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Hur MH, Ko S. Metastatic axillary node ratio predicts recurrence and poor long-term prognosis in patients with advanced stage IIIC (pN3) breast cancer. Ann Surg Treat Res 2017; 92:340-347. [PMID: 28480179 PMCID: PMC5416925 DOI: 10.4174/astr.2017.92.5.340] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 02/28/2017] [Accepted: 05/15/2017] [Indexed: 11/30/2022] Open
Abstract
Purpose Patients with stage IIIC breast cancer are classified as having pathologic nodal stage 3 (pN3) according to the 7th American Joint Committee on Cancer Tumor Node Metastasis (AJCC TNM) staging system. However, the prognosis of patients with this stage is still highly variable. This study was carried out to investigate the validity of metastatic axillary lymph node ratio (mALNR) as a predictor of long-term prognosis in stage IIIC breast cancer. Methods Medical records of 297 patients who underwent surgery with more than level II axillary dissection for breast cancer and who were diagnosed with pN3 by pathology between 1990 and 2010, were reviewed. Clinicopathologic variables were evaluated as prognostic factors of disease-free and overall survival by univariate and multivariate analyses. Results A preliminary analysis revealed the cutoff value of mALNR to be 0.65 (Low65 group vs. High65 group). The mean mALNR was 0.62 (0.16–1.0) and was the most significant independent predictor of disease-free and overall survival on multivariate analysis. The rates of recurrence were significantly different according to mALNR (Low65, 40.3%; High65, 63.0%; P < 0.001). The 10-year disease-free (Low65, 57.0%; High65, 35.0%) and overall (Low65, 64.2%; High65, 38.3%) survival rates decreased significantly with increased mALNR (P < 0.001). Conclusion Patients with stage IIIC breast cancer can be subdivided into subgroups with significantly different long-term prognoses. Our data suggest that the mALNR is an independent risk factor of recurrence and mortality. The mALNR is a valuable prognostic factor to predict the long-term prognosis of stage IIIC breast cancer patients.
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Affiliation(s)
- Min Hee Hur
- Department of Surgery, Inha University Hospital, Inha University College of Medicine, Incheon, Korea
| | - SeungSang Ko
- Department of Surgery, Cheil General Hospital, Dankook University College of Medicine, Seoul, Korea
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Grassadonia A, Vici P, Gamucci T, Moscetti L, Pizzuti L, Mentuccia L, Iezzi L, Scognamiglio MT, Zilli M, Giampietro J, Graziano V, Natoli C, Tinari N. Long-term outcome of breast cancer patients with pathologic N3a lymph node stage. Breast 2017; 32:79-86. [DOI: 10.1016/j.breast.2016.12.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 12/22/2016] [Accepted: 12/25/2016] [Indexed: 01/10/2023] Open
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Kim YY, Park HK, Lee KH, Kim KI, Chun YS. Prognostically Distinctive Subgroup in Pathologic N3 Breast Cancer. J Breast Cancer 2016; 19:163-8. [PMID: 27382392 PMCID: PMC4929257 DOI: 10.4048/jbc.2016.19.2.163] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 05/23/2016] [Indexed: 11/30/2022] Open
Abstract
Purpose The aim of this retrospective study was to investigate whether there are prognostically different subgroups among patients with pathologic N3 (pN3) breast cancer. Methods The records of 220 patients who underwent surgery for pN3 breast cancer from January 2006 to September 2012 were reviewed. All patients received adjuvant therapy according to standard protocols. The primary outcome was disease-free survival (DFS). Results Patients were followed for a median time of 68.3 months after their primary surgery (range, 10–122 months), during which time 75 patients (34.1%) had developed disease recurrence and 48 patients (21.8%) had died. The DFS and overall survival were 67.8% and 86.1%, respectively, at 5 years. Multiple logistic regression analysis showed that young age (<35 years, p=0.009), high serum neutrophil/lymphocyte ratio (>3.0) (p=0.020), high nodal ratio (number of metastatic lymph nodes divided by number of removed nodes) (>0.65) (p=0.062), and molecular phenotype (p=0.012) were significantly associated with tumor recurrence. Tumor biological subtype was the most significant predictor of recurrence. The 5-year DFS rates in patients with hormone receptor (HR) positive and human epidermal growth factor receptor 2 (HER2) negative, HR+HER2+, HR–HER2+, and triple negative subtypes were 82%, 63%, 58%, and 37%, respectively. Conclusion Clinical outcomes of patients with extensive nodal metastasis were heterogeneous in terms of prognosis. Tumor biological subtype was the most important prognostic factor for pN3 disease. The prognosis of patients with HR+HER2– subtype in pN3 breast cancer was similar to that of patients with stage II breast cancer.
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Affiliation(s)
- Yun Yeong Kim
- Department of Surgery, Breast Cancer Center, Gachon University Gill Medical Center, Incheon, Korea
| | - Heung Kyu Park
- Department of Surgery, Breast Cancer Center, Gachon University Gill Medical Center, Incheon, Korea
| | - Kyung Hee Lee
- Department of Surgery, Breast Cancer Center, Gachon University Gill Medical Center, Incheon, Korea
| | - Kwan Il Kim
- Department of Surgery, Breast Cancer Center, Gachon University Gill Medical Center, Incheon, Korea
| | - Yong Soon Chun
- Department of Surgery, Breast Cancer Center, Gachon University Gill Medical Center, Incheon, Korea
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Yu JI, Park W, Choi DH, Huh SJ, Nam SJ, Kim SW, Lee JE, Kil WH, Im YH, Ahn JS, Park YH, Cho EY. Clinical Outcomes and Prognostic Factors of Pathologic N3 Breast Cancer Treated With Modern Standard Treatments. Clin Breast Cancer 2015; 15:512-8. [DOI: 10.1016/j.clbc.2015.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 06/11/2015] [Indexed: 01/25/2023]
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Abstract
Lymph node ratio (LNR) is a powerful prognostic factor for breast cancer. We conducted a recursive partitioning analysis (RPA) of the LNR to identify the prognostic risk groups in breast cancer patients. Records of newly diagnosed breast cancer patients between 2002 and 2006 were searched in the Taiwan Cancer Database. The end of follow-up was December 31, 2009. We excluded patients with distant metastases, inflammatory breast cancer, survival <1 month, no mastectomy, or missing lymph node status. Primary outcome was 5-year overall survival (OS). For univariate significant predictors, RPA were used to determine the risk groups. Among the 11,349 eligible patients, we identified 4 prognostic factors (including LNR) for survival, resulting in 8 terminal nodes. The LNR cutoffs were 0.038, 0.259, and 0.738, which divided LNR into 4 categories: very low (LNR ≤ 0.038), low (0.038 < LNR ≤ 0.259), moderate (0.259 < LNR ≤ 0.738), and high (0.738 < LNR). Then, 4 risk groups were determined as follows: Class 1 (very low risk, 8,265 patients), Class 2 (low risk, 1,901 patients), Class 3 (moderate risk, 274 patients), and Class 4 (high risk, 900 patients). The 5-year OS for Class 1, 2, 3, and 4 were 93.2%, 83.1%, 72.3%, and 56.9%, respectively (P< 0.001). The hazard ratio of death was 2.70, 4.52, and 8.59 (95% confidence interval 2.32-3.13, 3.49-5.86, and 7.48-9.88, respectively) times for Class 2, 3, and 4 compared with Class 1 (P < 0.001). In conclusion, we identified the optimal cutoff LNR values based on RPA and determined the related risk groups, which successfully predict 5-year OS in breast cancer patients.
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Affiliation(s)
- Yao-Jen Chang
- From the Department of Surgery (Yao-Jen Chang), Taipei Branch, Buddhist Tzu Chi General Hospital; Graduate Institute of Health Policy and Management (K-PC, L-JC), College of Public Health, National Taiwan University; Department of Ophthalmology (L-JC), HepingFuyou Branch; Department of General Surgery (Yun-Jau Chang), Zhong-Xing Branch, Taipei City Hospital; and Department of General Surgery (Yun-Jau Chang), National Taiwan University Hospital, Taipei, Taiwan
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Liu D, Chen Y, Deng M, Xie G, Wang J, Zhang L, Liu Q, Yuan P, Feng X. Lymph node ratio and breast cancer prognosis: a meta-analysis. Breast Cancer 2013; 21:1-9. [DOI: 10.1007/s12282-013-0497-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 09/24/2013] [Indexed: 12/26/2022]
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Koca E, Kuzan TY, Dizdar O, Babacan T, Sahin I, Ararat E, Altundag K. Outcomes of locally advanced breast cancer patients with ≥ 10 positive axillary lymph nodes. Med Oncol 2013; 30:615. [PMID: 23729267 DOI: 10.1007/s12032-013-0615-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 05/17/2013] [Indexed: 11/30/2022]
Abstract
Breast cancers with 10 or more positive lymph nodes at the time of diagnosis are staged as pathological N3a (pN3a) and they have poor prognosis. Recent studies showed five-year disease-free survival (DFS) and overall survival (OS) rates of N3a disease as 43-66 and 58-81 %, respectively. We herein present outcomes of our patients with stage pN3a breast cancer. Among 2,578 patients diagnosed with invasive breast carcinoma at Hacettepe University Hospital between 2002 and 2012, 218 patients (8.4 %) had pN3a disease and were included and analyzed retrospectively in this study. Patients with internal mammary, infraclavicular, and supraclavicular node metastasis or distant metastasis at initial diagnosis were excluded. Demographic features, tumor characteristics, treatment regimens, and patient outcomes in terms of DFS and OS were analyzed. Lymph node ratio was defined as the ratio of positive to total removed lymph nodes. The median age was 49. Most common histological subtype was ductal carcinoma (82.1 %). About 82.6 % of patients had stage T2/T3 cancers and 47.7 % (104) had grade III cancers. Estrogen and progesterone receptors were positive in 133 (61 %) and 121 (55.5 %) patients, respectively. HER2 status was known for 213 patients and was positive in 87 (39.9 %) patients. A total of 27 (12.6 %) patients had triple-negative tumors. Lymphovascular invasion, extracapsular extension, and perineural invasion were present in 106 (48.6 %), 105 (48.2 %), 20 (9.2 %) cases, respectively. A total of 18 patients (8.3 %) received neoadjuvant and 200 patients (91.7 %) received adjuvant chemotherapy, mostly with anthracycline- (95 %) and taxane (60 %)-containing regimens. A total of 210 patients (96.3 %) received radiotherapy. Median follow-up was 39.5 months. A total of 96 patients relapsed on follow-up and 64 patients died. Nineteen of the relapses were locoregional and 77 were distant relapses. The 5-year DFS rate was 46.2 % and the OS rate was 69.8 %. In multivariate Cox regression analysis, grade III disease (HR 1.899, 95 % CI 1.196-3.017, P = 0.007), perineural invasion (HR 2.519, 95 % CI 1.341-4.731, P = 0.004), and lymph node ratio (≥ 0.9 vs. <0.9) (HR 2.290, 95 % CI 1.368-3.835, P = 0.002) were significantly associated with DFS, and grade III disease (HR 2.679, 95 % CI 1.500-4.782, P = 0.001) and lymph node ratio (≥ 0.9 vs. <0.9) (HR 2.182, 95 % CI 1.211-3.932, P = 0.009) were significantly associated with OS. Patients with pN3a disease in our cohort have comparable survival rates with other reports in the literature. Within this high risk group of patients, those with grade III disease, perineural invasion, and lymph node ratio ≥ 0.9 seem to confer poorer prognosis.
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Affiliation(s)
- Emre Koca
- Hacettepe University Cancer Institute, Ankara, Turkey
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Duraker N, Batı B, Çaynak ZC, Demir D. Lymph Node Ratio May Be Supplementary to TNM Nodal Classification in Node-positive Breast Carcinoma Based on the Results of 2,151 Patients. World J Surg 2013; 37:1241-8. [DOI: 10.1007/s00268-013-1965-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Duraker N, Demir D, Bati B, Yilmaz BD, Bati Y, Caynak ZC, Sobutay E. Survival Benefit of Post-mastectomy Radiotherapy in Breast Carcinoma Patients with T1-2 Tumor and 1-3 Axillary Lymph Node(s) Metastasis. Jpn J Clin Oncol 2012; 42:601-8. [DOI: 10.1093/jjco/hys052] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Zhu C, Wu XZ. Proposal of new classification for stage III breast cancer on the number and ratio of metastatic lymph nodes. J Surg Oncol 2012; 106:696-702. [PMID: 22488301 DOI: 10.1002/jso.23118] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 03/17/2012] [Indexed: 11/05/2022]
Abstract
BACKGROUND The objective of the retrospective study was to confirm whether the current staging system of stage III was appropriate for breast cancer. METHODS Four hundred fifteen patients with breast cancer in stage III were analyzed. The survival analysis was performed by Kaplan-Meier. RESULTS Survival time of the patients with T1N3M0 was significantly better than the patients with other subgroups of stage IIIC (T2,3,4N3M0) and similar that of patients with T4N0,1,2M0 who formed the stage IIIB group based on pN stage. Tumor size, number of positive lymph nodes and lymph node ratio (LNR) were associated with overall survival (OS). The greatest survival difference was found when 0.60 as the cutoff point of LNR for the patients with current stage IIIC (pN3). rN1 included the patients in pN3 with LNR ≤ 0.60 and rN2 included the patients in pN3 with LNR >0.60. Survival time of the patients with T1,2,3,4N3(rN1)M0 and T1N3(rN2)M0 was differently better than the patients with T2,3,4N3(rN2)M0 and similar that of patients with T4N0,1,2M0. CONCLUSION We suggested current staging system should be modified combining pN with rN. We presumed the patients with T1N3M0 and T2,3,4N3(rN1)M0 disease were excluded from the current stage IIIC and included in stage IIIB group.
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Affiliation(s)
- Cong Zhu
- Department of Zhong-Shan-Men In-Patient, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
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Duraker N, Batı B, Demir D, Caynak ZC. Prognostic Significance of the Number of Removed and Metastatic Lymph Nodes and Lymph Node Ratio in Breast Carcinoma Patients with 1-3 Axillary Lymph Node(s) Metastasis. ISRN ONCOLOGY 2011; 2011:645450. [PMID: 22091427 PMCID: PMC3195782 DOI: 10.5402/2011/645450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Accepted: 07/17/2011] [Indexed: 12/28/2022]
Abstract
We evaluated the prognostic significance of lymph node ratio (LNR), number of metastatic lymph nodes divided by number of removed nodes in 924 breast carcinoma patients with 1-3 metastatic axillary lymph node(s). The most significant LNR threshold value separating patients in low- and high-risk groups with significant survival difference was 0.20 for disease-free survival (P < 0.001), 0.30 for locoregional recurrence-free survival (P < 0.001), and 0.15 for distant metastasis-free survival (P < 0.001), and the patients with lower LNR had better survival. All three LNR threshold values had independent prognostic significance in Cox analysis (P < 0.001 for all three of them). In conclusion, LNR is a useful tool in separating breast carcinoma patients with 1-3 metastatic lymph node(s) into low- and high-risk prognostic groups.
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Affiliation(s)
- Nüvit Duraker
- Third Department of Surgery, SB Okmeydanı Training and Research Hospital, Istanbul, Turkey
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Factors influencing the outcome of breast cancer patients with 10 or more metastasized axillary lymph nodes. Int J Clin Oncol 2011; 16:473-81. [PMID: 21360123 DOI: 10.1007/s10147-011-0207-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Accepted: 02/07/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND The purpose of this study was to investigate prognostic factors in breast cancer patients with metastasis of ten or more lymph nodes (pathologic N3a). METHODS We conducted a retrospective analysis of the cases of 304 breast cancer patients with pathologic N3a disease who had undergone definitive surgery between 1986 and 2006, and investigated the correlation between clinicopathologic characteristics and treatment outcomes. RESULTS With a median follow-up period of 55 months, the 5-year disease-free survival rate was 42.9% and the overall survival rate was 57.8%. Univariate analysis showed that the factors associated with poor disease-free survival were: age < 35 years (P = 0.001), history of neoadjuvant chemotherapy (P < 0.001), T4 stage (P < 0.001), 20 or more positive lymph nodes (P < 0.001), presence of lymphovascular invasion (P = 0.003), and negative progesterone receptor expression (P = 0.003). Multivariate analysis showed the factors with independent prognostic significance to be: history of neoadjuvant chemotherapy (hazard ratio [HR] 3.163; 95% confidence interval [CI], 2.025-4.941; P < 0.001), 20 or more positive nodes (HR 1.598; 95% CI, 1.063-2.402; P = 0.024), and presence of lymphovascular invasion (HR 1.636; 95% CI, 1.009-2.654; P = 0.046). Factors associated with poor overall survival in univariate analysis were: age < 35 years (P = 0.033), history of neoadjuvant chemotherapy (P < 0.001), T4 stage (P = 0.001), 20 or more positive lymph nodes (P < 0.001), and negative progesterone receptor expression (P = 0.013). Multivariate analysis showed these factors to be: history of neoadjuvant chemotherapy (HR 2.900; 95% CI, 2.011-4.182; P < 0.001), and 20 or more positive nodes (HR 1.956; 95% CI, 1.419-2.696; P < 0.001). CONCLUSION Cases of breast tumors with extensive nodal metastasis were found to be heterogeneous in terms of prognosis. History of previous neoadjuvant chemotherapy and higher numbers of metastatic lymph nodes were found to be the two most important prognostic markers for pathologic N3a disease. New strategies such as biologic therapy and novel combinations should be considered for application in patients with poor prognosis, rather than conventional treatment.
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Vinh-Hung V, Nguyen NP, Cserni G, Truong P, Woodward W, Verkooijen HM, Promish D, Ueno NT, Tai P, Nieto Y, Joseph S, Janni W, Vicini F, Royce M, Storme G, Wallace AM, Vlastos G, Bouchardy C, Hortobagyi GN. Prognostic value of nodal ratios in node-positive breast cancer: a compiled update. Future Oncol 2009; 5:1585-603. [PMID: 20001797 DOI: 10.2217/fon.09.129] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The number of positive axillary nodes is a strong prognostic factor in breast cancer, but is affected by variability in nodal staging technique yielding varying numbers of excised nodes. The nodal ratio of positive to excised nodes is an alternative that could address this variability. Our 2006 review found that the nodal ratio consistently outperformed the number of positive nodes, providing strong arguments for the use of nodal ratios in breast cancer staging and management. New evidence has continued to accrue confirming the prognostic significance of nodal ratios in various worldwide population settings. This review provides an updated summary of available data, and discusses the potential application of the nodal ratio to breast cancer staging and prognostication, its role in the context of modern surgical techniques such as sentinel node biopsy, and its potential correlations with new biologic markers such as circulating tumor cells and breast cancer stem cells.
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Metze K. Lymph Node Yield as a Prognostic Factor in Cancer Studies—Due to Undersampling of Tumor-Free Lymph Nodes at Higher N Stages? Ann Surg Oncol 2008; 16:1080-2; author reply 1083. [DOI: 10.1245/s10434-008-0142-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Accepted: 08/12/2008] [Indexed: 01/21/2023]
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Duraker N. Stage IIIC Breast Carcinoma and Prognostically Different Subgroups. Ann Surg Oncol 2008. [DOI: 10.1245/s10434-008-9868-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Kuru B. Staging of invasive breast carcinoma patients with T4anyNM0 and T1-3N3M0. Ann Surg Oncol 2007; 15:1785-6; author reply 1787. [PMID: 18163172 DOI: 10.1245/s10434-007-9740-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2007] [Accepted: 11/02/2007] [Indexed: 11/18/2022]
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