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Wu Z, Lin Q, Wang H, Chen J, Wang G, Fu G, Li L, Bian T. Intratumoral and Peritumoral Radiomics Based on Preoperative MRI for Evaluation of Programmed Cell Death Ligand-1 Expression in Breast Cancer. J Magn Reson Imaging 2024; 60:588-599. [PMID: 37916918 DOI: 10.1002/jmri.29109] [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: 08/06/2023] [Revised: 10/17/2023] [Accepted: 10/17/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Programmed cell death ligand-1 (PD-L1) is a promising target for immune checkpoint blockade therapy in breast cancer. However, the preoperative evaluation of PD-L1 expression in breast cancer is rarely explored. PURPOSE To determine the ability of radiomics signatures based on preoperative dynamic contrast-enhanced (DCE) MRI to evaluate PD-L1 expression in breast cancer. STUDY TYPE Retrospective. POPULATION 196 primary breast cancer patients with preoperative MRI and postoperative pathological evaluation of PD-L1 expression, divided into training (n = 137, 28 PD-L1-positive) and test cohorts (n = 59, 12 PD-L1-positive). FIELD STRENGTH/SEQUENCE 3.0T; volume imaging for breast assessment DCE sequence. ASSESSMENT Radiomics features were extracted from the first phase of DCE-MRI by using the minimum redundancy maximum relevance method and least absolute shrinkage and selection operator algorithm. Three radiomics signatures were constructed based on the intratumoral, peritumoral, and combined intra- and peritumoral regions. The performance of the signatures was assessed using area under the receiver operating characteristic (ROC) curve (AUC), sensitivity, specificity, and accuracy. STATISTICAL TESTS Univariable and multivariable logistic regression analysis, t-tests, chi-square tests, Fisher exact test or Yates correction, ROC analysis, and one-way analysis of variance. P < 0.05 was considered significant. RESULTS In the test cohort, the combined radiomics signature (AUC, 0.853) exhibited superior performance compared to the intratumoral (AUC, 0.816; P = 0.528) and peritumoral radiomics signatures (AUC, 0.846; P = 0.905) in PD-L1 status evaluation, although the differences did not reach statistical significance. DATA CONCLUSION Intratumoral and peritumoral radiomics signatures based on preoperative breast MRI showed some potential accuracy for the non-invasive evaluation of PD-L1 status in breast cancer. LEVEL OF EVIDENCE 4 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Zengjie Wu
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Qing Lin
- Breast Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Haibo Wang
- Breast Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Jingjing Chen
- Breast Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Guanqun Wang
- Department of Pathology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Guangming Fu
- Department of Pathology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Lili Li
- Breast Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Tiantian Bian
- Breast Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
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Luangwattananun P, Sangsuwannukul T, Supimon K, Thuwajit C, Chieochansin T, Sa-Nguanraksa D, Samarnthai N, O-Charoenrat P, Junking M, Yenchitsomanus PT. Anti-PD-L1 × anti-CD3 bispecific T-cell engager-armed T cells can overcome immunosuppression and redirect T cells to kill breast cancer cells expressing PD-L1. Int Immunopharmacol 2023; 124:111012. [PMID: 37804657 DOI: 10.1016/j.intimp.2023.111012] [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: 06/01/2023] [Revised: 09/20/2023] [Accepted: 09/27/2023] [Indexed: 10/09/2023]
Abstract
T cell-based immunotherapy has transformed cancer treatment. Nonetheless, T cell antitumor activity can be inhibited by an immune checkpoint molecule expressed on cancer cells, program death ligand 1 (PD-L1), which interacts with the PD-1 on T cells. We generated αPD-L1 × αCD3 bispecific T-cell engager-armed T cells (BATs) to prevent PD-L1/PD-1 interaction and hence to redirect T cells to kill cancer cells. αPD-L1 × αCD3 bispecific T-cell engagers (BTEs) were produced from Chinese hamster ovary (CHO) cells to arm human primary T cells. Flow cytometry was used to investigate BTE binding to BATs. The cytotoxicity of BATs against PD-L1-expressing breast cancer (BC) cell lines was assessed in 2-dimensional (2D) and 3-dimensional (3D) culture models. The binding stability of BTE on BATs and their efficacy after cryopreservation were also examined. The CHO cell BTE expression yield was 3.34 mg/ml. The binding ability on T cells reached 91.02 ± 4.2 %. BATs specifically lysed PD-L1-expressing BC cells, with 56.4 ± 15.3 % HCC70 cells and 70.67 ± 15.6 % MDA-MB-231 cells lysed at a 10:1 effector-to-target ratio. BATs showed slight, nonsignificant lysis of PD-L1-negative BC cells, MCF-7, and T47D. Moreover, BATs significantly disrupted MDA-MB-231 3D spheroids expressing PD-L1 after 48 and 72 h of coculture. Cryopreserved BATs maintained BTE binding stability, cell viability, and anticancer activity, comparable to fresh BATs. αPD-L1 × αCD3 BATs induced the cytolysis of PD-L1-expressing BC cells in 2D and 3D coculture assays. BATs can be prepared and preserved, facilitating their use and transportation. This study demonstrates the potential of αPD-L1 × αCD3 BATs in treating cancers with positive PD-L1 expression.
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Affiliation(s)
- Piriya Luangwattananun
- Siriraj Center of Research Excellence for Cancer Immunotherapy (SiCORE-CIT), Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Division of Molecular Medicine, Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thanich Sangsuwannukul
- Siriraj Center of Research Excellence for Cancer Immunotherapy (SiCORE-CIT), Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Division of Molecular Medicine, Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kamonlapat Supimon
- Siriraj Center of Research Excellence for Cancer Immunotherapy (SiCORE-CIT), Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Division of Molecular Medicine, Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanitra Thuwajit
- Siriraj Center of Research Excellence for Cancer Immunotherapy (SiCORE-CIT), Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thaweesak Chieochansin
- Siriraj Center of Research Excellence for Cancer Immunotherapy (SiCORE-CIT), Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Division of Molecular Medicine, Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Doonyapat Sa-Nguanraksa
- Division of Head Neck and Breast Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Norasate Samarnthai
- Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Mutita Junking
- Siriraj Center of Research Excellence for Cancer Immunotherapy (SiCORE-CIT), Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Division of Molecular Medicine, Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pa-Thai Yenchitsomanus
- Siriraj Center of Research Excellence for Cancer Immunotherapy (SiCORE-CIT), Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Division of Molecular Medicine, Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Geršak K, Geršak BM, Gazić B, Klevišar Ivančič A, Drev P, Ružić Gorenjec N, Grašič Kuhar C. The Possible Role of Anti- and Protumor-Infiltrating Lymphocytes in Pathologic Complete Response in Early Breast Cancer Patients Treated with Neoadjuvant Systemic Therapy. Cancers (Basel) 2023; 15:4794. [PMID: 37835488 PMCID: PMC10571934 DOI: 10.3390/cancers15194794] [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: 08/18/2023] [Revised: 09/20/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
The tumor microenvironment, composed of pro- and antitumor immune cells, affects cancer cell behavior. We aimed to evaluate whether tumor-infiltrating lymphocyte (TIL) density and TIL subtypes in core biopsies at the diagnosis of breast cancer patients could predict a pathologic complete response (pCR; ypT0/is ypN0) from neoadjuvant systemic therapy (NST). The TIL subtypes were determined based on the proportions of presumably antitumor (CD8+, CXCL13+) and protumor (PD-1+, FOXP3+) immune cells. A prospective, noninterventional study, including 171 participants undergoing NST, was performed. The median TIL density for the entire cohort was 10% (IQR: 3.5-23.8), and 59 (35%) patients achieved pCR. TIL density was positively associated with pCR (univariately and multivariably). In the multivariable logistic regression model, TIL density was an independent predictor of pCR (p = 0.012, OR 1.27; 95% CI 1.05-1.54) when controlled for age (p = 0.232), Ki-67 (p = 0.001), node-negative status (p = 0.024), and HER2+/triple negative vs. luminal B-like subtype (p < 0.001). In our sample, higher proportions of PD-1+ TILs and FOXP3+ TILs were associated with a higher probability of pCR but the association was not statistically significant and we could not make any conclusions on the direction of associations in the model with all four biomarkers. In the exploratory multivariable analysis, we showed that only higher CD8+ TILs were associated with pCR. In conclusion, TIL density and its subtypes are associated with pCR.
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Affiliation(s)
- Klara Geršak
- Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, 1000 Ljubljana, Slovenia (B.G.); (A.K.I.); (C.G.K.)
- Division of Medical Oncology, Institute of Oncology Ljubljana, Zaloška Cesta 2, 1000 Ljubljana, Slovenia
| | - Blaž Matija Geršak
- Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, 1000 Ljubljana, Slovenia (B.G.); (A.K.I.); (C.G.K.)
| | - Barbara Gazić
- Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, 1000 Ljubljana, Slovenia (B.G.); (A.K.I.); (C.G.K.)
- Department of Pathology, Institute of Oncology Ljubljana, Zaloška Cesta 2, 1000 Ljubljana, Slovenia;
| | - Andreja Klevišar Ivančič
- Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, 1000 Ljubljana, Slovenia (B.G.); (A.K.I.); (C.G.K.)
- Department of Pathology, Institute of Oncology Ljubljana, Zaloška Cesta 2, 1000 Ljubljana, Slovenia;
| | - Primož Drev
- Department of Pathology, Institute of Oncology Ljubljana, Zaloška Cesta 2, 1000 Ljubljana, Slovenia;
| | - Nina Ružić Gorenjec
- Institute for Biostatistics and Medical Informatics, Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, 1000 Ljubljana, Slovenia;
| | - Cvetka Grašič Kuhar
- Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, 1000 Ljubljana, Slovenia (B.G.); (A.K.I.); (C.G.K.)
- Division of Medical Oncology, Institute of Oncology Ljubljana, Zaloška Cesta 2, 1000 Ljubljana, Slovenia
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Zaakouk M, Van Bockstal M, Galant C, Callagy G, Provenzano E, Hunt R, D’Arrigo C, Badr NM, O’Sullivan B, Starczynski J, Tanchel B, Mir Y, Lewis P, Shaaban AM. Inter- and Intra-Observer Agreement of PD-L1 SP142 Scoring in Breast Carcinoma-A Large Multi-Institutional International Study. Cancers (Basel) 2023; 15:cancers15051511. [PMID: 36900303 PMCID: PMC10000421 DOI: 10.3390/cancers15051511] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/15/2023] [Accepted: 02/24/2023] [Indexed: 03/04/2023] Open
Abstract
The assessment of PD-L1 expression in TNBC is a prerequisite for selecting patients for immunotherapy. The accurate assessment of PD-L1 is pivotal, but the data suggest poor reproducibility. A total of 100 core biopsies were stained using the VENTANA Roche SP142 assay, scanned and scored by 12 pathologists. Absolute agreement, consensus scoring, Cohen's Kappa and intraclass correlation coefficient (ICC) were assessed. A second scoring round after a washout period to assess intra-observer agreement was carried out. Absolute agreement occurred in 52% and 60% of cases in the first and second round, respectively. Overall agreement was substantial (Kappa 0.654-0.655) and higher for expert pathologists, particularly on scoring TNBC (6.00 vs. 0.568 in the second round). The intra-observer agreement was substantial to almost perfect (Kappa: 0.667-0.956), regardless of PD-L1 scoring experience. The expert scorers were more concordant in evaluating staining percentage compared with the non-experienced scorers (R2 = 0.920 vs. 0.890). Discordance predominantly occurred in low-expressing cases around the 1% value. Some technical reasons contributed to the discordance. The study shows reassuringly strong inter- and intra-observer concordance among pathologists in PD-L1 scoring. A proportion of low-expressors remain challenging to assess, and these would benefit from addressing the technical issues, testing a different sample and/or referring for expert opinions.
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Affiliation(s)
- Mohamed Zaakouk
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Cancer Pathology, National Cancer Institue, Cairo University, Cairo 12613, Egypt
| | - Mieke Van Bockstal
- Department of Pathology, Cliniques Universitaires Saint-Luc Bruxelles, 1200 Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1348 Brussels, Belgium
| | - Christine Galant
- Department of Pathology, Cliniques Universitaires Saint-Luc Bruxelles, 1200 Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1348 Brussels, Belgium
| | - Grace Callagy
- Discipline of Pathology, School of Medicine, Lambe Institute for Translational Research, University of Galway, H91 TK33 Galway, Ireland
| | - Elena Provenzano
- NIHR Cambridge Biomedical Research Centre, Cambridge CB2 0QQ, UK
- Addenbrookes Hospital, Cambridge CB2 0QQ, UK
- Department of Histopathology, Cambridge University NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Roger Hunt
- Department of Histopathology, Wythenshawe Hospital, Manchester M23 9LT, UK
| | | | - Nahla M. Badr
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Department of Pathology, Faculty of Medicine, Menoufia University, Shebin El-Kom 32952, Egypt
| | - Brendan O’Sullivan
- Cellular Pathology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - Jane Starczynski
- Cellular Pathology, Heart of England NHS Foundation Trust, Birmingham B9 5ST, UK
| | - Bruce Tanchel
- Cellular Pathology, Heart of England NHS Foundation Trust, Birmingham B9 5ST, UK
| | - Yasmeen Mir
- Pathology, Royal Liverpool and Broadgreen University Hospitals, Liverpool L7 8YE, UK
| | - Paul Lewis
- Medical School, Swansea University, Singleton Park, Swansea SA2 8PP, UK
| | - Abeer M. Shaaban
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Cellular Pathology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
- Correspondence: ; Tel.: +44-121-371-3356
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Shi C, Qin K, Lin A, Jiang A, Cheng Q, Liu Z, Zhang J, Luo P. The role of DNA damage repair (DDR) system in response to immune checkpoint inhibitor (ICI) therapy. J Exp Clin Cancer Res 2022; 41:268. [PMID: 36071479 PMCID: PMC9450390 DOI: 10.1186/s13046-022-02469-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 08/18/2022] [Indexed: 11/10/2022] Open
Abstract
As our understanding of the mechanisms of cancer treatment has increased, a growing number of studies demonstrate pathways through which DNA damage repair (DDR) affects the immune system. At the same time, the varied response of patients to immune checkpoint blockade (ICB) therapy has prompted the discovery of various predictive biomarkers and the study of combination therapy. Here, our investigation explores the interactions involved in combination therapy, accompanied by a review that summarizes currently identified and promising predictors of response to immune checkpoint inhibitors (ICIs) that are useful for classifying oncology patients. In addition, this work, which discusses immunogenicity and several components of the tumor immune microenvironment, serves to illustrate the mechanism by which higher response rates and improved efficacy of DDR inhibitors (DDRi) in combination with ICIs are achieved.
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Gershtein ES, Korotkova EA, Vorotnikov IK, Sokolov NY, Ermilova VD, Mochalova AS, Kushlinskii NE. Soluble forms of PD-1/PD-L immune checkpoint receptor and ligand in blood serum of breast cancer patients: association with clinical pathologic factors and molecular type of the tumor. Klin Lab Diagn 2022; 67:76-80. [PMID: 35192751 DOI: 10.51620/0869-2084-2022-67-2-76-80] [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] [Indexed: 06/14/2023]
Abstract
Results of enzyme-linked immunosorbent assay of the soluble forms of PD-1/PD-L immune checkpoint receptor and ligand (sPD-1 and sPD-L1) in pretreatment blood serum of 88 breast cancer patients at various disease stages aged 30-83 years are presented. The control group included 55 practically healthy women aged 19-82 years. Serum sPD-1 and sPD-L1 levels in breast cancer patients highly significantly (p<0.0001) differ from control and these changes are opposite: soluble receptor level is more than 6-fold decreased, while soluble ligand concentration - 5.5 fold increased. Both markers separately, as well as their ratio demonstrate very high sensitivity (94-100%) and specificity (95-100%) in relation to healthy control. No statistically significant associations of sPD-1 and sPD-L1 levels with clinical stage, individual TNM system criteria, tumor histological structure, grade, receptor status, and molecular type were established. In particular, no significant peculiarities of the markers' levels in triple negative breast cancer successfully treated with anti-PD-1/PD-L1 preparations were revealed. Long-term follow-up and dynamic studies of sPD-1 and sPD-L1serum levels in the course of treatment are required for evaluation of their independent from clinical and morphological factors prognostic significance and the possibility of application as low invasive tests for prediction and monitoring of corresponding targeted therapy efficiency.
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Affiliation(s)
| | - E A Korotkova
- N.N. Blokhin National Medical Research Center of Oncology Ministry of Health of the Russian Federation
| | - I K Vorotnikov
- N.N. Blokhin National Medical Research Center of Oncology Ministry of Health of the Russian Federation
| | - N Yu Sokolov
- N.N. Blokhin National Medical Research Center of Oncology Ministry of Health of the Russian Federation
| | - V D Ermilova
- N.N. Blokhin National Medical Research Center of Oncology Ministry of Health of the Russian Federation
| | - A S Mochalova
- N.N. Blokhin National Medical Research Center of Oncology Ministry of Health of the Russian Federation
| | - N E Kushlinskii
- N.N. Blokhin National Medical Research Center of Oncology Ministry of Health of the Russian Federation
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Ayoub NM, Fares M, Marji R, Al Bashir SM, Yaghan RJ. Programmed Death-Ligand 1 Expression in Breast Cancer Patients: Clinicopathological Associations from a Single-Institution Study. BREAST CANCER (DOVE MEDICAL PRESS) 2021; 13:603-615. [PMID: 34803400 PMCID: PMC8597920 DOI: 10.2147/bctt.s333123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/28/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE Tumor expression of programmed death-ligand 1 (PD-L1) is associated with evasion of immune response in several types of malignancies and such expression may render patients eligible for PD-L1 inhibitors. The use of immune checkpoint blockade therapy has been recently approved for the treatment of breast cancer. However, PD-L1 expression data are lacking among Jordanian breast cancer patients. In this study, the tumor PD-L1 expression was characterized in breast cancer patients to assess their eligibility for immune checkpoint blockade therapy. The study also aimed to explore the association between tumoral PD-L1 expression and the clinicopathologic characteristics and the prognostic factors in patients with breast cancer. PATIENTS AND METHODS Tissue samples were available from 153 female patients with primary invasive breast cancer. Immunohistochemistry was performed on paraffin-embedded tumor sections that were stained with a PD-L1 antibody. Expression of tumor PD-L1 was correlated with demographics, clinicopathologic characteristics, and prognosis. RESULTS The mean age at diagnosis was 54.2±12.8 years (median 52, interquartile range 45-65). The percentage of PD-L1-positive tumors was 26.1%. PD-L1 expression on tumor cells significantly and positively correlated with tumor size (rho=0.174, p=0.032). PD-L1 positivity was significantly associated with the grade of carcinoma (p=0.001), HER2-positivity (p=0.015), and lymphovascular invasion (p=0.036). PD-L1 intensity was significantly associated with tumor stage (p=0.046). No significant associations were observed for the PD-L1 expression status or intensity with patient menopausal status, hormone receptor expression, and molecular subtypes. PD-L1 expression significantly correlated with a worse prognosis of breast cancer patients at the time of diagnosis (rho=0.230, p=0.005). CONCLUSION Tumor PD-L1 expression was associated with advanced clinicopathologic features and worse prognosis in this cohort of Jordanian breast cancer patients. Future studies are needed to better understand the impact of PD-L1 blockade therapy on treatment outcomes in eligible breast cancer patients in Jordan.
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Affiliation(s)
- Nehad M Ayoub
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology (JUST), Irbid, 22110, Jordan
| | - Mona Fares
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology (JUST), Irbid, 22110, Jordan
| | - Raya Marji
- Department of Pathology and Microbiology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Samir M Al Bashir
- Department of Pathology and Microbiology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Rami J Yaghan
- Department of Surgery, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
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