 2023; 13:1097197. [PMID: 36712687 PMCID: PMC9880322 DOI: 10.3389/fphar.2022.1097197] [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: 11/13/2022] [Accepted: 12/28/2022] [Indexed: 01/14/2023] Open
Abstract
Background: There is an urgent need to identify which patients would benefit from TPF chemotherapy in hypopharyngeal squamous cell carcinoma (HPSCC) and to explore new combinations to improve the treatment effect. Materials and methods: Gene-expression profiles in 15 TPF-sensitive patients were compared to 13 resistant patients. Immunohistochemistry (IHC) was performed to detect CD8+ T cells in 28 samples. Patient-Derived Tumor Xenograft (PDX) model and IHC were used to verify markers that optimize treatment for HPSCC. Results: Through RNA sequencing 188 genes were up-regulated in TPF chemotherapy-resistant (CR) tissues were involved in T cell activation, while 60 down-regulated genes were involved in glycolysis. Gene set enrichment analysis (GSEA) showed that chemotherapy-sensitive (CS) group upregulation of the pathways of glycolysis, while immune response was downregulated. CIBERSORT, MCP-counter, and IHC proved that most immune cells including CD8+ T cells in the CR significantly higher than that in CS group. Among the 16 up-regulated genes in CS had close associations, the most significant negative correlation between the gene level and CD8+ T cells existed in SEC61G. SEC61G was related to glycolysis, which was transcriptionally regulated by E2F1, and participated in antigen degradation through ubiquitin-dependent protein catabolic process. Palbociclib, combined with Cetuximab decreased the tumor burden and significantly suppressed the expression of E2F1 and SEC61G while activating MHC-I in PDX model. Conclusion: Enhanced glycolysis promoted immune escape, but increased response to TPF chemotherapy. SEC61G was the center of the molecular network and targeting the E2F1/SEC61G pathway increased the expression level of MHC-I.
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Affiliation(s)
| | | | - Shu Tian
- *Correspondence: Xiaoshen Wang, ; Yi Zhu, ; Shu Tian,
| | | | - Yi Zhu
- *Correspondence: Xiaoshen Wang, ; Yi Zhu, ; Shu Tian,
| | - Xiaoshen Wang
- *Correspondence: Xiaoshen Wang, ; Yi Zhu, ; Shu Tian,
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Yuan X, Lau H, Shen Y, Huang Q, Huang H, Zhang M, Tao L, Hsueh CY, Gong H, Zhou L. Tumour microbiota structure predicts hypopharyngeal carcinoma recurrence and metastasis. J Oral Microbiol 2023; 15:2146378. [DOI: 10.1080/20002297.2022.2146378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Xiaohui Yuan
- Department of Otorhinolaryngology Head and Neck Surgery, Eye and ENT Hospital, Fudan University, Shanghai, China
- Shanghai Key Clinical Disciplines of Otorhinolaryngology, Shanghai, China
| | - Hui‑Ching Lau
- Department of Otorhinolaryngology Head and Neck Surgery, Eye and ENT Hospital, Fudan University, Shanghai, China
- Shanghai Key Clinical Disciplines of Otorhinolaryngology, Shanghai, China
| | - Yujie Shen
- Department of Otorhinolaryngology Head and Neck Surgery, Eye and ENT Hospital, Fudan University, Shanghai, China
- Shanghai Key Clinical Disciplines of Otorhinolaryngology, Shanghai, China
| | - Qiang Huang
- Department of Otorhinolaryngology Head and Neck Surgery, Eye and ENT Hospital, Fudan University, Shanghai, China
- Shanghai Key Clinical Disciplines of Otorhinolaryngology, Shanghai, China
| | - Huiying Huang
- Department of Otorhinolaryngology Head and Neck Surgery, Eye and ENT Hospital, Fudan University, Shanghai, China
- Shanghai Key Clinical Disciplines of Otorhinolaryngology, Shanghai, China
| | - Ming Zhang
- Department of Otorhinolaryngology Head and Neck Surgery, Eye and ENT Hospital, Fudan University, Shanghai, China
- Shanghai Key Clinical Disciplines of Otorhinolaryngology, Shanghai, China
| | - Lei Tao
- Department of Otorhinolaryngology Head and Neck Surgery, Eye and ENT Hospital, Fudan University, Shanghai, China
- Shanghai Key Clinical Disciplines of Otorhinolaryngology, Shanghai, China
| | - Chi-Yao Hsueh
- Department of Otorhinolaryngology Head and Neck Surgery, Eye and ENT Hospital, Fudan University, Shanghai, China
- Shanghai Key Clinical Disciplines of Otorhinolaryngology, Shanghai, China
| | - Hongli Gong
- Department of Otorhinolaryngology Head and Neck Surgery, Eye and ENT Hospital, Fudan University, Shanghai, China
- Shanghai Key Clinical Disciplines of Otorhinolaryngology, Shanghai, China
| | - Liang Zhou
- Department of Otorhinolaryngology Head and Neck Surgery, Eye and ENT Hospital, Fudan University, Shanghai, China
- Shanghai Key Clinical Disciplines of Otorhinolaryngology, Shanghai, China
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Liu H, Zhao D, Huang Y, Li C, Dong Z, Tian H, Sun Y, Lu Y, Chen C, Wu H, Zhang Y. Comprehensive prognostic modeling of locoregional recurrence after radiotherapy for patients with locoregionally advanced hypopharyngeal squamous cell carcinoma. Front Oncol 2023; 13:1129918. [PMID: 37025592 PMCID: PMC10072214 DOI: 10.3389/fonc.2023.1129918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/13/2023] [Indexed: 04/08/2023] Open
Abstract
Purpose To propose and evaluate a comprehensive modeling approach combing radiomics, dosiomics and clinical components, for more accurate prediction of locoregional recurrence risk after radiotherapy for patients with locoregionally advanced HPSCC. Materials and methods Clinical data of 77 HPSCC patients were retrospectively investigated, whose median follow-up duration was 23.27 (4.83-81.40) months. From the planning CT and dose distribution, 1321 radiomics and dosiomics features were extracted respectively from planning gross tumor volume (PGTV) region each patient. After stability test, feature dimension was further reduced by Principal Component Analysis (PCA), yielding Radiomic and Dosiomic Principal Components (RPCs and DPCs) respectively. Multiple Cox regression models were constructed using various combinations of RPC, DPC and clinical variables as the predictors. Akaike information criterion (AIC) and C-index were used to evaluate the performance of Cox regression models. Results PCA was performed on 338 radiomic and 873 dosiomic features that were tested as stable (ICC1 > 0.7 and ICC2 > 0.95), yielding 5 RPCs and DPCs respectively. Three comprehensive features (RPC0, P<0.01, DPC0, P<0.01 and DPC3, P<0.05) were found to be significant in the individual Radiomic or Dosiomic Cox regression models. The model combining the above features and clinical variable (total stage IVB) provided best risk stratification of locoregional recurrence (C-index, 0.815; 95%CI, 0.770-0.859) and prevailing balance between predictive accuracy and complexity (AIC, 143.65) than any other investigated models using either single factors or two combined components. Conclusion This study provided quantitative tools and additional evidence for the personalized treatment selection and protocol optimization for HPSCC, a relatively rare cancer. By combining complementary information from radiomics, dosiomics, and clinical variables, the proposed comprehensive model provided more accurate prediction of locoregional recurrence risk after radiotherapy.
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Affiliation(s)
- Hongjia Liu
- Institute of Medical Technology, Peking University Health Science Center, Beijing, China
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Dan Zhao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Yuliang Huang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
- Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Chenguang Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Zhengkun Dong
- Institute of Medical Technology, Peking University Health Science Center, Beijing, China
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Hongbo Tian
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Yijie Sun
- School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China
| | - Yanye Lu
- Institute of Medical Technology, Peking University Health Science Center, Beijing, China
| | - Chen Chen
- School of Electronics Engineering and Computer Science, Peking University, Beijing, China
| | - Hao Wu
- Institute of Medical Technology, Peking University Health Science Center, Beijing, China
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Yibao Zhang
- Institute of Medical Technology, Peking University Health Science Center, Beijing, China
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
- *Correspondence: Yibao Zhang,
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Lin TY, Lee TL, Hsu YB, Tai SK, Wang LW, Yang MH, Chu PY. Survival analyses of different treatment modalities and clinical stage for hypopharyngeal carcinoma. Front Oncol 2023; 13:1109417. [PMID: 36937435 PMCID: PMC10020644 DOI: 10.3389/fonc.2023.1109417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 02/13/2023] [Indexed: 03/06/2023] Open
Abstract
Objective We investigated the effects of different treatment modalities and clinical stage for hypopharyngeal carcinoma (HPC) patients. Methods Between February 2004 and December 2012, 167 HPC patients were reviewed. We calculated overall survival (OS), progression-free survival (PFS), local failure-free survival (LFFS), regional failure-free survival (RFFS), and distant metastasis failure-free survival (DMFFS) using the Kaplan-Meier method and compared various survival outcomes between definitive chemoradiotherapy (CRT) and surgery-based therapy (SBT). Results There were no significant differences in baseline characteristics between SBT (n = 102) and definitive CRT (n = 65) groups. The 5-year rates of OS (59.7% vs. 24.0%, p < 0.0001) and PFS (49.9% vs. 22.6%, p = 0.0002) were significantly better in patients who received SBT than in those who received definitive CRT. The SBT group also obtained better LFFS (p < 0.0001), RFFS (p = 0.0479), and DMFFS (p = 0.0110). We did similar analyses by different T-classification (T1-2, T3, and T4) and found that SBT had better OS (p < 0.0001 and p = 0.0020), PFS (p < 0.0001 and p = 0.0513), LFFS (p = 0.0002 and p = 0.0075), RFFS (p = 0.1949 and p = 0.0826), and DMFFS (p = 0.0248 and p = 0.0436) in the T4 and T1-2 subgroups but similar OS (p = 0.9598), PFS (p = 0.5052), RFFS (p = 0.9648), and DMFFS (p = 0.8239) in T3 patients. Analyses by different overall stages revealed no differences between definitive CRT and SBT for stage III patients but significantly better results for stage IV patients who received SBT. Conclusions SBT can obtain significant survival benefits when compared with definitive CRT for the whole cohort of patients. Definitive CRT has similar survival outcomes compared with SBT only for T3 tumors or overall stage III disease.
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Affiliation(s)
- Tian-Yun Lin
- Department of Otolaryngology-Head and Neck Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tsung-Lun Lee
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Bin Hsu
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shyh-Kuan Tai
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ling-Wei Wang
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Radiation Oncology, Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Muh-Hwa Yang
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Medical Oncology, Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Pen-Yuan Chu
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- *Correspondence: Pen-Yuan Chu, ;
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Chen C, Hang L, Liu Y, Xie J, Yang J. Oncological Analysis and Surgical Outcomes in Postcricoid Carcinoma: A 14 Years Retrospective Study. Cancers (Basel) 2022; 14:cancers14133146. [PMID: 35804918 PMCID: PMC9264822 DOI: 10.3390/cancers14133146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/19/2022] [Accepted: 06/24/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Postcricoid carcinoma is a rare but aggressive type of hypopharyngeal carcinoma with poor prognosis and high mortality; thus, it is indispensable to investigate the surgical efficacy and multimodal strategies. Methods: This retrospective study included postcricoid carcinoma patients undergoing surgical resection from 2008 to 2022. Treatment methods and clinical characteristics were analyzed to evaluate prognostic factors for oncological outcomes. Results: Of 72 patients, 13 cases were in the I−II stage and 59 in the III−IV stage. The overall survival (OS) was 50.0%; the laryngeal function preservation rate was 69.4%. Univariate analysis found that high mortality was associated with low tumor differentiation, lymph node metastasis, neck recurrence, and smoke history via log-rank test (p < 0.05); postoperative radiotherapy (RT) remained positive in OS (p = 0.04). The multivariable model further revealed that lymph node metastasis was a dominant determinant after accounting for covariates (HR 1.75; 95% CI 0.85−3.59). The data also indicated that neoadjuvant chemotherapy (NAC) and tumor diameter ≤ 2 cm were causing lower rates of pharyngeal fistula and locoregional relapse. Conclusions: Surgeons should emphasize high-risk features and optimize individualized surgical procedures for postcricoid carcinoma patients. Combined with multimodal treatments, it is feasible to reconstruct laryngeal function and lessen postoperative morbidities in advanced patients.
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Affiliation(s)
- Chun Chen
- Department of Otorhinolaryngology-Head & Neck Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; (C.C.); (Y.L.)
- Ear Institute, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai 200092, China
| | - Lei Hang
- Business School, Shanghai Normal University Tianhua College, Shanghai 201815, China;
| | - Yupeng Liu
- Department of Otorhinolaryngology-Head & Neck Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; (C.C.); (Y.L.)
- Ear Institute, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai 200092, China
| | - Jin Xie
- Department of Otorhinolaryngology-Head & Neck Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; (C.C.); (Y.L.)
- Ear Institute, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai 200092, China
- Correspondence: (J.X.); (J.Y.)
| | - Jun Yang
- Department of Otorhinolaryngology-Head & Neck Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; (C.C.); (Y.L.)
- Ear Institute, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai 200092, China
- Correspondence: (J.X.); (J.Y.)
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Bertlich M, Zeller N, Freytag S, Spiegel JL, Weiss BG, Canis M, Haubner F, Ihler F. Factors influencing outcomes in selective neck dissection in 661 patients with head and neck squamous cell carcinoma. BMC Surg 2022; 22:196. [PMID: 35590282 PMCID: PMC9118639 DOI: 10.1186/s12893-022-01644-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 05/03/2022] [Indexed: 12/04/2022] Open
Abstract
Background Selective neck dissection (SND) is the surgical treatment of choice in squamous cell carcinoma of the head and neck (HNSCC) with suspected or manifest metastases in the cervical lymph nodes. For SND to be successful, treated lymph node levels should be selected according to anatomic considerations and the extent of the disease. Aim of this study was to identify neck dissection levels that had an impact on individual prognosis.
Methods We conducted a retrospective review of SND as part of primary treatment of HNSCC. Overall survival (OS) and regional control rates (RCR) were calculated for all patients treated at one academic tertiary referral center. Results 661 patients with HNSCC were included, 644 underwent ipsilateral and 319 contralateral SND. Average follow-up was 78.9 ± 106.4 months. 67 (10.1%) patients eventually developed nodal recurrence. Tumor sites were oral cavity (135), oropharynx (179), hypopharynx (118) and larynx (229). Tumor categories pT1–pT4a, and all clinical and pathological nodal categories were included. Multivariate analysis indicated improved OS rates for patients undergoing SND in ipsilateral levels I and V as well as level III contralaterally. Analysis for tumor origin showed that SND in ipsilateral level I showed significantly improved OS in HNSCC of the oral cavity. Conclusion The dissection of ipsilateral level I in oral cavity cancer was of particular relevance in our exploratory, retrospective analysis. To clarify the relevance for the determination of the extent of SND, this should be investigated prospectively in a more homogenous patient cohort.
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Affiliation(s)
- Mattis Bertlich
- Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilians-University of Munich, Marchioninistr. 15, 81377, Munich, Germany.,Department of Otorhinolaryngology, University Hospital, Ludwig-Maximilians-University of Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Nina Zeller
- Department of Otorhinolaryngology, Klinikum Frankfurt Höchst, Gotenstraße 6-8, 65929, Frankfurt am Main, Germany
| | - Saskia Freytag
- Epigenetics and Genomics, Harry Perkins Institute of Medical Research, Nedlands, WA, Australia
| | - Jennifer L Spiegel
- Department of Otorhinolaryngology, University Hospital, Ludwig-Maximilians-University of Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Bernhard G Weiss
- Department of Otorhinolaryngology, University Hospital, Ludwig-Maximilians-University of Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Martin Canis
- Department of Otorhinolaryngology, University Hospital, Ludwig-Maximilians-University of Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Frank Haubner
- Department of Otorhinolaryngology, University Hospital, Ludwig-Maximilians-University of Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Friedrich Ihler
- Department of Otorhinolaryngology, Head and Neck Surgery, Greifswald University Medicine, University of Greifswald, Fleischmannstraße 8, 17475, Greifswald, Germany.
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11
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Luo X, Huang X, Liu S, Wang X, Luo J, Xiao J, Wang K, Qu Y, Chen X, Zhang Y, Wang J, Zhang J, Xu G, Gao L, Wu R, Yi J. Evaluation of the prevalence of metachronous second primary malignancies in hypopharyngeal carcinoma and their effect on outcomes. Cancer Med 2022; 11:1059-1067. [PMID: 35080148 PMCID: PMC8855899 DOI: 10.1002/cam4.4501] [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: 07/02/2021] [Revised: 11/06/2021] [Accepted: 11/26/2021] [Indexed: 01/08/2023] Open
Abstract
Background To investigate the clinical characteristics of metachronous second primary malignancies (Met‐SPMs) and its impact on prognosis in hypopharyngeal carcinoma (HPC). Methods We reviewed 593 newly diagnosed HPC patients without invasive synchronous SPMs (Syn‐SPMs) who were treated in our cancer center between 2009 and 2019. According to the status during follow‐up, patients were classified into three groups: (a) without SPMs (No‐SPMs, n = 440), (b) with tumors in situ in the esophagus or stomach (Tis, n = 80), or (c) with Met‐SPMs (n = 73). Results The median follow‐up time for entire cohort (n = 593) was 66.7 months. Met‐SPMs were present in 12.3% of the cohort (73/593). The predominant site of SPMs was esophagus, followed by lung, oral cavity, thyroid, stomach, and oropharynx. In Met‐SPMs group, both index tumor and SPMs were the main causes of death. Tis group exhibited comparable 5‐year overall survival (OS) and disease‐specific survival (DSS) with that of No‐SPMs group. The Met‐SPMs group had similar 5‐year OS rate and better 5‐year DSS rate of 47.3% versus 43.6% (odds ratio [OR], 0.931; 95% confidence interval [CI], 0.681–1.274, p = 0.657) and 66.3% vs. 46.2% (OR, 0.600; 95% CI, 0.402–0.896, p = 0.012), respectively, compared with the No‐SPMs group. Conclusion The overall incidence of Met‐SPMs in HPC was 12.3%. The occurrence of Met‐SPMs does not jeopardize the survival outcome of HPC. Routine surveillance of Met‐SPMs was requisite for patients with HPC.
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Affiliation(s)
- Xi Luo
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaodong Huang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shaoyan Liu
- Department of Head and Neck Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaolei Wang
- Department of Head and Neck Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingwei Luo
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianping Xiao
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kai Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Qu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuesong Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ye Zhang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingbo Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianghu Zhang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guozhen Xu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li Gao
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Runye Wu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junlin Yi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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12
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Therapeutic strategies, oncologic and swallowing outcomes and their predictive factors in patients with locally advanced hypopharyngeal cancer. Eur Arch Otorhinolaryngol 2022; 279:3629-3637. [DOI: 10.1007/s00405-021-07196-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/20/2021] [Indexed: 12/17/2022]
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13
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Yang H, Zeng M, Cao S, Jin L. Nomograms predicting prognosis for locally advanced hypopharyngeal squamous cell carcinoma. Eur Arch Otorhinolaryngol 2021; 279:3041-3052. [PMID: 34648051 DOI: 10.1007/s00405-021-07109-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/24/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE This study aimed to construct nomograms to predict the overall survival (OS) and cancer-specific survival (CSS) for patients with locally advanced hypopharyngeal squamous cell carcinoma (HSCC). METHODS 864 patients with locally advanced HSCC during 2010-2015 from the surveillance, epidemiology and end results (SEER) database were selected. After classifying continuous data by risk, Cox regression analyses were applied to detect significant independent prognostic factors, with which nomograms were established. To evaluate the value of nomograms, concordance index (C-index), area under the receiver-operating characteristic (ROC) curve (AUC), calibration curves, and decision curve analysis (DCA), Kaplan-Meier analysis was adopted. The efficacy of surgery in different risk groups was also studied to figure out people who can benefit from surgery. RESULTS A total of 864 locally advanced HSCC patients were randomized into the training cohort (n = 608) and the validation cohort (n = 256). Age, race, tumor size, T stage, N stage, primary site, radiotherapy, and chemotherapy were independent prognostic factors for OS and CSS (except race) and formed the nomograms. The nomograms revealed satisfied performance in C-index, AUC, DCA, and calibration curves, and prevailed over American Joint Committee on Cancer (AJCC) TNM staging system in predicting OS and CSS. After risk stratification, patients of low-risk group resulted in the best outcomes. Patients in moderate-risk may benefit from surgery. CONCLUSIONS Convenient and well-calibrated nomograms to predict OS and CSS for III/IVA/IVB-stage HSCC patients were set up and assessed and may do a favor to make clinical decisions.
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Affiliation(s)
- Huiyun Yang
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Mengsi Zeng
- Department of Oncology, The First People's Hospital of Changde, Changde, 415000, China
| | - Sudan Cao
- Department of Oncology, Third Xiangya Hospital, Central South University, Changsha, 410000, China
| | - Long Jin
- Department of Oncology, Third Xiangya Hospital, Central South University, Changsha, 410000, China.
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Saito S, Ozawa H, Imanishi Y, Sekimizu M, Watanabe Y, Ito F, Ikari Y, Nakahara N, Kameyama K, Ogawa K. Cyclooxygenase-2 expression is associated with chemoresistance through cancer stemness property in hypopharyngeal carcinoma. Oncol Lett 2021; 22:533. [PMID: 34084214 PMCID: PMC8161457 DOI: 10.3892/ol.2021.12794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/20/2021] [Indexed: 01/05/2023] Open
Abstract
Cyclooxygenase-2 (COX-2) is one of the two isoforms of COX, an enzyme that catalyzes the conversion of arachidonic acid to prostaglandins. COX-2 is associated with the progression in various types of cancer, and its expression has been associated with a poor prognosis in head and neck squamous cell carcinoma (HNSCC). Furthermore, COX-2 expression has been associated with resistance to anticancer drugs. However, the precise mechanism of COX-2 for chemoresistance in HNSCC has not been fully elucidated. The present study aimed to investigate the effect of COX-2 on cancer stem cell (CSC) property and to reveal its effect on chemoresistance using in vitro and clinicopathological assays in HNSCC cells and tissues. The current study analyzed the immunohistochemical expression levels of COX-2 and clinicopathological factors using matched samples of pretreatment biopsy and surgical specimens from patients with hypopharyngeal carcinoma who underwent tumor resection with preoperative chemotherapy, including docetaxel. Additionally, the chemoresistance to docetaxel with or without a COX-2 inhibitor (celecoxib) was examined in HNSCC cell lines by MTS assays. To evaluate the association of COX-2 expression with stemness property, the expression levels of CSC-associated genes after exposure to celecoxib were assessed by reverse transcription-quantitative PCR. A sphere formation assay was also performed using ultra-low attachment dishes and microscopic imaging. The immunohistochemical analysis of biopsy specimens revealed a negative association between COX-2 expression in biopsy specimens and the pathological effect of induction chemotherapy in surgical specimens. The cell survival rate under exposure to docetaxel was decreased by the addition of celecoxib. COX-2 inhibition led to downregulation of CSC-associated gene expression and sphere formation. The present findings suggested that COX-2 expression may be associated with chemoresistance through the cancer stemness property, and inhibition of COX-2 may enhance chemo-sensitivity in HNSCC. Therefore, COX-2 may be an attractive target for the treatment of HNSCC.
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Affiliation(s)
- Shin Saito
- Department of Otorhinolaryngology-Head and Neck Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Hiroyuki Ozawa
- Department of Otorhinolaryngology-Head and Neck Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Yorihisa Imanishi
- Department of Otorhinolaryngology-Head and Neck Surgery, International University of Health and Welfare, Narita, Chiba 286-8582, Japan
| | - Mariko Sekimizu
- Department of Otorhinolaryngology-Head and Neck Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Yoshihiro Watanabe
- Department of Otorhinolaryngology-Head and Neck Surgery, International University of Health and Welfare, Narita, Chiba 286-8582, Japan
| | - Fumihiro Ito
- Department of Otorhinolaryngology-Head and Neck Surgery, National Hospital Organization Tokyo Medical Center, Tokyo 152-8902, Japan
| | - Yuichi Ikari
- Department of Otorhinolaryngology-Head and Neck Surgery, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Kanagawa 210-0013, Japan
| | - Nana Nakahara
- Department of Otorhinolaryngology-Head and Neck Surgery, Saitama City Hospital, Saitama 336-8522, Japan
| | - Kaori Kameyama
- Department of Pathology, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Kaoru Ogawa
- Department of Otorhinolaryngology-Head and Neck Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
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15
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Wu J, You K, Chen C, Zhong H, Jiang Y, Mo H, Song J, Qiu X, Liu Y. High Pretreatment LDH Predicts Poor Prognosis in Hypopharyngeal Cancer. Front Oncol 2021; 11:641682. [PMID: 33777804 PMCID: PMC7991725 DOI: 10.3389/fonc.2021.641682] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/02/2021] [Indexed: 12/30/2022] Open
Abstract
Background Elevated pretreatment lactate dehydrogenase (LDH) has been associated with poor prognosis in various malignancies; however, its prognostic role in hypopharyngeal cancer remains elusive. In this study, we aimed to assess the association between pretreatment LDH and clinical outcome of hypopharyngeal cancer. Methods We retrospectively collected 198 hypopharyngeal cancer patients treated with surgery in our institution between 2004 and 2018. The prognostic role of pretreatment LDH was explored by using univariate and multivariate analyses. Besides, subgroup analysis was performed based on T stage. Results Three-year and Five-year of disease-free survival (DFS, 67.0 vs. 57.4%, 65.8 vs. 39.8%, p = 0.007) and overall survival (OS, 74.8 vs. 68.9%, 66.8 vs. 50.8%, p = 0.006) exhibited significant differences between low LDH level and high LDH level groups. Univariate analysis showed that pretreatment elevated serum LDH served as an unfavorable determinant with regard to DFS and OS. Further multivariate analysis also confirmed that LDH was an independent predictor for DFS and OS. Additionally, N status and age were also found to be significantly associated with both DFS and OS. Conclusion Pretreatment elevated serum LDH is an inferior prognostic factor for patients with hypopharyngeal cancer. These results should be validated by more multicenter and prospective studies.
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Affiliation(s)
- Jialing Wu
- Department of Radiation Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Kaiyun You
- Department of Radiation Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Changlong Chen
- Department of Radiation Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Huimin Zhong
- Department of Radiation Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yanhui Jiang
- Department of Radiation Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Huaqian Mo
- Department of Radiation Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Juanjuan Song
- Department of Radiation Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xingsheng Qiu
- Department of Radiation Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yimin Liu
- Department of Radiation Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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