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Ogmen BE, Ince N, Aksoy Altınboga A, Akdogan L, Polat SB, Genc B, Menekse E, Aydin C, Topaloglu O, Ersoy R, Cakir B. An old friend, a new insight: Calcitonin measurement in serum and aspiration needle washout fluids significantly increases the early and accurate detection of medullary thyroid cancer. Cancer Cytopathol 2024; 132:161-168. [PMID: 37950525 DOI: 10.1002/cncy.22779] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The sensitivity of cytological (CY) evaluation after fine-needle aspiration (FNA) for detecting medullary thyroid carcinoma (MTC) is a subject of controversy. The routine use of serum calcitonin (CT) in patients with thyroid nodules is not universally adopted. The authors conducted CT screening of FNA washout fluid (FNA-CT) to address the diagnostic challenges. The objective was to assess the contributions of serum CT, FNA cytology (FNA-CY), and FNA-CT to the diagnosis. METHODS Between February 2019 and June 2022 (group 1), the authors prospectively screened the CT of patients with thyroid nodules. Both FNA-CY and FNA-CT were performed for patients with persistently elevated CT values. The sensitivity of FNA-CY, serum CT, and FNA-CT for accurate diagnosis was evaluated. Additionally, the authors retrospectively examined data from patients with thyroid nodules before CT screening (2008-2019) (group 2). They compared the characteristics of MTC patients in groups 1 and 2. RESULTS MTC was identified in 30 patients (0.25%) in group 1 and 19 (0.07%) in group 2. A FNA-CT cutoff value of 4085.5 pg/mL detected MTC with a sensitivity of 96.8%, and a serum CT cutoff value of 28.3 pg/mL detected MTC with a sensitivity of 86.7%. In contrast, FNA-CY detected MTC with a sensitivity of 42.4%. In group 1, 18 patients (60%) with MTC were diagnosed with microcarcinoma, whereas only two patients (10.5%) in group 2 had microcarcinoma. CONCLUSIONS This study detected MTC earlier by routinely measuring serum CT in all patients with nodular thyroid disease and performing FNA-CT in those with elevated values. FNA-CT and serum CT sensitivities were significantly higher than those of FNA-CY. This study revealed different FNA-CT cutoff values compared to other studies, emphasizing the need for determining clinic-specific cutoff values.
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Affiliation(s)
- Berna Evranos Ogmen
- Department of Endocrinology and Metabolism, Ankara Yildirim Beyazit University, Faculty of Medicine, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Nurcan Ince
- Department of Endocrinology and Metabolism, Ankara Yildirim Beyazit University, Faculty of Medicine, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Aysegul Aksoy Altınboga
- Department of Pathology, Ankara Yildirim Beyazit University, Faculty of Medicine, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Leyla Akdogan
- Department of Endocrinology and Metabolism, Ankara Yildirim Beyazit University, Faculty of Medicine, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Sefika Burcak Polat
- Department of Endocrinology and Metabolism, Ankara Yildirim Beyazit University, Faculty of Medicine, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Birgul Genc
- Department of Endocrinology and Metabolism, Ankara Yildirim Beyazit University, Health Sciences Institute, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Ebru Menekse
- Department of Surgery, University of Health Sciences, Faculty of Medicine, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Cevdet Aydin
- Department of Endocrinology and Metabolism, Ankara Yildirim Beyazit University, Faculty of Medicine, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Oya Topaloglu
- Department of Endocrinology and Metabolism, Ankara Yildirim Beyazit University, Faculty of Medicine, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Reyhan Ersoy
- Department of Endocrinology and Metabolism, Ankara Yildirim Beyazit University, Faculty of Medicine, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Bekir Cakir
- Department of Endocrinology and Metabolism, Ankara Yildirim Beyazit University, Faculty of Medicine, Ankara Bilkent City Hospital, Ankara, Turkey
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Kiriakopoulos A, Giannakis P, Menenakos E. Calcitonin: current concepts and differential diagnosis. Ther Adv Endocrinol Metab 2022; 13:20420188221099344. [PMID: 35614985 PMCID: PMC9125613 DOI: 10.1177/20420188221099344] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 04/21/2022] [Indexed: 01/27/2023] Open
Abstract
Calcitonin (CT) is most effectively produced by the parafollicular cells of the thyroid gland. It acts through the calcitonin receptor (CTR), a seven-transmembrane class II G-protein-coupled receptor linked to multiple signal transduction pathways with its main secretagogues being calcium and gastrin. It is clinically used mostly in the diagnosis and follow-up of medullary thyroid carcinoma (MTC). Hypercalcitoninemia can be attributed to primary (e.g. CT-secreting tumor) or secondary (e.g. due to hypercalcemia) overproduction, underexcretion (e.g. renal insufficiency), drug reaction (e.g. β-blockers), or false-positive results. In clinical practice, elevated basal calcitonin (bCT) is indicative, but not pathognomonic, of MTC. Current literature leans toward an age as well as gender-specific cutoff approach. bCT >100 pg/ml has up to 100% positive prognostic value (PPV) for MTC, whereas bCT between 8 and 100 pg/ml for adult males and 6 and 80 pg/ml for adult females should be possibly further investigated with stimulation calcitonin (sCT) tests. Calcium is showing similar efficacy with pentagastrin (Pg) sCT; however, the real value of these provocative tests has been disputed given the availability of new, highly sensitive CT immunoassays. Anyhow, evidence concludes that sCT <2 times bCT may not be suggestive of MTC, in which case, thyroid in addition to whole body workup based on clinical evaluation is further warranted. Moreover, measurement of basal and stimulated procalcitonin has been proposed as an emerging concept in this clinical scenario. Measuring bCT levels in patients with thyroid nodules as a screening tool for MTC remains another controversial topic. It has been well established, though, that bCT levels raise the sensitivity of FNAB (Fine Needle Aspiration Biopsy) and correlate with disease progression both pre- and postoperatively in this situation. There have been numerous reports about extrathyroidal neoplasms that express CT. Pancreatic, laryngeal, and lung neuroendocrine neoplasms (NENs) are most frequently associated with hypercalcitoninemia, but CT production has also been described in various other neoplasms such as duodenal, esophageal, cutaneous, and paranasal NENs as well as prostate, colon, breast, and lung non-NENs. This review outlines the current biosynthetic and physiology concepts about CT and presents up-to-date information regarding the differential diagnosis of its elevation in various clinical situations.
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Affiliation(s)
| | - Periklis Giannakis
- 5th Surgical Clinic, Department of Surgery,
‘Evgenidion Hospital’, National and Kapodistrian University of Athens
Medical School, Athens, Greece
| | - Evangelos Menenakos
- 5th Surgical Clinic, Department of Surgery,
‘Evgenidion Hospital’, National and Kapodistrian University of Athens
Medical School, Athens, Greece
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Yue W, Zhang Y. Oncologic outcomes of calcitonin-negative medullary thyroid carcinoma. Front Endocrinol (Lausanne) 2022; 13:1025629. [PMID: 36506082 PMCID: PMC9727137 DOI: 10.3389/fendo.2022.1025629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Calcitonin (Ct)-negative medullary thyroid carcinoma (MTC) is a rare neuroendocrine tumor. This study aimed to clarify its incidence, clinicopathologic characteristics, management, and treatment outcome. METHODS We retrospectively analyzed data of patients with primary MTC. Patients were divided into two groups according to the preoperative serum Ct level (Ct-negative and Ct-positive). The demographic, pathologic, and molecular characteristics, and treatment outcomes were compared between the two groups. In the Ct-negative group, we analyzed the association between the operation type and treatment outcome. RESULTS Of the total 312 patients, 24 were diagnosed with Ct-negative MTC. The rate of lymph node metastasis was significantly higher in the Ct-positive than in the Ct-negative group (47.9% vs. 0%, p<0.001). The proportion of patients with Ki-67 ≤10% was significantly higher in the Ct-negative than in the Ct-positive group (87.5% vs. 38.2%, p<0.001). Excellent response was achieved by 91.7% and 34.7% of patients in the Ct-negative and Ct-positive groups, respectively (p<0.001). In the Ct-negative group, excellent response was achieved by all female patients, but only 50% of male patients. CONCLUSIONS Ct-negative MTC is rare and unlikely to develop lymph node metastasis. Unilateral lobectomy tends to provide a satisfactory chance of excellent response; however, this requires further validation.
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Salh AM, Ahmed SF, Omar SS, Hassan SH, Mohammed SH, Kakamad FH. Medullary thyroid carcinoma with normal serum calcitonin and carcinoembryonic levels; a case with review of literature. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kim SJ, Yun HJ, Shin SJ, Lee YS, Chang HS. Serum Calcitonin-Negative Medullary Thyroid Carcinoma: A Case Series of 19 Patients in a Single Center. Front Endocrinol (Lausanne) 2021; 12:747704. [PMID: 34803914 PMCID: PMC8602843 DOI: 10.3389/fendo.2021.747704] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/20/2021] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Medullary thyroid carcinoma (MTC) is a rare cancer that accounts for 5% of thyroid cancers. Serum calcitonin is a good biomarker for MTC, which is used for diagnosis, prognosis, and monitoring of recurrence. Calcitonin-negative MTC (CNMTC) is rare but confounds diagnostic and prognostic directions. This study introduces 19 cases of CNMTC in a single center. METHOD From 2002 March to 2020 July, more than 76,500 patients had undergone thyroid surgery due to thyroid cancer at the Severance Hospital, and a total of 320 patients were diagnosed with MTC (0.4%). Serum calcitonin levels were obtained from every patient who was suspected with MTC. These patients had undergone either bilateral total thyroidectomy or unilateral thyroidectomy with central compartment lymph node dissection, and additional modified radical lymph node dissection if lateral lymph node metastasis was positive. Postoperative monitoring and out-patient clinic follow-up were performed with obtaining the serum calcitonin levels. RESULT Nineteen patients tested negative for calcitonin preoperatively (6%). The mean preoperative calcitonin level was 5.1pg/mL if undetectable level is regarded as 0pg/mL. Only two patients were males, and the female bias was significant (p = 0.017). No one except two patients with modified radical neck dissection showed central compartment lymph node metastasis. Every patient's postoperative calcitonin level remained low. The median follow-up period was 71 months. There was no recurrence and only one fatality, and the overall survival rate was 95%. CONCLUSION Since incidence of CNMTC is not negligible, MTC should not be ruled out in the diagnostic phase even if serum calcitonin is negative in preoperative examination. We presented 19 cases of CNMTC whose prognosis in general were favorable. Markers of serum and immunohistochemical samples other than calcitonin should be actively examined.
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Affiliation(s)
- Sun Jung Kim
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyeok Jun Yun
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
| | - Su-Jin Shin
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong Sang Lee
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
- *Correspondence: Yong Sang Lee,
| | - Hang-Seok Chang
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
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Gambardella C, Offi C, Clarizia G, Romano RM, Cozzolino I, Montella M, Di Crescenzo RM, Mascolo M, Cangiano A, Di Martino S, Candela G, Docimo G. Medullary thyroid carcinoma with double negative calcitonin and CEA: a case report and update of literature review. BMC Endocr Disord 2019; 19:103. [PMID: 31619220 PMCID: PMC6794852 DOI: 10.1186/s12902-019-0435-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 09/24/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Medullary thyroid carcinoma is a malignant uncommon and aggressive tumour of the parafollicular C cells. In about 75% of cases it is sporadic while, in case of RET mutation, it is associated to multiple endocrine neoplasia type 2 (25% of cases). The biochemical features of medullary thyroid carcinoma include the production of calcitonin and carcinoembryogenic antigen. The above-mentioned features are useful in the diagnostic process as well as in the follow up and in the prognostication of the disease. Even if calcitonin elevation is strongly associated to MTC, it can also be found increased in many pathological different conditions as pregnancy, lactation, C-cells hyperplasia, autoimmune thyroiditis, end stage renal disease, lung and prostate cancer and several neuroendocrine tumours. Major medullary thyroid tumours are usually connected to high doses of circulating calcitonin, in fact non-secretory variants have hardly been described. CASE PRESENTATION We herein report the case of a 59 years old male, who had undergone total thyroidectomy for multinodular goiter with negative preoperative calcitonin, showing medullary thyroid carcinoma at definitive pathology. To the best of our knowledge, this is the first case documenting a non-secretory medullary thyroid carcinoma, with double negative markers at the time of diagnosis and at the relapse. CONCLUSION A Literature review underlining pathological hypothesis, differential diagnosis and alternative and innovative biomarkers to identify non-secretory medullary thyroid carcinoma was carried out.
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Affiliation(s)
- Claudio Gambardella
- Division of Thyroid Surgery - Department of Medical and Advanced Surgical Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini, 5, 80131 Naples, Italy
- Department of Cardiothoracic Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Chiara Offi
- Division of Thyroid Surgery - Department of Medical and Advanced Surgical Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Guglielmo Clarizia
- Division of Thyroid Surgery - Department of Medical and Advanced Surgical Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Roberto Maria Romano
- Division of Thyroid Surgery - Department of Medical and Advanced Surgical Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Immacolata Cozzolino
- Pathology Unit, Department of Mental and Physical Health and Preventive, Medicine University of Campania “Luigi Vanvitelli”, School of Medicine, Piazza Miraglia 2, 80138 Naples, Italy
| | - Marco Montella
- Pathology Unit, Department of Mental and Physical Health and Preventive, Medicine University of Campania “Luigi Vanvitelli”, School of Medicine, Piazza Miraglia 2, 80138 Naples, Italy
| | - Rosa Maria Di Crescenzo
- Department of Advanced Biomedical Sciences, Pathology Section, University of Naples Federico II, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Massimo Mascolo
- Department of Advanced Biomedical Sciences, Pathology Section, University of Naples Federico II, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Angelo Cangiano
- Division of Thyroid Surgery - Department of Medical and Advanced Surgical Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Sergio Di Martino
- Division of Thyroid Surgery - Department of Medical and Advanced Surgical Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Giancarlo Candela
- Division of Thyroid Surgery - Department of Medical and Advanced Surgical Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Giovanni Docimo
- Division of Thyroid Surgery - Department of Medical and Advanced Surgical Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini, 5, 80131 Naples, Italy
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Zhang G, Jiang Y, Zhang S, Zhao L, Fan J, Zhang Z, Ma J, Chen R, Xu Y. Genetic analysis of a hereditary medullary thyroid carcinoma case with normal preoperative serum calcitonin levels. Pathol Res Pract 2019; 215:152529. [PMID: 31409511 DOI: 10.1016/j.prp.2019.152529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 06/12/2019] [Accepted: 07/05/2019] [Indexed: 11/29/2022]
Abstract
CONTEXT Serum calcitonin is often elevated in medulla thyroid carcinoma (MTC) and thus serves as an indicator of primary and recurrent disease. However, there are MTC patients with normal Serum calcitonin and the underlying mechanisms are largely unknown. CASE DESCRIPTION A 48-year-old female patient presenting with a right anterior cervical mass was diagnosed with medullary carcinoma. She had elevated carcinoembryonic antigen (CEA) but normal Serum calcitonin levels. Next generation sequencing (NGS) of paired tumor and peripheral blood revealed a germline pathogenic RET mutation, indicating the hereditary nature of MTC in this patient. Two somatic loss-of-function mutations in DICER1 gene were also found, which we postulated to account for the normal calcitonin levels found in this patient. To our knowledge, this is the first report of a hereditary MTC case displaying a normal Serum calcitonin. CONCLUSIONS The case suggests NGS can be used in the diagnosis of hereditary MTC and exploring the reasons of normal Serum calcitonin in these patients.
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Affiliation(s)
- Gang Zhang
- Department of Breast and Thyroid Surgery, Daping Hospital, Army Military Medical University, Chongqing, 400042, China.
| | - Yan Jiang
- Department of Breast and Thyroid Surgery, Daping Hospital, Army Military Medical University, Chongqing, 400042, China.
| | - Shu Zhang
- Department of Breast and Thyroid Surgery, Daping Hospital, Army Military Medical University, Chongqing, 400042, China.
| | - Lianhua Zhao
- Department of Pathology, Daping Hospital, Army Military Medical University, Chongqing, 400042, China.
| | - Jun Fan
- Department of Breast and Thyroid Surgery, Daping Hospital, Army Military Medical University, Chongqing, 400042, China.
| | - Zhe Zhang
- Department of Breast and Thyroid Surgery, Daping Hospital, Army Military Medical University, Chongqing, 400042, China.
| | - Jianhui Ma
- Ludwig Institute for Cancer Research, La Jolla, CA, 92037, USA; Geneplus-Beijing Institute, Beijing, China.
| | | | - Yan Xu
- Department of Breast and Thyroid Surgery, Daping Hospital, Army Military Medical University, Chongqing, 400042, China.
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Gambardella C, Offi C, Patrone R, Clarizia G, Mauriello C, Tartaglia E, Di Capua F, Di Martino S, Romano RM, Fiore L, Conzo A, Conzo G, Docimo G. Calcitonin negative Medullary Thyroid Carcinoma: a challenging diagnosis or a medical dilemma? BMC Endocr Disord 2019; 19:45. [PMID: 31142313 PMCID: PMC6541563 DOI: 10.1186/s12902-019-0367-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/08/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Medullary thyroid carcinoma is a neuroendocrine tumor belonging form a malignant growth of the thyroid parafollicular C-cells, representing from 1 to 10% of all thyroid cancer. The biochemical activity of medullary thyroid carcinoma includes the production of calcitonin and carcinoembryogenic antigen, which are sensitive tumor markers, facilitating the diagnosis, follow-up and prognostication. The diagnosis is reached through the identification of high basal calcitonin serum level or after pentagastrin stimulation test. Medullary thyroid carcinoma is able to produce other relevant biomarkers as procalcitonin, carcinoembryionic antigen and chromogranin A. In Literature are described few cases of medullary thyroid carcinoma without elevation of serum calcitonin, an extremely rare event. The aim of this study was to analyse the presentation, the main features and therapeutic management of medullary thyroid carcinoma associated with negative serum calcitonin levels. METHODS Using the PubMed database, a systematic review of the current Literature was carried out, up to February 2018. Finally, nineteen articles met our inclusion criteria and were selected according to the modified Newcastle-Ottawa scale. RESULTS Fourty-nine patients with definitive pathology confirming medullary thyroid carcinoma and with calcitonin serum level in the normal range were identified (24 female, 24 male and not reported gender in 1 case). Mean age was 51.7 years. Serum calcitonin levels were reported for 20 patients with a mean value of 8.66 pg/mL and a range of 0.8-38 pg/mL. Despite the low or undetectable calcitonin serum level, at immunochemistry in almost the half of the cases reported by the Authors, the tumors presented diffuse or focal positivity for calcitonin and carcinoembryionic antigen, while was reported a chromogranin A positivity in 41 of the 43 tested patients. CONCLUSIONS Calcitonin negative medullary thyroid carcinoma is an extremely rare pathology. The diagnosis and the surveillance is often challenging and delayed, due to the lack of elevation of serum markers as calcitonin and carcinoembryionic antigen. Further studies are needed, to better define options for management of non secretory medullary thyroid carcinoma and to identify new and reliable biomarkers associated to diagnosis and relapse of this medical dilemma.
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Affiliation(s)
- Claudio Gambardella
- Division of General and Oncologic Surgery, Department of Cardiothoracic Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Chiara Offi
- Division of General and Oncologic Surgery, Department of Cardiothoracic Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Renato Patrone
- Division of General and Oncologic Surgery, Department of Cardiothoracic Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Guglielmo Clarizia
- Division of General and Oncologic Surgery, Department of Cardiothoracic Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Claudio Mauriello
- Division of General and Oncologic Surgery, Department of Cardiothoracic Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Ernesto Tartaglia
- Division of General and Oncologic Surgery, Department of Cardiothoracic Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Francesco Di Capua
- Division of General and Oncologic Surgery, Department of Cardiothoracic Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Sergio Di Martino
- Division of General and Oncologic Surgery, Department of Cardiothoracic Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Roberto Maria Romano
- Division of General and Oncologic Surgery, Department of Cardiothoracic Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Lorenzo Fiore
- Division of General and Oncologic Surgery, Department of Cardiothoracic Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Alessandra Conzo
- Division of General and Oncologic Surgery, Department of Cardiothoracic Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Giovanni Conzo
- Division of General and Oncologic Surgery, Department of Cardiothoracic Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Giovanni Docimo
- Division of General and Oncologic Surgery, Department of Cardiothoracic Sciences, University of Campania “Luigi Vanvitelli”, School of Medicine, Via Sergio Pansini 5, 80131 Naples, Italy
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