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Zhou Y, Li K, Adelson DL. An unmet need for pharmacology: Treatments for radiation-induced gastrointestinal mucositis. Biomed Pharmacother 2024; 175:116767. [PMID: 38781863 DOI: 10.1016/j.biopha.2024.116767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/07/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
Gastrointestinal mucositis (GIM) continues to be a significant issue in the management of abdominal cancer radiation treatments and chemotherapy, causing significant patient discomfort and therapy interruption or even cessation. This review will first focus on radiotherapy induced GIM, providing an understanding of its clinical landscape. Subsequently, the aetiology of GIM will be reviewed, highlighting diverse contributing factors. The cellular and tissue damage and associated molecular responses in GIM will be summarised in the context of the underlying complex biological processes. Finally, available drugs and pharmaceutical therapies will be evaluated, underscoring their insufficiency, and highlighting the need for further research and innovation. This review will emphasize the urgent need for improved pharmacologic therapeutics for GIM, which is a key research priority in oncology.
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Affiliation(s)
- Yan Zhou
- Department of Molecular and Biomedical Science, School of Biological Sciences, The University of Adelaide, Adelaide, South Australia 5005, Australia; Zhendong Australia China Centre for Molecular Chinese Medicine, The University of Adelaide, Adelaide, South Australia 5005, Australia.
| | - Kun Li
- Beijing Zhendong Guangming Pharmaceutical Research Institute, Beijing 100120, China.
| | - David L Adelson
- Department of Molecular and Biomedical Science, School of Biological Sciences, The University of Adelaide, Adelaide, South Australia 5005, Australia; Zhendong Australia China Centre for Molecular Chinese Medicine, The University of Adelaide, Adelaide, South Australia 5005, Australia.
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Zhang HW, Pang HW, Wang YH, Jiang W. A Neural Network-based Method for Predicting Dose to Organs at Risk in Intensity-modulated Radiotherapy for Nasopharyngeal Carcinoma. Clin Oncol (R Coll Radiol) 2024; 36:46-55. [PMID: 37996310 DOI: 10.1016/j.clon.2023.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 10/06/2023] [Accepted: 11/08/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE A neural network method was used to establish a dose prediction model for organs at risk (OARs) during intensity-modulated radiotherapy (IMRT) for nasopharyngeal carcinoma (NPC). MATERIALS AND METHODS In total, 103 patients with NPC were randomly selected for IMRT. Suborgans were automatically generated for OARs using ring structures based on distance to the target using a MATLAB program and the corresponding volume of each suborgan was determined. The correlation between the volume of each suborgan and the dose to each OAR was analysed and neural network prediction models of the OAR dose were established using the MATLAB Neural Net Fitting application. The R-value and mean square error in the regression analysis were used to evaluate the prediction model. RESULTS The OAR dose was related to the volume of the corresponding sub-OAR. The average R-values for the normalised mean dose (Dnmean) to parallel organs and serial organs and the normalised maximum dose (Dn0) to serial organs in the training set were 0.880, 0.927 and 0.905, respectively. The mean square error for each OAR in the prediction model was low (ranging from 1.72 × 10-4 to 7.06 × 10-3). CONCLUSION The neural network-based model for predicting OAR dose during IMRT for NPC is simple, reliable and worth further investigation and application.
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Affiliation(s)
- H-W Zhang
- Department of Radiotherapy, Jiang-xi Cancer Hospital, The Second Affiliated Hospital of Nanchang Medical College, NHC Key Laboratory of Personalized Diagnosis and Treatment of Nasopharyngeal Carcinoma, Nanchang, China; Department of Oncology, The Third People's Hospital of Jingdezhen, The third people's hospital of Jingdezhen affiliated to Nanchang Medical College, Jingdezhen, China
| | - H-W Pang
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Sichuan, China
| | - Y-H Wang
- Department of Oncology, Gulin County People's Hospital, Luzhou, China
| | - W Jiang
- Academy of Medical Engineering and Translational Medicine, Department of Biomedical Engineering, School of Precision Instrument and Opto-electronics Engineering, Tianjin University, Tianjin, 300072, China; Department of Radiotherapy, Yantai Yuhuangding Hospital Affiliated to Qingdao University, No. 20 Yuhuangding East Road, Yantai 264000, Shandong, China.
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Bi Z, Wang Q, Yang T, Liu Y, Yuan J, Li L, Guo Y. Effect of Lactobacillus delbrueckii subsp. lactis on vaginal radiotherapy for gynecological cancer. Sci Rep 2023; 13:10105. [PMID: 37344615 DOI: 10.1038/s41598-023-37241-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 06/19/2023] [Indexed: 06/23/2023] Open
Abstract
The aim of this study was to evaluate the effect of Lactobacillus delbrueckii subsp. lactis (L.del) on vaginal microbiota (VM) dysbiosis and vaginal radiation injury in gynecologic cancer patients. The inhibitory effects of L.del on cervical cancer cells were also studied in vitro. Gynecologic cancer patients receiving radiotherapy were randomized into control and L.del intervention groups. The control group received radiotherapy, while the intervention group received radiotherapy and L.del intervention (1 capsule/day placed into the deep vagina from the first day of radiotherapy until the end of treatment). Vaginal swab samples were collected on the first day pre-treatment and the last day post-treatment. DNA from 54 patients was extracted and assessed by the 16S rRNA sequencing method. Radiotherapy resulted in vaginal microbiome dysbiosis characterized by increased phylogenetic diversity and increased abundance of Brevundimonas, Streptococcus and Prevotella, but a decreased abundance of Lactobacillus. Level 2 vaginal radiation injury was positively associated with the abundance of Brevundimonas and gram-negative non-fermenting bacteria. Administration of L.del attenuated the reduction of Lactobacillus while also inhibiting the abundance of Streptococcus and Prevotella, thereby ameliorating radiotherapy-related vaginal microbiota dysbiosis. CLD inhibited the in vitro proliferation of SiHa cells by altering the expression of BCL2, HPV16-E6, HPV16-E7, IL6, MAP7, BAX, Caspase-3, Caspase-9 and LTF. In conclusion, L. del application can alleviate radiation-induced vaginal dysbiosis and restore Lactobacillus dominance of the vaginal microbiome. Moreover, CLD was found to inhibit cell growth and promote the apoptosis of SiHa cells in vitro. The registration number for this clinical trial is ChiCTR1900021784.
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Affiliation(s)
- Zhichao Bi
- Department of Microecology, School of Basic Medical Science, Dalian Medical University, Dalian, China
| | - Qi Wang
- Department of Microecology, School of Basic Medical Science, Dalian Medical University, Dalian, China
| | - Tiancizhuo Yang
- Department of Microecology, School of Basic Medical Science, Dalian Medical University, Dalian, China
| | - Yinhui Liu
- Department of Microecology, School of Basic Medical Science, Dalian Medical University, Dalian, China
| | - Jieli Yuan
- Department of Microecology, School of Basic Medical Science, Dalian Medical University, Dalian, China
| | - Longjie Li
- Department of Radiation Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
| | - Yanjie Guo
- Department of Microecology, School of Basic Medical Science, Dalian Medical University, Dalian, China.
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Caminha RDG, Fuzisaki TT, Siosaki ATF, da Silva Santos PS. Case-control study analyzing the relationship between oral microcirculation and oral mucositis and pain in patients under antineoplastic therapy. Lasers Med Sci 2023; 38:118. [PMID: 37154854 DOI: 10.1007/s10103-023-03777-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 04/16/2023] [Indexed: 05/10/2023]
Abstract
The study aimed to evaluate the relation between microcirculation of the genian region using laser Doppler flowmetry and oral mucositis (OM) and pain in individuals undergoing antineoplastic therapy. A case-control clinical study was conducted with the participants divided into three groups: chemotherapy (CTG), radiation therapy and chemotherapy group (RCTG), and control group (CG). Pain was assessed by visual analog scale; OM was classified by oral mucositis assessment and WHO scales. The blood flow was assessed by laser Doppler flowmetry. Kruskal-Wallis statistical test, Friedman test, and Spearman test were used for statistical analysis of this study. CTG (7 individuals/25.93%) showed the worst manifestations of OM between 2nd and 4th evaluations (OM-WHO: T2, p = 0.006; T3, p = 0.006; T4, p = 0.003; OM-OMAS: T2, p = 0.004; T3, p = 0.000; T4, p = 0.011), and increased blood flow over time, with the exception of the 3rd evaluation (p = 0.138). The RCTG (9 individuals/33.33%) showed the worst manifestations of oral mucositis on the 4th week (OM-WHO and OM-OMAS: p = 0.000) with a decrease in blood flow (p = 0.068). The decreased blood flow is associated with greater severity of oral mucositis and greater pain intensity.
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Affiliation(s)
- Raquel D'Aquino Garcia Caminha
- Department of Surgery, Stomatology, Pathology and Radiology, Bauru School of Dentistry, University of São Paulo, Bauru, Brazil.
| | | | | | - Paulo Sérgio da Silva Santos
- Department of Surgery, Stomatology, Pathology and Radiology, Bauru School of Dentistry, University of São Paulo, Bauru, Brazil
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Bromberger L, Heise B, Felbermayer K, Leiss-Holzinger E, Ilicic K, Schmid TE, Bergmayr A, Etzelstorfer T, Geinitz H. Radiation-induced alterations in multi-layered, in-vitro skin models detected by optical coherence tomography and histological methods. PLoS One 2023; 18:e0281662. [PMID: 36862637 PMCID: PMC9980765 DOI: 10.1371/journal.pone.0281662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 01/28/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Inflammatory skin reactions and skin alterations are still a potential side effect in radiation therapy (RT), which also need attention for patients' health care. METHOD In a pre-clinical study we consider alterations in irradiated in-vitro skin models of epidermal and dermal layers. Typical dose regimes in radiation therapy are applied for irradiation. For non-invasive imaging and characterization optical coherence tomography (OCT) is used. Histological staining method is additionally applied for comparison and discussion. RESULTS Structural features, such as keratinization, modifications in epidermal cell layer thickness and disorder in the layering-as indications for reactions to ionizing radiation and aging-could be observed by means of OCT and confirmed by histology. We were able to recognize known RT induced changes such as hyper-keratosis, acantholysis, and epidermal hyperplasia as well as disruption and/or demarcation of the dermo-epidermal junction. CONCLUSION The results may pave the way for OCT to be considered as a possible adjunctive tool to detect and monitor early skin inflammation and side effects of radiotherapy, thus supporting patient healthcare in the future.
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Affiliation(s)
- Luisa Bromberger
- Department of Radiation Oncology, Ordensklinikum Linz Barmherzige Schwestern (BHS), Linz, Austria
| | - Bettina Heise
- Institute for Mathematical Methods in Medicine and Data Based Modelling, Johannes Kepler University (JKU), Linz, Austria
- Research Center for Non-Destructive Testing (RECENDT)-GmbH, Linz, Austria
- * E-mail:
| | | | | | - Katarina Ilicic
- Department of Radiation Oncology, Klinikum rechts der Isar (MRI), TUM München, München, Germany
| | - Thomas Ernst Schmid
- Department of Radiation Oncology, Klinikum rechts der Isar (MRI), TUM München, München, Germany
| | - Alexandra Bergmayr
- Department of Pathology, Ordensklinikum Linz Barmherzige Schwestern (BHS), Linz, Austria
| | - Tanja Etzelstorfer
- Department of Radiation Oncology, Ordensklinikum Linz Barmherzige Schwestern (BHS), Linz, Austria
| | - Hans Geinitz
- Department of Radiation Oncology, Ordensklinikum Linz Barmherzige Schwestern (BHS), Linz, Austria
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Qu W, Wang X, Qiao Q, Wang Y. Chemotherapy for locoregionally advanced nasopharyngeal carcinoma: Who really needs it. Cancer Med 2022; 12:6994-7004. [PMID: 36494918 PMCID: PMC10067101 DOI: 10.1002/cam4.5497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/08/2022] [Accepted: 11/19/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES The CSCO and ASCO guidelines in 2021 recommend chemotherapy for stage III-IVA (8th edition of AJCC staging) nasopharyngeal carcinoma (NPC). Actually, patients with stage T3-4N0M0 are often excluded from various clinical trials of the locoregionally advanced NPC, and the survival benefit of chemotherapy in such patients has always been controversial. This study aims to explore the benefit of chemotherapy in patients with locoregionally advanced NPC, especially those with negative lymph nodes. METHODS A total of 2741 patients were extracted from the SEER database. After a 1:1 PSM analysis, 272 patients were obtained to further explore whether the addition of chemotherapy would achieve survival benefits. RESULTS After PSM, Kaplan-Meier curves showed that the overall survival (OS) of patients receiving chemoradiotherapy (p = 0.031) was higher than those receiving radiotherapy alone. Similar results were observed for cancer-specific survival (CSS). We further stratified the patients according to lymph node status and found that the addition of chemotherapy in patients with positive lymph nodes could significantly improve 5-year OS rates (58.08% vs. 43.95%; p = 0.025) and 5-year CSS rates (67.42% vs. 51.95%; p = 0.015) compared with radiotherapy alone, but there was no additional benefit of chemotherapy in patients with negative lymph nodes. For all 449 cases of T3-4N0M0 NPC, radiotherapy improved the OS rates (HR 0.293, 95% CI 0.203-0.424) and the CSS rates (HR 0.252, 95% CI 0.171-0.371) compared with no radiotherapy, while chemotherapy did not show significant survival benefit compared with no chemotherapy. CONCLUSION Our results reveal that stage T3-4N0M0 NPC may be exempted from chemotherapy, and use radiotherapy alone to reduce toxic and side effects. These results still need to be verified by future prospective trials.
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Affiliation(s)
- Weiling Qu
- Department of Radiation Oncology the First Hospital of China Medical University Shenyang Liaoning China
- Department of Radiation Oncology, Women's Hospital, School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Xuan Wang
- Department of Radiation Oncology the First Hospital of China Medical University Shenyang Liaoning China
| | - Qiao Qiao
- Department of Radiation Oncology the First Hospital of China Medical University Shenyang Liaoning China
| | - Yanli Wang
- Department of Radiation Oncology the First Hospital of China Medical University Shenyang Liaoning China
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Clinical Characteristics and Predictive Outcomes of Recurrent Nasopharyngeal Carcinoma-A Lingering Pitfall of the Long Latency. Cancers (Basel) 2022; 14:cancers14153795. [PMID: 35954458 PMCID: PMC9367553 DOI: 10.3390/cancers14153795] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 12/28/2022] Open
Abstract
Purpose: To investigate the clinical characteristics, risk factors, and clinical outcomes of long-latent recurrence (>five years) of nasopharyngeal carcinoma (NPC). Methods: This retrospective study enrolled newly diagnosed NPC patients from the Chang Gung Research Database between January 2007 and December 2019. We analyzed the patients’ characteristics and survival outcomes after recurrence. Results: A total of 2599 NPC patients were enrolled. The overall recurrence rate was 20.5%, while 8.1% of patients had long-latent recurrence (>five years). These patients had a higher percentage of initial AJCC (The American Joint Committee on Cancer) stage I/II (60.5%, p = 0.001) and local recurrence (46.5%, p < 0.001). Unresectable rT3 and rT4 were found in 60% of patients when recurrence and 30% of local recurrence occurred in the skull base, which could not be detected by the regular endoscopy. The five-year overall survival rate of long-latent recurrence was 19.7%. Alive patients tended to be asymptomatic but have regular follow-ups with the interval less than six months. Multivariate analysis showed age and initial advanced AJCC stages were independent risk factors of death after recurrence. In contrast, patients with recurrence between two and five years, salvage surgeries, and regional recurrence had favorable survival outcomes. Conclusion: Long-latent NPC recurrence is not rare, and the survival outcome is poor. Regular follow-up for early detection of NPC recurrence is necessary even after five years of disease-free period.
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Wang BC, Kuang BH, Liu XX, Lin GH, Liu Q. Induction chemotherapy in locoregionally advanced nasopharyngeal carcinoma: A systematic review and meta-analysis. Front Oncol 2022; 12:927510. [PMID: 35965543 PMCID: PMC9373136 DOI: 10.3389/fonc.2022.927510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background Adding induction chemotherapy to concurrent platinum-based chemoradiotherapy has significantly prolonged the survival time of patients with locoregionally advanced nasopharyngeal carcinoma. In this study, we intend to evaluate the survival outcomes, responses, and incidences of toxicities of induction chemotherapy and the differences between different strategies. Methods A comprehensive search was conducted in PubMed, Embase, Web of Science, and Cochrane CENTRAL on August 10, 2021. Single-arm or multi-arm prospective clinical trials on induction chemotherapy without targeted therapies or immune checkpoint inhibitors were included. Primary outcomes included survival outcomes, objective response rate, and disease control rate, and the secondary outcome was the rates of grade 3 or higher treatment-related adverse events. Results The 39 studies included in the systematic review and meta-analysis comprised 36 clinical trials and 5389 patients. The estimates for 3-year overall and fail-free survival rates were 87% and 77%. The estimates for 5-year rates of overall and fail-free survival were 81% and 73%. Gemcitabine plus platinum and docetaxel combined with 5-fluorouracil plus platinum strategies were associated with the highest rates of 3-year and 5-year overall survival. The objective response and disease control rates were 85% and 98% after the completion of induction chemotherapy. Neutropenia (27%) and nausea/vomiting (7%) were the most common grade 3 or higher treatment-related hematological and non-hematological adverse events during the induction phase. Conclusions Different induction chemotherapeutic strategies appear to have varying effects and risks; a comprehensive summary of the survival outcomes, responses, and toxicities in clinical trials may provide a crucial guide for clinicians.
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Affiliation(s)
- Bi-Cheng Wang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Bi-Cheng Wang,
| | - Bo-Hua Kuang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin-Xiu Liu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guo-He Lin
- Department of Oncology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Quentin Liu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Cancer Center, Sun Yat-sen University, Guangzhou, China
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Dechaphunkul T, Arundon T, Raungkhajon P, Jiratrachu R, Geater SL, Dechaphunkul A. Benefits of immunonutrition in patients with head and neck cancer receiving chemoradiation: A phase II randomized, double-blind study. Clin Nutr 2021; 41:433-440. [PMID: 35007812 DOI: 10.1016/j.clnu.2021.12.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/07/2021] [Accepted: 12/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND & AIMS The benefits of immunonutrition in patients with head and neck cancer (HNC), especially for those undergoing definitive concurrent chemoradiation (CCRT), remain unclear. We evaluated the benefits of immunonutrition regarding the prevention of severe oral mucositis. Secondary objectives included assessments of other treatment-related toxicities, changes of nutritional and inflammatory marker levels, treatment tolerance, and survival. METHODS In total, 110 patients with HNC undergoing definitive CCRT including 3-week cycles of cisplatin were enrolled in our double-blind phase II study. Patients were randomly assigned to receive an immunonutrient formula containing omega-3-fatty acids, arginine, dietary nucleotides, and soluble fiber (n = 55) or an isocaloric isonitrogenous control (n = 55). All patients received the assigned product 5 consecutive days before each chemotherapy session. The proportion of patients with severe oral mucositis was compared between the immunonutrients and control groups. RESULTS The rates of nasopharyngeal cancer (NPC) were 67% and 51% in the immunonutrients and control groups, respectively. All patients had 100% compliance to the assigned product. There was no difference of the proportion of patients with grade 3-4 oral mucositis between the two groups (62% vs. 67%, p = 0.690). At the time of analyses, survival tended to be better in the immunonutrients group. The 3-year progression-free survival rates were 69% (95% confidence interval [CI] = 55%-80%) and 44% (95% CI = 30%-57%) in the immunonutrients and control groups, respectively (p = 0.056), whereas the 3-year overall survival rates in these groups were 69% (95% CI = 54%-80%) and 50% (95% CI = 36%-66%; p = 0.065), respectively. In subgroup analyses according to the primary tumor location, the survival benefits were apparently maintained in patients with NPC. CONCLUSIONS Although our study did not demonstrate a reduced risk of severe oral mucositis, we found that immunonutrition might improve survival. Larger studies are needed to determine the optimal dose and schedule of immunonutrition to prevent oral mucositis. In addition, randomized phase III trials evaluating the survival benefits of immunonutrition in patients with cancer are required, and NPC might be a primary malignancy of interest. TRIAL REGISTRATION ClinicalTrials.gov ID NCT05101889.
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Affiliation(s)
- Tanadech Dechaphunkul
- Department of Otorhinolaryngology Head and Neck Surgery, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Rd, Hatyai, Songkhla, 90110, Thailand.
| | - Tippawan Arundon
- Holistic Center for Cancer Study and Care (HOCC-PSU), Unit of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Rd, Hatyai, Songkhla, 90110, Thailand.
| | - Ponpis Raungkhajon
- Nutrition Dietetics Division, Songklanagarind Hospital, Prince of Songkla University, 15 Kanjanavanich Rd, Hatyai, Songkhla, 90110, Thailand.
| | - Rungarun Jiratrachu
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Rd, Hatyai, Songkhla, 90110, Thailand.
| | - Sarayut Lucien Geater
- Division of Respiratory and Respiratory Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Rd, Hatyai, Songkhla, 90110, Thailand.
| | - Arunee Dechaphunkul
- Holistic Center for Cancer Study and Care (HOCC-PSU), Unit of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Rd, Hatyai, Songkhla, 90110, Thailand.
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