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Angerilli V, Sabella G, Centonze G, Lonardi S, Bergamo F, Mangogna A, Pietrantonio F, Fassan M, Milione M. BRAF-mutated colorectal adenocarcinomas: pathological heterogeneity and clinical implications. Crit Rev Oncol Hematol 2022; 172:103647. [PMID: 35248712 DOI: 10.1016/j.critrevonc.2022.103647] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 02/07/2023] Open
Abstract
Advances in molecular biology have markedly increased our understanding of the heterogeneous molecular landscape of colorectal cancer (CRC). Up to 15% of CRCs harbor the BRAF p.V600E somatic mutation (BRAFmt), a well-established negative prognostic marker in patients with metastatic CRC (mCRC). The BEACON CRC trial set a new standard of care in patients with progressive BRAFmt cancers, consisting of the combination of encorafenib and cetuximab. On these bases, BRAF mutational testing is now recommended in patients with mCRC. However, efforts are needed to further stratify patients carrying this mutation. Here, we discuss the heterogeneous pathologic and molecular landscape of BRAFmt CRCs, focusing on the promises and pitfalls of molecular diagnostics, on novel biomarkers to improve patients' stratification and on the current diagnostic scenario for CRC. We believe that a better stratification based on histopathological features and novel molecular biomarkers should be performed to optimize patient management and therapeutic decision-making.
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Affiliation(s)
| | - Giovanna Sabella
- Pathology Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Giovanni Centonze
- Pathology Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Sara Lonardi
- Oncology Unit 1, Department of Oncology, Veneto Institute of Oncology, IOV-IRCCS, Padua
| | - Francesca Bergamo
- Oncology Unit 1, Department of Oncology, Veneto Institute of Oncology, IOV-IRCCS, Padua
| | - Alessandro Mangogna
- Institute for Maternal and Child Health, IRCCS Burlo Garofalo, 34137 Trieste, Italy
| | | | - Matteo Fassan
- Department of Medicine, Surgical Pathology Unit, University of Padua; Veneto Institute of Oncology, IOV-IRCCS, Padua
| | - Massimo Milione
- Pathology Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy.
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2
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Del Genio G, Lucido FS, Gambardella C. TECHNICAL ASPECTS OF ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD). FROM LATERAL TO LONGITUDINAL DISSECTION: A NEW APPROACH TO TREAT COLONIC TUMORS. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:566-568. [PMID: 34909866 DOI: 10.1590/s0004-2803.202100000-99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/11/2021] [Indexed: 11/22/2022]
Affiliation(s)
- Gianmattia Del Genio
- University of Campania Luigi Vanvitelli, Division of General, Mininvasive and Bariatric Surgery, Naples, Italy
| | - Francesco Saverio Lucido
- University of Campania Luigi Vanvitelli, Division of General, Mininvasive and Bariatric Surgery, Naples, Italy
| | - Claudio Gambardella
- University of Campania Luigi Vanvitelli, Division of General, Mininvasive and Bariatric Surgery, Naples, Italy
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3
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Fassan M, Scarpa A, Remo A, De Maglio G, Troncone G, Marchetti A, Doglioni C, Ingravallo G, Perrone G, Parente P, Luchini C, Mastracci L. Current prognostic and predictive biomarkers for gastrointestinal tumors in clinical practice. Pathologica 2021; 112:248-259. [PMID: 33179625 PMCID: PMC7931577 DOI: 10.32074/1591-951x-158] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 06/24/2020] [Indexed: 12/12/2022] Open
Abstract
The pathologist emerged in the personalized medicine era as a central actor in the definition of the most adequate diagnostic and therapeutic algorithms. In the last decade, gastrointestinal oncology has seen a significantly increased clinical request for the integration of novel prognostic and predictive biomarkers in histopathological reports. This request couples with the significant contraction of invasive sampling of the disease, thus conferring to the pathologist the role of governor for both proper pathologic characterization and customized processing of the biospecimens. This overview will focus on the most commonly adopted immunohistochemical and molecular biomarkers in the routine clinical characterization of gastrointestinal neoplasms referring to the most recent published recommendations, guidelines and expert opinions.
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Affiliation(s)
- Matteo Fassan
- Surgical Pathology Unit, Department of Medicine (DIMED), University of Padua, Italy
| | - Aldo Scarpa
- ARC-NET Research Centre, University of Verona, Italy.,Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Andrea Remo
- Pathology Unit, Service Department, ULSS9 "Scaligera", Verona, Italy
| | | | - Giancarlo Troncone
- Department of Public Health, Federico II University Medical School Naples, Italy
| | - Antonio Marchetti
- Center of Predictive Molecular Medicine, Center for Excellence on Aging and Translational Medicine, University of Chieti-Pescara, Italy
| | - Claudio Doglioni
- Vita e Salute University, Milan, Italy.,Pathology Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe Ingravallo
- Department of Emergency and Organ Transplantation, Section of Pathological Anatomy, University of Bari Aldo Moro, Bari, Italy
| | - Giuseppe Perrone
- Department of Pathology, Campus Bio-Medico University, Rome, Italy
| | - Paola Parente
- Pathology Unit, Fondazione IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Luca Mastracci
- Anatomic Pathology, San Martino IRCCS Hospital,, Genova, Italy.,Anatomic Pathology, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genova, Italy
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4
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Lawlor RT, Mattiolo P, Mafficini A, Hong SM, Piredda ML, Taormina SV, Malleo G, Marchegiani G, Pea A, Salvia R, Kryklyva V, Shin JI, Brosens LA, Milella M, Scarpa A, Luchini C. Tumor Mutational Burden as a Potential Biomarker for Immunotherapy in Pancreatic Cancer: Systematic Review and Still-Open Questions. Cancers (Basel) 2021; 13:cancers13133119. [PMID: 34206554 PMCID: PMC8269341 DOI: 10.3390/cancers13133119] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/13/2021] [Accepted: 06/17/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Tumor mutational burden (TMB) represents the number of mutations per megabase (muts/Mb) harbored by tumor cells in a given neoplasm, and can be determined with next-generation sequencing. High values are an indicator of potential response to immunotherapy. With this systematic review, we assessed its role in pancreatic ductal adenocarcinoma (PDAC). Our main findings can be summarized as: (i) high-TMB can be found in about 1% of PDAC; (ii) it is associated with mucinous/colloid and medullary histology; (iii) high-TMB PDAC frequently harbor other actionable alterations, with microsatellite instability as the most common; (iv) immunotherapy has shown promising results in high-TMB PDAC. Abstract Tumor mutational burden (TMB) is a numeric index that expresses the number of mutations per megabase (muts/Mb) harbored by tumor cells in a neoplasm. TMB can be determined using different approaches based on next-generation sequencing. In the case of high values, it indicates a potential response to immunotherapy. In this systematic review, we assessed the potential predictive role of high-TMB in pancreatic ductal adenocarcinoma (PDAC), as well as the histo-molecular features of high-TMB PDAC. High-TMB appeared as a rare but not-negligible molecular feature in PDAC, being present in about 1.1% of cases. This genetic condition was closely associated with mucinous/colloid and medullary histology (p < 0.01). PDAC with high-TMB frequently harbored other actionable alterations, with microsatellite instability/defective mismatch repair as the most common. Immunotherapy has shown promising results in high-TMB PDAC, but the sample size of high-TMB PDAC treated so far is quite small. This study highlights interesting peculiarities of PDAC harboring high-TMB and may represent a reliable starting point for the assessment of TMB in the clinical management of patients affected by pancreatic cancer.
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Affiliation(s)
- Rita T. Lawlor
- ARC-Net Research Center, University and Hospital Trust of Verona, 37134 Verona, Italy; (R.T.L.); (A.M.); (M.L.P.); (S.V.T.)
| | - Paola Mattiolo
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134 Verona, Italy;
| | - Andrea Mafficini
- ARC-Net Research Center, University and Hospital Trust of Verona, 37134 Verona, Italy; (R.T.L.); (A.M.); (M.L.P.); (S.V.T.)
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134 Verona, Italy;
| | - Seung-Mo Hong
- Asan Medical Center, Department of Pathology, University of Ulsan College of Medicine, Seoul 05505, Korea;
| | - Maria L. Piredda
- ARC-Net Research Center, University and Hospital Trust of Verona, 37134 Verona, Italy; (R.T.L.); (A.M.); (M.L.P.); (S.V.T.)
| | - Sergio V. Taormina
- ARC-Net Research Center, University and Hospital Trust of Verona, 37134 Verona, Italy; (R.T.L.); (A.M.); (M.L.P.); (S.V.T.)
| | - Giuseppe Malleo
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, 37134 Verona, Italy; (G.M.); (G.M.); (A.P.); (R.S.)
| | - Giovanni Marchegiani
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, 37134 Verona, Italy; (G.M.); (G.M.); (A.P.); (R.S.)
| | - Antonio Pea
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, 37134 Verona, Italy; (G.M.); (G.M.); (A.P.); (R.S.)
| | - Roberto Salvia
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, 37134 Verona, Italy; (G.M.); (G.M.); (A.P.); (R.S.)
| | - Valentyna Kryklyva
- Department of Pathology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (V.K.); (L.A.B.)
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 120-752, Korea;
| | - Lodewijk A. Brosens
- Department of Pathology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (V.K.); (L.A.B.)
- Department of Pathology, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Michele Milella
- Department of Medicine, Section of Oncology, University and Hospital Trust of Verona, 37134 Verona, Italy;
| | - Aldo Scarpa
- ARC-Net Research Center, University and Hospital Trust of Verona, 37134 Verona, Italy; (R.T.L.); (A.M.); (M.L.P.); (S.V.T.)
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134 Verona, Italy;
- Correspondence: (A.S.); (C.L.); Tel.: +39-045-812-7458 (A.S.); +39-045-812-4835 (C.L.)
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134 Verona, Italy;
- Correspondence: (A.S.); (C.L.); Tel.: +39-045-812-7458 (A.S.); +39-045-812-4835 (C.L.)
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5
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Piredda ML, Ammendola S, Sciammarella C, Turri G, Bagante F, Fassan M, Mafficini A, Mombello A, Cataldi S, Paolino G, Mattiolo P, Florena AM, Genna M, Fior F, Cheng L, Lawlor RT, Scarpa A, Pedrazzani C, Luchini C. Colorectal cancer with microsatellite instability: Right-sided location and signet ring cell histology are associated with nodal metastases, and extranodal extension influences disease-free survival. Pathol Res Pract 2021; 224:153519. [PMID: 34119815 DOI: 10.1016/j.prp.2021.153519] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 02/08/2023]
Abstract
Colorectal cancer (CRC) with microsatellite instability (MSI) accounts for 15-18 % of all CRCs and represents the category with the best prognosis. This study aimed at determining any possible clinical/pathological features associated with a higher risk of nodal metastasization in MSI-CRC, and at defining any possible prognostic moderators in this setting. All surgically resected CRCs of the last 20 years (mono-institutional series) with a PCR-based diagnosis of MSI, with and without nodal metastasis, have been retrieved for histological review, which was performed following WHO guidelines. Furthermore, the most important prognostic moderators have been investigated with a survival analysis. The study of 33 cases of MSI-CRCs with nodal metastasis highlighted a high fidelity of histology maintenance between primary tumors and matched nodal metastases. At survival analysis, the strongest prognostic variable in MSI-CRCs with nodal metastasis was the extranodal extension (multivariate analysis, HR: 14.4, 95 %CI: 1.46-140.9, p = 0.022). Furthermore, through a comparison between nodal positive (33 cases) and nodal negative (71 cases) MSI-CRCs, right-sided location (p < 0.0001), pT4 stage (p = 0.0004) and signet-ring histology (p = 0.0089) emerged as parameters more commonly associated with nodal metastasization. These findings shed new light on the biology of MSI-CRC and can be of help for the prognostic stratification of MSI-CRC patients.
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Affiliation(s)
- Maria L Piredda
- ARC-Net Research Center, University and Hospital Trust of Verona, Verona, Italy
| | - Serena Ammendola
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | | | - Giulia Turri
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, Unit of General and Hepatobiliary Surgery, University of Verona, Verona, Italy
| | - Fabio Bagante
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, Unit of General and Hepatobiliary Surgery, University of Verona, Verona, Italy
| | - Matteo Fassan
- Department of Medicine (DIMED), Surgical Pathology and Cytopathology Unit, University of Padua, Padua, Italy
| | - Andrea Mafficini
- ARC-Net Research Center, University and Hospital Trust of Verona, Verona, Italy; Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Aldo Mombello
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Simone Cataldi
- Department of Sciences for Promotion of Health and Mother and Child Care, Anatomic Pathology, University of Palermo, Palermo, Italy
| | - Gaetano Paolino
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Paola Mattiolo
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Ada M Florena
- Department of Sciences for Promotion of Health and Mother and Child Care, Anatomic Pathology, University of Palermo, Palermo, Italy
| | - Michele Genna
- Department of General Surgery, Unit of General and Obesity Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Francesca Fior
- Department of General Surgery, Unit of General and Obesity Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Liang Cheng
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rita T Lawlor
- ARC-Net Research Center, University and Hospital Trust of Verona, Verona, Italy
| | - Aldo Scarpa
- ARC-Net Research Center, University and Hospital Trust of Verona, Verona, Italy; Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Corrado Pedrazzani
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, Unit of General and Hepatobiliary Surgery, University of Verona, Verona, Italy
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy.
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6
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Fanelli GN, Dal Pozzo CA, Depetris I, Schirripa M, Brignola S, Biason P, Balistreri M, Dal Santo L, Lonardi S, Munari G, Loupakis F, Fassan M. The heterogeneous clinical and pathological landscapes of metastatic Braf-mutated colorectal cancer. Cancer Cell Int 2020; 20:30. [PMID: 32015690 PMCID: PMC6990491 DOI: 10.1186/s12935-020-1117-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 01/20/2020] [Indexed: 12/24/2022] Open
Abstract
Colorectal cancer (CRC) is a complex and molecularly heterogeneous disease representing one of the most frequent causes of cancer-related death worldwide. About 8–15% of CRCs harbor a mutation in BRAF gene, a proto-oncogene involved in cell proliferation, differentiation and survival through the MAPK signaling cascade. The acquisition of BRAF mutation is an early event in the “serrated” CRC carcinogenetic pathway and is associated with specific and aggressive clinico-pathological and molecular features. Despite that the presence of BRAF mutation is a well-recognized negative prognostic biomarker in metastatic CRC (mCRC), a great heterogeneity in survival outcome characterizes these patients, due to the complex, and still not completely fully elucidated, interactions between the clinical, genetic and epigenetic landscape of BRAF mutations. Because of the great aggressiveness of BRAF-mutated mCRCs, only 60% of patients can receive a second-line chemotherapy; so intensive combined and tailored first-line approach could be a potentially effective strategy, but to minimize the selective pressure of resistant clones and to reduce side effects, a better stratification of patients bearing BRAF mutations is needed. ![]()
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Affiliation(s)
- Giuseppe Nicolò Fanelli
- 1Surgical Pathology Unit, Department of Medicine (DIMED), University of Padua, via Gabelli 61, 35121 Padua, Italy
| | - Carlo Alberto Dal Pozzo
- 1Surgical Pathology Unit, Department of Medicine (DIMED), University of Padua, via Gabelli 61, 35121 Padua, Italy
| | - Ilaria Depetris
- 2Department of Oncology, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Marta Schirripa
- 2Department of Oncology, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Stefano Brignola
- 1Surgical Pathology Unit, Department of Medicine (DIMED), University of Padua, via Gabelli 61, 35121 Padua, Italy
| | - Paola Biason
- 2Department of Oncology, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Mariangela Balistreri
- 1Surgical Pathology Unit, Department of Medicine (DIMED), University of Padua, via Gabelli 61, 35121 Padua, Italy
| | - Luca Dal Santo
- 1Surgical Pathology Unit, Department of Medicine (DIMED), University of Padua, via Gabelli 61, 35121 Padua, Italy
| | - Sara Lonardi
- 2Department of Oncology, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Giada Munari
- 1Surgical Pathology Unit, Department of Medicine (DIMED), University of Padua, via Gabelli 61, 35121 Padua, Italy.,2Department of Oncology, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Fotios Loupakis
- 2Department of Oncology, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Matteo Fassan
- 1Surgical Pathology Unit, Department of Medicine (DIMED), University of Padua, via Gabelli 61, 35121 Padua, Italy
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7
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Peluso G, Incollingo P, Calogero A, Tammaro V, Rupealta N, Chiacchio G, Sandoval Sotelo ML, Minieri G, Pisani A, Riccio E, Sabbatini M, Bracale UM, Dodaro CA, Carlomagno N. Current Tissue Molecular Markers in Colorectal Cancer: A Literature Review. BIOMED RESEARCH INTERNATIONAL 2017; 2017:2605628. [PMID: 29214162 PMCID: PMC5682052 DOI: 10.1155/2017/2605628] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 09/18/2017] [Accepted: 10/03/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) is one of the most spread neoplasia types all around the world, especially in western areas. It evolves from precancerous lesions and adenomatous polyps, through successive genetic and epigenetic mutations. Numerous risk factors intervene in its development and they are either environmental or genetic. AIM OF THE REVIEW Alongside common screening techniques, such as fecal screening tests, endoscopic evaluation, and CT-colonography, we have identified the most important and useful biomarkers and we have analyzed their role in the diagnosis, prevention, and prognosis of CRC. CONCLUSION Biomarkers can become an important tool in the diagnostic and therapeutic process for CRC. But further studies are needed to identify a noninvasive, cost-effective, and highly sensible and specific screening test for their detection and to standardize their use in clinical practice.
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Affiliation(s)
- Gaia Peluso
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Paola Incollingo
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Armando Calogero
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Vincenzo Tammaro
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Niccolò Rupealta
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Gaetano Chiacchio
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Maria Laura Sandoval Sotelo
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Gianluca Minieri
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Antonio Pisani
- Department of Public Health, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Eleonora Riccio
- Department of Public Health, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Massimo Sabbatini
- Department of Public Health, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Umberto Marcello Bracale
- Department of Public Health, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Concetta Anna Dodaro
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Nicola Carlomagno
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
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