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Chen G, Liu L, Tan C, Tan Q, Chen Y, An X, Liu X, Wang X. Prognostic significance of systemic immune-inflammation index in patients with nonfunction pancreatic neuroendocrine tumor undergoing surgical resection. Cancer Med 2024; 13:e7114. [PMID: 38553949 PMCID: PMC10980930 DOI: 10.1002/cam4.7114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 10/12/2023] [Accepted: 03/04/2024] [Indexed: 04/02/2024] Open
Abstract
PURPOSE The purpose of our study was to investigate the clinical significance and prognostic role of the systemic immune-inflammation index (SII) in patients who underwent surgical resection for nonfunctioning pancreatic neuroendocrine tumors (pNETs). METHODS We conducted a retrospective analysis of 364 patients with nonfunctioning pNETs. The association between the SII level and clinical parameters was investigated. The receiver operating characteristic (ROC) curve was used to calculate the optimal SII value. Cox proportional hazard analysis was performed to evaluate the prognostic factors. RESULTS Our study included 364 patients with nonfunctioning pNETs who underwent surgery. The median age was 51.0 (43.0, 59.3), and 164 (45.1%) were male. The optimal threshold of SII determined by ROC analysis was 523.95. Higher SII levels were significantly associated with older age (p = 0.001), sex (p = 0.011), tumor size (p = 0.032), and tumor grade (p = 0.002). Recurrence was observed in 70 (19.2%) patients following a median follow-up of 98 months. Univariate analysis showed that higher SII (p < 0.0001), tumor size >4 cm (p = 0.015), and G2/G3 grade (p = 0.002) were significantly associated with disease-free survival (DFS). Multivariate analysis revealed that higher SII (HR: 7.35; 95% CI: 3.44, 15.70; p < 0.0001) and G2/G3 grade (HR: 3.11; 95% CI: 1.42, 6.82; p = 0.005) remained significantly associated with tumor recurrence. Furthermore, 46 (12.6%) patients died during the follow-up. Higher SII (HR: 8.43; 95% CI: 3.19, 22.72; p < 0.0001) and G2/G3 grade (HR: 3.16; 95% CI: 1.01, 9.86; p = 0.048) were independent predictors of overall survival (OS) by multivariate analysis. CONCLUSION In conclusion, our study revealed that a higher SII level was associated with tumor-related features (larger tumor size and advanced grade) and subsequent shorter DFS and OS in patients with nonfunctioning pNETs. These results indicated that the SII could serve as an efficient prognostic biomarker for nonfunctioning pNETs.
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Affiliation(s)
- Guanhua Chen
- Division of Pancreatic Surgery, Department of General Surgery, West China HospitalSichuan UniversityChengduSichuanChina
| | - Li Liu
- Division of Pancreatic Surgery, Department of General Surgery, West China HospitalSichuan UniversityChengduSichuanChina
| | - Chunlu Tan
- Division of Pancreatic Surgery, Department of General Surgery, West China HospitalSichuan UniversityChengduSichuanChina
| | - Qingquan Tan
- Division of Pancreatic Surgery, Department of General Surgery, West China HospitalSichuan UniversityChengduSichuanChina
| | - Yonghua Chen
- Division of Pancreatic Surgery, Department of General Surgery, West China HospitalSichuan UniversityChengduSichuanChina
| | - Xiangrong An
- Department of PediatricsSouthwest Medical UniversityLuzhouSichuanChina
| | - Xubao Liu
- Division of Pancreatic Surgery, Department of General Surgery, West China HospitalSichuan UniversityChengduSichuanChina
| | - Xing Wang
- Division of Pancreatic Surgery, Department of General Surgery, West China HospitalSichuan UniversityChengduSichuanChina
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2
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Lee JH, Hong YM. The relationship between tumor-infiltrating neutrophils and clinical outcomes in patients with resectable hepatocellular carcinoma. BMC Cancer 2024; 24:327. [PMID: 38462640 DOI: 10.1186/s12885-024-12074-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 03/01/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND The impact of tumor-infiltrating neutrophils (TINs) on clinical outcomes has been reported in various cancer types, but their role in hepatocellular carcinoma (HCC) has not been fully evaluated. The aim of this study was to investigate the prognostic values for TINs in HCC patients undergoing curative resection. METHODS We assessed immune markers (CD3, CD4, CD8, CD66b) using immunohistochemistry in 115 patients who underwent curative resection for HCC. We analyzed the prognostic values for tumor-infiltrating immune cells, including neutrophils, and other clinicopathological factors. RESULTS In the Multivariate Cox analysis of overall survival (OS), alpha-fetoprotein (AFP) ≥ 100 ng/mL (hazard ratio (HR), 2.74, 95% confidence interval (CI), 1.17-6.44; P = 0.021) and Barcelona Clinic Liver Cancer (BCLC) B/C stage (HR, 3.98, 95% CI, 1.68-9.43; P = 0.020) were found to be independent poor prognostic factors in HCC patients undergoing resection. The presence of CD66b+TINs was observed in 66 (57.4%) patients. However, CD66b+TINs were not associated with recurrence-free survival and OS. CONCLUSIONS Our study identified low CD66b+TINs in resectable HCC, and CD66b+ TINs did not have a significant role for the clinical outcomes of patients undergoing curative resection. The results suggest that TINs may play a role in more advanced stages of HCC.
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Affiliation(s)
- Jung Hee Lee
- Department of Pathology, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Young Mi Hong
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.
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3
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Tang R, Xu J, Wang W, Meng Q, Shao C, Zhang Y, Lei Y, Zhang Z, Liu Y, Du Q, Sun X, Wu D, Liang C, Hua J, Zhang B, Yu X, Shi S. Targeting neoadjuvant chemotherapy-induced metabolic reprogramming in pancreatic cancer promotes anti-tumor immunity and chemo-response. Cell Rep Med 2023; 4:101234. [PMID: 37852179 PMCID: PMC10591062 DOI: 10.1016/j.xcrm.2023.101234] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 09/06/2023] [Accepted: 09/19/2023] [Indexed: 10/20/2023]
Abstract
The molecular dynamics of pancreatic ductal adenocarcinoma (PDAC) under chemotherapy remain incompletely understood. The widespread use of neoadjuvant chemotherapy (NAC) provides a unique opportunity to investigate PDAC samples post-chemotherapy. Leveraging a cohort from Fudan University Shanghai Cancer Center, encompassing PDAC samples with and without exposure to neoadjuvant albumin-bound paclitaxel and gemcitabine (AG), we have compiled data from single-cell and spatial transcriptomes, proteomes, bulk transcriptomes, and metabolomes, deepening our comprehension of the molecular changes in PDACs in response to chemotherapy. Metabolic flux analysis reveals that NAC induces a reprogramming of PDAC metabolic patterns and enhances immunogenicity. Notably, NAC leads to the downregulation of glycolysis and the upregulation of CD36. Tissue microarray analysis demonstrates that high CD36 expression is linked to poorer survival in patients receiving postoperative AG. Targeting CD36 synergistically improves the PDAC response to AG both in vitro and in vivo, including patient-derived preclinical models.
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Affiliation(s)
- Rong Tang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jin Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wei Wang
- Shanghai Pancreatic Cancer Institute, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Qingcai Meng
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Chenghao Shao
- Department of Pancreatic-Biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Yiyin Zhang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Yubin Lei
- Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, Zhejiang Province, China
| | - Zifeng Zhang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yuan Liu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Department of Endoscopy, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Qiong Du
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Department of Pharmacy, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xiangjie Sun
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Di Wu
- Shanghai Pancreatic Cancer Institute, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Chen Liang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jie Hua
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Bo Zhang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Si Shi
- Shanghai Pancreatic Cancer Institute, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China.
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4
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Sesti F, Puliani G, Feola T, Campolo F, Sciarra F, Hasenmajer V, Lenzi A, Faggiano A, Isidori AM, Venneri MA, Giannetta E. Characterization of circulating immune cells and correlation with Tie2/Angiopoietins level in well differentiated neuroendocrine gastroenteropancreatic tumors: a cross-sectional analysis. Endocrine 2023; 80:221-230. [PMID: 36509928 DOI: 10.1007/s12020-022-03257-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 11/06/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE The immune environment represents a new, but little explored, tool for understanding neuroendocrine neoplasms (NENs) behavior. An immunosuppressed microenvironment is hypothesized to promote NENs progression. A missing profiling of circulating leukocyte and peripheral blood mononuclear cells (PBMCs) subpopulations would open new perspectives in the still limited diagnostic-therapeutic management of NENs. METHODS A cross-sectional case-control pilot study was performed recruiting 30 consecutive subjects: 15 patients naïve to treatment, with histologically proven gastroenteropancreatic (GEP) neuroendocrine tumors (NETs) and 15 healthy controls, matched for age and sex. PBMCs subpopulations were studied by flow cytometry. Soluble Tie2 (sTie2), Angiopoietin-1 (Ang-1), Angiopoietin-2 (Ang-2) were evaluated by ELISA. RESULTS Immune cell profiling revealed a significant lower CD3-CD56+ natural killer (NK) cell count in NETs vs controls (p = 0.04). NK subset analysis showed a reduced relative count of CD56+CD16+ NK cells (p =0.002) in NETs vs controls. Patients with NET showed a higher percentage of CD14+CD16++ non-classical monocytes (p = 0.01), and a lower percentage of CD14+CD16+ intermediate monocytes (p = 0.04). A decrease in percentage (p = 0.004) of CD4+ T-helper lymphocytes was found in NET patients. Evaluation of cellular and serum angiopoietin pathway mediators revealed in NET patients a higher relative count of Tie2-expressing monocytes (TEMs) (p < 0.001), and high levels of Ang-1 (p = 0.003) and Ang-2 (p = 0.002). CONCLUSIONS Patients with GEP-NET presented an immunosuppressed environment characterized by a low count of cytotoxic NK cells, a high count of anti-inflammatory non-classical monocytes, and a low count of T-helper lymphocytes. Higher levels of TEMs and angiopoietins suggest a crosstalk between innate immunity and angiogenic pathways in NETs.
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Affiliation(s)
- F Sesti
- Department of Experimental Medicine Sapienza University of Rome, Rome, Italy
| | - G Puliani
- Department of Experimental Medicine Sapienza University of Rome, Rome, Italy
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - T Feola
- Department of Experimental Medicine Sapienza University of Rome, Rome, Italy
- Neuroendocrinology, Neuromed Institute, IRCCS, Pozzilli, Italy
| | - F Campolo
- Department of Experimental Medicine Sapienza University of Rome, Rome, Italy
| | - F Sciarra
- Department of Experimental Medicine Sapienza University of Rome, Rome, Italy
| | - V Hasenmajer
- Department of Experimental Medicine Sapienza University of Rome, Rome, Italy
| | - A Lenzi
- Department of Experimental Medicine Sapienza University of Rome, Rome, Italy
| | - A Faggiano
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, ENETS Center of Excellence, Sapienza University of Rome, Rome, Italy
| | - A M Isidori
- Department of Experimental Medicine Sapienza University of Rome, Rome, Italy
| | - M A Venneri
- Department of Experimental Medicine Sapienza University of Rome, Rome, Italy.
| | - E Giannetta
- Department of Experimental Medicine Sapienza University of Rome, Rome, Italy.
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5
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Zhang WH, Xu JF, Hu YH, Qin Y, Chen J, Yu XJ, Xu XW, Ji SR. The Surgical and Therapeutic Activities of Non-Functional Pancreatic Neuroendocrine Tumors at a High-Volume Institution. Cancers (Basel) 2023; 15:cancers15071955. [PMID: 37046616 PMCID: PMC10093673 DOI: 10.3390/cancers15071955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND This study aimed to summarize the surgical and therapeutic activities of non-functional pancreatic neuroendocrine tumors (NF-PanNETs) and perform survival analyses of a 15-year single-institutional cohort of NF-PanNETs. METHODS In total, 1001 patients with neuroendocrine neoplasms treated at Fudan University Shanghai Cancer Center were screened for inclusion, and 509 patients with NF-PanNETs from 2006 to 2020 were included. For time trend analyses, the 15-year study period was randomly divided into three periods. Survival analyses used the Kaplan-Meier method and Cox regression models. RESULTS The total number of resected NF-PanNETs increased over the 15-year study period, from 5 resections in 2006 to 94 resections in 2020. A significant decrease in the tumor size was observed, from a mean of 4.0 cm to 3.3 cm, and to 3.0 cm in the most recent period (p = 0.006). Minimally invasive techniques gradually increased from 3.5% to 12.9%, and finally to 46.4% in the most recent period (p < 0.001). In non-metastatic and resected tumors, the tumor size (p < 0.001), positive lymph node (p < 0.001), adjuvant treatment (p = 0.048), and tumor grade (p < 0.001) were independent prognostic factors for recurrence-free survival (RFS). The microvascular invasion (p = 0.024) and tumor grade (p = 0.013) were independent prognostic factors for overall survival (OS). A malignant transformation from NET into neuroendocrine carcinoma was observed. CONCLUSIONS An increasing number of NF-PanNETs resection and minimally invasive surgery was shown. In non-metastatic and resected tumors NF-PanNETs, tumor size, positive lymph node, adjuvant treatment, and tumor grade were independent predictors of RFS. Microvascular invasion and tumor grade were independent prognostic factors for OS.
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Affiliation(s)
- Wu-Hu Zhang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Jun-Feng Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yu-Heng Hu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yi Qin
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Jie Chen
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
- Department of Head & Neck Tumors and Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Xian-Jun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Xiao-Wu Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Shun-Rong Ji
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
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6
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Wang X, Li X, Wu Y, Hong J, Zhang M. The prognostic significance of tumor-associated neutrophils and circulating neutrophils in glioblastoma (WHO CNS5 classification). BMC Cancer 2023; 23:20. [PMID: 36609243 PMCID: PMC9817270 DOI: 10.1186/s12885-022-10492-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 12/27/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Tumor-associated neutrophils (TANs) in the tumor microenvironment are prognostic biomarkers in many malignancies. However, it is unclear whether TANs can serve as a prognostic marker for clinical outcomes in patients with glioblastoma (GBM), as classified according to World Health Organization Classification of Tumors of the Central Nervous System, fifth edition (CNS5). In the present study, we analyzed correlations of TANs and peripheral blood neutrophils prior to radiotherapy with overall survival (OS) in GBM (CNS5). METHODS RNA-seq expression profiles of patients with newly diagnosed GBM (CNS5) were extracted from The Cancer Genome Atlas (TCGA), and The Chinese Glioma Genome Atlas (CGGA). TAN infiltration was inferred using CIBERSORTx algorithm. Neutrophil counts prior to radiotherapy in newly diagnosed GBM (CNS5) were obtained from the First Affiliated Hospital of Fujian Medical University. The prognostic value of TANs and peripheral blood neutrophils before radiotherapy was investigated using Kaplan-Meier analysis and Cox proportional hazards models. The robustness of these findings was evaluated by sensitivity analysis, and E values were calculated. RESULTS A total of 146 and 173 individuals with GBM (CNS5) were identified from the TCGA and CGGA cohorts, respectively. High infiltration of TANs was of prognostic of poor OS in TCGA (HR = 1.621, 95% CI: 1.004-2.619) and CGGA (HR = 1.546, 95% CI: 1.029-2.323). Levels of peripheral blood neutrophils before radiotherapy (HR = 2.073, 95% CI: 1.077-3.990) were independently associated with poor prognosis. Sensitivity analysis determined that the E-value of high TANs infiltration was 2.140 and 2.465 in the TCGA and CGGA cohorts. CONCLUSIONS TANs and peripheral blood neutrophil levels before radiotherapy are prognostic of poor outcomes in GBM (CNS5).
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Affiliation(s)
- Xuezhen Wang
- grid.412683.a0000 0004 1758 0400Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China ,grid.412683.a0000 0004 1758 0400Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xiaoxia Li
- grid.412683.a0000 0004 1758 0400Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China ,grid.412683.a0000 0004 1758 0400Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yufan Wu
- grid.412683.a0000 0004 1758 0400Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China ,grid.412683.a0000 0004 1758 0400Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jinsheng Hong
- grid.412683.a0000 0004 1758 0400Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China ,grid.412683.a0000 0004 1758 0400Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital of Fujian Medical University, Fuzhou, China ,grid.412683.a0000 0004 1758 0400Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Mingwei Zhang
- grid.412683.a0000 0004 1758 0400Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China ,grid.412683.a0000 0004 1758 0400Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital of Fujian Medical University, Fuzhou, China ,grid.412683.a0000 0004 1758 0400Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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7
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Chen Q, Yin H, Liu S, Shoucair S, Ding N, Ji Y, Zhang J, Wang D, Kuang T, Xu X, Yu J, Wu W, Pu N, Lou W. Prognostic value of tumor-associated N1/N2 neutrophil plasticity in patients following radical resection of pancreas ductal adenocarcinoma. J Immunother Cancer 2022; 10:jitc-2022-005798. [PMID: 36600557 PMCID: PMC9730407 DOI: 10.1136/jitc-2022-005798] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND As an integral part of the tumor microenvironment (TME), tumor-associated neutrophils play a crucial role in tumor development. The objective of this study was to investigate the plasticity of tumor-associated N1 and N2 neutrophils in the TME of pancreatic ductal adenocarcinoma (PDAC), along with its impact on survival and association with immune infiltrations. METHODS The primary and validation cohorts including 90 radical resection patients from September 2012 to May 2016 and 29 radical resection patients from September 2018 to October 2019, respectively, with complete survival data, were enrolled. Immunofluorescence staining was used to identify tumor-associated N1 and N2 neutrophils, and the N1/N2 ratio was used to evaluate N1 and N2 plasticity. Thereafter, the association between tumor-associated N1/N2 neutrophil plasticity, clinical features, and immune infiltrations was investigated. RESULTS There was a significant increase in tumor-associated N2 neutrophils compared with tumor-associated N1 neutrophils. Low N1/N2 ratios were associated with the poorer differentiation of tumors, easier lymph node metastases, and a higher TNM stage. The median overall survival (OS) and recurrence-free survival (RFS) of the high tumor-associated N1 neutrophil group were significantly longer than those of the low group, while the tumor-associated N2 neutrophils played an opposite role. The multivariable analysis revealed that a high N1/N2 ratio was a significant prognostic indicator for OS and RFS. In addition, tumor-associated N1/N2 neutrophils showed an opposite correlation with tumor-infiltrating CD8+ T cells and Tregs. CONCLUSION The plasticity of tumor-associated N1/N2 neutrophils was identified as a crucial prognostic indicator that might reflect the TME and immune escape in patients with PDAC. On further investigation and validation, our findings may be used to further stratify patients with varying prognoses to optimize treatment.
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Affiliation(s)
- Qiangda Chen
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hanlin Yin
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Siyao Liu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Sami Shoucair
- Department of Surgery, MedStar Health, Baltimore, Maryland, USA,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ni Ding
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuan Ji
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China,Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jicheng Zhang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dansong Wang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tiantao Kuang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xuefeng Xu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jun Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Departments of Medicine and Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Wenchuan Wu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ning Pu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenhui Lou
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
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8
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Xu S, Ye C, Chen R, Li Q, Ruan J. The Landscape and Clinical Application of the Tumor Microenvironment in Gastroenteropancreatic Neuroendocrine Neoplasms. Cancers (Basel) 2022; 14:cancers14122911. [PMID: 35740577 PMCID: PMC9221445 DOI: 10.3390/cancers14122911] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/28/2022] [Accepted: 06/08/2022] [Indexed: 02/08/2023] Open
Abstract
Simple Summary The tumor microenvironment (TME) plays a role in promoting tumor progression. Elucidating the relationship between the TME and tumor cells will benefit current therapies. Therefore, this review summarizes the most recent relationship between the TME and tumor characteristics, discusses the differences in the TME at various sites along the digestive tract, and compares the TMEs of neuroendocrine tumors and neuroendocrine carcinomas. Microbial ecological changes in the TME were reviewed. The clinical application of the TME was summarized from bench to bedside. The TME can be used as a tumor drug target for diagnostic value, prognosis prediction, and efficacy evaluation, further revealing the potential of immune checkpoints combined with antiangiogenic drugs. The clinical application prospects of adoptive cell therapy and oncolytic viruses were described. The potential therapeutic approaches and strategies for gastrointestinal neuroendocrine neoplasms are considered. Abstract Gastroenteropancreatic neuroendocrine neoplasms feature high heterogeneity. Neuroendocrine tumor cells are closely associated with the tumor microenvironment. Tumor-infiltrating immune cells are mutually educated by each other and by tumor cells. Immune cells have dual protumorigenic and antitumorigenic effects. The immune environment is conducive to the invasion and metastasis of the tumor; in turn, tumor cells can change the immune environment. These cells also form cytokines, immune checkpoint systems, and tertiary lymphoid structures to participate in the process of mutual adaptation. Additionally, the fibroblasts, vascular structure, and microbiota exhibit interactions with tumor cells. From bench to bedside, clinical practice related to the tumor microenvironment is also regarded as promising. Targeting immune components and angiogenic regulatory molecules has been shown to be effective. The clinical efficacy of immune checkpoint inhibitors, adoptive cell therapy, and oncolytic viruses remains to be further discussed in clinical trials. Moreover, combination therapy is feasible for advanced high-grade tumors. The regulation of the tumor microenvironment based on multiple omics results can suggest innovative therapeutic strategies to prevent tumors from succeeding in immune escape and to support antitumoral effects.
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Affiliation(s)
- Shuaishuai Xu
- Department of Medical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; (S.X.); (C.Y.); (R.C.); (Q.L.)
- Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, Hangzhou 310000, China
| | - Chanqi Ye
- Department of Medical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; (S.X.); (C.Y.); (R.C.); (Q.L.)
- Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, Hangzhou 310000, China
| | - Ruyin Chen
- Department of Medical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; (S.X.); (C.Y.); (R.C.); (Q.L.)
- Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, Hangzhou 310000, China
| | - Qiong Li
- Department of Medical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; (S.X.); (C.Y.); (R.C.); (Q.L.)
- Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, Hangzhou 310000, China
| | - Jian Ruan
- Department of Medical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; (S.X.); (C.Y.); (R.C.); (Q.L.)
- Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, Hangzhou 310000, China
- Correspondence:
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9
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Peng W, Sheng Y, Xiao H, Ye Y, Kwantwi LB, Cheng L, Wang Y, Xu J, Wu Q. Lung Adenocarcinoma Cells Promote Self-Migration and Self-Invasion by Activating Neutrophils to Upregulate Notch3 Expression of Cancer Cells. Front Mol Biosci 2022; 8:762729. [PMID: 35118116 PMCID: PMC8804382 DOI: 10.3389/fmolb.2021.762729] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 12/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Invasion and migration of cancer cells play a key role in lung cancer progression and metastasis. Tumor-associated neutrophils (TANs) are related to poor prognosis in many types of cancer. However, the role of TANs in lung cancer is controversial. In this study, we investigated the effect of TANs on the invasion and migration of lung adenocarcinoma.Methods: Immunohistochemistry was performed to detect the density of infiltrating TANs and the expression of Notch3 in 100 lung adenocarcinoma tissues. Flow cytometry was used to observe the viability of neutrophils, which were isolated from healthy peripheral blood and then exposed to the supernatant of cultured lung adenocarcinoma cell lines. After treating with tumor-associated neutrophils culture supernatant, NeuCS (supernatant of cultured neutrophils), tumor cells culture supernatant, Medium (serum-free medium), respectively, the migration and invasion of the lung cancer cells before and after transfected by si-Notch3 were detected by transwell assay and wound healing assay. Kaplan-Meier plotter (http://kmplot.com/analysis/index.php?p) was used to analyze the prognostic role of the density of TANs on lung adenocarcinoma and TIMER ((http://cistrome.dfci.harvard.edu/TIMER/) was used to detect the expression of Notch3 on lung adenocarcinoma.Results: The infiltration of TANs was observed in the parenchyma and stroma of the lung adenocarcinoma, the density of TANs was positively related to the TNM stage and negatively related to the differentiation and prognosis. Notch3 expression of cancer cells was negatively related to the tumor differentiation and prognosis. Compared to quiescent neutrophils, the viability of TCCS-activated neutrophils was enhanced. Both migration and invasion of A549 and PC9 cells were significantly promoted by TANs, while after knocking down Notch3, the migration and invasion of the cancer cells were not affected by TANs. Bioinformatics analysis showed that the density of TANs and the expression of Notch3 were related to the poor prognosis.Conclusion: The results indicated that lung adenocarcinoma cells promote self-invasion and self-migration by activating neutrophils to upregulate the Notch3 expression of cancer cells. The density of infiltrating TANs may be a novel marker for the poor prognosis of lung adenocarcinoma. Targeting TANs might be a potential therapeutic strategy for lung cancer treatment.
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Affiliation(s)
- Weidong Peng
- Department of Pathology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of Pathology, School of Basic Medical Science, Anhui Medical University, Hefei, China
| | - Youjing Sheng
- Department of Pathology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of Pathology, School of Basic Medical Science, Anhui Medical University, Hefei, China
| | - Han Xiao
- Department of Pathology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yuanzi Ye
- Department of Pathology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Louis Boafo Kwantwi
- Department of Pathology, School of Basic Medical Science, Anhui Medical University, Hefei, China
| | - Lanqing Cheng
- Department of Pathology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yuanchong Wang
- Department of Neonatology, Anhui Provincial Children’s Hospital, Hefei, China
| | - Jiegou Xu
- Department of Immunology, School of Basic Medical Science, Anhui Medical University, Hefei, China
- *Correspondence: Qiang Wu, ; Jiegou Xu,
| | - Qiang Wu
- Department of Pathology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of Pathology, School of Basic Medical Science, Anhui Medical University, Hefei, China
- *Correspondence: Qiang Wu, ; Jiegou Xu,
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10
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Zhang WH, Gao HL, Liu WS, Qin Y, Ye Z, Lou X, Wang F, Zhang Y, Chen XM, Chen J, Yu XJ, Zhuo QF, Xu XW, Ji SR. A real-life treatment cohort of pancreatic neuroendocrine tumors: High-grade increase in metastases confers poor survival. Front Endocrinol (Lausanne) 2022; 13:941210. [PMID: 36034463 PMCID: PMC9399842 DOI: 10.3389/fendo.2022.941210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/15/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Tumor grade determined by the Ki67 index is the best prognostic factor for pancreatic neuroendocrine tumors (PanNETs). However, we often observe that the grade of metastases differs from that of their primary tumors. This study aimed to investigate the frequency of grade changes between primary tumors and metastases, explore its association with clinical characteristics, and correlate the findings with the prognosis. METHODS Six hundred forty-eight patients with pancreatic neuroendocrine neoplasms treated at Fudan University Shanghai Cancer Center were screened for inclusion, and 103 patients with PanNETs who had paired primary tumors and metastases with an available Ki67 index were included. Re-evaluation of Ki67 was performed on 98 available samples from 69 patients. RESULTS Fifty cases (48.5%) had a Ki67 index variation, and 18 cases (17.5%) displayed a grade increase. Metachronous metastases showed significantly higher Ki67 index variation than synchronous metastases (P=0.028). Kaplan-Meier analyses showed that high-grade metastases compared to low-grade primary tumors were significantly associated with decreased progression-free survival (PFS, P=0.012) and overall survival (OS, P=0.027). Multivariable Cox regression analyses demonstrated that a low-grade increase to high-grade was an unfavorable and independent prognostic factor for PFS and OS (P=0.010, and P=0.041, respectively). CONCLUSIONS A high-grade increase in metastases was an unfavorable predictor of PanNETs, which emphasized the importance of accurate pathological grading and could provide a reference for clinical decision-making.
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Affiliation(s)
- Wu-Hu Zhang
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Pancreatic Cancer Institute, Shanghai, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - He-Li Gao
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Pancreatic Cancer Institute, Shanghai, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Wen-Sheng Liu
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Pancreatic Cancer Institute, Shanghai, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Yi Qin
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Pancreatic Cancer Institute, Shanghai, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Zeng Ye
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Pancreatic Cancer Institute, Shanghai, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Xin Lou
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Pancreatic Cancer Institute, Shanghai, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Fei Wang
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Pancreatic Cancer Institute, Shanghai, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Yue Zhang
- The First People’s Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xue-Min Chen
- The First People’s Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Jie Chen
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Pancreatic Cancer Institute, Shanghai, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Xian-Jun Yu
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Pancreatic Cancer Institute, Shanghai, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, China
- *Correspondence: Xian-Jun Yu, ; ; Qi-Feng Zhuo, ; Xiao-Wu Xu, ; Shun-Rong Ji,
| | - Qi-Feng Zhuo
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Pancreatic Cancer Institute, Shanghai, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, China
- *Correspondence: Xian-Jun Yu, ; ; Qi-Feng Zhuo, ; Xiao-Wu Xu, ; Shun-Rong Ji,
| | - Xiao-Wu Xu
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Pancreatic Cancer Institute, Shanghai, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, China
- *Correspondence: Xian-Jun Yu, ; ; Qi-Feng Zhuo, ; Xiao-Wu Xu, ; Shun-Rong Ji,
| | - Shun-Rong Ji
- Center for Neuroendocrine Tumors, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Pancreatic Cancer Institute, Shanghai, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, China
- *Correspondence: Xian-Jun Yu, ; ; Qi-Feng Zhuo, ; Xiao-Wu Xu, ; Shun-Rong Ji,
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Rawat K, Syeda S, Shrivastava A. Hyperactive neutrophils infiltrate vital organs of tumor bearing host and contribute to gradual systemic deterioration via upregulated NE, MPO and MMP-9 activity. Immunol Lett 2021; 241:35-48. [PMID: 34890699 DOI: 10.1016/j.imlet.2021.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/27/2021] [Accepted: 12/06/2021] [Indexed: 12/15/2022]
Abstract
Cancer is known to have systemic impact by targeting various organs that ultimately compromises the overall physiology of the host. Several reports have demonstrated the role of neutrophils in cancer wherein the focus has been drawn on the elevated neutrophil count in blood or at tumor loci. However, their role in mediating systemic effects during cancer progression has not been deciphered so far. Therefore, it is worthwhile to explore whether and how neutrophils contribute to systemic deterioration in cancer. To discern their systemic role, we evaluated neutrophil count and function at different stages of tumor growth in Dalton's Lymphoma mice model. Notably, our results displayed a gradual increase in Ly6G+ neutrophils in peripheral blood and their infiltration in vital organs including liver, lungs, spleen, kidney, lymph nodes and peritoneum of tumor bearing host. We showed remarkable alterations in histoarchitecture and serum enzyme levels that aggravated with tumor progression. We next examined neutrophil function by assessing its granular cargoes including neutrophil elastase (NE), myeloperoxidase (MPO), and matrix metalloproteinases (MMP-8 and MMP-9). Interestingly, blood neutrophils of tumor bearing mice exhibited a marked change in morphology with gradual increase in NE and MPO expression with tumor growth. In addition, we observed upregulated expression of NE, MPO, MMP-8 and MMP-9 in the vital organs of tumor bearing host. Taken together, our results demonstrate heightened infiltration and function of neutrophils in vital organs of tumor bearing host which possibly account for gradual systemic deterioration during cancer progression. Our findings thus implicate neutrophils as a potential therapeutic target that may help to reduce the overall fatality rate of cancer.
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Affiliation(s)
- Kavita Rawat
- Department of Zoology, University of Delhi, Delhi 110007, India
| | - Saima Syeda
- Department of Zoology, University of Delhi, Delhi 110007, India
| | - Anju Shrivastava
- Department of Zoology, University of Delhi, Delhi 110007, India.
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12
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Tanno L, Naheed S, Dunbar J, Tod J, Lopez MA, Taylor J, Machado M, Green B, Ashton-Key M, Chee SJ, Wood O, Pearce NW, Thomas GJ, Friedmann PS, Cave J, Ottensmeier CH. Analysis of Immune Landscape in Pancreatic and Ileal Neuroendocrine Tumours Demonstrates an Immune Cold Tumour Microenvironment. Neuroendocrinology 2021; 112:370-383. [PMID: 34157710 DOI: 10.1159/000517688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/08/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Neuroendocrine tumours (NETs) are rare tumours with an increasing incidence. While low- and intermediate-grade pancreatic NET (PanNET) and small intestinal NET (siNET) are slow growing, they have a relatively high rate of metastasizing to the liver, leading to substantially worse outcomes. In many solid tumours, the outcome is determined by the quality of the antitumour immune response. However, the quality and significance of antitumour responses in NETs are incompletely understood. This study provides clinico-pathological analyses of the tumour immune microenvironment in PanNET and siNETs. METHODS Formalin-fixed paraffin-embedded tissue from consecutive resected PanNETs (61) and siNETs (131) was used to construct tissue microarrays (TMAs); 1-mm cores were taken from the tumour centre, stroma, tumour edge, and adjacent healthy tissue. TMAs were stained with antibodies against CD8, CD4, CD68, FoxP3, CD20, and NCR1. T-cell counts were compared with counts from lung cancers. RESULTS For PanNET, median counts were CD8+ 35.4 cells/mm2, CD4+ 7.6 cells/mm2, and CD68+ macrophages 117.7 cells/mm2. For siNET, there were CD8+ 39.2 cells/mm2, CD4+ 24.1 cells/mm2, and CD68+ 139.2 cells/mm2. The CD8+ cell density in the tumour and liver metastases were significantly lower than in the adjacent normal tissues, without evidence of a cell-rich area at the tumour edge that might have suggested immune exclusion. T-cell counts in lung cancer were significantly higher than those in PanNET and siNETs: CD8+ 541 cells/mm2 and CD4+ 861 cells/mm2 (p ≤ 0.0001). CONCLUSION PanNETs and siNETs are immune cold with no evidence of T cell exclusion; the low density of immune infiltrates indicates poor antitumour immune responses.
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Affiliation(s)
- Lulu Tanno
- School of Cancer Sciences, and CRUK and NIHR Experimental Cancer Medicine Centre, University of Southampton, Southampton, UK
- Department of Hepato-Pancreato-Biliary Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Salma Naheed
- School of Cancer Sciences, and CRUK and NIHR Experimental Cancer Medicine Centre, University of Southampton, Southampton, UK
- Department of Medical Oncology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jonathan Dunbar
- Department of Radiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jo Tod
- Department of Gastroenterology, University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
| | - Maria A Lopez
- Department of Research Histology, University of Southampton, Southampton, UK
| | - Julian Taylor
- Department of Research Histology, University of Southampton, Southampton, UK
| | - Maria Machado
- Department of Research Histology, University of Southampton, Southampton, UK
| | - Bryan Green
- Department of Histopathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Margaret Ashton-Key
- School of Cancer Sciences, and CRUK and NIHR Experimental Cancer Medicine Centre, University of Southampton, Southampton, UK
- Department of Histopathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Serena J Chee
- School of Cancer Sciences, and CRUK and NIHR Experimental Cancer Medicine Centre, University of Southampton, Southampton, UK
| | - Oliver Wood
- School of Cancer Sciences, and CRUK and NIHR Experimental Cancer Medicine Centre, University of Southampton, Southampton, UK
| | - Neil W Pearce
- Department of Hepato-Pancreato-Biliary Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Gareth J Thomas
- School of Cancer Sciences, and CRUK and NIHR Experimental Cancer Medicine Centre, University of Southampton, Southampton, UK
- Department of Histopathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Peter S Friedmann
- Division of Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, University of Southampton, Southampton, UK
| | - Judith Cave
- School of Cancer Sciences, and CRUK and NIHR Experimental Cancer Medicine Centre, University of Southampton, Southampton, UK
- Department of Medical Oncology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Christian H Ottensmeier
- School of Cancer Sciences, and CRUK and NIHR Experimental Cancer Medicine Centre, University of Southampton, Southampton, UK
- Department of Molecular & Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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Involvement of Neutrophils in Metastatic Evolution of Pancreatic Neuroendocrine Tumors. Cancers (Basel) 2021; 13:cancers13112771. [PMID: 34199561 PMCID: PMC8199674 DOI: 10.3390/cancers13112771] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/19/2021] [Accepted: 05/28/2021] [Indexed: 12/17/2022] Open
Abstract
Simple Summary The neutrophil-to-lymphocytes (NLR) reflects the systemic inflammation. Based on a cohort of 144 patients treated for localized or metastatic well-differentiated pancreatic neuroendocrine tumors (pNET), we identified the NLR ≥ 4 to be associated with worse overall survival. Using MCP-Counter on a publicly available pNET RNA-sequencing dataset, we inferred the tumor microenvironment composition of 83 primary pNET and 30 liver metastasis. The neutrophils scores were statistically higher in liver metastasis relative to primary pancreatic tumors (p = 0.005). Gene set enrichment analysis further revealed activation of complement pathway signature in liver metastasis. Through combination of the neutrophil and complement pathway genes, we found that pNET can be classified into two clusters: Neu-Comp1 and Neu-Comp2. Notably, the Neu-Compt1 cluster was enriched in neutrophils and complement pathway signatures and was associated with liver metastasis. These data offer new insights into the role of inflammatory factors in the metastatic progression of the pNET. Abstract Well-differentiated pancreatic neuroendocrine tumors (pNET) have an unpredictable natural history. The identification of both blood and tumor immune features associated with patients’ outcomes remains limited. Herein, we evaluated the best prognostic value of the neutrophils-to-lymphocyte ratio (NLR) in a cohort of 144 pNETs. The NLR ≥ 4 was associated with worse overall survival in both univariate analysis (HR = 3.53, CI95% = 1.50–8.31, p = 0.004) and multivariate analysis (HR = 2.57, CI95% = 1.061–6.216, p = 0.036). The presence of synchronous liver metastasis was identified as a prognostic factor in multivariate analysis (HR = 3.35, CI95% = 1.411–7.973, p = 0.006). Interestingly, the absolute tumor-associated neutrophils count was higher in liver metastasis as compared to their paired primary tumor (p = 0.048). Deconvolution of immune cells from the transcriptome of 83 primary tumors and 30 liver metastases reveals enrichment for neutrophils in metastasis relative to primary tumors (p = 0.005), and this was associated with upregulation of the complement pathway (NES = 1.84, p < 0.0001). Combining neutrophils signature and complement pathway genes, unsupervised clustering identified two pNETs subgroups, namely Neu-Comp1 and Neu-Comp2. Characterized by neutrophils infiltration and activation of the complement pathway, Neu-Comp1 was highly enriched for metastatic liver samples as compared to Neu-Comp2 (p < 0.0001). These data suggest the possible link between liver metastasis, complement pathway activation, and neutrophils infiltration in well-differentiated pNET and open avenues for targeting complement pathways in these tumors.
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Veglia F, Hashimoto A, Dweep H, Sanseviero E, De Leo A, Tcyganov E, Kossenkov A, Mulligan C, Nam B, Masters G, Patel J, Bhargava V, Wilkinson P, Smirnov D, Sepulveda MA, Singhal S, Eruslanov EB, Cristescu R, Loboda A, Nefedova Y, Gabrilovich DI. Analysis of classical neutrophils and polymorphonuclear myeloid-derived suppressor cells in cancer patients and tumor-bearing mice. J Exp Med 2021; 218:211778. [PMID: 33566112 PMCID: PMC7879582 DOI: 10.1084/jem.20201803] [Citation(s) in RCA: 117] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/28/2020] [Accepted: 01/07/2021] [Indexed: 01/08/2023] Open
Abstract
In this study, using single-cell RNA-seq, cell mass spectrometry, flow cytometry, and functional analysis, we characterized the heterogeneity of polymorphonuclear neutrophils (PMNs) in cancer. We describe three populations of PMNs in tumor-bearing mice: classical PMNs, polymorphonuclear myeloid-derived suppressor cells (PMN-MDSCs), and activated PMN-MDSCs with potent immune suppressive activity. In spleens of mice, PMN-MDSCs gradually replaced PMNs during tumor progression. Activated PMN-MDSCs were found only in tumors, where they were present at the very early stages of the disease. These populations of PMNs in mice could be separated based on the expression of CD14. In peripheral blood of cancer patients, we identified two distinct populations of PMNs with characteristics of classical PMNs and PMN-MDSCs. The gene signature of tumor PMN-MDSCs was similar to that in mouse activated PMN-MDSCs and was closely associated with negative clinical outcome in cancer patients. Thus, we provide evidence that PMN-MDSCs are a distinct population of PMNs with unique features and potential for selective targeting opportunities.
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Affiliation(s)
| | | | | | | | | | | | | | - Charles Mulligan
- Helen F. Graham Cancer Center and Research Institute, Christiana Care, Newark, DE
| | - Brian Nam
- Helen F. Graham Cancer Center and Research Institute, Christiana Care, Newark, DE
| | - Gregory Masters
- Helen F. Graham Cancer Center and Research Institute, Christiana Care, Newark, DE
| | - Jaymala Patel
- Janssen Research and Development, LLC, Pharmaceutical Companies of Johnson & Johnson, Spring House, PA
| | - Vipul Bhargava
- Janssen Research and Development, LLC, Pharmaceutical Companies of Johnson & Johnson, Spring House, PA
| | - Patrick Wilkinson
- Janssen Research and Development, LLC, Pharmaceutical Companies of Johnson & Johnson, Spring House, PA
| | - Denis Smirnov
- Janssen Research and Development, LLC, Pharmaceutical Companies of Johnson & Johnson, Spring House, PA
| | - Manuel A Sepulveda
- Janssen Research and Development, LLC, Pharmaceutical Companies of Johnson & Johnson, Spring House, PA
| | - Sunil Singhal
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Evgeniy B Eruslanov
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Razvan Cristescu
- Department of Genetics and Pharmacogenomics, Merck Research Laboratories, Merck & Co., Inc., Boston, MA
| | - Andrey Loboda
- Department of Genetics and Pharmacogenomics, Merck Research Laboratories, Merck & Co., Inc., Boston, MA
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Fan T, Zhu M, Wang L, Liu Y, Tian H, Zheng Y, Tan F, Sun N, Li C, He J. Immune profile of the tumor microenvironment and the identification of a four-gene signature for lung adenocarcinoma. Aging (Albany NY) 2020; 13:2397-2417. [PMID: 33318300 PMCID: PMC7880407 DOI: 10.18632/aging.202269] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/22/2020] [Indexed: 12/11/2022]
Abstract
The composition and relative abundances of immune cells in the tumor microenvironment are key factors affecting the progression of lung adenocarcinomas (LUADs) and the efficacy of immunotherapy. Using the cancer gene expression dataset from The Cancer Genome Atlas (TCGA) program, we scored stromal and immune cells for tumor purity prediction by CIBERSORT and ESTMATE. Differential expression analysis was employed to identify 374 genes between the high-score group and the low-score group, which were utilized to conduct Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis. Protein-protein interaction (PPI) and Cox regression analysis were performed on the differentially expressed genes (DEGs) to identify four key tumor microenvironment (TME) -related genes (CCR2, CCR4, P2RY12, and P2RY13). The expression levels of the four DEGs differed significantly among LUAD patients of different ages, genders, and TNM stages. We found that the infiltration of resting memory CD4+ T cells, memory B cells, and M0 macrophages into the TME was co-regulated by these four DEGs. These four genes were closely related to the prognosis of LUAD and affected the infiltration of immune cells into the TME, which had predictive prognostic value in LUAD.
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Affiliation(s)
- Tao Fan
- Department of Oncology, Renmin Hospital of Wuhan University, Wuhan 430060, China.,Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Mingchuang Zhu
- Department of Oncology, Renmin Hospital of Wuhan University, Wuhan 430060, China.,Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Liyu Wang
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yu Liu
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - He Tian
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yujia Zheng
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Fengwei Tan
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Nan Sun
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Chunxiang Li
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jie He
- Department of Oncology, Renmin Hospital of Wuhan University, Wuhan 430060, China.,Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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16
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Tanase C, Gheorghisan-Galateanu AA, Popescu ID, Mihai S, Codrici E, Albulescu R, Hinescu ME. CD36 and CD97 in Pancreatic Cancer versus Other Malignancies. Int J Mol Sci 2020; 21:E5656. [PMID: 32781778 PMCID: PMC7460590 DOI: 10.3390/ijms21165656] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 02/06/2023] Open
Abstract
Starting from the recent identification of CD36 and CD97 as a novel marker combination of fibroblast quiescence in lung during fibrosis, we aimed to survey the literature in search for facts about the separate (or concomitant) expression of clusters of differentiation CD36 and CD97 in either tumor- or pancreatic-cancer-associated cells. Here, we provide an account of the current knowledge on the diversity of the cellular functions of CD36 and CD97 and explore their potential (common) contributions to key cellular events in oncogenesis or metastasis development. Emphasis is placed on quiescence as an underexplored mechanism and/or potential target in therapy. Furthermore, we discuss intricate signaling mechanisms and networks involving CD36 and CD97 that may regulate different subpopulations of tumor-associated cells, such as cancer-associated fibroblasts, adipocyte-associated fibroblasts, tumor-associated macrophages, or neutrophils, during aggressive pancreatic cancer. The coexistence of quiescence and activated states in cancer-associated cell subtypes during pancreatic cancer should be better documented, in different histological forms. Remodeling of the local microenvironment may also change the balance between growth and dormant state. Taking advantage of the reported data in different other tissue types, we explore the possibility to induce quiescence (similar to that observed in normal cells), as a therapeutic option to delay the currently observed clinical outcome.
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Affiliation(s)
- Cristiana Tanase
- Victor Babeș National Institute of Pathology, 99-101 Splaiul Independentei, 050096 Bucharest, Romania; (I.D.P.); (S.M.); (E.C.); (R.A.); (M.E.H.)
- Faculty of Medicine, Titu Maiorescu University, 001863 Bucharest, Romania
| | - Ancuta-Augustina Gheorghisan-Galateanu
- Department of Cellular and Molecular Biology and Histology, Carol Davila University of Medicine and Pharmacy, 8 Eroilor Sanitari Str., 050474 Bucharest, Romania;
- ‘C.I. Parhon’ National Institute of Endocrinology, 001863 Bucharest, Romania
| | - Ionela Daniela Popescu
- Victor Babeș National Institute of Pathology, 99-101 Splaiul Independentei, 050096 Bucharest, Romania; (I.D.P.); (S.M.); (E.C.); (R.A.); (M.E.H.)
| | - Simona Mihai
- Victor Babeș National Institute of Pathology, 99-101 Splaiul Independentei, 050096 Bucharest, Romania; (I.D.P.); (S.M.); (E.C.); (R.A.); (M.E.H.)
| | - Elena Codrici
- Victor Babeș National Institute of Pathology, 99-101 Splaiul Independentei, 050096 Bucharest, Romania; (I.D.P.); (S.M.); (E.C.); (R.A.); (M.E.H.)
| | - Radu Albulescu
- Victor Babeș National Institute of Pathology, 99-101 Splaiul Independentei, 050096 Bucharest, Romania; (I.D.P.); (S.M.); (E.C.); (R.A.); (M.E.H.)
- National Institute for Chemical Pharmaceutical R&D, 001863 Bucharest, Romania
| | - Mihail Eugen Hinescu
- Victor Babeș National Institute of Pathology, 99-101 Splaiul Independentei, 050096 Bucharest, Romania; (I.D.P.); (S.M.); (E.C.); (R.A.); (M.E.H.)
- Department of Cellular and Molecular Biology and Histology, Carol Davila University of Medicine and Pharmacy, 8 Eroilor Sanitari Str., 050474 Bucharest, Romania;
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17
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Ugras N, Hasdemir S, Yerci Ö, Taşar P, Dündar HZ, Macunluoğlu AC. Do morphologic characteristics play a role in nodal metastatic progression of well-differentiated pancreatic neuroendocrine tumors? TUMORI JOURNAL 2020; 107:80-85. [PMID: 32705937 DOI: 10.1177/0300891620941921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pancreatic neuroendocrine neoplasms (NENs) are tumors with histopathologic and prognostic heterogeneity that pose difficulties in establishing standards for diagnosis, classification, and treatment. Among NENs, well-differentiated neuroendocrine tumors (NETs) have been classified as grade 1, 2, and 3 in the most recently released World Health Organization classification. Although well-differentiated NETs are associated with relatively better prognosis, they have a potential for malignant behavior such as extrapancreatic spread, metastasis, or recurrence. The present study aimed to evaluate clinical and histomorphologic findings of patients with well-differentiated pancreatic NETs and to identify histopathologic findings effective in predicting nodal metastatic progression. METHODS The study group consisted of 54 patients diagnosed with well-differentiated NET. All preparations and blocks of the patients were examined for the following histopathologic parameters: tumor diameter, microscopic tumor growth pattern (solid, trabecular, acinar, and mixed), cellular features (clear, eosinophilic, oncocytic, peliotic, and pseudopapillary), stromal changes (calcification, lymphocytic infiltration, and stromal hyalinization), presence of necrosis, perineural invasion, lymphovascular invasion, mitotic activity, and Ki67 proliferative index. RESULTS Lymph node metastasis was present in 7 patients. Lymph node metastasis was significantly associated with tumor diameter of >2 cm (p = 0.012), Ki67 proliferative index of >20% (p = 0.022), grade 3 tumors (p = 0.002), presence of dense stromal hyalinization (p = 0.034), and mild lymphocytic infiltration (p = 0.041). CONCLUSION The present study revealed that the new findings such as presence of dense stromal hyalinization and absence of remarkable lymphocytic infiltration could be predictive morphologic findings for the development of lymph node metastasis.
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Affiliation(s)
- Nesrin Ugras
- Department of Surgical Pathology, Uludag University Medical Faculty, Bursa, Turkey
| | - Seçil Hasdemir
- Department of Surgical Pathology, Uludag University Medical Faculty, Bursa, Turkey
| | - Ömer Yerci
- Department of Surgical Pathology, Uludag University Medical Faculty, Bursa, Turkey
| | - Pınar Taşar
- Department of General Surgery, Uludag University Medical Faculty, Bursa, Turkey
| | - Halit Ziya Dündar
- Department of General Surgery, Uludag University Medical Faculty, Bursa, Turkey
| | - Aslı Ceren Macunluoğlu
- Department of Biostatistics, Institute of Health Sciences, Uludag University Medical Faculty, Bursa, Turkey
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