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Heumann P, Albert A, Gülow K, Tümen D, Müller M, Kandulski A. Current and Future Therapeutic Targets for Directed Molecular Therapies in Cholangiocarcinoma. Cancers (Basel) 2024; 16:1690. [PMID: 38730642 PMCID: PMC11083102 DOI: 10.3390/cancers16091690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/17/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
We conducted a comprehensive review of the current literature of published data, clinical trials (MEDLINE; ncbi.pubmed.com), congress contributions (asco.org; esmo.org), and active recruiting clinical trains (clinicaltrial.gov) on targeted therapies in cholangiocarcinoma. Palliative treatment regimens were analyzed as well as preoperative and perioperative treatment options. We summarized the current knowledge for each mutation and molecular pathway that is or has been under clinical evaluation and discussed the results on the background of current treatment guidelines. We established and recommended targeted treatment options that already exist for second-line settings, including IDH-, BRAF-, and NTRK-mutated tumors, as well as for FGFR2 fusion, HER2/neu-overexpression, and microsatellite instable tumors. Other options for targeted treatment include EGFR- or VEGF-dependent pathways, which are known to be overexpressed or dysregulated in this cancer type and are currently under clinical investigation. Targeted therapy in CCA is a hallmark of individualized medicine as these therapies aim to specifically block pathways that promote cancer cell growth and survival, leading to tumor shrinkage and improved patient outcomes based on the molecular profile of the tumor.
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Affiliation(s)
- Philipp Heumann
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases University Hospital Regensburg Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
| | | | | | | | | | - Arne Kandulski
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases University Hospital Regensburg Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
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2
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Zhang YZ, Liu YC, Su T, Shi JN, Huang Y, Liang B. Current advances and future directions in combined hepatocellular and cholangiocarcinoma. Gastroenterol Rep (Oxf) 2024; 12:goae031. [PMID: 38628397 PMCID: PMC11018545 DOI: 10.1093/gastro/goae031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 03/17/2024] [Accepted: 03/24/2024] [Indexed: 04/19/2024] Open
Abstract
The low incidence of combined hepatocellular cholangiocarcinoma (cHCC-CCA) is an important factor limiting research progression. Our study extensively included nearly three decades of relevant literature and assembled the most comprehensive database comprising 5,742 patients with cHCC-CCA. We summarized the characteristics, tumor markers, and clinical features of these patients. Additionally, we present the evolution of cHCC-CCA classification and explain the underlying rationale for these classification standards. We reviewed cHCC-CCA diagnostic advances using imaging features, tumor markers, and postoperative pathology, as well as treatment options such as surgical, adjuvant, and immune-targeted therapies. In addition, recent advances in more effective chemotherapeutic regimens and immune-targeted therapies were explored. Furthermore, we described the molecular mutation features and potential specific markers of cHCC-CCA. The prognostic value of Nestin has been proven, and we speculate that Nestin will also play a role in classification and diagnosis. However, further research is needed. Moreover, we believe that the possibility of using machine learning liquid biopsy for preoperative diagnosis and establishing a scoring system are directions for future research.
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Affiliation(s)
- Yu-Zhu Zhang
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Jiangxi, Nanchang, Jiangxi, P. R. China
- The Second Clinical Medical College of Nanchang University, The Second Affiliated Hospital of Nanchang University, Jiangxi, Nanchang, Jiangxi, P. R. China
| | - Yu-Chen Liu
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Jiangxi, Nanchang, Jiangxi, P. R. China
- Queen Mary School, Jiangxi Medical College of Nanchang University, Nanchang, Jiangxi, P. R. China
| | - Tong Su
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Jiangxi, Nanchang, Jiangxi, P. R. China
- The Second Clinical Medical College of Nanchang University, The Second Affiliated Hospital of Nanchang University, Jiangxi, Nanchang, Jiangxi, P. R. China
| | - Jiang-Nan Shi
- The Second Clinical Medical College of Nanchang University, The Second Affiliated Hospital of Nanchang University, Jiangxi, Nanchang, Jiangxi, P. R. China
| | - Yi Huang
- The Second Clinical Medical College of Nanchang University, The Second Affiliated Hospital of Nanchang University, Jiangxi, Nanchang, Jiangxi, P. R. China
| | - Bo Liang
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Jiangxi, Nanchang, Jiangxi, P. R. China
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3
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Goodwin B, Lou J, Butchy M, Wilson T, Atabek U, Spitz F, Hong Y. Hepatocellular-Cholangiocarcinoma Collision Tumors: An Update of Current Management Practices. Am Surg 2023; 89:2685-2692. [PMID: 36031932 DOI: 10.1177/00031348221124323] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Combined hepatocellular-cholangiocarcinoma (cHCC-CC) is a rare form of primary hepatic collision tumor, with an incidence ranging from 0.4 to 14.2%. Given the diagnostic challenges and lack of randomized trials, standardized treatment has yet to be established. We aim to review the literature to summarize the diagnosis, molecular characteristics, current treatment modalities, and challenges for cHCC-CC. A literature review was performed using PubMed. We included studies investigating and describing cHCC-CC, focusing on surgical, medical, and radiologic treatments. Overall prognosis is poor, with a 5-year survival rate under 30%. Minor or major hepatectomy with R0 resection is the only curative treatment; however, recurrence is likely (as high as 50% within 5 years). The role of liver transplantation is also highly debated given the biliary nature of these tumors, with cHCC-CC as a relative contraindication for liver transplantation. Although gemcitabine-based treatments had higher progression-free survival over sorafenib, there is no standard chemotherapy regimen. Treatment with gemcitabine and platinum demonstrates improved disease control rates compared to gemcitabine in conjunction with 5-fluorouracil (78.4% verse 38.5% respectively). Additionally, platinum-containing chemotherapy regimens exhibit a higher overall response rate than non-platinum regimens (21.4% verse 7.0% respectively). These molecular-directed therapies have prolonged survival for HCC, but further investigation needs to be done to assess their utility in patients with cHCC-CC. cHCC-CC is a rare and complex subset of primary hepatic neoplasms with a dismal prognosis and unstandardized treatment options. Further trials need to be performed to investigate systemic chemotherapy and immunotherapy options for patients with unresectable disease.
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Affiliation(s)
- Brandon Goodwin
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | | | | | - Traeden Wilson
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | | | | | - Young Hong
- Cooper University Hospital, Camden, NJ, USA
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4
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Zhao J, Stephan-Falkenau S, Schuler M, Arndt B. Management of Locally Advanced or Metastatic Combined Hepatocellular Cholangiocarcinoma. Cancers (Basel) 2023; 15:cancers15030988. [PMID: 36765942 PMCID: PMC9913543 DOI: 10.3390/cancers15030988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/25/2023] [Accepted: 02/01/2023] [Indexed: 02/09/2023] Open
Abstract
Combined hepatocellular cholangiocarcinoma (cHCC-CC) is a rare primary liver malignancy that comprises features of hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC). Due to the rarity of this tumor, the treatment of choice has not yet been defined. For resectable disease, liver resection is the mainstay treatment. However, most patients relapse or display advanced disease and were not surgical candidates. Although the majority of patients are either primarily or secondarily treated in palliative intent, no guideline recommendations or prospective trial reports exist to allow reliable evaluation of debated treatment options. We review different locoregional or medical treatment options for advanced combined hepatocellular cholangiocarcinoma (cHCC-CC) in the neoadjuvant, adjuvant, or palliative setting and discuss the possibility of predictive biomarker-guided therapeutic options.
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Affiliation(s)
- Jemmy Zhao
- National Center of Tumor Diseases, German Cancer Research Center, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Susann Stephan-Falkenau
- Institute of Pathology, Medizinisches Versorgungszentrum am Helios Klinikum Emil von Behring, Walterhöferstr. 11, 14165 Berlin, Germany
| | - Markus Schuler
- Onkologischer Schwerpunkt am Oskar-Helene Heim, Clayallee 225a, 14195 Berlin, Germany
| | - Börge Arndt
- Department of Hematology and Oncology, Helios Klinikum Emil von Behring, Walterhöferstr. 11, 14165 Berlin, Germany
- Correspondence:
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Serra-Camprubí Q, Verdaguer H, Oliveros W, Lupión-Garcia N, Llop-Guevara A, Molina C, Vila-Casadesús M, Turpin A, Neuzillet C, Frigola J, Querol J, Yáñez-Bartolomé M, Castet F, Fabregat-Franco C, Escudero-Iriarte C, Escorihuela M, Arenas EJ, Bernadó-Morales C, Haro N, Giles FJ, Pozo ÓJ, Miquel JM, Nuciforo PG, Vivancos A, Melé M, Serra V, Arribas J, Tabernero J, Peiró S, Macarulla T, Tian TV. Human Metastatic Cholangiocarcinoma Patient-Derived Xenografts and Tumoroids for Preclinical Drug Evaluation. Clin Cancer Res 2023; 29:432-445. [PMID: 36374558 PMCID: PMC9873249 DOI: 10.1158/1078-0432.ccr-22-2551] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/14/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE Cholangiocarcinoma (CCA) is usually diagnosed at advanced stages, with limited therapeutic options. Preclinical models focused on unresectable metastatic CCA are necessary to develop rational treatments. Pathogenic mutations in IDH1/2, ARID1A/B, BAP1, and BRCA1/2 have been identified in 30%-50% of patients with CCA. Several types of tumor cells harboring these mutations exhibit homologous recombination deficiency (HRD) phenotype with enhanced sensitivity to PARP inhibitors (PARPi). However, PARPi treatment has not yet been tested for effectiveness in patient-derived models of advanced CCA. EXPERIMENTAL DESIGN We have established a collection of patient-derived xenografts from patients with unresectable metastatic CCA (CCA_PDX). The CCA_PDXs were characterized at both histopathologic and genomic levels. We optimized a protocol to generate CCA tumoroids from CCA_PDXs. We tested the effects of PARPis in both CCA tumoroids and CCA_PDXs. Finally, we used the RAD51 assay to evaluate the HRD status of CCA tissues. RESULTS This collection of CCA_PDXs recapitulates the histopathologic and molecular features of their original tumors. PARPi treatments inhibited the growth of CCA tumoroids and CCA_PDXs with pathogenic mutations of BRCA2, but not those with mutations of IDH1, ARID1A, or BAP1. In line with these findings, only CCA_PDX and CCA patient biopsy samples with mutations of BRCA2 showed RAD51 scores compatible with HRD. CONCLUSIONS Our results suggest that patients with advanced CCA with pathogenic mutations of BRCA2, but not those with mutations of IDH1, ARID1A, or BAP1, are likely to benefit from PARPi therapy. This collection of CCA_PDXs provides new opportunities for evaluating drug response and prioritizing clinical trials.
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Affiliation(s)
- Queralt Serra-Camprubí
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Helena Verdaguer
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain.,Gastrointestinal and Endocrine Tumor Unit, Vall d'Hebron Institute of Oncology (VHIO), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Winona Oliveros
- Life Sciences Department, Barcelona Supercomputing Center (BSC), Barcelona, Spain
| | - Núria Lupión-Garcia
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Alba Llop-Guevara
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Cristina Molina
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Maria Vila-Casadesús
- Cancer Genomics Group, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Anthony Turpin
- Université de Lille, CNRS INSERM UMR9020-U1277, CANTHER Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France.,Medical Oncology Department, CHRU Lille, Lille, France
| | - Cindy Neuzillet
- Gastrointestinal Oncology, Medical Oncology Department, Curie Institute, Versailles St-Quentin-Paris Saclay University, Saint-Cloud, France
| | - Joan Frigola
- Clinical Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Jessica Querol
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Mariana Yáñez-Bartolomé
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Florian Castet
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain.,Gastrointestinal and Endocrine Tumor Unit, Vall d'Hebron Institute of Oncology (VHIO), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Carles Fabregat-Franco
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain.,Gastrointestinal and Endocrine Tumor Unit, Vall d'Hebron Institute of Oncology (VHIO), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Carmen Escudero-Iriarte
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Marta Escorihuela
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Enrique J. Arenas
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Cristina Bernadó-Morales
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Noemí Haro
- Neurosciences Research Program, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | | | - Óscar J. Pozo
- Neurosciences Research Program, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Josep M. Miquel
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Paolo G. Nuciforo
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Ana Vivancos
- Cancer Genomics Group, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Marta Melé
- Life Sciences Department, Barcelona Supercomputing Center (BSC), Barcelona, Spain
| | - Violeta Serra
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Joaquín Arribas
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Cáncer, Monforte de Lemos, Madrid, Spain.,Department of Medicine and Life Sciences, Universitat Pompeu Fabra (UPF), Barcelona, Spain.,Cancer Research Program, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Josep Tabernero
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain.,Gastrointestinal and Endocrine Tumor Unit, Vall d'Hebron Institute of Oncology (VHIO), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Sandra Peiró
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain.,Corresponding Authors: Tian V. Tian, Vall d'Hebron Institute of Oncology (VHIO), Barcelona 08035, Spain. Phone: (34)932543450, ext. 8656; E-mail: ; Teresa Macarulla, ; and Sandra Peiró,
| | - Teresa Macarulla
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain.,Gastrointestinal and Endocrine Tumor Unit, Vall d'Hebron Institute of Oncology (VHIO), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.,Corresponding Authors: Tian V. Tian, Vall d'Hebron Institute of Oncology (VHIO), Barcelona 08035, Spain. Phone: (34)932543450, ext. 8656; E-mail: ; Teresa Macarulla, ; and Sandra Peiró,
| | - Tian V. Tian
- Preclinical and Translational Research Program, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain.,Corresponding Authors: Tian V. Tian, Vall d'Hebron Institute of Oncology (VHIO), Barcelona 08035, Spain. Phone: (34)932543450, ext. 8656; E-mail: ; Teresa Macarulla, ; and Sandra Peiró,
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6
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Duwe L, Fouassier L, Lafuente-Barquero J, Andersen JB. Unraveling the actin cytoskeleton in the malignant transformation of cholangiocyte biology. Transl Oncol 2022; 26:101531. [PMID: 36113344 PMCID: PMC9483793 DOI: 10.1016/j.tranon.2022.101531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/31/2022] [Accepted: 09/02/2022] [Indexed: 11/13/2022] Open
Abstract
Correct actin cytoskeleton organization is vital in the liver organ homeostasis and disease control. Rearrangements of the actin cytoskeleton may play a vital role in the bile duct cells cholangiocytes. An abnormal actin network leads to aberrant cell morphology, deregulated signaling networks and ultimately triggering the development of cholangiocarcinoma (CCA) and paving the route for cancer cell dissemination (metastasis). In this review, we will outline alterations of the actin cytoskeleton and the potential role of this dynamic network in initiating CCA, as well as regulating the course of this malignancy. Actin rearrangements not only occur because of signaling pathways, but also regulate and modify cellular signaling. This emphasizes the importance of the actin cytoskeleton itself as cause for aberrant signaling and in promoting tumorigenic phenotypes. We will highlight the impact of aberrant signaling networks on the actin cytoskeleton and its rearrangement as potential cause for CCA. Often, these exact mechanisms in CCA are limited understood and still must be elucidated. Indeed, focusing future research on how actin affects and regulates other signaling pathways may provide more insights into the mechanisms of CCA development, progression, and metastasis. Moreover, manipulation of the actin cytoskeleton organization highlights the potential for a novel therapeutic area.
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Affiliation(s)
- Lea Duwe
- Biotech Research and Innovation Centre (BRIC), Department of Health and Medical Sciences, University of Copenhagen, Copenhagen N DK2200, Denmark
| | - Laura Fouassier
- Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine, CRSA, Paris, France
| | - Juan Lafuente-Barquero
- Biotech Research and Innovation Centre (BRIC), Department of Health and Medical Sciences, University of Copenhagen, Copenhagen N DK2200, Denmark
| | - Jesper B Andersen
- Biotech Research and Innovation Centre (BRIC), Department of Health and Medical Sciences, University of Copenhagen, Copenhagen N DK2200, Denmark.
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Normanno N, Martinelli E, Melisi D, Pinto C, Rimassa L, Santini D, Scarpa A. Role of molecular genetics in the clinical management of cholangiocarcinoma. ESMO Open 2022; 7:100505. [PMID: 35696744 PMCID: PMC9198375 DOI: 10.1016/j.esmoop.2022.100505] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/05/2022] [Accepted: 05/07/2022] [Indexed: 11/13/2022] Open
Abstract
The incidence of cholangiocarcinoma (CCA) has steadily increased during the past 20 years, and mortality is increasing. The majority of patients with CCA have advanced or metastatic disease at diagnosis, and treatment options for unresectable disease are limited, resulting in poor prognosis. However, recent identification of targetable genomic alterations has expanded treatment options for eligible patients. Given the importance of early and accurate diagnosis in optimizing patient outcomes, this review discusses best practices in CCA diagnosis, with a focus on categorizing molecular genetics and available targeted therapies. Imaging and staging of CCAs are discussed, as well as recommended biopsy collection techniques, and molecular and genomic profiling methodologies, which have become increasingly important as molecular biomarker data accumulate. Approved agents targeting actionable genomic alterations specifically in patients with CCA include ivosidenib for tumors harboring IDH1 mutations, and infigratinib and pemigatinib for those with FGFR2 fusions. Other agents currently under development in this indication have shown promising results, which are presented here.
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Affiliation(s)
- N Normanno
- Cell Biology and Biotherapy Unit, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale-IRCCS, Naples, Italy.
| | - E Martinelli
- Medical Oncology, Department of Precision Medicine, Università della Campania 'L. Vanvitelli', Naples, Italy
| | - D Melisi
- Investigational Cancer Therapeutics Clinical Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; Digestive Molecular Clinical Oncology Research Unit, University of Verona, Policlinico B.B. Rossi, Verona, Italy
| | - C Pinto
- Medical Oncology Unit, Comprehensive Cancer Centre, AUSL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - L Rimassa
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Milan, Italy
| | - D Santini
- Medical Oncology, University Campus Bio-Medico, Rome, Italy
| | - A Scarpa
- ARC-Net Research Centre and Section of Pathology, Department of Diagnostics and Public Health, University of Verona, Policlinico G.B. Rossi, Verona, Italy
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