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Castaneda CA, Castillo M, Bernabe LA, Sanchez J, Fassan M, Tello K, Wistuba II, Chavez Passiuri I, Ruiz E, Sanchez J, Barreda F, Valdivia D, Bazan Y, Abad-Licham M, Mengoa C, Fuentes H, Montenegro P, Poquioma E, Alatrista R, Flores CJ, Taxa L. Association between Helicobacter pylori infection, mismatch repair, HER2 and tumor-infiltrating lymphocytes in gastric cancer. World J Gastrointest Oncol 2024; 16:2487-2503. [PMID: 38994161 PMCID: PMC11236231 DOI: 10.4251/wjgo.v16.i6.2487] [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: 02/07/2024] [Revised: 04/04/2024] [Accepted: 04/11/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND The influence of Helicobacter-pylori (H. pylori) infection and the characteristics of gastric cancer (GC) on tumor-infiltrating lymphocyte (TIL) levels has not been extensively studied. Analysis of infiltrating-immune-cell subtypes as well as survival is necessary to obtain comprehensive information. AIM To determine the rates of deficient mismatch-repair (dMMR), HER2-status and H. pylori infection and their association with TIL levels in GC. METHODS Samples from 503 resected GC tumors were included and TIL levels were evaluated following the international-TILs-working-group recommendations with assessment of the intratumoral (IT), stromal (ST) and invasive-border (IB) compartments. The density of CD3, CD8 and CD163 immune cells, and dMMR and HER2-status were determined by immunohistochemistry (IHC). H. pylori infection was evaluated by routine histology and quantitative PCR (qPCR) in a subset of samples. RESULTS dMMR was found in 34.4%, HER2+ in 5% and H. pylori-positive in 55.7% of samples. High IT-TIL was associated with grade-3 (P = 0.038), while ST-TIL with grade-1 (P < 0.001), intestinal-histology (P < 0.001) and no-recurrence (P = 0.003). dMMR was associated with high TIL levels in the ST (P = 0.019) and IB (P = 0.01) compartments, and ST-CD3 (P = 0.049) and ST-CD8 (P = 0.05) densities. HER2- was associated with high IT-CD8 (P = 0.009). H. pylori-negative was associated with high IT-TIL levels (P = 0.009) when assessed by routine-histology, and with high TIL levels in the 3 compartments (P = 0.002-0.047) and CD8 density in the IT and ST compartments (P = 0.001) when assessed by qPCR. A longer overall survival was associated with low IT-CD163 (P = 0.003) and CD8/CD3 (P = 0.001 in IT and P = 0.002 in ST) and high IT-CD3 (P = 0.021), ST-CD3 (P = 0.003) and CD3/CD163 (P = 0.002). CONCLUSION TIL levels were related to dMMR and H. pylori-negativity. Low CD8/CD3 and high CD163/CD3 were associated with lower recurrence and longer survival.
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Affiliation(s)
- Carlos A Castaneda
- Faculty of Health Sciences, Universidad Cientifica del Sur, Lima 15038, Peru
- GECO PERU, Grupo de Estudios Clinicos Oncologicos del Peru, Lima 15038, Peru
| | - Miluska Castillo
- Department of Research, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Luis A Bernabe
- Department of Research, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Joselyn Sanchez
- Department of Research, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
- Faculty of Human Medicine, Universidad Ricardo Palma, Lima 15039, Peru
| | - Matteo Fassan
- Department of Medicine, Surgical Pathology & Cytopathology Unit, University of Padua, Padua 35121, Italy
| | - Katherine Tello
- Department of Research, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Ignacio Ivan Wistuba
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Ivan Chavez Passiuri
- Department of Abdominal Surgery, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Eloy Ruiz
- Department of Abdominal Surgery, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Juvenal Sanchez
- Department of Pathology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Fernando Barreda
- Department of Medical Specialties, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Daniel Valdivia
- Department of Medical Specialties, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Yaqueline Bazan
- Department of Pathology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Milagros Abad-Licham
- Department of Pathology, Instituto Regional de Enfermedades Neoplasicas del Norte, Trujillo 13001, Peru
- Faculty of Human Medicine, Universidad Privada Antenor Orrego, Trujillo 13008, Peru
| | - Claudio Mengoa
- Department of Surgery, Instituto Regional de Enfermedades Neoplasicas del Sur, Arequipa 04002, Peru
| | - Hugo Fuentes
- Department of Medical Oncology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Paola Montenegro
- Department of Medical Oncology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Ebert Poquioma
- Department of Epidemiology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Raul Alatrista
- Department of Research, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Claudio J Flores
- Unidad de Investigación Básica y Traslacional, Oncosalud-AUNA, Lima 15038, Peru
| | - Luis Taxa
- Department of Pathology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
- Faculty of Medicine, Universidad San Martin de Porres, Lima 15008, Peru
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Castaneda CA, Castillo M, Bernabe LA, Sanchez J, Fassan M, Tello K, Wistuba II, Chavez Passiuri I, Ruiz E, Sanchez J, Barreda F, Valdivia D, Bazan Y, Abad-Licham M, Mengoa C, Fuentes H, Montenegro P, Poquioma E, Alatrista R, Flores CJ, Taxa L. Association between Helicobacter pylori infection, mismatch repair, HER2 and tumor-infiltrating lymphocytes in gastric cancer. World J Gastrointest Oncol 2024; 16:2475-2491. [DOI: 10.4251/wjgo.v16.i6.2475] [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: 02/07/2024] [Revised: 04/04/2024] [Accepted: 04/11/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND The influence of Helicobacter-pylori (H. pylori) infection and the characteristics of gastric cancer (GC) on tumor-infiltrating lymphocyte (TIL) levels has not been extensively studied. Analysis of infiltrating-immune-cell subtypes as well as survival is necessary to obtain comprehensive information.
AIM To determine the rates of deficient mismatch-repair (dMMR), HER2-status and H. pylori infection and their association with TIL levels in GC.
METHODS Samples from 503 resected GC tumors were included and TIL levels were evaluated following the international-TILs-working-group recommendations with assessment of the intratumoral (IT), stromal (ST) and invasive-border (IB) compartments. The density of CD3, CD8 and CD163 immune cells, and dMMR and HER2-status were determined by immunohistochemistry (IHC). H. pylori infection was evaluated by routine histology and quantitative PCR (qPCR) in a subset of samples.
RESULTS dMMR was found in 34.4%, HER2+ in 5% and H. pylori-positive in 55.7% of samples. High IT-TIL was associated with grade-3 (P = 0.038), while ST-TIL with grade-1 (P < 0.001), intestinal-histology (P < 0.001) and no-recurrence (P = 0.003). dMMR was associated with high TIL levels in the ST (P = 0.019) and IB (P = 0.01) compartments, and ST-CD3 (P = 0.049) and ST-CD8 (P = 0.05) densities. HER2- was associated with high IT-CD8 (P = 0.009). H. pylori-negative was associated with high IT-TIL levels (P = 0.009) when assessed by routine-histology, and with high TIL levels in the 3 compartments (P = 0.002-0.047) and CD8 density in the IT and ST compartments (P = 0.001) when assessed by qPCR. A longer overall survival was associated with low IT-CD163 (P = 0.003) and CD8/CD3 (P = 0.001 in IT and P = 0.002 in ST) and high IT-CD3 (P = 0.021), ST-CD3 (P = 0.003) and CD3/CD163 (P = 0.002).
CONCLUSION TIL levels were related to dMMR and H. pylori-negativity. Low CD8/CD3 and high CD163/CD3 were associated with lower recurrence and longer survival.
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Affiliation(s)
- Carlos A Castaneda
- Faculty of Health Sciences, Universidad Cientifica del Sur, Lima 15038, Peru
- GECO PERU, Grupo de Estudios Clinicos Oncologicos del Peru, Lima 15038, Peru
| | - Miluska Castillo
- Department of Research, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Luis A Bernabe
- Department of Research, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Joselyn Sanchez
- Department of Research, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
- Faculty of Human Medicine, Universidad Ricardo Palma, Lima 15039, Peru
| | - Matteo Fassan
- Department of Medicine, Surgical Pathology & Cytopathology Unit, University of Padua, Padua 35121, Italy
| | - Katherine Tello
- Department of Research, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Ignacio Ivan Wistuba
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Ivan Chavez Passiuri
- Department of Abdominal Surgery, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Eloy Ruiz
- Department of Abdominal Surgery, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Juvenal Sanchez
- Department of Pathology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Fernando Barreda
- Department of Medical Specialties, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Daniel Valdivia
- Department of Medical Specialties, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Yaqueline Bazan
- Department of Pathology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Milagros Abad-Licham
- Department of Pathology, Instituto Regional de Enfermedades Neoplasicas del Norte, Trujillo 13001, Peru
- Faculty of Human Medicine, Universidad Privada Antenor Orrego, Trujillo 13008, Peru
| | - Claudio Mengoa
- Department of Surgery, Instituto Regional de Enfermedades Neoplasicas del Sur, Arequipa 04002, Peru
| | - Hugo Fuentes
- Department of Medical Oncology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Paola Montenegro
- Department of Medical Oncology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Ebert Poquioma
- Department of Epidemiology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Raul Alatrista
- Department of Research, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Claudio J Flores
- Unidad de Investigación Básica y Traslacional, Oncosalud-AUNA, Lima 15038, Peru
| | - Luis Taxa
- Department of Pathology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
- Faculty of Medicine, Universidad San Martin de Porres, Lima 15008, Peru
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Li P, Li Z, Linghu E, Ji J. Chinese national clinical practice guidelines on the prevention, diagnosis, and treatment of early gastric cancer. Chin Med J (Engl) 2024; 137:887-908. [PMID: 38515297 PMCID: PMC11046028 DOI: 10.1097/cm9.0000000000003101] [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: 04/17/2023] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Gastric cancer is one of the most common malignant tumors in the digestive system in China. Few comprehensive practice guidelines for early gastric cancer in China are currently available. Therefore, we created the Chinese national clinical practice guideline for the prevention, diagnosis, and treatment of early gastric cancer. METHODS This clinical practice guideline (CPG) was developed in accordance with the World Health Organization's recommended process and with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) in assessing evidence quality. We used the Evidence to Decision framework to formulate clinical recommendations to minimize bias and increase transparency in the CPG development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guidelines to ensure completeness and transparency of the CPG. RESULTS This CPG contains 40 recommendations regarding the prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer based on available clinical studies and guidelines. We provide recommendations for the timing of Helicobacter pylori eradication, screening populations for early gastric cancer, indications for endoscopic resection and surgical gastrectomy, follow-up interval after treatment, and other recommendations. CONCLUSIONS This CPG can lead to optimum care for patients and populations by providing up-to-date medical information. We intend this CPG for widespread adoption to increase the standard of prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer; thereby, contributing to improving national health care and patient quality of life.
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Affiliation(s)
- Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing 100050, China
| | - Ziyu Li
- Department of Gastrointestinal Surgery, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Enqiang Linghu
- Department of Gastroenterology and Hepatology, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing 100853, China
| | - Jiafu Ji
- Department of Gastrointestinal Surgery, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing 100142, China
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Shen Y, Chen JX, Li M, Xiang Z, Wu J, Wang YJ. Role of tumor-associated macrophages in common digestive system malignant tumors. World J Gastrointest Oncol 2023; 15:596-616. [PMID: 37123058 PMCID: PMC10134211 DOI: 10.4251/wjgo.v15.i4.596] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/12/2023] [Accepted: 03/30/2023] [Indexed: 04/12/2023] Open
Abstract
Many digestive system malignant tumors are characterized by high incidence and mortality rate. Increasing evidence has revealed that the tumor microenvironment (TME) is involved in cancer initiation and tumor progression. Tumor-associated macrophages (TAMs) are a predominant constituent of the TME, and participate in the regulation of various biological behaviors and influence the prognosis of digestive system cancer. TAMs can be mainly classified into the antitumor M1 phenotype and protumor M2 phenotype. The latter especially are crucial drivers of tumor invasion, growth, angiogenesis, metastasis, immunosuppression, and resistance to therapy. TAMs are of importance in the occurrence, development, diagnosis, prognosis, and treatment of common digestive system malignant tumors. In this review, we summarize the role of TAMs in common digestive system malignant tumors, including esophageal, gastric, colorectal, pancreatic and liver cancers. How TAMs promote the development of tumors, and how they act as potential therapeutic targets and their clinical applications are also described.
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Affiliation(s)
- Yue Shen
- Department of Dermatology, Suzhou Municipal Hospital, Suzhou 215008, Jiangsu Province, China
| | - Jia-Xi Chen
- School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Ming Li
- Department of Pathology, Suzhou Municipal Hospital, Suzhou 215008, Jiangsu Province, China
| | - Ze Xiang
- School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Jian Wu
- Department of Clinical Laboratory, Suzhou Municipal Hospital, Suzhou 215008, Jiangsu Province, China
| | - Yi-Jin Wang
- School of Medicine, Southern University of Science and Technology, Shenzhen 518055, Guangdong Province, China
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5
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Strategies targeting tumor immune and stromal microenvironment and their clinical relevance. Adv Drug Deliv Rev 2022; 183:114137. [PMID: 35143893 DOI: 10.1016/j.addr.2022.114137] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/23/2022] [Accepted: 02/03/2022] [Indexed: 12/13/2022]
Abstract
The critical role of tumor microenvironment (TME) in tumor initiation and development has been well-recognized after more than a century of studies. Numerous therapeutic approaches targeting TME are rapidly developed including those leveraging nanotechnology, which have been further accelerated since the emergence of immune checkpoint blockade therapies in the past decade. While there are many reviews focusing on TME remodeling therapies via drug delivery and engineering strategies in animal models, state-of-the-art evaluation of clinical development states of TME-targeted therapeutics is rarely found. Here, we illustrate opportunities for integrating nano-delivery system for the development of TME-specific therapeutic regimen, followed by a comprehensive summary of the most up to date approved or clinically evaluated therapeutics targeting cellular and extracellular components within tumor immune and stromal microenvironment, including small molecule and monoclonal antibody drugs as well as nanomedicines. In the end, we also discuss challenges and possible solutions for clinical translation of TME-targeted nanomedicines.
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M1 Polarized Tumor-Associated Macrophages (TAMs) as Promising Prognostic Signature in Stage I–II Gastric Adenocarcinomas. GASTROINTESTINAL DISORDERS 2021. [DOI: 10.3390/gidisord3040020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Tumor-associated macrophages (TAMs) may be noticed in gastric carcinomas (GC), but their clinicopathological significance has not been yet explored. From a histological review of 400 cases of tubular/papillary adenocarcinomas, 24 cases of stage I–II gastric adenocarcinomas with intraglandular and stromal TAMs were identified. Their clinicopathological features were compared with 72 pT-matched as well as stage-matched control cases of adenocarcinomas without TAMs. TAMs present in GC cases were present either in glands or in neoplastic stroma, showing an immunoreactivity for CD68 and CD80; sometimes, they were organized in mature granulomas with occasional giant cells. Therefore, the stained TAMs were reminiscent of a specific polarized macrophage M1 phenotype; however, in any case of our cohort, no M2 phenotype macrophages were documented by CD 163 and CD 204 immunostainings. Statistically, no significant differences in age, gender, tumor location, size, and lymphovascular and perineural invasion between the case group with TAMs and pT- as well as stage-matched controls were reported; furthermore, the case group showed lower frequency of lymph node metastasis (p = 0.02). In addition, a significantly different clinical course and overall survival rate were also observed in gastric adenocarcinomas with M1 TAMs (p = 0.02) in comparison to controls. These results suggest that tumor-associated M1 macrophages are related to a quite indolent growth and a better prognosis of patients with this peculiar variant of gastric adenocarcinomas.
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Hu J, Ma Y, Ma J, Yang Y, Ning Y, Zhu J, Wang P, Chen G, Liu Y. M2 Macrophage-Based Prognostic Nomogram for Gastric Cancer After Surgical Resection. Front Oncol 2021; 11:690037. [PMID: 34458140 PMCID: PMC8397443 DOI: 10.3389/fonc.2021.690037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/29/2021] [Indexed: 12/24/2022] Open
Abstract
A good prediction model is useful to accurately predict patient prognosis. Tumor-node-metastasis (TNM) staging often cannot accurately predict prognosis when used alone. Some researchers have shown that the infiltration of M2 macrophages in many tumors indicates poor prognosis. This approach has the potential to predict prognosis more accurately when used in combination with TNM staging, but there is less research in gastric cancer. A multivariate analysis demonstrated that CD163 expression, TNM staging, age, and gender were independent risk factors for overall survival. Thus, these parameters were assessed to develop the nomogram in the training data set, which was tested in the validation and whole data sets. The model showed a high degree of discrimination, calibration, and good clinical benefit in the training, validation, and whole data sets. In conclusion, we combined CD163 expression in macrophages, TNM staging, age, and gender to develop a nomogram to predict 3- and 5-year overall survivals after curative resection for gastric cancer. This model has the potential to provide further diagnostic and prognostic value for patients with gastric cancer.
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Affiliation(s)
- Jianwen Hu
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Yongchen Ma
- Endoscopy Center, Peking University First Hospital, Beijing, China
| | - Ju Ma
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Yanpeng Yang
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Yingze Ning
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Jing Zhu
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Pengyuan Wang
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Guowei Chen
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Yucun Liu
- Department of General Surgery, Peking University First Hospital, Beijing, China
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How Macrophages Become Transcriptionally Dysregulated: A Hidden Impact of Antitumor Therapy. Int J Mol Sci 2021; 22:ijms22052662. [PMID: 33800829 PMCID: PMC7961970 DOI: 10.3390/ijms22052662] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/26/2021] [Accepted: 03/01/2021] [Indexed: 12/12/2022] Open
Abstract
Tumor-associated macrophages (TAMs) are the essential components of the tumor microenvironment. TAMs originate from blood monocytes and undergo pro- or anti-inflammatory polarization during their life span within the tumor. The balance between macrophage functional populations and the efficacy of their antitumor activities rely on the transcription factors such as STAT1, NF-κB, IRF, and others. These molecular tools are of primary importance, as they contribute to the tumor adaptations and resistance to radio- and chemotherapy and can become important biomarkers for theranostics. Herein, we describe the major transcriptional mechanisms specific for TAM, as well as how radio- and chemotherapy can impact gene transcription and functionality of macrophages, and what are the consequences of the TAM-tumor cooperation.
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