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Li X, Zhu Y, Yi J, Deng Y, Lei B, Ren H. Adoptive cell immunotherapy for breast cancer: harnessing the power of immune cells. J Leukoc Biol 2024; 115:866-881. [PMID: 37949484 DOI: 10.1093/jleuko/qiad144] [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: 08/15/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
Breast cancer is the most prevalent malignant neoplasm worldwide, necessitating the development of novel therapeutic strategies owing to the limitations posed by conventional treatment modalities. Immunotherapy is an innovative approach that has demonstrated significant efficacy in modulating a patient's innate immune system to combat tumor cells. In the era of precision medicine, adoptive immunotherapy for breast cancer has garnered widespread attention as an emerging treatment strategy, primarily encompassing cellular therapies such as tumor-infiltrating lymphocyte therapy, chimeric antigen receptor T/natural killer/M cell therapy, T cell receptor gene-engineered T cell therapy, lymphokine-activated killer cell therapy, cytokine-induced killer cell therapy, natural killer cell therapy, and γδ T cell therapy, among others. This treatment paradigm is based on the principles of immune memory and antigen specificity, involving the collection, processing, and expansion of the patient's immune cells, followed by their reintroduction into the patient's body to activate the immune system and prevent tumor recurrence and metastasis. Currently, multiple clinical trials are assessing the feasibility, effectiveness, and safety of adoptive immunotherapy in breast cancer. However, this therapeutic approach faces challenges associated with tumor heterogeneity, immune evasion, and treatment safety. This review comprehensively summarizes the latest advancements in adoptive immunotherapy for breast cancer and discusses future research directions and prospects, offering valuable guidance and insights into breast cancer immunotherapy.
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Affiliation(s)
- Xue Li
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, 150 Haping Road, Harbin 150076, Heilongjiang, China
| | - Yunan Zhu
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, 150 Haping Road, Harbin 150076, Heilongjiang, China
| | - Jinfeng Yi
- Department of Pathology, Harbin Medical University, 157 Baojian Road, Harbin 150081, Heilongjiang, China
| | - Yuhan Deng
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, 150 Haping Road, Harbin 150076, Heilongjiang, China
| | - Bo Lei
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, 150 Haping Road, Harbin 150076, Heilongjiang, China
| | - He Ren
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, 150 Haping Road, Harbin 150076, Heilongjiang, China
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Laheurte C, Seffar E, Gravelin E, Lecuelle J, Renaudin A, Boullerot L, Malfroy M, Marguier A, Lecoester B, Gaugler B, Saas P, Truntzer C, Ghiringhelli F, Adotevi O. Interplay between plasmacytoid dendritic cells and tumor-specific T cells in peripheral blood influences long-term survival in non-small cell lung carcinoma. Cancer Immunol Immunother 2023; 72:579-589. [PMID: 35989364 DOI: 10.1007/s00262-022-03271-9] [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: 01/10/2022] [Accepted: 07/28/2022] [Indexed: 02/24/2023]
Abstract
Plasmacytoid dendritic cells (pDCs) represent a subset of antigen-presenting cells that play an ambivalent role in cancer immunity. Here, we investigated the clinical significance of circulating pDCs and their interaction with tumor-specific T cell responses in patients with non-small cell lung cancer (NSCLC, n = 126) . The relation between intratumoral pDC signature and immune checkpoint inhibitors efficacy was also evaluated. Patients with NSCLC had low level but activated phenotype pDC compared to healthy donors. In overall population, patients with high level of pDC (pDChigh) had improved overall survival (OS) compared to patients with pDClow, median OS 30.4 versus 20.7 months (P = 0.013). This clinical benefit was only observed in stage I to III patients, but not in metastatic disease. We showed that patients harboring pDChigh profile had high amount of Th1-diffentiation cytokine interleukin-12 (IL-12) in blood and had functional T cells directed against a broad range of tumor antigens. Furthermore, a high pDC signature in the tumor microenvironment was associated with improved clinical outcome in patients treated with anti-PD-(L)1 therapy. Overall, this study showed that circulating pDChigh is associated with long-term OS in NSCLC and highlighted the predictive value of intratumor pDC signature in the efficacy of immune checkpoint inhibitors.
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Affiliation(s)
- Caroline Laheurte
- INSERM, EFS BFC, UMR1098, RIGHT Interactions Greffon-Hôte Tumeur/Ingénierie Cellulaire et Génique, Univ. Bourgogne Franche-Comté, 25000, Besançon, France.,INSERM CIC-1431, Clinical Investigation Center in Biotherapy, Plateforme de Biomonitoring, 25000, Besançon, France
| | - Evan Seffar
- INSERM, EFS BFC, UMR1098, RIGHT Interactions Greffon-Hôte Tumeur/Ingénierie Cellulaire et Génique, Univ. Bourgogne Franche-Comté, 25000, Besançon, France
| | - Eléonore Gravelin
- INSERM, EFS BFC, UMR1098, RIGHT Interactions Greffon-Hôte Tumeur/Ingénierie Cellulaire et Génique, Univ. Bourgogne Franche-Comté, 25000, Besançon, France.,INSERM CIC-1431, Clinical Investigation Center in Biotherapy, Plateforme de Biomonitoring, 25000, Besançon, France
| | - Julie Lecuelle
- Platform of Transfer in Biological Oncology, Georges François Leclerc Cancer Center - UNICANCER, 1 rue du Professeur Marion, 21000, Dijon, France.,UMR INSERM 1231, 7 Boulevard Jeanne d'Arc, 21000, Dijon, France
| | - Adeline Renaudin
- INSERM, EFS BFC, UMR1098, RIGHT Interactions Greffon-Hôte Tumeur/Ingénierie Cellulaire et Génique, Univ. Bourgogne Franche-Comté, 25000, Besançon, France.,INSERM CIC-1431, Clinical Investigation Center in Biotherapy, Plateforme de Biomonitoring, 25000, Besançon, France
| | - Laura Boullerot
- INSERM, EFS BFC, UMR1098, RIGHT Interactions Greffon-Hôte Tumeur/Ingénierie Cellulaire et Génique, Univ. Bourgogne Franche-Comté, 25000, Besançon, France.,INSERM CIC-1431, Clinical Investigation Center in Biotherapy, Plateforme de Biomonitoring, 25000, Besançon, France
| | - Marine Malfroy
- INSERM, EFS BFC, UMR1098, RIGHT Interactions Greffon-Hôte Tumeur/Ingénierie Cellulaire et Génique, Univ. Bourgogne Franche-Comté, 25000, Besançon, France
| | - Amélie Marguier
- INSERM, EFS BFC, UMR1098, RIGHT Interactions Greffon-Hôte Tumeur/Ingénierie Cellulaire et Génique, Univ. Bourgogne Franche-Comté, 25000, Besançon, France
| | - Benoit Lecoester
- INSERM, EFS BFC, UMR1098, RIGHT Interactions Greffon-Hôte Tumeur/Ingénierie Cellulaire et Génique, Univ. Bourgogne Franche-Comté, 25000, Besançon, France
| | - Béatrice Gaugler
- INSERM UMR938, Centre de Recherche Saint-Antoine (CRSA), 75012, Paris, France
| | - Philippe Saas
- INSERM, EFS BFC, UMR1098, RIGHT Interactions Greffon-Hôte Tumeur/Ingénierie Cellulaire et Génique, Univ. Bourgogne Franche-Comté, 25000, Besançon, France.,INSERM CIC-1431, Clinical Investigation Center in Biotherapy, Plateforme de Biomonitoring, 25000, Besançon, France
| | - Caroline Truntzer
- Platform of Transfer in Biological Oncology, Georges François Leclerc Cancer Center - UNICANCER, 1 rue du Professeur Marion, 21000, Dijon, France.,UMR INSERM 1231, 7 Boulevard Jeanne d'Arc, 21000, Dijon, France
| | - Francois Ghiringhelli
- Platform of Transfer in Biological Oncology, Georges François Leclerc Cancer Center - UNICANCER, 1 rue du Professeur Marion, 21000, Dijon, France.,UMR INSERM 1231, 7 Boulevard Jeanne d'Arc, 21000, Dijon, France
| | - Olivier Adotevi
- INSERM, EFS BFC, UMR1098, RIGHT Interactions Greffon-Hôte Tumeur/Ingénierie Cellulaire et Génique, Univ. Bourgogne Franche-Comté, 25000, Besançon, France. .,INSERM CIC-1431, Clinical Investigation Center in Biotherapy, Plateforme de Biomonitoring, 25000, Besançon, France. .,Service Oncologie médicale, University Hospital of Besançon, 25000, Besançon, France. .,INSERM UMR1098, RIGHT Institute, EFS Bourgogne Franche-Comté, 8, rue du Docteur JF-Xavier Girod, BP 1937, 25020, Besançon Cedex, France.
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Fortis SP, Sofopoulos M, Goulielmaki M, Arnogiannaki N, Ardavanis A, Perez SA, Gritzapis AD, Baxevanis CN. Association between Intratumoral CD8+ T Cells with FoxP3+ and CD163+ Cells: A Potential Immune Intrinsic Negative Feedback Mechanism for Acquired Immune Resistance. Cancers (Basel) 2022; 14:cancers14246208. [PMID: 36551693 PMCID: PMC9777444 DOI: 10.3390/cancers14246208] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/08/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Acquired immune resistance (AIR) describes a situation in which cancer patients who initially responded clinically to immunotherapies, after a certain period of time, progress with their disease. Considering that AIR represents a feedback response of the tumor against the immune attack generated during the course of immunotherapies, it is conceivable that AIR may also occur before treatment initiation as a mechanism to escape endogenous adaptive antitumor immunity (EAAI). In the present study, we assessed the EAAI in paraffin-embedded breast primary tumor tissue samples and drew correlations with the clinical outcomes. In particular, we analyzed densities of CD8+ cells as elements mediating antitumor cytotoxicity, and of CD163+ and FoxP3+ cells as suppressor elements. We found a direct correlation between the densities of CD8+ cells and of CD163+ and/or FoxP3+ cells in the vast majority of patients' tumors. Importantly, the vast majority of patients whose tumors were overpopulated by CD8+ cells developed AIR, which was characterized by high intratumoral CD163+ and/or FoxP3+ cell densities and reduced overall survival (OS). We also showed that AIR depends on the levels of CD8+ cell-ratios in the tumor center to the invasive margin. Our data suggest that tumors develop AIR only when under a robust endogenous immune pressure.
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Affiliation(s)
- Sotirios P. Fortis
- Cancer Immunology and Immunotherapy Center, Cancer Research Center, Saint Savas Cancer Hospital, 11522 Athens, Greece
| | | | - Maria Goulielmaki
- Cancer Immunology and Immunotherapy Center, Cancer Research Center, Saint Savas Cancer Hospital, 11522 Athens, Greece
| | - Niki Arnogiannaki
- Pathology Department, Saint Savas Cancer Hospital, 11522 Athens, Greece
| | - Alexandros Ardavanis
- First Medical Oncology Clinic, Saint Savas Cancer Hospital, 11522 Athens, Greece
| | - Sonia A. Perez
- Cancer Immunology and Immunotherapy Center, Cancer Research Center, Saint Savas Cancer Hospital, 11522 Athens, Greece
| | - Angelos D. Gritzapis
- Cancer Immunology and Immunotherapy Center, Cancer Research Center, Saint Savas Cancer Hospital, 11522 Athens, Greece
| | - Constantin N. Baxevanis
- Cancer Immunology and Immunotherapy Center, Cancer Research Center, Saint Savas Cancer Hospital, 11522 Athens, Greece
- Correspondence: ; Tel.: +30-21064-09380
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Zhang M, Lu X, Wei C, Li X. Association between αβ and γδ T-cell subsets and clinicopathological characteristics in patients with breast cancer. Oncol Lett 2020; 20:325. [PMID: 33123241 PMCID: PMC7584013 DOI: 10.3892/ol.2020.12188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 09/14/2020] [Indexed: 12/30/2022] Open
Abstract
The aim of the present study was to discuss the effect of surgery on the T-lymphocyte subsets of patients with breast cancer (BC) and investigate the association between peripheral blood αβ and γδ T-cell counts and the clinicopathological characteristics of BC. The CD3+, CD4+, CD8+ and γδ T-cell subsets in the peripheral blood of healthy volunteers and Patients with BC before and after surgery were determined using flow cytometry. The association between αβ and γδ T-cell counts in the peripheral blood and clinicopathological characteristics was analyzed by comparing the differences in the αβ and γδ T-cell counts in the peripheral blood of Patients with BC before and after surgery with those of healthy volunteers and combining with clinicopathological data. The CD3+, CD4+ and γδ T-cell counts in the peripheral blood of Patients with BC were lower compared with those in healthy volunteers (P=0.0077, 0.0116 and 0.0003, respectively), whereas the number of CD8+ cells was higher (P=0.0241). The CD3+, CD4+ and γδ T-cell counts and the CD4+/CD8+ ratio after surgery were significantly higher compared with those before surgery (P=0.0109, 0.0031, 0.0165 and 0.018, respectively). There was no significant difference between the number of CD8+ cells before and after surgery (P=0.0053), but the number of CD8+ cells was higher in healthy volunteers compared with that in Patients with BC (P<0.05). Moreover, the CD3+ cell number was higher in patients with TNM stage II/III compared with those with TNM stage I disease (P=0.187 and 0.022, respectively), and the peripheral blood CD4+/CD8+ ratio and number of γδ T cells were lower in stage III compared with stage I Patients with BC (P=0.0065 and 0.0176, respectively). Histological grading demonstrated that the CD4+/CD8+ ratio and number of γδ T cells in patients with stage III BC were lower compared with those with stage I BC (P=0.02 and 0.0128, respectively). The γδ T-cell count in patients with luminal A and B subtypes was significantly higher compared with that in patients with basal-like subtype (P=0.004 and 0.0104, respectively). The CD3+, CD4+ and γδ T-cell counts were significantly lower in patients with lymph node (LN) metastasis compared with those without LN metastasis, and the CD8+ cell number was lower in patients without LN metastasis compared with that in patients with >10 LN metastases (P=0.0086, 0.0000 and 0.00468, respectively). The CD8+ cell count in patients without LN metastasis was lower compared with that in patients with 4–9 and >10 LN metastases (P=0.0435 and 0.0283, respectively). Surgery affects the T-lymphocyte subpopulations in patients with BC, and αβ and γδ T-cell counts may increase following mastectomy. Therefore, measurement of peripheral blood lymphocyte subsets is crucial for understanding the immune function status of Patients with BC with differences in TNM stage, histological grade, cell subtypes and LN metastases, and may provide a basis for the application of T-cell subsets in the comprehensive treatment of BC.
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Affiliation(s)
- Meng Zhang
- First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, P.R. China
| | - Xueling Lu
- Department of Nuclear Medicine, Tai'an City Central Hospital, Tai'an, Shandong 271000, P.R. China
| | - Changran Wei
- First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, P.R. China
| | - Xiangqi Li
- Department of Breast Surgery, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, Shandong 271000, P.R. China
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Lafrenie RM, Speigl L, Buckner CA, Pawelec G, Conlon MS, Shipp C. Frequency of Immune Cell Subtypes in Peripheral Blood Correlates With Outcome for Patients With Metastatic Breast Cancer Treated With High-Dose Chemotherapy. Clin Breast Cancer 2019; 19:433-442. [PMID: 31383605 DOI: 10.1016/j.clbc.2019.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 04/16/2019] [Accepted: 05/09/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND The frequency of circulating leukocytes has been shown to be a prognostic factor in patients being treated for different types of cancer. In breast cancer, tumor-infiltrating leukocytes may predict patient outcome, but few studies have investigated such associations for circulating leukocytes. PATIENTS AND METHODS Multiparametric flow cytometry was used to examine the immunophenotypes of circulating peripheral blood mononuclear cells for 88 patients with metastatic breast cancer, which was then correlated to breast cancer-specific survival. Patients had been treated either with high-dose cyclophosphamide-containing regimens (group 1, n = 51 patients) or high-dose paclitaxel-containing regimens (group 2, n = 37 patients). RESULTS The frequency of peripheral blood CD14+ monocytes indicated prognosis for patients in group 1 (but not group 2), while higher levels of CD11c+ dendritic cells indicated a better prognosis for patients in group 2 (but not group 1). The frequency of a number of different CD4+ or CD8+ T cell subtypes also predicted prognosis for patients in group 2. For example, patients in group 2 with a higher frequency of circulating CD4+ or CD8+ naive T cells (CD45RA+CD95-CD27+CD28+) showed a poorer prognosis. In contrast, T cells were not associated with prognosis for patients in group 1. CONCLUSION Circulating leukocytes can predict clinical outcome for patients with breast cancer. Prediction of clinical outcome in this cohort of metastatic breast cancer patients was specific to the type of chemotherapy, and this finding is likely to apply to other therapies.
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Affiliation(s)
- Robert M Lafrenie
- Health Sciences North Research Institute, Sudbury, Ontario, Canada; Laurentian University, Sudbury, Ontario, Canada; Northern Ontario School of Medicine, Sudbury, Ontario, Canada.
| | - Lisa Speigl
- Department of Internal Medicine II, University Hospital Tübingen, Tübingen, Germany
| | - Carly A Buckner
- Health Sciences North Research Institute, Sudbury, Ontario, Canada; Laurentian University, Sudbury, Ontario, Canada
| | - Graham Pawelec
- Health Sciences North Research Institute, Sudbury, Ontario, Canada; Department of Internal Medicine II, University Hospital Tübingen, Tübingen, Germany
| | - Michael S Conlon
- Health Sciences North Research Institute, Sudbury, Ontario, Canada
| | - Christopher Shipp
- Department of Internal Medicine II, University Hospital Tübingen, Tübingen, Germany
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Martens A, Pawelec G, Shipp C. Expansion and Determination of Antigen-Reactive T Cells by Flow Cytometry. Methods Mol Biol 2019; 1913:141-151. [PMID: 30666604 DOI: 10.1007/978-1-4939-8979-9_10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The detection of antigen-reactive T cells has shown great utility for patient clinical monitoring. However, many of the methods commonly used to detect these cells face major limitations, like the predetermination of the given HLA type. The herein described protocol provides a means of overcoming many of the obstacles associated with the use of multimers and other common approaches in this field. In order to be able to detect rare cells which are below the detection limit of direct ex vivo measurement, in the present protocol, antigen-reactive T cells are first expanded in vitro using libraries of overlapping peptides which span the entire protein of interest and consist of 15 amino acid-long peptides that share a 12-amino-acid overlap. This theoretically allows the detection of T cells to any epitope within a protein of interest and consequently does not require the patient's HLA type to be characterized. Furthermore, this method simultaneously detects CD4+ and CD8+ T cells that produce cytokines upon encounter with antigen and thereby provides a functional insight into the behavior of the responding T cells. In our case, we have investigated the pro- or anti-inflammatory cytokines IL-2, IL-5, IL-10, IL-17, TNF-α, and IFN-γ.
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Affiliation(s)
- Alexander Martens
- Department of Dermatology, University Medical Center Tübingen, Tübingen, Germany
| | - Graham Pawelec
- Department of Internal Medicine II, University Medical Center, Tübingen, Germany
- Health Sciences North Research Institute of Canada, Sudbury, ON, Canada
| | - Christopher Shipp
- Department of Internal Medicine II, University Medical Center, Tübingen, Germany.
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Fortis SP, Vaxevanis CK, Mahaira LG, Sofopoulos M, Sotiriadou NN, Dinou A, Arnogiannaki N, Stavropoulos-Giokas C, Thanos D, Baxevanis CN, Perez SA. Serum miRNA-based distinct clusters define three groups of breast cancer patients with different clinicopathological and immune characteristics. Cancer Immunol Immunother 2019; 68:57-70. [PMID: 30276443 PMCID: PMC11028120 DOI: 10.1007/s00262-018-2252-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 09/26/2018] [Indexed: 01/19/2023]
Abstract
Breast cancer (BCa) is a heterogeneous disease with different histological, prognostic and clinical aspects. Therefore, the need for identification of novel biomarkers for diagnosis, prognosis and monitoring of disease, as well as treatment outcome prediction remains at the forefront of research. The search for circulating elements, obtainable by simple peripheral blood withdrawal, which may serve as possible biomarkers, constitutes still a challenge. In the present study, we have evaluated the expression of 6 circulating miRNAs, (miR-16, miR-21, miR-23α, miR-146α, miR-155 and miR-181α), in operable BCa patients, with non-metastatic, invasive ductal carcinoma, not receiving neoadjuvant chemotherapy. These miRNAs, known to be involved in both tumor cell progression and immune pathways regulation, were analyzed in relation to circulating cytokines, tumor immune-cell infiltration and established prognostic clinicopathological characteristics. We have identified three different clusters, with overall low (C1), moderate (C2) or high (C3) expression levels of these six circulating miRNAs, which define three distinct groups of non-metastatic BCa patients characterized by different clinicopathological and immune-related characteristics, with possibly different clinical outcomes. Our data provide the proof-of-principle to support the notion that, up- or down-regulation of the same circulating miRNA may reflect different prognosis in BCa. Nonetheless, the prognostic and/or predictive potential of these three "signatures" needs to be further evaluated in larger cohorts of BCa patients with an, at least, 5-year clinical follow-up.
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Affiliation(s)
- Sotirios P Fortis
- Cancer Immunology and Immunotherapy Center, Saint Savas Cancer Hospital, 171 Alexandras avenue, 11522, Athens, Greece
| | - Christoforos K Vaxevanis
- Cancer Immunology and Immunotherapy Center, Saint Savas Cancer Hospital, 171 Alexandras avenue, 11522, Athens, Greece
| | - Louisa G Mahaira
- Cancer Immunology and Immunotherapy Center, Saint Savas Cancer Hospital, 171 Alexandras avenue, 11522, Athens, Greece
| | | | | | - Amalia Dinou
- Hellenic Cord Blood Bank, Biomedical Research Foundation Academy of Athens, Athens, Greece
| | | | | | - Dimitris Thanos
- Biomedical Research Foundation, Academy of Athens, Athens, Greece
| | - Constantin N Baxevanis
- Cancer Immunology and Immunotherapy Center, Saint Savas Cancer Hospital, 171 Alexandras avenue, 11522, Athens, Greece
| | - Sonia A Perez
- Cancer Immunology and Immunotherapy Center, Saint Savas Cancer Hospital, 171 Alexandras avenue, 11522, Athens, Greece.
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