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Giuliano A, Pimentel PAB, Horta RS. Checkpoint Inhibitors in Dogs: Are We There Yet? Cancers (Basel) 2024; 16:2003. [PMID: 38893123 PMCID: PMC11171034 DOI: 10.3390/cancers16112003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
Immune checkpoint inhibitors (ICI) have revolutionised cancer treatment in people. Immune checkpoints are important regulators of the body's reaction to immunological stimuli. The most studied immune checkpoint molecules are programmed death (PD-1) with its ligand (PD-L1) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) with its ligands CD80 (B7-1) and CD86 (B7-2). Certain tumours can evade immunosurveillance by activating these immunological checkpoint targets. These proteins are often upregulated in cancer cells and tumour-infiltrating lymphocytes, allowing cancer cells to evade immune surveillance and promote tumour growth. By blocking inhibitory checkpoints, ICI can help restore the immune system to effectively fight cancer. Several studies have investigated the expression of these and other immune checkpoints in human cancers and have shown their potential as therapeutic targets. In recent years, there has been growing interest in studying the expression of immune checkpoints in dogs with cancer, and a few small clinical trials with ICI have already been performed on these species. Emerging studies in veterinary oncology are centred around developing and validating canine-targeted antibodies. Among ICIs, anti-PD-1 and anti-PD-L1 treatments stand out as the most promising, mirroring the success in human medicine over the past decade. Nevertheless, the efficacy of caninized antibodies remains suboptimal, especially for canine oral melanoma. To enhance the utilisation of ICIs, the identification of predictive biomarkers for treatment response and the thorough screening of individual tumours are crucial. Such endeavours hold promise for advancing personalised medicine within veterinary practice, thereby improving treatment outcomes. This article aims to review the current research literature about the expression of immune checkpoints in canine cancer and the current results of ICI treatment in dogs.
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Affiliation(s)
- Antonio Giuliano
- Department of Veterinary Clinical Science, Jockey Club College of Veterinary Medicine, City University of Hong Kong, Hong Kong, China
- Veterinary Medical Centre, City University of Hong Kong, Hong Kong, China
| | - Pedro A. B. Pimentel
- Department of Veterinary Medicine and Surgery, Veterinary School, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte 31270-901, MG, Brazil;
| | - Rodrigo S. Horta
- Department of Veterinary Medicine and Surgery, Veterinary School, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte 31270-901, MG, Brazil;
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Liatsou E, Tsilimigras DI, Malandrakis P, Gavriatopoulou M, Ntanasis-Stathopoulos I. Current status and novel insights into the role of metastasectomy in the era of immunotherapy. Expert Rev Anticancer Ther 2023; 23:57-66. [PMID: 36527305 DOI: 10.1080/14737140.2023.2160323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION New perspectives on the role of metastasectomy have emerged along with the advances in cancer immunotherapy. Despite accumulating evidence that encourages the use of immunotherapy in the metastatic setting, current data regarding its combination with surgical resection of secondary lesions, as well as the best timeline and sequence of such a therapeutic approach is limited. AREAS COVERED We review the currently available literature on the role of metastasectomy in the era of novel immunotherapeutic agents and provide comprehensive evidence from ongoing trials about the available treatment strategies. In metastatic melanoma, immune checkpoint inhibitors (ICIs) play a key role both in the neoadjuvant and adjuvant setting to achieve long-term disease control. In metastatic renal cell carcinoma, investigation is ongoing regarding the emerging role of ICIs before metastasectomy. ICIs have improved outcomes in patients with metastatic colorectal and head and neck cancer. EXPERT OPINION In the neoadjuvant setting, the high response rates and the durability of responses to immunotherapy may enable the resectability of metastatic lesions. In the adjuvant setting post metastasectomy, immunotherapy constitutes a safe and efficacious approach to support immune tumor surveillance and delay or even prevent disease relapse. Patient participation in relevant clinical trials should be encouraged.
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Affiliation(s)
- Efstathia Liatsou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, the Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, USA
| | - Panagiotis Malandrakis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Hamid O, Chiappori AA, Thompson JA, Doi T, Hu-Lieskovan S, Eskens FALM, Ros W, Diab A, Spano JP, Rizvi NA, Wasser JS, Angevin E, Ott PA, Forgie A, Yang W, Guo C, Chou J, El-Khoueiry AB. First-in-human study of an OX40 (ivuxolimab) and 4-1BB (utomilumab) agonistic antibody combination in patients with advanced solid tumors. J Immunother Cancer 2022; 10:jitc-2022-005471. [PMID: 36302562 PMCID: PMC9621185 DOI: 10.1136/jitc-2022-005471] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Ivuxolimab (PF-04518600) and utomilumab (PF-05082566) are humanized agonistic IgG2 monoclonal antibodies against OX40 and 4-1BB, respectively. This first-in-human, multicenter, open-label, phase I, dose-escalation/dose-expansion study explored safety, tolerability, pharmacokinetics, pharmacodynamics, and antitumor activity of ivuxolimab+utomilumab in patients with advanced solid tumors. METHODS Dose-escalation: patients with advanced bladder, gastric, or cervical cancer, melanoma, head and neck squamous cell carcinoma, or non-small cell lung cancer (NSCLC) who were unresponsive to available therapies, had no standard therapy available or declined standard therapy were enrolled into five dose cohorts: ivuxolimab (0.1-3 mg/kg every 2 weeks (Q2W)) intravenously plus utomilumab (20 or 100 mg every 4 weeks (Q4W)) intravenously. Dose-expansion: patients with melanoma (n=10) and NSCLC (n=20) who progressed on prior anti-programmed death receptor 1/programmed death ligand-1 and/or anti-cytotoxic T-lymphocyte-associated antigen 4 (melanoma) received ivuxolimab 30 mg Q2W intravenously plus utomilumab 20 mg Q4W intravenously. Adverse events (AEs) were graded per National Cancer Institute Common Terminology Criteria for Adverse Events V.4.03 and efficacy was assessed using Response Evaluation Criteria in Solid Tumors (RECIST) V.1.1 and immune-related RECIST (irRECIST). Paired tumor biopsies and whole blood were collected to assess pharmacodynamic effects and immunophenotyping. Whole blood samples were collected longitudinally for immunophenotyping. RESULTS Dose-escalation: 57 patients were enrolled; 2 (3.5%) patients with melanoma (0.3 mg/kg+20 mg and 0.3 mg/kg+100 mg) achieved partial response (PR), 18 (31.6%) patients achieved stable disease (SD); the disease control rate (DCR) was 35.1% across all dose levels. Dose-expansion: 30 patients were enrolled; 1 patient with NSCLC achieved PR lasting >77 weeks. Seven of 10 patients with melanoma (70%) and 7 of 20 patients with NSCLC (35%) achieved SD: median (range) duration of SD was 18.9 (13.9-49.0) weeks for the melanoma cohort versus 24.1 (14.3-77.9+) weeks for the NSCLC cohort; DCR (NSCLC) was 40%. Grade 3-4 treatment-emergent AEs were reported in 28 (49.1%) patients versus 11 (36.7%) patients in dose-escalation and dose-expansion, respectively. There were no grade 5 AEs deemed attributable to treatment. Ivuxolimab area under the concentration-time curve increased in a dose-dependent manner at 0.3-3 mg/kg doses. CONCLUSIONS Ivuxolimab+utomilumab was found to be well tolerated and demonstrated preliminary antitumor activity in selected groups of patients. TRIAL REGISTRATION NUMBER NCT02315066.
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Affiliation(s)
- Omid Hamid
- Translational Research and Immunotherapy, The Angeles Clinic and Research Institute, A Cedars-Sinai Affiliate, Los Angeles, California, USA
| | | | | | - Toshihiko Doi
- Department of Experimental Therapeutics, National Cancer Center Hospital East, Kashiwa, Japan
| | - Siwen Hu-Lieskovan
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Ferry A L M Eskens
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Willeke Ros
- Department of Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Adi Diab
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, Texas, USA
| | - Jean-Philippe Spano
- Medical Oncology, APHP-Sorbonne University, IPLEs Inserm1136, Pitie-Salpetrière Hospital-Paris, Paris, France
| | - Naiyer A Rizvi
- Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Jeffrey S Wasser
- Neag Comprehensive Cancer Center, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Eric Angevin
- Drug Development Department, Institut Gustave Roussy, Villejuif, France
| | - Patrick A Ott
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Alison Forgie
- Translational Oncology, Pfizer Inc, San Francisco, California, USA
| | - Wenjing Yang
- Oncology Computational Biology, Pfizer Inc, San Diego, Calfornia, USA
| | - Cen Guo
- Clinical Pharmacology, Pfizer Inc, San Diego, California, USA
| | - Jeffrey Chou
- Early Oncology Development and Clinical Research, Pfizer Inc, San Francisco, California, USA
| | - Anthony B El-Khoueiry
- Department of Internal Medicine, Division of Medical Oncology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, California, USA
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Liang W, He X, Bi J, Hu T, Sun Y. Role of reactive oxygen species in tumors based on the 'seed and soil' theory: A complex interaction (Review). Oncol Rep 2021; 46:208. [PMID: 34328200 PMCID: PMC8329912 DOI: 10.3892/or.2021.8159] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/24/2021] [Indexed: 12/12/2022] Open
Abstract
Tumor microenvironment (TME) can serve as the 'soil' for the growth and survival of tumor cells and function synergically with tumor cells to mediate tumor progression and therapeutic resistance. Reactive oxygen species (ROS) is somewhat of a double‑edged sword for tumors. Accumulating evidence has reported that regulating ROS levels can serve an anti‑tumor role in the TME, including the promotion of cancer cell apoptosis, inhibition of angiogenesis, preventing immune escape, manipulating tumor metabolic reorganization and improving drug resistance. In the present review, the potential role of ROS in anti‑tumor therapy was summarized, including the possibility of directly or indirectly targeting the TME.
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Affiliation(s)
- Wei Liang
- Department of Radiation Oncology, Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Affiliated Hospital of Hebei Medical University, Cangzhou, Hebei 061000, P.R. China
| | - Xinying He
- Department of Radiation Oncology, Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Affiliated Hospital of Hebei Medical University, Cangzhou, Hebei 061000, P.R. China
| | - Jianqiang Bi
- Department of Radiation Oncology, Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Affiliated Hospital of Hebei Medical University, Cangzhou, Hebei 061000, P.R. China
| | - Tingting Hu
- Department of Radiation Oncology, Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Affiliated Hospital of Hebei Medical University, Cangzhou, Hebei 061000, P.R. China
| | - Yunchuan Sun
- Department of Radiation Oncology, Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Affiliated Hospital of Hebei Medical University, Cangzhou, Hebei 061000, P.R. China
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Abstract
Brain metastases are associated with poor prognosis irrespective of the primary tumor they originate from. Current treatments for brain metastases are palliative, and patients with symptomatic brain metastasis have a one-year survival of <20%. Lung cancer, breast cancer, and melanoma have higher incidences of brain metastases compared with other types of cancers. However, it is not very clear why some cancers metastasize to the brain more frequently than others. Studies thus far suggest that brain-specific tropism of certain types of cancers is defined by a winning combination of the following factors: unique genetic subtypes of primary tumors or its subclones enabling detachment, dissemination, blood-brain barrier penetration, plus proliferation and survival in hypoxic low-glucose microenvironment; specific transcriptomic and epigenetic changes of colony-forming metastatic cells, allowing their outgrowth; favorable metastasis-permissive microenvironment of the brain created by interactions of cancer cells and cells in the brain through triggering inflammation, recruiting myeloid-derived suppressor cells, and promoting metabolic adaptation; immunosuppression resulting in the failure of adaptive immune response to recognize or kill cancer cells in the brain. Here, we briefly review recent advances in understanding brain metastasis organotropism and outline directions for future research.
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Affiliation(s)
- Arseniy E Yuzhalin
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Dihua Yu
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
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Age-associated changes in the immune system may influence the response to anti-PD1 therapy in metastatic melanoma patients. Cancer Immunol Immunother 2020; 69:717-730. [PMID: 32036449 PMCID: PMC7183505 DOI: 10.1007/s00262-020-02497-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/20/2020] [Indexed: 12/12/2022]
Abstract
Anti-PD1 treatment has improved the survival of metastatic melanoma patients, yet it is unknown which patients benefit from the treatment. In this exploratory study, we aimed to understand the effects of anti-PD1 therapy on the patients’ immune system and discover the characteristics that would result in successful treatment. We collected peripheral blood (PB) samples from 17 immuno-oncology-naïve metastatic melanoma patients before and after 1 and 3 months of anti-PD1 therapy. In addition, matching tumor biopsies at the time of diagnosis were collected for tissue microarray. The complete blood counts, PB immunophenotype, serum cytokine profiles, and tumor-infiltrating lymphocytes were analyzed and correlated with the clinical data. Patients were categorized based on their disease control into responders (complete response, partial response, stable disease > 6 months, N = 11) and non-responders (progressive disease, stable disease ≤ 6 months, N = 6). During therapy, the PB natural killer T (NKT) cell frequency, expression of CD25 and CD45RO on cytotoxic natural killer (NK) cells, and serum CXC chemokine levels were significantly increased in responders. Furthermore, higher age together with age-associated characteristics from PB, lower frequency of PB-naïve CD8+ T cells, and elevated levels of serum MCP-4 and OPG were discovered as baseline predictors of treatment response. We therefore propose that in addition to T cells, anti-PD1 treatment is associated with NK- and NKT-cell population dynamics, and that the age-associated characteristics from PB together with older age may contribute to prolonged PFS in anti-PD1-treated melanoma patients.
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Gómez-Abenza E, Ibáñez-Molero S, García-Moreno D, Fuentes I, Zon LI, Mione MC, Cayuela ML, Gabellini C, Mulero V. Zebrafish modeling reveals that SPINT1 regulates the aggressiveness of skin cutaneous melanoma and its crosstalk with tumor immune microenvironment. J Exp Clin Cancer Res 2019; 38:405. [PMID: 31519199 PMCID: PMC6743187 DOI: 10.1186/s13046-019-1389-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/23/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Skin cutaneous melanoma (SKCM) is the most lethal form of skin cancer and while incidence rates are declining for most cancers, they have been steadily rising for SKCM. Serine protease inhibitor, kunitz-type, 1 (SPINT1) is a type II transmembrane serine protease inhibitor that has been shown to be involved in the development of several types of cancer, such as squamous cell carcinoma and colorectal cancer. METHODS We used the unique advantages of the zebrafish to model the impact of Spint1a deficiency in early transformation, progression and metastatic invasion of SKCM together with in silico analysis of the occurrence and relevance of SPINT1 genetic alterations of the SKCM TCGA cohort. RESULTS We report here a high prevalence of SPINT1 genetic alterations in SKCM patients and their association with altered tumor immune microenvironment and poor patient survival. The zebrafish model reveals that Spint1a deficiency facilitates oncogenic transformation, regulates the tumor immune microenvironment crosstalk, accelerates the onset of SKCM and promotes metastatic invasion. Notably, Spint1a deficiency is required at both cell autonomous and non-autonomous levels to enhance invasiveness of SKCM. CONCLUSIONS These results reveal a novel therapeutic target for SKCM.
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Affiliation(s)
- Elena Gómez-Abenza
- Departamento de Biología Celular e Histología, Facultad de Biología, Universidad de Murcia, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, Murcia, Spain
| | - Sofía Ibáñez-Molero
- Departamento de Biología Celular e Histología, Facultad de Biología, Universidad de Murcia, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, Murcia, Spain
| | - Diana García-Moreno
- Departamento de Biología Celular e Histología, Facultad de Biología, Universidad de Murcia, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, Murcia, Spain
| | - Inmaculada Fuentes
- Departamento de Biología Celular e Histología, Facultad de Biología, Universidad de Murcia, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, Murcia, Spain
| | - Leonard I. Zon
- Department of Stem Cell and Regenerative Biology, Harvard Stem Cell Institute, Cambridge, MA USA
- Stem Cell Program and Division of Hematology/Oncology, Boston Children’s Hospital and Dana-Farber Cancer Institute, Howard Hughes Medical Institute, Harvard Stem Cell Institute, Harvard Medical School, Boston, MA USA
| | - Maria C. Mione
- Laboratory of Experimental Cancer Biology, Cibio, University of Trento, Trento, Italy
| | - María L. Cayuela
- Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, Murcia, Spain
| | - Chiara Gabellini
- Departamento de Biología Celular e Histología, Facultad de Biología, Universidad de Murcia, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, Murcia, Spain
- Present Address: Unit of Cell and Developmental Biology, Department of Biology, University of Pisa, S.S. 12 Abetone e Brennero 4, Pisa, Italy
| | - Victoriano Mulero
- Departamento de Biología Celular e Histología, Facultad de Biología, Universidad de Murcia, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, Murcia, Spain
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De Angelis ML, Francescangeli F, La Torre F, Zeuner A. Stem Cell Plasticity and Dormancy in the Development of Cancer Therapy Resistance. Front Oncol 2019; 9:626. [PMID: 31355143 PMCID: PMC6636659 DOI: 10.3389/fonc.2019.00626] [Citation(s) in RCA: 126] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/24/2019] [Indexed: 12/11/2022] Open
Abstract
Cancer treatment with either standard chemotherapy or targeted agents often results in the emergence of drug-refractory cell populations, ultimately leading to therapy failure. The biological features of drug resistant cells are largely overlapping with those of cancer stem cells and include heterogeneity, plasticity, self-renewal ability, and tumor-initiating capacity. Moreover, drug resistance is usually characterized by a suppression of proliferation that can manifest as quiescence, dormancy, senescence, or proliferative slowdown. Alterations in key cellular pathways such as autophagy, unfolded protein response or redox signaling, as well as metabolic adaptations also contribute to the establishment of drug resistance, thus representing attractive therapeutic targets. Moreover, a complex interplay of drug resistant cells with the micro/macroenvironment and with the immune system plays a key role in dictating and maintaining the resistant phenotype. Recent studies have challenged traditional views of cancer drug resistance providing innovative perspectives, establishing new connections between drug resistant cells and their environment and indicating unexpected therapeutic strategies. In this review we discuss recent advancements in understanding the mechanisms underlying drug resistance and we report novel targeting agents able to overcome the drug resistant status, with particular focus on strategies directed against dormant cells. Research on drug resistant cancer cells will take us one step forward toward the development of novel treatment approaches and the improvement of relapse-free survival in solid and hematological cancer patients.
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Affiliation(s)
- Maria Laura De Angelis
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
| | | | - Filippo La Torre
- Department of Surgical Sciences Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Ann Zeuner
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
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Langan EA, Kümpers C, Graetz V, Perner S, Zillikens D, Terheyden P. Intralesional interleukin‐2: A novel option to maximize response to systemic immune checkpoint therapy in loco‐regional metastatic melanoma. Dermatol Ther 2019; 32:e12901. [DOI: 10.1111/dth.12901] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 04/05/2019] [Indexed: 12/25/2022]
Affiliation(s)
- Ewan A. Langan
- Department of DermatologyUniversity of Luebeck Lubeck Germany
- Department of Dermatological ScienceUniversity of Manchester Manchester United Kingdom
| | - Christiane Kümpers
- Department of Pathology of the University Hospital Schleswig‐Holstein, Campus Luebeck and the Research Center Borstel, Leibniz Lung Center, Luebeck and Borstel Lubeck Germany
| | - Victoria Graetz
- Department of DermatologyUniversity of Luebeck Lubeck Germany
| | - Sven Perner
- Department of Pathology of the University Hospital Schleswig‐Holstein, Campus Luebeck and the Research Center Borstel, Leibniz Lung Center, Luebeck and Borstel Lubeck Germany
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