1
|
Su K, Zhou Z, Yi Q, Liu J, Luo T, Cui X, Zhang H. Systemic Analysis on the Features of Immune Microenvironment Related to Prognostic Signature in Head and Neck Squamous Cell Carcinoma. Front Genet 2022; 13:860712. [PMID: 35646054 PMCID: PMC9130752 DOI: 10.3389/fgene.2022.860712] [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: 01/23/2022] [Accepted: 03/30/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Head and neck squamous cell carcinoma's tumor immune microenvironment (TIME) plays an important role in tumorigenesis and progression, but its clinical significance remains unclear. Therefore, the TIME needs to be better understood in order to improve the response of diagnosis and therapy. Methods: The gene expression and clinical data of 569 HNSCC patients were obtained from The Cancer Genome Atlas (TCGA) and the Gene Expression Omnibus (GEO). Immune-related genes (IRGs) from the ImmPort database were used for immunotyping of HNSCC patients, and independent GEO datasets were used for subtype verification and comprehensive molecular identification. Results: The patients were divided into three subtypes (C1, C2, and C3) related to different gene expression profiles. The three subtypes showed widely different patterns in tumor genetic distortion, immune cell composition, cytokine profile, and so on, verifying that the immune-enhanced C2 subtype was associated with better prognosis. In addition, the stroma-deficient C1 subtype may be more efficient for the immune response than the C3 subtype. Furthermore, using WGCNA on the IRGs of those three subtypes, we found two C2-positive gene modules closely related to infection- and immune-associated pathways in the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway database, and the two modules had 22 common pathways. Conclusion: This study improves the power for prognosis prediction and develops new therapeutic strategies to stratify HNSCC patients into clinically significant groups through TIME-related prognostic signature.
Collapse
Affiliation(s)
- Kaixin Su
- Academician Workstation for Oral-Maxilofacial and Regenerative Medicine, Central South University, Changsha, China.,Hunan Key Laboratory of Oral Health Research, Central South University, Changsha, China.,Hunan 3D Printing Engineering Research Center of Oral Care, Central South University, Changsha, China.,Hunan Clinical Research Center of Oral Major Diseases and Oral Health, Central South University, Changsha, China.,Xiangya Stomatological Hospital, Central South University, Changsha, China.,Xiangya School of Stomatology, Central South University, Changsha, China
| | - Zekun Zhou
- Academician Workstation for Oral-Maxilofacial and Regenerative Medicine, Central South University, Changsha, China.,Hunan Key Laboratory of Oral Health Research, Central South University, Changsha, China.,Hunan 3D Printing Engineering Research Center of Oral Care, Central South University, Changsha, China.,Hunan Clinical Research Center of Oral Major Diseases and Oral Health, Central South University, Changsha, China.,Xiangya Stomatological Hospital, Central South University, Changsha, China.,Xiangya School of Stomatology, Central South University, Changsha, China
| | - Qiao Yi
- Academician Workstation for Oral-Maxilofacial and Regenerative Medicine, Central South University, Changsha, China.,Hunan Key Laboratory of Oral Health Research, Central South University, Changsha, China.,Hunan 3D Printing Engineering Research Center of Oral Care, Central South University, Changsha, China.,Hunan Clinical Research Center of Oral Major Diseases and Oral Health, Central South University, Changsha, China.,Xiangya Stomatological Hospital, Central South University, Changsha, China.,Xiangya School of Stomatology, Central South University, Changsha, China
| | - Junjie Liu
- Academician Workstation for Oral-Maxilofacial and Regenerative Medicine, Central South University, Changsha, China.,Hunan Key Laboratory of Oral Health Research, Central South University, Changsha, China.,Hunan 3D Printing Engineering Research Center of Oral Care, Central South University, Changsha, China.,Hunan Clinical Research Center of Oral Major Diseases and Oral Health, Central South University, Changsha, China.,Xiangya Stomatological Hospital, Central South University, Changsha, China.,Xiangya School of Stomatology, Central South University, Changsha, China
| | - Tiao Luo
- Academician Workstation for Oral-Maxilofacial and Regenerative Medicine, Central South University, Changsha, China.,Hunan Key Laboratory of Oral Health Research, Central South University, Changsha, China.,Hunan 3D Printing Engineering Research Center of Oral Care, Central South University, Changsha, China.,Hunan Clinical Research Center of Oral Major Diseases and Oral Health, Central South University, Changsha, China.,Xiangya Stomatological Hospital, Central South University, Changsha, China.,Xiangya School of Stomatology, Central South University, Changsha, China
| | - Xinyan Cui
- Academician Workstation for Oral-Maxilofacial and Regenerative Medicine, Central South University, Changsha, China.,Hunan Key Laboratory of Oral Health Research, Central South University, Changsha, China.,Hunan 3D Printing Engineering Research Center of Oral Care, Central South University, Changsha, China.,Hunan Clinical Research Center of Oral Major Diseases and Oral Health, Central South University, Changsha, China.,Xiangya Stomatological Hospital, Central South University, Changsha, China.,Xiangya School of Stomatology, Central South University, Changsha, China
| | - Haixia Zhang
- The Oncology Department of Xiangya Second Hospital, Central South University, Changsha, China
| |
Collapse
|
2
|
Lo Nigro C, Vivenza D, Denaro N, Lattanzio L, Fortunato M, Crook T, Merlano MC. DUSP2 methylation is a candidate biomarker of outcome in head and neck cancer. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:271. [PMID: 30094257 DOI: 10.21037/atm.2018.06.39] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Biomarkers predictive of response to chemoradiotherapy (CRT) regimens for locally advanced head and neck squamous cell carcinoma (LA-HNSCC) are urgently required to identify patients in whom this approach is likely to be effective. TP53 mutations and epidermal growth factor (EGFR) overexpression are common markers of disease. Dual-specificity-phosphatase-2 (DUSP2) has an essential role in cell proliferation, cancer and immune responses. Methods Aberrant DUSP2 methylation was investigated by pyrosequencing in 5 HNSCC cell lines, 112 LA-HNSCC tumours. EGFR was investigated by immunohistochemistry and TP53 was analysed by sequencing. Results We demonstrate methylation-dependent transcriptional silencing of DUSP2 in HNSCC cell lines. In LA-HNSCC patients, aberrant methylation in the DUSP2 CpG island was present in 51/112 cases (45.5%). LA-HNSCC cases with wild-type TP53, overexpression of EGFR and unmethylated DUSP2 had the worst overall survival (P≤0.001). Conclusions DUSP2 methylation, when combined with EGFR and TP53, is a candidate biomarker of clinical outcome in LA-HNSCC treated with CRT.
Collapse
Affiliation(s)
- Cristiana Lo Nigro
- Medical Oncology, Department of Oncology, S. Croce & Carle Teaching Hospital, Cuneo, Italy
| | - Daniela Vivenza
- Medical Oncology, Department of Oncology, S. Croce & Carle Teaching Hospital, Cuneo, Italy
| | - Nerina Denaro
- Medical Oncology, Department of Oncology, S. Croce & Carle Teaching Hospital, Cuneo, Italy
| | - Laura Lattanzio
- Medical Oncology, Department of Oncology, S. Croce & Carle Teaching Hospital, Cuneo, Italy
| | - Mirella Fortunato
- Department of Pathology, S. Croce & Carle Teaching Hospital, Cuneo, Italy
| | - Tim Crook
- Department of Oncology, St. Lukes Cancer Centre, Guildford, UK
| | - Marco Carlo Merlano
- Medical Oncology, Department of Oncology, S. Croce & Carle Teaching Hospital, Cuneo, Italy
| |
Collapse
|
3
|
Kozomara R, Brankovic-Magic M, Jovic N, Stosic S, Magic Z. Prognostic Significance of TP53 Mutations in Oral Squamous Cell Carcinoma with Human Papilloma virus Infection. Int J Biol Markers 2018; 22:252-7. [DOI: 10.1177/172460080702200403] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose The aim of this study was to analyze the prognostic impact of mutated TP53 in patients with oral squamous cell carcinoma (OSCC) whose tumors were infected with human papillomavirus (HPV). Methods Thirty-two HPV-positive OSCC patients were included. Most of them were clinically classified as stage III (n=29). All patients underwent postoperative radiotherapy (follow-up from 12 to 60 months, median 32). There were 21 relapses. DNA was isolated by phenol extraction from tumor tissue. HPV DNA (type 16, 18, 31, 33) was detected in genomic DNA of the tumors by the PCR-PAGE method. TP53 mutations (exons 4–8) were detected by the PCR-SSCP method. Results A statistically significant difference in the number of relapses in HPV-infected (13/21) versus HPV-infected and TP53-mutated (8/8) patients was observed. Patients with both TP53 mutation and HPV infection had a significantly shorter disease-free interval than patients with HPV infection only (median 6 versus 31 months, respectively). Conclusions TP53 mutations are associated with a higher risk of relapse and contribute to an even worse prognosis of patients with OSCC when the tumors are HPV infected. The shorter disease-free interval in patients with TP53 mutations indicates that the response to postoperative radiotherapy may be influenced by TP53 status. The presence of both HPV infection and TP53 mutations may define a particular group of tumors with a more aggressive phenotype in advanced OSCC.
Collapse
Affiliation(s)
- R.J. Kozomara
- Clinic of Maxillofacial Surgery, Military Medical Academy, Belgrade
- These authors contributed equally to this paper
| | - M.V. Brankovic-Magic
- Institute for Oncology and Radiology of Serbia, Belgrade
- These authors contributed equally to this paper
| | - N.R. Jovic
- Clinic of Maxillofacial Surgery, Military Medical Academy, Belgrade
| | - S.M. Stosic
- Clinic of Maxillofacial Surgery, Military Medical Academy, Belgrade
| | - Z.M. Magic
- Institute for Medical Research, Military Medical Academy, Belgrade - Serbia
| |
Collapse
|
4
|
Baumann M, Krause M, Overgaard J, Debus J, Bentzen SM, Daartz J, Richter C, Zips D, Bortfeld T. Radiation oncology in the era of precision medicine. Nat Rev Cancer 2016; 16:234-49. [PMID: 27009394 DOI: 10.1038/nrc.2016.18] [Citation(s) in RCA: 512] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Technological advances and clinical research over the past few decades have given radiation oncologists the capability to personalize treatments for accurate delivery of radiation dose based on clinical parameters and anatomical information. Eradication of gross and microscopic tumours with preservation of health-related quality of life can be achieved in many patients. Two major strategies, acting synergistically, will enable further widening of the therapeutic window of radiation oncology in the era of precision medicine: technology-driven improvement of treatment conformity, including advanced image guidance and particle therapy, and novel biological concepts for personalized treatment, including biomarker-guided prescription, combined treatment modalities and adaptation of treatment during its course.
Collapse
Affiliation(s)
- Michael Baumann
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden
- OncoRay - National Center for Radiation Research in Oncology (NCRO), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, and Helmholtz-Zentrum Dresden-Rossendorf, Fetscherstrasse 74, 01307 Dresden
- National Center for Tumor Diseases (NCT), Fetscherstrasse 74, 01307 Dresden
- German Cancer Consortium (DKTK) Dresden, Germany
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiation Oncology, Bautzner Landstrasse 400, 01328 Dresden, Germany
| | - Mechthild Krause
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden
- OncoRay - National Center for Radiation Research in Oncology (NCRO), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, and Helmholtz-Zentrum Dresden-Rossendorf, Fetscherstrasse 74, 01307 Dresden
- National Center for Tumor Diseases (NCT), Fetscherstrasse 74, 01307 Dresden
- German Cancer Consortium (DKTK) Dresden, Germany
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiation Oncology, Bautzner Landstrasse 400, 01328 Dresden, Germany
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus C, Denmark
| | - Jürgen Debus
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), University of Heidelberg Medical School and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg
- Heidelberg Ion Therapy Center (HIT), Department of Radiation Oncology, University of Heidelberg Medical School, Im Neuenheimer Feld 400, 69120 Heidelberg
- German Cancer Consortium (DKTK) Heidelberg, Germany
| | - Søren M Bentzen
- Department of Epidemiology and Public Health and Greenebaum Cancer Center, University of Maryland School of Medicine, 22 S Greene Street S9a03, Baltimore, Maryland 21201, USA
| | - Juliane Daartz
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital and Harvard Medical School, 1000 Blossom Street Cox 362, Boston, Massachusetts 02114, USA
| | - Christian Richter
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden
- OncoRay - National Center for Radiation Research in Oncology (NCRO), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, and Helmholtz-Zentrum Dresden-Rossendorf, Fetscherstrasse 74, 01307 Dresden
- National Center for Tumor Diseases (NCT), Fetscherstrasse 74, 01307 Dresden
- German Cancer Consortium (DKTK) Dresden, Germany
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Daniel Zips
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- German Cancer Consortium Tübingen, Postfach 2669, 72016 Tübingen
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Tübingen, Eberhard Karls Universität Tübingen, Hoppe-Seyler-Strasse 3, 72016 Tübingen, Germany
| | - Thomas Bortfeld
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital and Harvard Medical School, 1000 Blossom Street Cox 362, Boston, Massachusetts 02114, USA
| |
Collapse
|
5
|
Wu ES, Park JY, Zeitouni JA, Gomez CR, Reis IM, Zhao W, Kwon D, Lee E, Nelson OL, Lin HY, Franzmann EJ, Savell J, McCaffrey TV, Goodwin WJ, Hu JJ. Effect of actionable somatic mutations on racial/ethnic disparities in head and neck cancer prognosis. Head Neck 2016; 38:1234-41. [PMID: 27028310 DOI: 10.1002/hed.24420] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 11/23/2015] [Accepted: 12/30/2015] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer worldwide and minorities have the worst survival. However, the molecular mechanisms underlying survival disparities have not been elucidated. METHODS In a retrospective study, we assessed association between HNSCC early death (<2 years) and 208 somatic mutations of 10 cancer-related genes in 214 patients: 98 non-Hispanic whites (46%), 72 Hispanic whites (34%), and 44 African Americans (20%). RESULTS Hispanic whites and African Americans had significantly higher mutation rates for EGFR, HRAS, KRAS, and TP53. HNSCC early death was significantly associated with 3+ mutations (odds ratio [OR] = 2.78, 95% confidence interval [CI] = 1.16, 6.69), NOTCH1 mutations in non-Hispanic whites (OR = 5.51; 95% CI = 1.22-24.83) and TP53 mutations in Hispanic whites (OR = 3.84; 95% CI = 1.08-13.68) in multivariable analysis adjusted for age, sex, tumor site, and tumor stage. CONCLUSION We have provided the proof-of-principal data to link racial/ethnic-specific somatic mutations and HNSCC prognosis and pave the way for precision medicine to overcome HNSCC survival disparities. © 2016 Wiley Periodicals, Inc. Head Neck 38:1234-1241, 2016.
Collapse
Affiliation(s)
- Evan S Wu
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Jong Y Park
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Joseph A Zeitouni
- Department of Pathology, University of Miami Miller School of Medicine, Miami, Florida
| | - Carmen R Gomez
- Department of Pathology, University of Miami Miller School of Medicine, Miami, Florida
| | - Isildinha M Reis
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Wei Zhao
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Deukwoo Kwon
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Eunkyung Lee
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Omar L Nelson
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Hui-Yi Lin
- Department of Biostatistics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Elizabeth J Franzmann
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.,Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida
| | - Jason Savell
- Department of Pathology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Thomas V McCaffrey
- Head and Neck Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - W Jarrard Goodwin
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.,Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida
| | - Jennifer J Hu
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| |
Collapse
|
6
|
Ow TJ, Pitts CE, Kabarriti R, Garg MK. Effective Biomarkers and Radiation Treatment in Head and Neck Cancer. Arch Pathol Lab Med 2015; 139:1379-88. [PMID: 26046489 DOI: 10.5858/arpa.2014-0574-ra] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Radiation is a key arm in the multidisciplinary treatment of patients with head and neck squamous cell carcinoma. During the past 2 decades, significant changes in the way radiation therapy is planned and delivered have improved efficacy and decreased toxicity. Refined approaches in the application of radiation and chemoradiation have led to organ-sparing treatment regimens for laryngeal and pharyngeal cancers and have improved local and regional control rates in the postoperative, adjuvant setting. The molecular and genetic determinants of tumor cell response to radiation have been studied, and several potential biomarkers are emerging that could further improve application and efficacy of radiation treatment in head and neck squamous cell carcinoma. OBJECTIVE To discuss the current understanding of potential biomarkers related to radiation response in head and neck squamous cell carcinoma. DATA SOURCES Existing published literature. CONCLUSIONS Several potential biomarkers are actively being studied as predictors and targets to improve the use and efficacy of radiation therapy to treat head and neck squamous cell carcinoma. Several promising candidates have been defined, and new markers are on the horizon.
Collapse
Affiliation(s)
| | | | | | - Madhur K Garg
- From the Departments of Otorhinolaryngology-Head and Neck Surgery (Drs Ow and Garg), Pathology (Dr Ow), Radiation Oncology (Drs Kabarriti and Garg), and Urology (Dr Garg) Montefiore Medical Center, Bronx, New York; and the Albert Einstein College of Medicine (Drs Ow, Kabarriti, and Garg, and Ms Pitts), Bronx
| |
Collapse
|
7
|
Mallick S, Agarwal J, Kannan S, Pawar S, Kane S, Teni T. Bcl-xL protein: predictor of complete tumor response in patients with oral cancer treated with curative radiotherapy. Head Neck 2012; 35:1448-53. [PMID: 22987535 DOI: 10.1002/hed.23153] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2012] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND We earlier observed altered expression of p53 and Bcl-xL in oral cancer cell lines/tissues and wanted to evaluate these proteins for prediction of radiotherapy response and outcome. METHODS Thirty-nine paraffin-embedded, pretreatment oral cancer biopsies were analyzed for protein expression using immunohistochemistry and correlated with tumor response to radiotherapy and disease-free survival (DFS). RESULT High p53 (p = .040) was observed in female versus male patients. Increased p53 intensity (p = .063) was observed in tobacco habitués (chewers ± smokers) versus patients with no habits. In univariate analysis, nodal positivity (p = .044) and favorable/complete tumor response (p = .002) exhibited a significant correlation with DFS, whereas tumor response emerged as an independent predictor of DFS in multivariate analysis. Significantly high Bcl-xL (p = .048) was observed in the unfavorable versus favorable responders. CONCLUSION Our study suggests that Bcl-xL expression along with clinical parameters may be useful for identifying patients with oral cancer likely to draw maximum benefit from curative radiotherapy.
Collapse
Affiliation(s)
- Sanchita Mallick
- Teni Lab, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai-410210, India
| | | | | | | | | | | |
Collapse
|
8
|
Pedicini P, Nappi A, Strigari L, Jereczek-Fossa BA, Alterio D, Cremonesi M, Botta F, Vischioni B, Caivano R, Fiorentino A, Improta G, Storto G, Benassi M, Orecchia R, Salvatore M. Correlation between EGFr expression and accelerated proliferation during radiotherapy of head and neck squamous cell carcinoma. Radiat Oncol 2012; 7:143. [PMID: 22920680 PMCID: PMC3537603 DOI: 10.1186/1748-717x-7-143] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 07/29/2012] [Indexed: 11/10/2022] Open
Abstract
Purpose To investigate the correlation between the expression of Epidermal Growth Factor receptor (EGFr) and the reduction of the effective doubling time (TD) during radiotherapy treatment and also to determine the dose per fraction to be taken into account when the overall treatment time (OTT) is reduced in accelerated radiotherapy of head and neck squamous cell carcinoma (HNSCC). Methods A survey of the published papers comparing 3-years of local regional control rate (LCR) for a total of 2162 patients treated with conventional and accelerated radiotherapy and with a pretreatment assessment of EGFr expression, was made. Different values of TD were obtained by a model incorporating the overall time corrected biologically effective dose (BED) and a 3-year clinical LCR for high and low EGFr groups of patients (HEGFr and LEGFr), respectively. By obtaining the TD from the above analysis and the sub-sites’ potential doubling time (Tpot) from flow cytometry and immunohistochemical methods, we were able to estimate the average TD for each sub-site included in the analysis. Moreover, the dose that would be required to offset the modified proliferation occurring in one day (Dprolif), was estimated. Results The averages of TD were 77 (27-90)95% days in LEGFr and 8.8 (7.3-11.0)95% days in HEGFr, if an onset of accelerated proliferation TK at day 21 was assumed. The correspondent HEGFr sub-sites’ TD were 5.9 (6.6), 5.9 (6.6), 4.6 (6.1), 14.3 (12.9) days, with respect to literature immunohistochemical (flow cytometry) data of Tpot for Oral-Cavity, Oro-pharynx, Hypo-pharynx, and Larynx respectively. The Dprolif for the HEGFr groups were 0.33 (0.29), 0.33 (0.29), 0.42 (0.31), 0.14 (0.15) Gy/day if α = 0.3 Gy-1 and α/β = 10 Gy were assumed. Conclusions A higher expression of the EGFr leads to enhanced proliferation. This study allowed to quantify the extent of the effect which EGFr expression has in terms of reduced TD and Dprolif for each head and neck sub-site.
Collapse
|
9
|
Peltonen JK, Vähäkangas KH, Helppi HM, Bloigu R, Pääkkö P, Turpeenniemi-Hujanen T. Specific TP53 mutations predict aggressive phenotype in head and neck squamous cell carcinoma: a retrospective archival study. HEAD & NECK ONCOLOGY 2011; 3:20. [PMID: 21513535 PMCID: PMC3094329 DOI: 10.1186/1758-3284-3-20] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 04/22/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Head and neck squamous cell carcinoma (HNSCC) is the sixth most common malignancy in the world in developed countries. Despite the intense research in the area of squamous cell carcinomas of head and neck (HNSCC), long-term survival rate has not changed significantly in this malignancy during recent decades. METHODS In this study, we focused on TP53 mutations in specific regions, including DNA-binding surface, to determine whether mutations at specific locations of TP53 could be used to help in setting up prognosis and response to therapy of head and neck squamous cell carcinoma patients. We analysed TP53 mutations in 46 HNSCC by PCR-SSCP and sequencing and characterized how different TP53 mutations affect the patient outcome. RESULTS Tumours containing TP53 mutations in DNA-binding regions (L2, L3 and LSH motif) had a significantly poorer prognosis and response to radiotherapy than tumours outside those regions. Disease-specific 5-year survival of patients with TP53 mutations affecting DNA contacts was 43.5% while it was 77.8% (p < 0.05) in patients with TP53 mutations in other residues not involved in DNA contact. Moreover, nodal metastasis were more prevalent (although not statistically significantly) with TP53 mutations in DNA-binding surface regions. We noticed that the patients with TP53 mutations in L3/LSH motifs had a significantly poorer response (11.4% responding) to radiation than the patients with a wild type p53 (48.6%) or TP53 mutations outside the DNA-binding regions (40%) (p < 0.05). CONCLUSIONS These data indicate that a TP53 mutation in L2, L3 or LSH is worth pursuing as a marker for predicting prognosis and response to radiation among HNSCC patients.
Collapse
Affiliation(s)
- Jenni K Peltonen
- Department of Oncology and Radiotherapy, Oulu University Hospital, University of Oulu, Oulu, Finland.
| | | | | | | | | | | |
Collapse
|
10
|
p53 in head and neck cancer: functional consequences and environmental implications of TP53 mutations. HEAD & NECK ONCOLOGY 2010; 2:36. [PMID: 21159183 PMCID: PMC3022569 DOI: 10.1186/1758-3284-2-36] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 12/15/2010] [Indexed: 01/08/2023]
Abstract
Background Although TP53 mutations in human tumours generally have been extensively studied, the significance of p53 in the aetiology of head and neck cancers is still incompletely characterized. In recent years, considerable interest has been focused on mutant forms of p53, the abnormal protein product of TP53 alleles with missense mutation that often accumulate in cancer cells. Methods We compared the nature of TP53 mutations in primary 46 head and neck squamous cell carcinomas (HNSCC) analyzed by PCR-SSCP and sequencing, immunohistochemistry, and using structural information available at IARC p53 database. Results Sequencing confirmed 36 TP53 mutations in 23 tumours of the 39 mutations in 26 tumours found by PCR-SSCP. Only half (17) putatively affect the function of p53 protein. Of these 8 were in the L2 domain, three affected the LSH motif and three the L3 domain. Three were in other domains. Codon 259 (GAC > GAA) which is a very rare mutation was found in 4 samples in our study. There were indications of p53 aberrations being associated with the combined effect of smoking, alcohol and work history. Patients with a negative family history of cancer had more often TP53 mutations than patients with a positive family history (71% vs. 46%). Conclusions Our study contributes to the knowledge of cumulative chemical exposure and p53 aberrations in head and neck cancer, an area where literature is scarce.
Collapse
|
11
|
Choudhury A, Nelson LD, Teo MTW, Chilka S, Bhattarai S, Johnston CF, Elliott F, Lowery J, Taylor CF, Churchman M, Bentley J, Knowles MA, Harnden P, Bristow RG, Bishop DT, Kiltie AE. MRE11 expression is predictive of cause-specific survival following radical radiotherapy for muscle-invasive bladder cancer. Cancer Res 2010; 70:7017-26. [PMID: 20843819 PMCID: PMC2941719 DOI: 10.1158/0008-5472.can-10-1202] [Citation(s) in RCA: 160] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Radical radiotherapy and surgery achieve similar cure rates in muscle-invasive bladder cancer, but the choice of which treatment would be most beneficial cannot currently be predicted for individual patients. The primary aim of this study was to assess whether expression of any of a panel of DNA damage signaling proteins in tumor samples taken before irradiation could be used as a predictive marker of radiotherapy response, or rather was prognostic. Protein expression of MRE11, RAD50, NBS1, ATM, and H2AX was studied by immunohistochemistry in pretreatment tumor specimens from two cohorts of bladder cancer patients (validation cohort prospectively acquired) treated with radical radiotherapy and one cohort of cystectomy patients. In the radiotherapy test cohort (n = 86), low tumor MRE11 expression was associated with worse cancer-specific survival compared with high expression [43.1% versus 68.7% 3-year cause-specific survival (CSS), P = 0.012] by Kaplan-Meier analysis. This was confirmed in the radiotherapy validation cohort (n = 93; 43.0% versus 71.2%, P = 0.020). However, in the cystectomy cohort (n = 88), MRE11 expression was not associated with cancer-specific survival, commensurate with MRE11 being a predictive marker. High MRE11 expression in the combined radiotherapy cohort had a significantly better cancer-specific survival compared with the high-expression cystectomy cohort (69.9% versus 53.8% 3-year CSS, P = 0.021). In this validated immunohistochemistry study, MRE11 protein expression was shown and confirmed as a predictive factor associated with survival following bladder cancer radiotherapy, justifying its inclusion in subsequent trial designs. MRE11 expression may ultimately allow patient selection for radiotherapy or cystectomy, thus improving overall cure rates.
Collapse
Affiliation(s)
- Ananya Choudhury
- Sections of Experimental Oncology and Epidemiology and Biostatistics, Leeds Institute of Molecular Medicine, Cancer Research UK Genome Variation Laboratory Service, Leeds, United Kingdom
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Holmila R, Bornholdt J, Heikkilä P, Suitiala T, Févotte J, Cyr D, Hansen J, Snellman SM, Dictor M, Steiniche T, Schlünssen V, Schneider T, Pukkala E, Savolainen K, Wolff H, Wallin H, Luce D, Husgafvel-Pursiainen K. Mutations in TP53 tumor suppressor gene in wood dust-related sinonasal cancer. Int J Cancer 2010; 127:578-88. [PMID: 19950227 DOI: 10.1002/ijc.25064] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The causal role of work-related exposure to wood dust in the development of sinonasal cancer has long been established by numerous epidemiologic studies. To study molecular changes in these tumors, we analyzed TP53 gene mutations in 358 sinonasal cancer cases with or without occupational exposure to wood dust, using capillary electrophoresis single-strand conformation polymorphism analysis and direct sequencing. A significant association between wood-dust exposure and adenocarcinoma histology was observed [adjusted odds ratio (OR) 12.6, 95% confidence interval (CI), 5.0-31.6]. TP53 mutations occurred in all histologies, with an overall frequency of 77%. TP53 mutation positive status was most common in adenocarcinoma (OR 2.0, 95% CI, 1.1-3.7; compared with squamous cell carcinoma), and mutation positivity showed an overall, nonsignificant association with wood-dust exposure (OR 1.6, 95% CI, 0.8-3.1). Risk of TP53 mutation was significantly increased in association with duration (> or =24 years, OR 5.1, 95% CI, 1.5-17.1), average level (>2 mg/m(3); OR 3.6, 95% CI, 1.2-10.8) and cumulative level (> or =30 mg/m(3) x years; OR 3.5, 95% CI, 1.2-10.7) of wood-dust exposure; adjustment for formaldehyde affected the ORs only slightly. Smoking did not influence the occurrence of TP53 mutation; however, it was associated with multiple mutations (p = 0.03). As far as we are aware, this is the first study to demonstrate a high prevalence of TP53 mutation-positive cases in a large collection of sinonasal cancers with data on occupational exposure. Our results indicate that mutational mechanisms, in particular TP53 mutations, are associated with work-related exposure to wood dust in sinonasal cancer.
Collapse
Affiliation(s)
- Reetta Holmila
- Finnish Institute of Occupational Health, Helsinki, Finland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Sahoo R, Chittibabu V, Patil G, Rao S, Thakur S, Dhondalay G, Kulkarni A, Banerjee A, Ajaikumar B, Korlimarla A, Nargund A, Niti R, Gopinath K, Prabhudesai S, Raghavendra R. Relationship between molecular markers and treatment response in a retrospective cohort of Indian patients with primary carcinoma of the larynx. Oral Oncol 2009; 45:e216-21. [DOI: 10.1016/j.oraloncology.2009.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2009] [Revised: 07/16/2009] [Accepted: 07/16/2009] [Indexed: 02/01/2023]
|
14
|
Fallai C, Perrone F, Licitra L, Pilotti S, Locati L, Bossi P, Orlandi E, Palazzi M, Olmi P. Oropharyngeal Squamous Cell Carcinoma Treated With Radiotherapy or Radiochemotherapy: Prognostic Role of TP53 and HPV Status. Int J Radiat Oncol Biol Phys 2009; 75:1053-9. [DOI: 10.1016/j.ijrobp.2008.12.088] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2008] [Revised: 12/02/2008] [Accepted: 12/02/2008] [Indexed: 12/28/2022]
|
15
|
Baumann M, Krause M, Thames H, Trott K, Zips D. Cancer stem cells and radiotherapy. Int J Radiat Biol 2009; 85:391-402. [DOI: 10.1080/09553000902836404] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|
16
|
Baumann M, Krause M. Tumor Biology’s Impact on Clinical Cure Rates. THE IMPACT OF TUMOR BIOLOGY ON CANCER TREATMENT AND MULTIDISCIPLINARY STRATEGIES 2009. [DOI: 10.1007/978-3-540-74386-6_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
17
|
Abstract
Radiobiological research over the past decades has provided evidence that cancer stem cell content and the intrinsic radiosensitivity of cancer stem cells varies between tumours, thereby affecting their radiocurability. Translation of this knowledge into predictive tests for the clinic has so far been hampered by the lack of methods to discriminate between stem cells and non-stem cells. New technologies allow isolation of cells expressing specific surface markers that are differentially expressed in tumour cell subpopulations that are enriched for cancer stem cells. Combining these techniques with functional radiobiological assays holds the potential to elucidate the role of cancer stem cells in radioresistance in individual tumours, and to use this knowledge for the development of predictive markers for optimization of radiotherapy.
Collapse
Affiliation(s)
- Michael Baumann
- Department of Radiation Oncology and OncoRay Center for Radiation Research in Oncology, and Michael Baumann is also at the University Cancer Center, Technische Universität Dresden, 01307 Dresden, Germany.
| | | | | |
Collapse
|
18
|
Overgaard J, Baumann M. Translational research in radiotherapy - getting closer to the bedside. Radiother Oncol 2008; 83:217-9. [PMID: 17580242 DOI: 10.1016/j.radonc.2007.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Accepted: 06/04/2007] [Indexed: 10/23/2022]
|
19
|
de Castro G, Federico MHH. Evaluation, prevention and management of radiotherapy-induced xerostomia in head and neck cancer patients. Curr Opin Oncol 2008; 18:266-70. [PMID: 16552239 DOI: 10.1097/01.cco.0000219256.37843.83] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW As part of the multidisciplinary approach to head and neck cancer patients, radiation therapy plays an essential role, improving locoregional control. Radiation therapy-induced xerostomia is a late side-effect that increases the risk for developing dental caries and compromises oral mucosal integrity, resulting in oral pain, loss of taste, difficulties with swallowing and chewing, sleep disorders and worse quality of life. This review focuses on evaluation, prevention and management of radiation therapy-induced xerostomia. RECENT FINDINGS In terms of xerostomia prevention, some clinical trials evaluating amifostine and intensity-modulated radiation therapy have shown positive results. Pilocarpine is a useful agent as a treatment of radiation-induced xerostomia in head and neck cancer patients. SUMMARY Despite some advances in radiation therapy-induced xerostomia prevention, its treatment is an area in which advances are urgently needed.
Collapse
Affiliation(s)
- Gilberto de Castro
- Clinical Oncology Service, InRad, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
| | | |
Collapse
|
20
|
Silva P, Homer JJ, Slevin NJ, Musgrove BT, Sloan P, Price P, West CML. Clinical and biological factors affecting response to radiotherapy in patients with head and neck cancer: a review. Clin Otolaryngol 2008; 32:337-45. [PMID: 17883552 DOI: 10.1111/j.1749-4486.2007.01544.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The main aim of this article was to review the clinical and biological factors that have been shown to influence the response of the head and neck squamous cell carcinoma (HNSCC) to primary radiotherapy and briefly discuss how some of these factors could be exploited to improve outcome. DESIGN Medline based search covering 1982-2006 to identify the HNSCC literature where the effect of clinical and biological factors on locoregional control and overall survival were investigated. RESULTS Clinical factors are routinely used in management decisions. Nevertheless, identically staged tumours receiving the same treatment may have different outcomes. Biological factors such as hypoxia, proliferation and radio-sensitivity play an important role in radiation response. However, these are not currently used in practise because tests that are clinically reliable and feasible are not available. CONCLUSION High-quality translational research will allow us to develop biological tests that can be used in routine clinical practise to tailor individual treatment, with the ability to improve patient outcome further by modifying the underlying tumour biology.
Collapse
Affiliation(s)
- P Silva
- Academic Department of Radiation Oncology, The University of Manchester, Manchester, UK.
| | | | | | | | | | | | | |
Collapse
|
21
|
Déterminants et facteurs prédictifs pour la radiosensibilité tumorale. Cancer Radiother 2008; 12:3-13. [DOI: 10.1016/j.canrad.2007.11.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2007] [Revised: 11/22/2007] [Accepted: 11/23/2007] [Indexed: 11/16/2022]
|
22
|
de Castro G, Snitcovsky IML, Gebrim EMMS, Leitão GM, Nadalin W, Ferraz AR, Federico MHH. High-dose cisplatin concurrent to conventionally delivered radiotherapy is associated with unacceptable toxicity in unresectable, non-metastatic stage IV head and neck squamous cell carcinoma. Eur Arch Otorhinolaryngol 2007; 264:1475-82. [PMID: 17643256 DOI: 10.1007/s00405-007-0395-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Accepted: 06/28/2007] [Indexed: 10/23/2022]
Abstract
Unresectable head and neck squamous cell carcinoma (HNSCC), non-metastatic, comprises a heterogeneous group of patients (pts), formed of stage III and IV pts. Since the available literature had not distinguished among these two groups, we prospectively addressed whether the recommended regimen involving cisplatin 100 mg/m2 concurrent to conventionally delivered radiotherapy (RT) is feasible in stage IV pts, based on the efficacy and safety of this regimen. A total of 30 pts were enrolled onto this study. Chemoradiation (CRT) consisted of RT 70 Gy, delivered in 35 daily fractions of 2 Gy, in 7 weeks, concurrent to cisplatin 100 mg/m2 on days 1, 22 and 43. Supportive treatment was provided as needed. Twenty-eight pts had tumors staged as T4 and 20 had N2 or N3 cervical involvement. The most common primary sites were the oral cavity and the oropharynx (23 pts). We observed six complete responses and 12 partial responses, with an overall response rate of 60%. A high rate of treatment-related toxicities was observed, with three deaths during CRT, and 26 pts suffering from one or more grade 3/4 toxicities, mainly dysphagia, mucositis, dermatitis, vomiting, infection or anemia. A prolonged treatment time was observed (63 days), as a result of unplanned treatment breaks. The lack of requirement of red blood cell transfusion was favorably related to the response to the treatment (93% vs. 50%, P=0.033). For the whole population, with a median follow-up of 20.8 months, the median progression-free survival (PFS) was 8.0 months, and the median overall survival (OS) was 17.3 months. Longer median PFS and OS were seen in responding pts (12.8 vs. 4.1 months, P=0.0001; and not reached (NR) vs. 10.4 months, P=0.0037, respectively), as well as in those pts not requiring red blood cell transfusion (12.8 vs. 3.9 months, P=0.0162; and NR vs. 10.4 months, P=0.0176, respectively). In conclusion, this concurrent CRT regimen is hardly delivered in stage IV, unresectable, locally advanced HNSCC pts, due to treatment-related toxicities and longer RT duration. As a subset of pts may benefit from this regimen, adequate patient selection and aggressive supportive measures are essential.
Collapse
Affiliation(s)
- Gilberto de Castro
- Centro de Oncologia-InRad, Hospital das Clínicas da Faculdade de Medicina da USP, Av. Dr. Ovídio Pires de Campos, s/n-2o andar, São Paulo, SP, 05403-010, Brazil.
| | | | | | | | | | | | | |
Collapse
|
23
|
Krause M, Zips D, Thames HD, Kummermehr J, Baumann M. Preclinical evaluation of molecular-targeted anticancer agents for radiotherapy. Radiother Oncol 2006; 80:112-22. [PMID: 16916560 DOI: 10.1016/j.radonc.2006.07.017] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2006] [Accepted: 07/19/2006] [Indexed: 12/24/2022]
Abstract
The combination of molecular-targeted agents with irradiation is a highly promising avenue for cancer research and patient care. Molecular-targeted agents are in themselves not curative in solid tumours, whereas radiotherapy is highly efficient in eradicating tumour stem cells. Recurrences after high-dose radiotherapy are caused by only one or few surviving tumour stem cells. Thus, even if a novel agent has the potential to kill only few tumour stem cells, or if it interferes in mechanisms of radioresistance of tumours, combination with radiotherapy may lead to an important improvement in local tumour control and survival. To evaluate the effects of novel agents combined with radiotherapy, it is therefore necessary to use experimental endpoints which reflect the killing of tumour stem cells, in particular tumour control assays. Such endpoints often do not correlate with volume-based parameters of tumour response such as tumour regression and growth delay. This calls for radiotherapy specific research strategies in the preclinical testing of novel anti-cancer drugs, which in many aspects are different from research approaches for medical oncology.
Collapse
Affiliation(s)
- Mechthild Krause
- Department of Radiation Oncology, Medical Faculty Carl Gustav Carus, University of Technology Dresden, Germany
| | | | | | | | | |
Collapse
|
24
|
Bernier J, Overgaard J. Bridging gaps in translational radiation oncology. Radiother Oncol 2006; 80:109-11. [PMID: 16919823 DOI: 10.1016/j.radonc.2006.07.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2006] [Accepted: 07/24/2006] [Indexed: 01/09/2023]
|
25
|
Awada A, de Castro G. Management of advanced head and neck squamous cell carcinoma in elderly patients. Curr Opin Oncol 2006; 18:225-7. [PMID: 16552232 DOI: 10.1097/01.cco.0000219249.07418.4c] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|