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Czarnecka AM, Skoczylas J, Bartnik E, Świtaj T, Rutkowski P. Management Strategies for Adults with Locally Advanced, Unresectable or Metastatic Malignant Perivascular Epithelioid Cell Tumor (PEComa): Challenges and Solutions. Cancer Manag Res 2023; 15:615-623. [PMID: 37440783 PMCID: PMC10335286 DOI: 10.2147/cmar.s351284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
PEComa (PEC tumor; perivascular epithelioid cell tumors) is a rare group of tumors of mesenchymal origin composed of perivascular epithelioid cells (PEC) with features of melanotic and smooth muscle differentiation. In this article, we would like to present the current treatment options for this group of tumors. PEComas are classified as tumors of uncertain malignant potential because recurrences occur after radical treatment. The primary treatment is surgical resection with negative margins. Due to the different locations of the tumors, often the cooperation of multispecialty surgeons is required during the operations. In locally advanced cases, cytoreduction and HIPEC may be effective but still are an experimental treatment. For nonresectable PEComa chemotherapy, mTOR inhibitors and VEGFR inhibitors are used.
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Affiliation(s)
- Anna M Czarnecka
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Jacek Skoczylas
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Ewa Bartnik
- Institute of Genetics and Biotechnology, Faculty of Biology, University of Warsaw, Warsaw, Poland
- Institute of Biochemistry and Biophysics, Polish Academy of Sciences, Warsaw, Poland
| | - Tomasz Świtaj
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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Testa S, Bui NQ, Ganjoo KN. Systemic Treatments and Molecular Biomarkers for Perivascular Epithelioid Cell Tumors: A Single-institution Retrospective Analysis. CANCER RESEARCH COMMUNICATIONS 2023; 3:1212-1223. [PMID: 37448552 PMCID: PMC10335919 DOI: 10.1158/2767-9764.crc-23-0139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/01/2023] [Accepted: 06/06/2023] [Indexed: 07/15/2023]
Abstract
Perivascular epithelioid cell tumors (PEComa) are a large family of mesenchymal neoplasms, with variable clinical course. Evidence regarding treatment of advanced PEComas is scarce, with only one FDA-approved treatment available. The goals of this study were to provide data regarding systemic treatments for advanced PEComas and to identify biomarkers of prognostic relevance. This is a single-institution retrospective study of patients with advanced PEComas requiring systemic treatment, including malignant PEComa, angiomyolipoma (including the epithelioid variant), and lymphangioleiomyomatosis. Outcomes measured were overall survival (OS), first-line and combined progression-free survival (PFS), and tumor response. Kaplan-Meier, univariable, and multivariable Cox proportional hazards analysis were performed. A total of 29 patients were included, most with malignant PEComa (n = 17). Median OS was 204.9 months, while median PFS was 92.4 months from first-line, and 15.8 months for all lines combined. TFE3 overexpression correlated with higher risk of death (HR: 11.8, P = 0.04), and shorter median OS (P = 0.001). Chemotherapy and mTOR inhibitors showed similar OS (P = 0.84), and first-line PFS (P = 0.67). Combined PFS was similar between individual mTOR inhibitors, chemotherapy, immune checkpoint inhibitors and other treatments (P = 0.19). Different mTOR inhibitors demonstrated similar efficacy, making cost and availability important considerations when choosing a specific agent. mTOR inhibitors showed similar outcomes as chemotherapy, suggesting that these should be preferred whenever possible for patients with PEComas given the morbidity associated with chemotherapy. TFE3 overexpression highlighted a subgroup of PEComas with worse prognosis and more aggressive behavior. Significance This study examines systemic treatments for advanced PEComas, a rare group of sarcomas, and identifies molecular biomarkers of prognosis. Our results show that mTOR inhibitors have similar efficacy as chemotherapy, and that TFE3 overexpression, on IHC or FISH, correlates with a more aggressive disease course.
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Affiliation(s)
- Stefano Testa
- Department of Medicine, Stanford University, Stanford, California
- Division of Oncology, Department of Medicine, Stanford University, Stanford, California
| | - Nam Q. Bui
- Division of Oncology, Department of Medicine, Stanford University, Stanford, California
| | - Kristen N. Ganjoo
- Division of Oncology, Department of Medicine, Stanford University, Stanford, California
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Saleh JS, Whittington CP, Bresler SC, Patel RM. Mesenchymal tumours with melanocytic expression: a potential pitfall in the differential diagnosis of malignant melanoma. Pathology 2023; 55:258-268. [PMID: 36639332 DOI: 10.1016/j.pathol.2022.12.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/02/2022] [Accepted: 12/07/2022] [Indexed: 12/29/2022]
Abstract
Mesenchymal tumours with melanocytic expression can pose a diagnostic challenge because they frequently demonstrate both morphological and immunohistochemical overlap with other cutaneous melanocytic neoplasms. Therefore, they present potential pathological pitfalls that may lead to a misdiagnosis of malignant melanoma. Mesenchymal neoplasms that closely mimic melanoma include malignant melanotic nerve sheath tumour (melanotic schwannoma), epithelioid schwannoma, malignant peripheral nerve sheath, cutaneous syncytial myoepithelioma, clear cell sarcoma of soft tissue, and perivascular epithelioid cell tumour. Awareness of these melanoma mimics is necessary for establishing the correct diagnosis so that the appropriate clinical management can be rendered to the patient. This in-depth review highlights key diagnostic features and molecular genetics and also discusses the differential diagnosis and treatment of mesenchymal tumours that exhibit melanocytic expression.
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Affiliation(s)
- Jasmine S Saleh
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | | | - Scott C Bresler
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA; Department of Dermatology, University of Michigan, Ann Arbor, MI, USA
| | - Rajiv M Patel
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA; Department of Dermatology, University of Michigan, Ann Arbor, MI, USA.
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Bourgmayer A, Nannini S, Bonjean P, Kurtz JE, Malouf GG, Gantzer J. Natural History and Treatment Strategies of Advanced PEComas: A Systematic Review. Cancers (Basel) 2021; 13:cancers13205227. [PMID: 34680376 PMCID: PMC8533842 DOI: 10.3390/cancers13205227] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/15/2021] [Accepted: 10/16/2021] [Indexed: 01/11/2023] Open
Abstract
Simple Summary In this article, we review the clinical features of advanced PEComas and show the diversity of reported data among authors, emphasizing the heterogeneity of molecular characterization and treatment strategy. Based on clinical data collected from 124 case reports, metastatic disease at diagnosis and a grouped version of the Bleeker’s risk category were the only factors significantly associated with death. Due to a significant number of missing data or short follow-ups, results regarding prognostic factors should, however, be interpreted with caution. Abstract PEComas is a family of rare mesenchymal tumors. This systematic review aims to better understand the natural history of advanced PEComas. After a search on the PubMed database and main oncology meeting libraries according to the PRISMA guidelines, 88 articles reported in the English literature were included. Data on clinical and histological features, treatments and outcomes were collected. To identify risk factors, univariate and multivariate analyses were performed. Seven cohorts of patients and 124 individual patients were identified. Focusing on case reports, most patients were metastatic, and the median overall survival (OS) of the entire cohort was 60 months (95%CI 33; NA). Risk factors significantly associated with OS in the multivariate analysis were the presence of metastasis at diagnosis (HR: 2.59, 95%CI 1.06; 6.33, p = 0.036) and the grouped-Bleeker’s risk category (HR: 4.66; 95%CI 1.07; 20.19; p = 0.039). In the metastatic population, only the presence of lymph node metastasis was associated with OS (HR: 3.11; 95%CI 1.13; 8.60, p < 0.05). Due to a lack of events, it was not possible to conclude on other factors. This review of the literature highlights the heterogeneity of literature data and shows the great diversity of clinical management strategies.
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Affiliation(s)
- Agathe Bourgmayer
- Department of Medical Oncology, Strasbourg-Europe Cancer Institute (ICANS), 67033 Strasbourg, France; (A.B.); (S.N.); (J.-E.K.); (G.G.M.)
| | - Simon Nannini
- Department of Medical Oncology, Strasbourg-Europe Cancer Institute (ICANS), 67033 Strasbourg, France; (A.B.); (S.N.); (J.-E.K.); (G.G.M.)
| | - Paul Bonjean
- Department of Clinical Research and Pharmacology Innovation Unit, CHU de Saint-Etienne, Hôpital Nord, 42270 Saint-Priest en Jarez, France;
| | - Jean-Emmanuel Kurtz
- Department of Medical Oncology, Strasbourg-Europe Cancer Institute (ICANS), 67033 Strasbourg, France; (A.B.); (S.N.); (J.-E.K.); (G.G.M.)
| | - Gabriel G. Malouf
- Department of Medical Oncology, Strasbourg-Europe Cancer Institute (ICANS), 67033 Strasbourg, France; (A.B.); (S.N.); (J.-E.K.); (G.G.M.)
- Davidson Team, Department of Cancer and Functional Genomics, INSERM UMR_S1258, Institute of Genetics and Molecular and Cellular Biology, 67400 Illkirch, France
| | - Justine Gantzer
- Department of Medical Oncology, Strasbourg-Europe Cancer Institute (ICANS), 67033 Strasbourg, France; (A.B.); (S.N.); (J.-E.K.); (G.G.M.)
- Davidson Team, Department of Cancer and Functional Genomics, INSERM UMR_S1258, Institute of Genetics and Molecular and Cellular Biology, 67400 Illkirch, France
- Correspondence:
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Liapi A, Mathevet P, Herrera FG, Hastir D, Sarivalasis A. VEGFR Inhibitors for Uterine Metastatic Perivascular Epithelioid Tumors (PEComa) Resistant to mTOR Inhibitors. A Case Report and Review of Literature. Front Oncol 2021; 11:641376. [PMID: 33842348 PMCID: PMC8032946 DOI: 10.3389/fonc.2021.641376] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/19/2021] [Indexed: 12/20/2022] Open
Abstract
Uterine perivascular epithelioid cell tumors (PEComas) are rare neoplasms. PI3K/AKT/mTOR pathway upregulation is critical for their pathogenesis and is often associated with TSC1/TSC2 inactivation. Although first line mTOR inhibitors are an effective treatment, metastatic PEComas eventually progress. A 53-year-old woman presented a 4-month history of post-menopausal vaginal bleeding. Clinical and radiological examination detected a uterine mass and a single S1 bone lesion. The patient underwent a radical hysterectomy and bone biopsy. The anatomopathological evaluation concluded to an oligo-metastatic uterine PEComa. The tumor harbored a heterozygous deletion of 9q34 that contains the TSC1 gene. Concerning the primary lesion, the resection was complete and the single bone metastasis was treated with radiotherapy. Three months later, the patient presented bone, lung and subcutaneous metastatic progression. An everolimus and denosumab treatment was initiated. After 2 years of treatment, a clinically significant bone, lung and subcutaneous progression was detected. Following a literature review of the possible therapeutic options, we initiated a second line treatment by pazopanib. This treatment resulted in regression of the subcutaneous lesions and stability of lung and bone metastases. In this challenging, rare setting, our report suggests single agent, anti-angiogenic, tyrosine kinase inhibitor to be effective as second line treatment of metastatic uterine PEComa progressing on mTOR inhibitors.
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Affiliation(s)
- Aikaterini Liapi
- Département d'oncologie, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Patrice Mathevet
- Département de Gynécologie, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Fernanda G Herrera
- Département d'oncologie, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Delfyne Hastir
- Institut Universitaire de Pathologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Apostolos Sarivalasis
- Département d'oncologie, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
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Machado I, Marhuenda A, Trallero M, Caballero M, Santos J, Cruz J, Estevan R. [Hepatic epithelioid angiomyolipoma/PEComa and focal nodular hyperplasia in a patient with a previous history of cutaneous melanoma]. REVISTA ESPANOLA DE PATOLOGIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ANATOMIA PATOLOGICA Y DE LA SOCIEDAD ESPANOLA DE CITOLOGIA 2019; 52:250-255. [PMID: 31530409 DOI: 10.1016/j.patol.2018.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/06/2018] [Accepted: 05/11/2018] [Indexed: 02/07/2023]
Abstract
Hepatic perivascular epithelioid cell tumors (PEComas) are uncommon mesenchymal neoplasms. PEComas concurrent with other hepatic lesions is a very rare occurrence, with only two previously reported cases. We report a primary hepatic PEComa associated with focal nodular hyperplasia in a patient with a previous history of cutaneous melanoma. Diagnostic imaging studies suggested a hepatic adenoma and the patient underwent a segmentectomy. The tumor was mainly composed of epithelioid cells, adipose tissue and smooth muscle fibers intermixed with blood vessels. The neoplastic cells were diffusely immunoreactive for HMB-45, Melan-A and smooth muscle actin, but not for Hepatocyte, S100, MITF or BRAF. Molecular studies were negative for BRAFV600 mutation. The final diagnosis was hepatic epithelioid angiomyolipoma/PEComa. The differential diagnosis of hepatic PEComa is discussed.
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Affiliation(s)
- Isidro Machado
- Departamento de Patología, Instituto Valenciano de Oncología, Valencia, España.
| | - Ana Marhuenda
- Departamento de Radiología, Instituto Valenciano de Oncología, Valencia, España
| | - Marta Trallero
- Servicio de Cirugía, Instituto Valenciano de Oncología, Valencia, España
| | - María Caballero
- Servicio de Cirugía, Instituto Valenciano de Oncología, Valencia, España
| | - Jesús Santos
- Departamento de Radiología, Instituto Valenciano de Oncología, Valencia, España
| | - Julia Cruz
- Departamento de Patología, Instituto Valenciano de Oncología, Valencia, España
| | - Rafael Estevan
- Servicio de Cirugía, Instituto Valenciano de Oncología, Valencia, España
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Sanfilippo R, Jones RL, Blay JY, Le Cesne A, Provenzano S, Antoniou G, Mir O, Fucà G, Fumagalli E, Bertulli R, Stacchiotti S, Brahmi M, Grosso F, Dufresne A, Hindi N, Sbaraglia M, Gronchi A, Collini P, Dei Tos AP, Casali PG. Role of Chemotherapy, VEGFR Inhibitors, and mTOR Inhibitors in Advanced Perivascular Epithelioid Cell Tumors (PEComas). Clin Cancer Res 2019; 25:5295-5300. [PMID: 31217199 DOI: 10.1158/1078-0432.ccr-19-0288] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 02/27/2019] [Accepted: 06/07/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Perivascular epitheliod cell tumors (PEComas) are rare mesenchymal neoplasms for which the role of systemic treatments is not established as there are no published prospective clinical trials or sufficiently large retrospective case series. The aim of this study is to clarify the activity of conventional chemotherapy and biological agents in advanced/metastatic PEComas. EXPERIMENTAL DESIGN This was an observational, retrospective, international study that included patients with advanced/metastatic PEComa treated with systemic therapy at 5 European sarcoma reference centers and within the Italian Rare Cancer Network. Survival analyses were performed using the Kaplan-Meier method and the Cox hazards regression models. RESULTS A total of 53 patients were included. Cytotoxic chemotherapy regimens were active only in a small proportion of PEComas. Gemcitabine-based regimens [objective response rate (ORR): 20%, median progression-free survival (PFS): 3.4 months] seemed to have the same activity of anthracycline-based regimens (ORR: 13%, median PFS: 3.2 months). Antiangiogenic agents resulted in disease stabilization in some patients, with a number having density changes/tissue response on imaging, with an ORR of 8.3% and a median PFS of 5.4 months. mTOR inhibitors were the most active agents, with an ORR of 41% and a median PFS of 9 months. CONCLUSIONS Our study provides data for the selection of systemic therapy in patients with advanced/metastatic PEComa: mTOR inhibitors are the most active agents. Antiangiogenics and chemotherapy with gemcitabine-based regimens or anthracycline-based regimens are options in further line, but with a lower response rate and PFS.
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Affiliation(s)
- Roberta Sanfilippo
- Medical Oncology Unit 2, Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy.
| | - Robin L Jones
- Sarcoma Unit, Royal Marsden Hospital, London, United Kingdom
| | - Jean-Yves Blay
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
| | - Axel Le Cesne
- Department of Cancer Medicine, Gustave Roussy Cancer Campus, Villejuif, France
| | - Salvatore Provenzano
- Medical Oncology Unit 2, Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | | | - Olivier Mir
- Department of Cancer Medicine, Gustave Roussy Cancer Campus, Villejuif, France
| | - Giovanni Fucà
- Medical Oncology Unit 2, Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Elena Fumagalli
- Medical Oncology Unit 2, Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Rossella Bertulli
- Medical Oncology Unit 2, Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Silvia Stacchiotti
- Medical Oncology Unit 2, Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Mehdi Brahmi
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
| | - Federica Grosso
- Azienda Ospedaliera Nazionale SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Armelle Dufresne
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
| | - Nadia Hindi
- Medical Oncology Department, Hospital Universitario Virgen del Rocío, Sevilla, Spain.,Instituto de Biomedicina de Sevilla, IBiS/Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Marta Sbaraglia
- Department of Pathology and Molecular Genetics, Treviso General Hospital, Treviso, Italy
| | - Alessandro Gronchi
- Melanoma and Sarcoma Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Paola Collini
- Department of Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Angelo P Dei Tos
- Department of Pathology and Molecular Genetics, Treviso General Hospital, Treviso, Italy.,Department of Medicine, University of Padova School of Medicine, Padova, Italy
| | - Paolo G Casali
- Medical Oncology Unit 2, Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy.,Oncology and Haemato-Oncology Department, University of Milan, Milan, Italy
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Zhan R, Li YQ, Chen CY, Hu HY, Zhang C. Primary kidney malignant epithelioid angiomyolipoma: Two cases report and review of literature. Medicine (Baltimore) 2018; 97:e11805. [PMID: 30095646 PMCID: PMC6133394 DOI: 10.1097/md.0000000000011805] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
RATIONALE Epithelioid angiomyolipoma (EAML) is a subtype of angiomyolipoma with malignant potential. A diagnosis of malignant EAML of the kidney is based on extrarenal metastasis, and predicting early transformation is difficult. To propose criteria for indicators of malignant transformation, herein we report 2 cases and review 17 cases reported in the literature (2000-2017). PATIENT CONCERNS Tumor of the kidney was determined in 2 patients, and tissues after nephrectomy were pathologically, histologically, and immunochemically examined. DIAGNOSIS Malignant EAML. INTERVENTION The 2 present patients were treated with nephrectomy only. OUTCOMES Case 1 involved a 48-year-old woman with a 7.5-cm solid mass in the right kidney who underwent nephrectomy. CT detected a mass in the liver after 13 months, which was speculated to be metastasis from the kidney lesion. Case 2 involved a 62-year-old man with a 7-cm cystic solid mass in the left kidney who accepted nephrectomy and at 10 months post-surgery lived with no disease. Both cases presented a large tumor, atypical epithelioid cells, mitotic figures, and necrosis; tested positive for melanocytic markers (HMB45, MelanA). LESSONS The literature review of malignant EAML led to the identification of 8 malignant features: size ≥5 cm; metastasis; infiltration; necrosis; ≥50% atypical epithelioid cells; cytologic atypia; atypical mitosis; and vessel invasion. The co-existence of at least 5 of these is proposed to indicate malignant EAML. Features of our 2 new cases of primary malignant EAML of the kidney matched these criteria. Our proposal of criteria for predicting malignant feature, based on 2 new cases and 17 cases in the literature, should aid understanding and avoid misdiagnosis. Nephrectomy is currently the common treatment strategy for malignant EAML, but more effective treatment strategies are needed to provide a better prognosis for patients.
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Affiliation(s)
- Rui Zhan
- Department of Pathology, First People's Hospital of Wujiang District, Suzhou
| | - Yan-Qing Li
- Department of Pathology, First People's Hospital of Wujiang District, Suzhou
| | - Chun-Yan Chen
- Department of Pathology, Chongqing Corps Hospital of Chinese People's Armed Polices, Chongqing, P.R. China
| | - Han-Yu Hu
- Department of Pathology, Chongqing Corps Hospital of Chinese People's Armed Polices, Chongqing, P.R. China
| | - Chun Zhang
- Department of Pathology, First People's Hospital of Wujiang District, Suzhou
- Department of Pathology, Chongqing Corps Hospital of Chinese People's Armed Polices, Chongqing, P.R. China
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