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Aglan SA, Awad AM, Elwany YN, Shawky S, Salam RMA, Omar RS, Ghazala RAM, Soliman NA, Khedr MI, Kandil LS, Sultan M, Hamed Y, Kandil NS. BECN1 mRNA expression in breast cancer tissue; significant correlation to tumor grade. Mol Genet Genomics 2024; 299:56. [PMID: 38787424 PMCID: PMC11126480 DOI: 10.1007/s00438-024-02145-2] [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: 04/19/2024] [Indexed: 05/25/2024]
Abstract
Breast cancer (BC) is a heterogenous disease with multiple pathways implicated in its development, progression, and drug resistance. Autophagy, a cellular process responsible for self-digestion of damaged organelles, had been recognized as eminent player in cancer progression and chemotherapeutic resistance. The haploinsufficiency of Beclin 1 (BECN1), autophagy protein, is believed to contribute to cancer pathogenesis and progression. In our study, we investigated the expression of BECN1 in a BC female Egyptian patient cohort, as well as its prognostic role through evaluating its association with disease free survival (DFS) after 2 years follow up and association of tumor clinicopathological features. Twenty frozen female BC tissue samples and 17 adjacent normal tissue were included and examined for the expression levels of BECN1. Although the tumor tissues showed lower expression 0.73 (0-8.95) than their corresponding normal tissues 1.02 (0.04-19.59), it was not statistically significant, p: 0.463. BECN1 expression was not associated with stage, nodal metastasis or tumor size, p:0.435, 0.541, 0.296, respectively. However, statistically significant negative correlation was found between grade and BECN1 mRNA expression in the studied cases, p:0.028. BECN1 expression had no statistically significant association with DFS, P = 0.944. However, we observed that triple negative (TNBC) cases had significantly lower DFS rate than luminal BC patients, p: 0.022, with mean DFS 19.0 months, while luminal BC patients had mean DFS of 23.41 months. Our study highlights the potential role of BECN1 in BC pathogenesis, showing that BECN1 expression correlates with poorer differentiation of BC, indicating its probable link with disease aggressiveness. DFS two years follow up showed that TNBC subtype remains associated with less favorable prognosis.
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Affiliation(s)
- Sarah Ahmed Aglan
- Department of Chemical Pathology, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Ahmed Mostafa Awad
- Department of Chemical Pathology, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Yasmine Nagy Elwany
- Department of Cancer Management and Research, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Sanaa Shawky
- Department of Pathology, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | | | - Rasha Said Omar
- Department of Biochemistry, faculty of medicine, Alexandria University, Alexandria, Egypt
| | | | - Nada Ahmed Soliman
- Department of Biochemistry, faculty of medicine, Alexandria University, Alexandria, Egypt
| | - Marwa Ibrahim Khedr
- Department of Biochemistry, faculty of medicine, Alexandria University, Alexandria, Egypt
| | - Lamia Said Kandil
- School of Pharmacy and Biomedical sciences, University of central Lancashire, Preston, UK
| | - Mohamed Sultan
- Department of Experimental and clinical surgery department, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Yasser Hamed
- Department of Experimental and clinical surgery department, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Noha Said Kandil
- Department of Chemical Pathology, Medical Research Institute, Alexandria University, Alexandria, Egypt.
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Ning L, Liu Y, He X, Han R, Xin Y, Zhao J, Liu X. Validation of CTS5 Model in Large-scale Breast Cancer Population and Combination of CTS5 and Ki-67 Status to Develop a Novel Nomogram for Prognosis Prediction. Am J Clin Oncol 2024; 47:228-238. [PMID: 38131531 DOI: 10.1097/coc.0000000000001080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND More than half of patients with early-stage estrogen receptor-positive (ER+) breast cancer relapse after completing 5 years of adjuvant endocrine therapy, so it is important to determine which patients are candidates for extended endocrine therapy. The clinical treatment score after 5 years (CTS5) is a prognostic tool developed based on postmenopausal ER+ breast cancer to assess the risk of late distant recurrence (LDR) after 5 years of adjuvant endocrine therapy for breast cancer. We aimed to externally validate the prognostic value of CTS5 in premenopausal and postmenopausal patients and combined with Ki-67 to develop a new model to improve the ability of prognosis prediction. METHODS We included a total of 516 patients with early-stage ER+ breast cancer who had received 5 years of adjuvant endocrine therapy and were recurrence-free for 5 years after surgery. According to menopausal status, we divided the study population into 2 groups: premenopausal and postmenopausal women. The CTS5 of each patient was calculated using a previously published formula, and the patients were divided into low, intermediate, and high CTS5 risk groups according to their CTS5 values. Based on the results of the univariate analysis ( P <0.01), a multivariate COX proportional hazards regression analysis was conducted to establish a nomogram with significant variables ( P <0.05). The discriminative power and accuracy of the nomograms were assessed using the concordance index (C-index), calibration curve, and area under the time-dependent receiver operating characteristic curve. Discrimination and calibration were evaluated by bootstrapping 1000 times. Finally, we utilized decision curve analysis to assess the performance of our novel predictive model in comparison to the CTS5 scoring system with regard to their respective benefits and advantages. RESULTS The median follow-up time was 7 years (6 to 9 years). The 516 women were categorized by CTS5 as follows: 246(47.7%) low risk, 179(34.7%) intermediate risk, and 91(17.6%) high risk. Using the CTS5 score as a continuous variable, patients' risk score was significantly positively associated with recurrence risk in both premenopausal and postmenopausal subgroups. For HER2- premenopausal patients and HER2+ postmenopausal patients, the CTS5 score was positively correlated with LDR risk. Patients with a Ki-67≥20% had a higher risk of LDR regardless of menopausal status. Using the CTS5 score as a categorical variable, the high-risk group of HER2- premenopausal patients had a higher risk of LDR. However, the CTS5 model could not distinguish the risk of LDR in different risk groups for HER2+ postmenopausal patients. In the high-risk group, patients with Ki-67≥20% had a higher risk of LDR, regardless of menopausal status. We developed a new nomogram model by combining the CTS5 model with Ki-67 levels. The C-indexes premenopausal and postmenopausal cohorts were 0.731 and 0.713, respectively. The nomogram model was well calibrated, and the time-dependent ROC curves indicated good specificity and sensitivity. Furthermore, decision curve analysis demonstrated that the new model had a wider and practical range of threshold probabilities, resulting in an increased net benefit compared with the CTS5 model. CONCLUSIONS Our study demonstrated that the CTS5 model can effectively predict the risk of LDR in early-stage ER+ breast cancer patients in both premenopausal and postmenopausal patients. Extended endocrine therapy is recommended for patients with Ki-67≥20% in the CTS5 high-risk group, as well as premenopausal patients with HER2-. Compared with CTS5, the new nomogram model has better identification and calibration capabilities, and further research is required to validate its efficacy in large-scale, multicenter, and prospective studies.
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Affiliation(s)
- Lizhi Ning
- Department of Medical Oncology, Xianyang Central Hospital, Shanxi
| | - Yaobang Liu
- Department of Surgical Oncology, General Hospital of Ningxia Medical University
| | - Xuefang He
- Department of Medical Oncology, General Hospital of Ningxia Medical University, Yinchuan
| | - Rui Han
- Department of Medical Oncology, General Hospital of Ningxia Medical University, Yinchuan
| | - Yuanfang Xin
- Breast Disease Diagnosis and Treatment Center of Affiliated Hospital of Qinghai University & Affiliated Cancer Hospital of Qinghai University, Xining, China
| | - Jiuda Zhao
- Breast Disease Diagnosis and Treatment Center of Affiliated Hospital of Qinghai University & Affiliated Cancer Hospital of Qinghai University, Xining, China
| | - Xinlan Liu
- Department of Medical Oncology, General Hospital of Ningxia Medical University, Yinchuan
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Bonni S, Brindley DN, Chamberlain MD, Daneshvar-Baghbadorani N, Freywald A, Hemmings DG, Hombach-Klonisch S, Klonisch T, Raouf A, Shemanko CS, Topolnitska D, Visser K, Vizeacoumar FJ, Wang E, Gibson SB. Breast Tumor Metastasis and Its Microenvironment: It Takes Both Seed and Soil to Grow a Tumor and Target It for Treatment. Cancers (Basel) 2024; 16:911. [PMID: 38473273 DOI: 10.3390/cancers16050911] [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: 01/09/2024] [Revised: 02/12/2024] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
Metastasis remains a major challenge in treating breast cancer. Breast tumors metastasize to organ-specific locations such as the brain, lungs, and bone, but why some organs are favored over others remains unclear. Breast tumors also show heterogeneity, plasticity, and distinct microenvironments. This contributes to treatment failure and relapse. The interaction of breast cancer cells with their metastatic microenvironment has led to the concept that primary breast cancer cells act as seeds, whereas the metastatic tissue microenvironment (TME) is the soil. Improving our understanding of this interaction could lead to better treatment strategies for metastatic breast cancer. Targeted treatments for different subtypes of breast cancers have improved overall patient survival, even with metastasis. However, these targeted treatments are based upon the biology of the primary tumor and often these patients' relapse, after therapy, with metastatic tumors. The advent of immunotherapy allowed the immune system to target metastatic tumors. Unfortunately, immunotherapy has not been as effective in metastatic breast cancer relative to other cancers with metastases, such as melanoma. This review will describe the heterogeneic nature of breast cancer cells and their microenvironments. The distinct properties of metastatic breast cancer cells and their microenvironments that allow interactions, especially in bone and brain metastasis, will also be described. Finally, we will review immunotherapy approaches to treat metastatic breast tumors and discuss future therapeutic approaches to improve treatments for metastatic breast cancer.
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Affiliation(s)
- Shirin Bonni
- Department of Biochemistry and Molecular Biology, University of Calgary, Calgary, AB T2N 4N1, Canada
- The Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - David N Brindley
- Department of Biochemistry, University of Alberta, Edmonton, AB T6G 2H7, Canada
- Cancer Research Institute of Northern Alberta, University of Alberta, Edmonton, AB T6G 2E1, Canada
| | - M Dean Chamberlain
- Division of Oncology, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N 0W8, Canada
- Saskatchewan Cancer Agency, University of Saskatchewan, 107 Wiggins Road, Saskatoon, SK S7N 5E5, Canada
| | - Nima Daneshvar-Baghbadorani
- Division of Oncology, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N 0W8, Canada
- Saskatchewan Cancer Agency, University of Saskatchewan, 107 Wiggins Road, Saskatoon, SK S7N 5E5, Canada
| | - Andrew Freywald
- Department of Pathology, Laboratory Medicine, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada
| | - Denise G Hemmings
- Cancer Research Institute of Northern Alberta, University of Alberta, Edmonton, AB T6G 2E1, Canada
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, AB T6G 2S2, Canada
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB T6G 2E1, Canada
- Li Ka Shing Institute of Virology, University of Alberta, Edmonton, AB T6G 2E1, Canada
| | - Sabine Hombach-Klonisch
- Department of Human Anatomy and Cell Science, Faculty of Health Sciences, College of Medicine, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
| | - Thomas Klonisch
- Department of Human Anatomy and Cell Science, Faculty of Health Sciences, College of Medicine, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
| | - Afshin Raouf
- Department of Immunology, Faculty of Medicine, University of Manitoba, Winnipeg, MB R3E OT5, Canada
- Cancer Care Manitoba Research Institute, Cancer Care Manitoba, Winnipeg, MB R3E OV9, Canada
| | - Carrie Simone Shemanko
- The Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
- Department of Biological Sciences, University of Calgary, 2500 University Dr. NW, Calgary, AB T2N 1N4, Canada
| | - Diana Topolnitska
- Department of Immunology, Faculty of Medicine, University of Manitoba, Winnipeg, MB R3E OT5, Canada
- Cancer Care Manitoba Research Institute, Cancer Care Manitoba, Winnipeg, MB R3E OV9, Canada
| | - Kaitlyn Visser
- Cancer Research Institute of Northern Alberta, University of Alberta, Edmonton, AB T6G 2E1, Canada
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, AB T6G 2S2, Canada
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB T6G 2E1, Canada
- Li Ka Shing Institute of Virology, University of Alberta, Edmonton, AB T6G 2E1, Canada
| | - Franco J Vizeacoumar
- Division of Oncology, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N 0W8, Canada
- Saskatchewan Cancer Agency, University of Saskatchewan, 107 Wiggins Road, Saskatoon, SK S7N 5E5, Canada
| | - Edwin Wang
- Department of Biochemistry and Molecular Biology, Medical Genetics, and Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Spencer B Gibson
- Department of Oncology, University of Alberta, Edmonton, AB T6G 2R3, Canada
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Amansyah F, Prihantono P, Hamid F, Syamsu SA, Pieter J, Faruk M. The relationship of changes in molecular subtypes with metastases and progression-free survival in breast cancer. Breast Dis 2024; 43:71-78. [PMID: 38669518 DOI: 10.3233/bd-249000] [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] [Indexed: 04/28/2024]
Abstract
BACKGROUND Molecular subtyping of breast cancer cells is increasingly being developed as an initial step in selecting therapy and predicting the prognosis of breast cancer patients. During breast cancer, the molecular subtype of cancer cells can change. This study aimed to analyze the relationship between changes in the intrinsic subtype of breast cancer with metastasis and progression-free survival in breast cancer patients. METHODS This was a retrospective cohort study of patients diagnosed with breast cancer from 2016 to 2021. The molecular subtypes from the immunohistochemical examination results were recorded twice, and metastasis and progression-free survival (PFS) were recorded. The data were analyzed using the chi-square test and SPSS 26. RESULTS Of the 44 patients, 19 (43.2%) experienced a change in molecular subtype, and 25 (56.8%) did not. No significant relationship existed between changes in molecular subtype and metastasis (p = 0.405). No significant relationship existed between changes in molecular subtype and PFS (p = 0.900). A significant relationship was found between changes in the molecular subtype and PFS in the patients with changes in the molecular subtype (p = 0.022). CONCLUSIONS Changes in the intrinsic subtype were associated with PFS in breast cancer patients. Patients with an intrinsic subtype that changed to triple-negative showed worse PFS.
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Affiliation(s)
- Fitran Amansyah
- Department of Surgery, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Prihantono Prihantono
- Department of Surgery, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Firdaus Hamid
- Department of Clinical Microbiology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Salman Ardi Syamsu
- Division of Oncology, Department of Surgery, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - John Pieter
- Division of Oncology, Department of Surgery, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Muhammad Faruk
- Department of Surgery, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
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Hao N, Li M, Wang J, Song Y, Zhao Y, Zhang L, Yang X, Chen L, Ma J, Jia Q, Sui F. High PGAP3 expression is associated with lymph node metastasis and low CD8 +T cell in patients with HER2 + breast cancer. Pathol Res Pract 2023; 251:154890. [PMID: 37839361 DOI: 10.1016/j.prp.2023.154890] [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: 09/10/2023] [Revised: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Breast cancer (BC) stands as the most prevalent malignancy among women and ranks as the second most frequently diagnosed cancer globally among newly identified cases. Post-GPI attachment to proteins factor 3(PGAP3)was reported to involve in lipid remodeling. However, its specific role in breast cancer remains inadequately elucidated. Consequently, the principal objective of this study was to investigate the clinical significance of PGAP3 in breast cancer. METHODS We conducted an extensive analysis using both public databases and our own sample cohort to assess the role of PGAP3 in breast cancer. Immunohistochemistry was employed to assess PGAP3 expression, immune markers, and the co-expression of PGAP3 with key susceptibility genes. Data analysis was performed using the R programming language. RESULTS Our findings revealed that PGAP3 is significantly overexpressed in breast cancer, particularly in human epidermal growth factor 2 positive (HER2 +) breast cancer cases (p < 0.001). Co-expression analyses demonstrated a significant correlation between PGAP3 and susceptibility genes associated with breast cancer, including BRCA1, BRCA2, PALB2, ATM, CHEK2, RAD51C, and RAD51D (p < 0.05). Logistic regression analysis identified PGAP3 as a significant predictor of estrogen receptor (ER), progesterone receptor (PR), HER2, and lymph node metastasis status (p < 0.01). Furthermore, higher PGAP3 expression was associated with decreased infiltration of CD8 + T cells in breast cancer samples. CONCLUSION Our study sheds light on the clinical significance of PGAP3 in breast cancer. PGAP3 is not only overexpressed in breast cancer but also correlates with key susceptibility genes, lymph node metastasis, and CD8 + T cell infiltration. These findings provide valuable insights into the potential role of PGAP3 as a biomarker in breast cancer and may contribute to our understanding of the disease's pathogenesis.
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Affiliation(s)
- Na Hao
- Department of Breast Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Mingyang Li
- State Key Laboratory of Cancer Biology, Department of Pathology, Xijing Hospital and School of Basic Medicine, Fourth Military Medical University, Xi'an, China
| | - Jiachen Wang
- Department of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Yichen Song
- Department of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Yuelei Zhao
- Department of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Ling Zhang
- School of Information Engineering, Chang'an University, Xi'an, China
| | - Xinyu Yang
- Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Ligang Chen
- Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, China.
| | - Junchi Ma
- School of Information Engineering, Chang'an University, Xi'an, China.
| | - Qingge Jia
- Department of Reproductive Medicine, Xi'an International Medical Center Hospital, Northwest University, Xi'an, China.
| | - Fang Sui
- Department of Otorhinolaryngology-Head and Neck Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
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Ivanova M, Porta FM, Giugliano F, Frascarelli C, Sajjadi E, Venetis K, Cursano G, Mazzarol G, Guerini-Rocco E, Curigliano G, Criscitiello C, Fusco N. Breast Cancer with Brain Metastasis: Molecular Insights and Clinical Management. Genes (Basel) 2023; 14:1160. [PMID: 37372340 DOI: 10.3390/genes14061160] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/16/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023] Open
Abstract
Breast cancer is the most frequently diagnosed malignancy worldwide and the leading cause of cancer-related death among women. Brain metastases are a primary contributor to mortality, as they often go undetected until late stages due to their dormant nature. Moreover, the clinical management of brain metastases is complicated by the relevant issue of blood-brain barrier penetration. The molecular pathways involved in the formation, progression, and colonization of primary breast tumors and subsequent brain metastases are diverse, posing significant hurdles due to the heterogeneous nature of breast cancer subtypes. Despite advancements in primary breast cancer treatments, the prognosis for patients with brain metastases remains poor. In this review, we aim to highlight the biological mechanisms of breast cancer brain metastases by evaluating multi-step genetic pathways and to discuss currently available and emerging treatment strategies to propose a prospective overview of the management of this complex disease.
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Affiliation(s)
- Mariia Ivanova
- Division of Pathology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
| | - Francesca Maria Porta
- Division of Pathology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
- School of Pathology, University of Milan, 20122 Milan, Italy
| | - Federica Giugliano
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
- Division of Early Drug Development for Innovative Therapies, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
| | - Chiara Frascarelli
- Division of Pathology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Elham Sajjadi
- Division of Pathology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Konstantinos Venetis
- Division of Pathology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
| | - Giulia Cursano
- Division of Pathology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
| | - Giovanni Mazzarol
- Division of Pathology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
| | - Elena Guerini-Rocco
- Division of Pathology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Giuseppe Curigliano
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
- Division of Early Drug Development for Innovative Therapies, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
| | - Carmen Criscitiello
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
- Division of Early Drug Development for Innovative Therapies, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
| | - Nicola Fusco
- Division of Pathology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
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