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Yadav R, El Kossi M, Belal D, Sharma A, Halawa A. Post-transplant malignancy: Focusing on virus-associated etiologies, pathogenesis, evidence-based management algorithms, present status of adoptive immunotherapy and future directions. World J Meta-Anal 2023; 11:317-339. [DOI: 10.13105/wjma.v11.i7.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/23/2023] [Accepted: 10/08/2023] [Indexed: 12/14/2023] Open
Abstract
Modern immunosuppression has led to a decrease in rejection rates and improved survival rates after solid organ transplantation. Increasing the potency of immunosuppression promotes post-transplant viral infections and associated cancers by impairing immune response against viruses and cancer immunoediting. This review reflects the magnitude, etiology and immunological characteristics of various virus-related post-transplant malignancies, emphasizing the need for future research. A multidisciplinary and strategic approach may serve best but overall literature evidence targeting it is sparse. However, the authors attempted to provide a more detailed update of the literature consensus for the prevention, diagnosis, management and surveillance of post-transplant viral infections and associated malignancies, with a focus on the current role of adoptive immunotherapy and the way forward. In order to achieve long-term patient and graft survival as well as superior post-transplant outcomes, collaborative research on holistic care of organ recipients is imperative.
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Affiliation(s)
- Rahul Yadav
- Department of Urology, Kidney Transplant and Robotic Uro-oncology, Tender Palm Super Speciality Hospital, Lucknow 226010, Uttar Pradesh, India
- Department of Urology and Kidney Transplant, Charak Hospital and Research Centre, Lucknow 226003, Uttar Pradesh, India
| | - Mohsen El Kossi
- Department of Nephrology, Doncaster Royal Infirmary, Doncaster DN2 5LT, United Kingdom
| | - Dawlat Belal
- Department of Nephrology and Medicine, Kasr El-Ainy School of Medicine, Cairo University, Cairo 11562, Egypt
| | - Ajay Sharma
- Department of Transplant Surgery, Royal Liverpool University Hospitals, Liverpool L7 8XP, United Kingdom
| | - Ahmed Halawa
- Department of Transplantation, Sheffield Teaching Hospitals, Sheffield S57AU, United Kingdom
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Scattered Violaceous Papules on the Trunk of an Adult Female: Answer. Am J Dermatopathol 2022; 44:230-231. [PMID: 35171887 DOI: 10.1097/dad.0000000000002127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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3
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Turshudzhyan A. Post-renal transplant malignancies: Opportunities for prevention and early screening. Cancer Treat Res Commun 2020; 26:100283. [PMID: 33338850 DOI: 10.1016/j.ctarc.2020.100283] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 11/18/2020] [Accepted: 12/08/2020] [Indexed: 12/14/2022]
Abstract
GOAL OF THE REVIEW While transplant recipients are aware of increased malignancy risk, there is little consensus on the preventative measures. The goal of this review is to bring available preventative measures to light and prompt more research to be done with ultimate goal of developing an individualized prevention plan for each patient based on risk factors and available screening tools. INTRODUCTION Transplant surgery offers patients with end-stage renal disease a longer life expectancy with help of immunosuppressive therapies. Nonetheless, life-long immunosuppression comes at a cost of post-renal transplant malignancies, which have become the leading cause of morbidity in this patient group. DISCUSSION Post-renal transplant cancers can develop through either de novo, by donor-related transmission, or recurrence of recipient's pre-transplant cancer. While immunosuppressive therapy is considered to be the leading cause, weakened immunosurveillance of neoplastic cells and inadequate immune response against oncogenic viruses also plays an important role. The most common cancers seen in renal transplant patients are skin cancers and post-transplant lymphoproliferative disorder (PTLD). Risk factors for skin cancers have are ultraviolet light, human papilloma virus infection, and use of cyclosporin and azathioprine. Numerous viral infections have been associated with transplant-related malignancies post-transplant. CONCLUSION While lowering of immunosuppressive therapy remains the treatment of choice, it may lead to graft failure. Given some of the presented malignancies have modifiable risk factors and options for screening, clinical outcomes can be improved. Limiting skin exposure, dermatologic screening, and prophylactic retinoids can help lower the incidence rate of skin malignancy. Endoscopic screening for renal transplant patients can help identify gastric adenocarcinoma early and improve survival rates. Some of the post-transplant malignancies have been responsive to anti-viral treatment.
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Affiliation(s)
- Alla Turshudzhyan
- University of Connecticut, Internal Medicine, 263 Farmington Avenue, Farmington, CT 06030-1235.
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4
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Roberts SJ, McNally B, Rosser JA, Willard N, Golitz L, Wisell J. Diverse clinical and histopathologic features of cutaneous post-transplant lymphoproliferative disorders: A presentation of two cases. Australas J Dermatol 2019; 60:e317-e321. [PMID: 31144292 DOI: 10.1111/ajd.13076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/24/2019] [Indexed: 11/28/2022]
Abstract
Heterogeneous lymphoproliferative disorders occurring in the post-transplant setting are considered together as post-transplant lymphoproliferative disorders and can rarely present as primary cutaneous lesions. These disorders are often Epstein-Barr virus-driven and in some cases need only be treated with reduction in immune suppressive medications. We present two cases of monomorphic post-transplant lymphoproliferative disorder, a plasmablastic lymphoma and a diffuse large B-cell lymphoma, and summarise common reported clinical and histopathological features.
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Affiliation(s)
- Sammie J Roberts
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Brandon McNally
- Department of Dermatology, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Julie A Rosser
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Nicholas Willard
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Loren Golitz
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Joshua Wisell
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Lin L, Zhang X, Dong M, Li L, Wang X, Zhang L, Fu X, Sun Z, Wu J, Li Z, Chang Y, Wang Y, Zhou Z, Zhang M, Chen Q. Human immunodeficiency virus-negative plasmablastic lymphoma: A case report and literature review. Medicine (Baltimore) 2017; 96:e6171. [PMID: 28207555 PMCID: PMC5319544 DOI: 10.1097/md.0000000000006171] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Plasmablastic lymphoma (PBL) is a rare subtype of human immunodeficiency virus (HIV)-related non-Hodgkin's lymphoma that predominantly manifests in the oral cavity. PATIENT CONCERNS Three cases of HIV-negative PBL were reported. DIAGNOSES HIV-negative PBL INTERVENTIONS:: The patient had undergone chemotherapy. OUTCOMES Clinical outcomes were very poor in Cases 1 and 3; Case 2, whose diagnosis suggested no bone marrow involvement, is still alive. LESSONS SUBSECTIONS These cases served to broaden the reported clinical spectrum of HIV-negative PBL. Clinicians and pathologists need to be familiar with lymphoma in the identified extra-oral PBL variation and there levant differential diagnosis procedures for this particular disease.
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Affiliation(s)
- Li Lin
- Department of oncology, Institute of Clinical Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou Henan
- Department of Medical Oncology, Fujian Provincial Hospital, Fuzhou, China
| | - Xudong Zhang
- Department of oncology, Institute of Clinical Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou Henan
| | - Meng Dong
- Department of oncology, Institute of Clinical Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou Henan
| | - Ling Li
- Department of oncology, Institute of Clinical Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou Henan
| | - Xinhua Wang
- Department of oncology, Institute of Clinical Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou Henan
| | - Lei Zhang
- Department of oncology, Institute of Clinical Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou Henan
| | - Xiaorui Fu
- Department of oncology, Institute of Clinical Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou Henan
| | - Zhenchang Sun
- Department of oncology, Institute of Clinical Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou Henan
| | - Jingjing Wu
- Department of oncology, Institute of Clinical Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou Henan
| | - Zhaoming Li
- Department of oncology, Institute of Clinical Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou Henan
| | - Yu Chang
- Department of oncology, Institute of Clinical Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou Henan
| | - Yingjun Wang
- Department of oncology, Institute of Clinical Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou Henan
| | - Zhiyuan Zhou
- Department of oncology, Institute of Clinical Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou Henan
| | - Mingzhi Zhang
- Department of oncology, Institute of Clinical Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou Henan
| | - Qingjiang Chen
- Department of oncology, Institute of Clinical Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou Henan
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Abstract
This article will focus on the cutaneous lymphoproliferative disorders associated with EBV, with an emphasis on the upcoming changes in the revised 4th Edition of the WHO classification of tumors of the hematopoietic system, many of which deal with cutaneous disorders derived from NK-cells or T-cells. Extranodal NK/T-cell lymphoma usually presents in the upper aerodigestive tract, but can involve the skin secondarily. EBV-associated T- and NK-cell lymphoproliferative disorders (LPD) in the pediatric age group include the systemic diseases, chronic active EBV infection (CAEBV) and systemic EBV+ T-cell lymphoma of childhood. Hydroa vacciniforme (HV)-like LPD is a primarily cutaneous form of CAEBV and encompasses the lesions previously referred to as HV and HV-like lymphoma (HVLL). All the T/NK-cell-EBV-associated diseases occur with higher frequency in Asians, and indigenous populations from Central and South America and Mexico. Among the B-cell EBV-associated LPD two major changes have been introduced in the WHO. The previously designated EBV-positive diffuse large B-cell lymphoma (EBV-DLBCL) of the elderly, has been changed to EBV-DLBCL with 'not otherwise specified' as a modifier (NOS). A new addition to the WHO system is the more recently identified EBV+ mucocutaneous ulcer, which involves skin and mucosal-associated sites.
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Affiliation(s)
- Alejandro A Gru
- Pathology & Dermatology, Hematopathology and Dermatopathology Sections, University of Virginia, Charlottesville, VA, USA.
| | - Elaine S Jaffe
- Hematopathology, National Cancer Institute (NCI), Bethesda, MD, USA
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7
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Carroll M, Biswas N, Wheller L, Shepherd V, Strutton GM. Uncommon cutaneous lymphoproliferative disorders in two patients with rheumatoid arthritis. Australas J Dermatol 2016; 58:e101-e104. [DOI: 10.1111/ajd.12479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/16/2016] [Indexed: 12/31/2022]
Affiliation(s)
- Melissa Carroll
- Department of Dermatology; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Neela Biswas
- Department of Dermatology; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Laura Wheller
- Department of Dermatology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Victoria Shepherd
- Department of Dermatology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Geoffrey M Strutton
- Pathology Queensland; Princess Alexandra Hospital; Brisbane Queensland Australia
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9
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Kempf W, Kazakov DV, Belousova IE, Mitteldorf C, Kerl K. Paediatric cutaneous lymphomas: a review and comparison with adult counterparts. J Eur Acad Dermatol Venereol 2015; 29:1696-709. [PMID: 25715748 DOI: 10.1111/jdv.13044] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 01/16/2015] [Indexed: 11/30/2022]
Abstract
Primary cutaneous lymphomas (CL) in children is rare. Only a few studies focused specifically on paediatric CL and therefore little is known whether primary CL in children are similar to or different from their adult counterparts with respect to the clinicopathological presentation, behaviour and prognosis. An extensive literature search using PubMed/MEDLINE from January 1995 through July 2014 was undertaken for articles reporting cases of paediatric CL. In addition, we identified 31 children with CL in our institutions. Mycosis fungoides and lymphomatoid papulosis are the two most prevalent lymphoma forms in children. A few entities of cutaneous lymphomas such as cutaneous diffuse large B-cell lymphoma leg type, and Sézary syndrome have not been reported so far in children. Other lymphoma entities such as hydroa vacciniforme-like lymphoma are mostly seen in certain geographic areas (Asia, Central and South America). In the paediatric population, low-malignant indolent forms such as primary cutaneous marginal zone lymphoma and primary cutaneous follicle centre lymphoma are very rare, whereas the more aggressive forms of B-cell lymphomas, precursor lymphoblastic lymphomas, and blastic plasmacytoid dendritic cell neoplasm are the most common forms in children, mostly involving the skin secondarily. Most paediatric lymphomas have similar clinicopathological features and course as their adults counterparts, particularly in the group of cutaneous T-cell lymphomas. The spectrum of cutaneous B-cell lymphomas in children significantly differs from the one in adults. Diagnostic work-up and treatment of paediatric patients with lymphomas are best achieved in close collaboration with paediatric haematopathologists and oncologists.
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Affiliation(s)
- W Kempf
- Kempf und Pfaltz, Histologische Diagnostik, Zürich, Switzerland.,Department of Dermatology, University Hospital Zürich, Zürich, Switzerland
| | - D V Kazakov
- Kempf und Pfaltz, Histologische Diagnostik, Zürich, Switzerland.,Department of Pathology, Medical Faculty in Pilsen, Charles University in Prague, Prague, Czech Republic
| | - I E Belousova
- Department of Dermatology, Medical Military Academy, Saint-Petersburg, Russia
| | - C Mitteldorf
- Department of Dermatology, HELIOS-Klinikum, Hildesheim, Germany
| | - K Kerl
- Department of Dermatology, University Hospital Zürich, Zürich, Switzerland
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10
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Human immunodeficiency virus-negative plasmablastic lymphoma: a comprehensive analysis of 114 cases. Oncol Rep 2015; 33:1615-20. [PMID: 25695332 PMCID: PMC4358079 DOI: 10.3892/or.2015.3808] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/22/2015] [Indexed: 12/29/2022] Open
Abstract
Human immunodeficiency virus-negative plasmablastic lymphoma (PBL) is an extremely rare entity. Its clinicopathological features, optimal treatment strategy and prognostic factors remain obsure. An extensive search was performed in the English language literature within the Pubmed database using the key words: ‘plasmablastic lymphoma and human immunodeficiency virus-negative or immunocompetent’. Data from 114 patients from 52 articles were analyzed. The mean patient age at diagnosis was 58.90 years (range, 2–86). HIV-negative PBL showed a predilection for elderly individuals (patients older than 60 years, 56.14%) and affected more males than females (M:F, 2.29:1). Ann Arbor stage IV patients accounted for 39.22% while bone marrow involvement was less frequent (12.79%). The Ki-67 index was high with a mean expression of 83%. Epstein-Barr virus (EBV) infection was common being positive in 58.70% of the patients while herpesvirus-8 (HHV-8) infection was rare being positive in only 7.55% of the patients. Immunosuppression was noted in 28.16% of patients. The median overall survival (OS) was 19 months. The 1- and 2-year survival rates were 52.3 and 45.3%, respectively. Age, gender and primary site showed no strong relationship with OS while Immunosuppression, Ann Arbor stage IV and EBV negativity were able to predict a poorer OS. Either complete remission (CR) or partial remission (PR) was superior to the refractory group in OS (P<0.0001 and P=0.0066, respectively). For stage I patients, the application of radiotherapy did not improve the OS. In conclusion, HIV-negative PBL is a distinct entity likely occurring in elderly and immunosuppressed individuals. Immunosuppression status, Ann Arbor stage IV, EBV negativity and refractory to treatment are poor prognostic factors of OS in HIV-negative PBL.
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Tavares MDL, Magalhães TC, de Moraes FMB, Piñeiro-Maceira J, Ramos-e-Silva M. Plasmablastic lymphoma: a rare and exuberant cutaneous emergence in an immunocompetent patient. Int J Dermatol 2014; 54:e175-8. [DOI: 10.1111/ijd.12705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mara D. L. Tavares
- Sector of Dermatology; University Hospital and School of Medicine; Federal University of Rio de Janeiro; Rio de Janeiro RJ Brazil
| | - Taíssa C. Magalhães
- Sector of Dermatology; University Hospital and School of Medicine; Federal University of Rio de Janeiro; Rio de Janeiro RJ Brazil
| | - Fernando M. B. de Moraes
- Sector of Pathology; University Hospital and School of Medicine; Federal University of Rio de Janeiro; Rio de Janeiro RJ Brazil
| | - Juan Piñeiro-Maceira
- Sector of Pathology; University Hospital and School of Medicine; Federal University of Rio de Janeiro; Rio de Janeiro RJ Brazil
| | - Marcia Ramos-e-Silva
- Sector of Dermatology; University Hospital and School of Medicine; Federal University of Rio de Janeiro; Rio de Janeiro RJ Brazil
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Horna P, Hamill JR, Sokol L, Glass LF. Primary cutaneous plasmablastic lymphoma in an immunocompetent patient. J Am Acad Dermatol 2013; 69:e274-e276. [PMID: 24124865 DOI: 10.1016/j.jaad.2013.06.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 06/06/2013] [Accepted: 06/09/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Pedro Horna
- Department of Hematopathology and Laboratory Medicine, H. Lee Moffitt Cancer Center, Tampa, Florida.
| | | | - Lubomir Sokol
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - L Frank Glass
- Department of Dermatology, H. Lee Moffitt Cancer Center, Tampa, Florida
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13
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Tiong IS, Strauss M, Lau MBY, Chiruka S. Cutaneous plasmablastic lymphoma in an immunocompetent patient with long-term pyrimethamine use for essential thrombocythemia: a case report and literature review. Case Rep Hematol 2013; 2013:541783. [PMID: 23476834 PMCID: PMC3580916 DOI: 10.1155/2013/541783] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 01/10/2013] [Indexed: 11/24/2022] Open
Abstract
We report a case of Epstein-Barr-virus-(EBV-) positive primary cutaneous plasmablastic lymphoma in a human-immunodeficiency-virus-(HIV-) negative, immunocompetent 62-year-old female patient. We postulate that her lymphoma development is due to the longstanding use of pyrimethamine for essential thrombocythemia. This has never been described in the literature.
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Affiliation(s)
- Ing Soo Tiong
- Southern Blood and Cancer Service, Dunedin Hospital, Private Bag 1921, Dunedin 9054, New Zealand
| | - Magreet Strauss
- Division of Haematology, Southern Community Laboratories, Dunedin 9016, New Zealand
| | - Michael B. Y. Lau
- Division of Haematology, Southern Community Laboratories, Dunedin 9016, New Zealand
| | - Shingirai Chiruka
- Southern Blood and Cancer Service, Dunedin Hospital, Private Bag 1921, Dunedin 9054, New Zealand
- Division of Haematology, Southern Community Laboratories, Dunedin 9016, New Zealand
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Benítez CE, Rey P, Zoroquiaín P, Martínez J, Ramírez P, Arrese M, Pérez-Ayuso RM, Valbuena JR. Early-Onset EBV-Positive Post-transplant Plasmablastic Lymphoma Arising in a Liver Allograft. Int J Surg Pathol 2012; 21:404-10. [DOI: 10.1177/1066896912467371] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report a case of a 51-year-old man who received a cadaveric liver allograft for autoimmune and hepatopulmonary syndrome. The patient was admitted with symptoms of progressive vomiting and diarrhea 16 months after transplantation. Laboratory studies showed abnormal liver functions, and abdominal magnetic resonance imaging (MRI) showed a 76-mm heterogeneous mass in the liver. Histological examination showed a malignant lymphoid neoplasm with plasmablastic features. Plasmablastic lymphoma (PL) is rare in the post-transplantation period. To the best of our knowledge, only 25 well-documented cases of posttransplant PL, including ours, have been described.
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Affiliation(s)
- Carlos E. Benítez
- Departments of Gastroenterology, Facultad de Medicina Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Paula Rey
- Departments of Gastroenterology, Facultad de Medicina Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo Zoroquiaín
- Anatomic Pathology, Facultad de Medicina Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | - Jorge Martínez
- Hepatobiliary Surgery, Facultad de Medicina Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | - Pablo Ramírez
- Hematology-Oncology, Facultad de Medicina Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | - Marco Arrese
- Departments of Gastroenterology, Facultad de Medicina Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rosa María Pérez-Ayuso
- Departments of Gastroenterology, Facultad de Medicina Pontificia Universidad Católica de Chile, Santiago, Chile
| | - José R. Valbuena
- Anatomic Pathology, Facultad de Medicina Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
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