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Gan W, Han X, Gong Y, Yang Y, Wang C, Zhang Z. Diagnostic and prognostic assessments of adrenocortical carcinomas by pathological features, immunohistochemical markers and reticular histochemistry staining. Diagn Pathol 2024; 19:71. [PMID: 38802933 PMCID: PMC11131238 DOI: 10.1186/s13000-024-01496-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Current diagnostic criteria of adrenocortical neoplasms are mostly based on morphology. The utility of immunohistochemistry (IHC) and histochemistry is limited. MATERIALS AND METHODS To evaluate the diagnostic and prognostic utility of clinicopathological features, morphology, ancillary biomarkers, and reticular histochemistry in adrenocortical neoplasms. We examined 28 adrenocortical carcinomas (ACCs) and 50 adrenocortical adenomas (ACAs) obtained from pathology archives. Clinical data were retrieved from medical records. Two pathologists independently assessed hematoxylin and eosin-stained slides, employing modified Weiss criteria for all tumors and Lin-Weiss-Bisceglia criteria for oncocytic variants. Immunohistochemical markers (Calretinin, alpha-inhibin, MelanA, SF-1, Ki-67, PHH3, IGF-2, β-catenin, P53, CYP11B1, CYP11B2, MLH1, MSH2, MSH6, PMS2, EPCAM) and Gomori's Silver histochemistry were applied. Statistical analysis utilized SPSS Statistics 26. RESULTS ACCs exhibited larger tumor sizes (P<0.001) and symptomatic presentations (P = 0.031) compared to ACAs. Parameters of modified Weiss criteria and angioinvasion demonstrated diagnostic value for ACCs. Six immunohistochemical antibodies((MelanA, Ki-67, IGF-2, β-catenin, P53 and CYP11B1) and reticulin framework alterations showed diagnostic value. Notably, Ki-67 and reticulin staining were most recommended. Evident reticulin staining was frequently present in ACCs (P<0.001). Ki-67 was significantly higher in ACCs (P<0.001). Twenty-one conventional and seven oncocytic entities showed different necrosis frequencies. Symptoms and Ki-67 index ≥ 30% were prognostic for ACCs, correlating with shorter survival. CONCLUSIONS This study emphasizes the diagnostic value of reticulin framework alterations and a high Ki-67 index. Markers such as CYP11B1, IGF2, P53, β-catenin and MelanA also contribute to the diagnosis of ACCs. Symptoms and Ki-67 index ≥ 30% predict shorter survival. These findings encourges the use of ancillary markers such as reticulin histochemistry and Ki-67 in the workup of evaluations of adrenocortical neoplasms.
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Affiliation(s)
- Wenting Gan
- Department of Pathology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, China
| | - Xue Han
- Department of Pathology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, China
| | - Yuxi Gong
- Department of Pathology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, China
| | - Yefan Yang
- Department of Pathology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, China
| | - Cong Wang
- Department of Pathology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, China.
| | - Zhihong Zhang
- Department of Pathology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, China.
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Huang Y, Liu L, Gan Q, Shen Z, Yao Y, Liao C, Lu S, zou Y, Huang Y, Kong J, Fan X. Estimation of the tumor size at cure threshold among adult patients with adrenocortical carcinoma: A populational-based study. Heliyon 2024; 10:e28160. [PMID: 38571632 PMCID: PMC10987901 DOI: 10.1016/j.heliyon.2024.e28160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 02/25/2024] [Accepted: 03/13/2024] [Indexed: 04/05/2024] Open
Abstract
Background The prognostic significance of tumor size with adrenocortical carcinoma (ACC) patients has not yet been thoroughly evaluated. Our objective was to investigate the influence of tumor size on prognostic value in adult ACC patients. Methods The Surveillance, Epidemiology and End Results Program (SEER) was employed to identify adult ACC patients who had been diagnosed from 2004 to 2015. The "X-Tile" program determined the optimal cutoff value of tumor size. Cancer-specific survival (CSS) and overall survive (OS) were estimated. The survival outcomes and risk factors were analyzed by the Kaplan-Meier methods and the multivariable cox regression respectively. Results A total 426 adult ACC patients were included. Univariable and multivariable cox analysis revealed age, larger tumor size and metastasis as consistent predictors of lower CSS and OS. The optimal cutoff value of tumor size was identified as 8.5 cm using X-tile software, and Kaplan-Meier method showed dramatic prognostic difference between patients with larger tumors (>8.5 cm) and smaller tumors (≤8.5 cm) (log-rank test, P < 0.001). Subgroup analyses revealed no statistical significance and a consistent proportionate effect of tumor size on CSS and OS across all eight pre-specified subgroups. Interestingly, an additional subgroup analysis showed that ACC patients could not benefit from chemotherapy in terms of CSS and OS. Conclusion The study suggests that tumor size is a crucial prognostic factor in ACC patients and a cutoff value 8.5 cm might indicate a poor outcome. Given the limitations of the available data, it is challenging to conclusively determine the benefit of chemotherapy in adult ACC patients across different tumor size ranges.
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Affiliation(s)
- Yi Huang
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Clinical Research Center for Urological Diseases, PR China
| | - Libo Liu
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Clinical Research Center for Urological Diseases, PR China
| | - Qinghua Gan
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Clinical Research Center for Urological Diseases, PR China
| | - Zefeng Shen
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Clinical Research Center for Urological Diseases, PR China
| | - Yuhui Yao
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Clinical Research Center for Urological Diseases, PR China
| | - Chengxiao Liao
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Clinical Research Center for Urological Diseases, PR China
| | - Sihong Lu
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Clinical Research Center for Urological Diseases, PR China
| | - Yitong zou
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Clinical Research Center for Urological Diseases, PR China
| | - Yaqiang Huang
- Department of Urology, Zhongshan City People's Hospital, Sunwen East Road, Zhongshan, 528400, Guangdong, PR China
| | - Jianqiu Kong
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Clinical Research Center for Urological Diseases, PR China
| | - Xinxiang Fan
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, PR China
- Guangdong Provincial Clinical Research Center for Urological Diseases, PR China
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Li M, Duan X, You D, Liu L. Construction of a novel clinical nomogram to predict cancer-specific survival in patients with primary malignant adrenal tumors: a large population-based retrospective study. Front Med (Lausanne) 2023; 10:1184607. [PMID: 37305122 PMCID: PMC10249662 DOI: 10.3389/fmed.2023.1184607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 05/08/2023] [Indexed: 06/13/2023] Open
Abstract
Background Primary malignant adrenal tumors were rare and had a poor prognosis. This investigation aimed to create a useful clinical prediction nomogram to anticipate cancer-specific survival (CSS) of patients with a primary malignant adrenal tumor. Method This study included 1748 patients with malignant adrenal tumor diagnoses subjects from 2000 to 2019. These subjects were allocated randomly into training (70%) and validation (30%) cohorts. Patients with adrenal tumors underwent univariate and multivariate Cox regression analyses to identify the CSS-independent predictive biomarkers. Therefore, a nomogram was created depending on those predictors, and calibration curves, receiver operating characteristic (ROC) curves, and decision curve analysis (DCA) were used to assess the calibration capacity of the nomogram, discriminative power, and clinical efficiency, respectively. Afterward, a risk system for categorizing patients with adrenal tumors was established. Result The univariate and multivariate Cox analysis demonstrated the CSS-independent predictive factors, including age, tumor stage, size, histological type, and surgery. As a result, a nomogram was developed using these variables. For the 3-, 5-, and 10-year CSS of this nomogram, the values of the area under the curve (AUC) of the ROC curves were 0.829, 0.827, and 0.822, respectively. Furthermore, the AUC values of the nomogram were higher than those of the individual independent prognostic components of CSS, indicating that the nomogram had stronger prognostic prediction reliability. A novel risk stratification method was created to further improve patient stratification and give clinical professionals a better reference for clinical decision-making. Conclusion Through the developed nomogram and risk stratification method, the CSS of patients with malignant adrenal tumors could be predicted more precisely, assisting physicians to differentiate patients better and creating personalized treatment strategies to optimize patient benefits.
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Affiliation(s)
- Mingzhen Li
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Xiaoying Duan
- Department of Acupuncture and Moxibustion, Second Hospital of Jilin University, Changchun, China
| | - Di You
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Linlin Liu
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, China
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Jangir H, Ahuja I, Agarwal S, Jain V, Meena JP, Agarwala S, Sharma R, Sharma MC, Iyer VK, Mani K. Pediatric Adrenocortical Neoplasms: A Study Comparing Three Histopathological Scoring Systems. Endocr Pathol 2023:10.1007/s12022-023-09767-z. [PMID: 37160532 DOI: 10.1007/s12022-023-09767-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 05/11/2023]
Abstract
Adrenocortical neoplasms are rare in childhood. Their histopathological categorization into benign and malignant is often challenging, impacting further management. While the AFIP/Wieneke scoring system is widely used for the prognostic classification of these tumors, it has limitations. Few other tumor scoring systems have evolved over the past few years. These have been validated in adults but not yet in pediatric patients. We evaluated a cohort of pediatric adrenocortical neoplasms to assess the applicability of AFIP/Wieneke criteria and the recently introduced Helsinki score and reticulin algorithm in predicting clinical outcomes. A tumor was considered 'clinically aggressive' in the presence of any of the following: metastases, recurrence, progressive disease, or death due to disease. Cases without any such event were considered 'clinically good'. Event-free survival time was the duration from the date of clinical presentation to any post-operative adverse event. For overall survival analysis, the endpoint was either the last follow-up or death due to disease.Using ROC curve analysis, the obtained cut-off Helsinki score of 24 could stratify the cases into two prognostically relevant groups. Survival analysis showed significant differences in the event-free and overall survival of these two groups of patients, validating the proposed cut-off. None of the three histopathological scoring systems could predict an unfavorable outcome with 100% accuracy. All showed a sensitivity of ≥ 80%, with the reticulin algorithm achieving 100% sensitivity. The specificity and accuracy of the AFIP/Wieneke criteria were the lowest (62.5% and 73.08%, respectively). While the Helsinki score (at the cut-off score of 24) and the reticulin algorithm had similar accuracy rates (80.77%, and 80%, respectively), the specificity of the former was higher (81.25%) than the latter (68.75%). A separate analysis revealed that the Ki-67 index at a cut-off of 18% had a sensitivity of 80% and a specificity of 81.25% for predicting an unfavorable outcome.
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Affiliation(s)
- Hemlata Jangir
- Department of Pathology, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
| | - Isheeta Ahuja
- Department of Pathology, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
| | - Shipra Agarwal
- Department of Pathology, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India.
| | - Vishesh Jain
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Jagdish Prasad Meena
- Department of Pediatric Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Agarwala
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Rajni Sharma
- Department of Pediatric Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Mehar Chand Sharma
- Department of Pathology, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
| | - Venkateswaran K Iyer
- Department of Pathology, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
| | - Kalaivani Mani
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
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Świeczkowski-Feiz S, Kaszczewski P, Gelo R, Krajewska E, Celejewski K, Toutounchi S, Ambroziak U, Pogorzelski R, Gałązka Z. Huge Hematoma as First Manifestation of Adrenocortical Carcinoma: A Case Report. Am J Case Rep 2023; 24:e937569. [PMID: 36617747 PMCID: PMC9837745 DOI: 10.12659/ajcr.937569] [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] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare malignancy associated with unfavorable prognosis. It is mainly diagnosed in the fifth or sixth decade of life. Symptoms of ACC are associated with hormonal activity, presence of metastases, and size of the tumor. The treatment and prognosis depend on the stage of the disease assessed with the ENSAT staging system. CASE REPORT A 38-year-old White man was admitted to our department from the city hospital due to a huge hematoma of the right adrenal gland (130×100 mm). On admission, the patient's condition was stable, and no active bleeding or other complications were present. Therefore, initially, conservative treatment was performed. The control CT scan showed reduction of the hematoma (90×80 mm). Due to the unknown character of the tumor and the sudden onset of bleeding, the patient was prepared for elective surgery according to the phaeochromocytoma surgery protocol. Following preparation, the patient underwent right-sided adrenalectomy. In the postoperative histopathological examination, adrenocortical carcinoma was diagnosed, which allowed the patient to receive appropriate oncological treatment. CONCLUSIONS There is currently no clear algorithm for the management of adrenal hemorrhage. A hemodynamically unstable patient requires urgent surgical treatment. Patients in good general condition should be prepared for early elective surgery.
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Affiliation(s)
- Siavash Świeczkowski-Feiz
- Department of General, Endocrine, and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland,University Clinical Center of the Medical University of Warsaw, Warsaw, Poland
| | - Piotr Kaszczewski
- Department of General, Endocrine, and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland,University Clinical Center of the Medical University of Warsaw, Warsaw, Poland,Corresponding Author: Piotr Kaszczewski, e-mail:
| | - Remigiusz Gelo
- 2 Clinic of Anesthesiology and Intensive Care, University Clinical Center of the Medical University of Warsaw, Warsaw, Poland
| | - Ewa Krajewska
- Department of General, Endocrine, and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland,University Clinical Center of the Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Celejewski
- Department of General, Endocrine, and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland,University Clinical Center of the Medical University of Warsaw, Warsaw, Poland
| | - Sadegh Toutounchi
- Department of General, Endocrine, and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland,University Clinical Center of the Medical University of Warsaw, Warsaw, Poland
| | - Urszula Ambroziak
- Department of Internal Diseases and Endocrinology, University Clinical Center of the Medical University of Warsaw, Warsaw, Poland
| | - Ryszard Pogorzelski
- Department of General, Endocrine, and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland,University Clinical Center of the Medical University of Warsaw, Warsaw, Poland
| | - Zbigniew Gałązka
- Department of General, Endocrine, and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland,University Clinical Center of the Medical University of Warsaw, Warsaw, Poland
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Xie W, Zhang Y, Cao R. Construction and validation of a prognostic model for predicting overall survival of primary adrenal malignant tumor patients: A population-based study with 1,080 patients. Front Surg 2022; 9:1025213. [PMID: 36353609 PMCID: PMC9637840 DOI: 10.3389/fsurg.2022.1025213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022] Open
Abstract
Objective Primary adrenal malignant tumor is rare. The factors affecting the prognosis remain poorly defined. This study targeted to construct and corroborate a model for predicting the overall survival of adrenal malignant tumor patients. Methods We investigated the SEER database for patients with primary adrenal malignant tumor. 1,080 patients were divided into a construction cohort (n = 756) and a validation cohort (n = 324), randomly. The prognostic factors for overall survival were evaluated using univariate and multivariate Cox analyses. The nomogram was constructed and then validated with C-index, calibration curve, time-dependent ROC curve, and decision curve analysis in both cohorts. Then we divided the patients into 3 different risk groups according to the total points of the nomogram and analyzed their survival status by Kaplan-Meier curve with log-rank test. Results The baseline characteristics of these two cohorts were not statistically different (P > 0.05). Using univariate and multivariate Cox analyses, 5 variables, including age, tumor size, histological type, tumor stage, and surgery of primary site, were distinguished as prognostic factors (P < 0.05). Based on these variables, we constructed a nomogram to predict the 3- year, 5- year, and 10-year overall survival. The C-indexes were 0.780 (0.760–0.800) in the construction cohort and 0.780 (0.751–0.809) in the validation cohort. In both cohorts, the AUC reached a fairly high level at all time points. The internal and external calibration curves and ROC analysis showed outstanding accuracy and discrimination. The decision curves indicated excellent clinical usefulness. The best cut-off values for the total points of the nomogram were 165.4 and 243.1, and the prognosis was significantly different for the three different risk groups (P < 0.001). Conclusion We successfully constructed a model to predict the overall survival of primary adrenal malignant tumor patients. This model was validated to perform brilliantly internally and externally, which can assist us in individualized clinical management.
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Affiliation(s)
| | | | - Runfu Cao
- Correspondence: Runfu Cao Yida Zhang
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Ronchi CL, Altieri B. Special Issue: Present and Future of Personalised Medicine for Endocrine Cancers. J Pers Med 2022; 12:710. [PMID: 35629133 PMCID: PMC9145565 DOI: 10.3390/jpm12050710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 04/25/2022] [Indexed: 02/01/2023] Open
Abstract
Major technological advances in genomics have made it possible to identify critical genetic alterations in cancer, rendering oncology well along the path to personalised cancer medicine [...].
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Affiliation(s)
- Cristina L. Ronchi
- Institute of Metabolism and System Research, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes, and Metabolism (CEDAM), Birmingham Health Partners, Birmingham B15 2TT, UK
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, 97080 Wuerzburg, Germany;
| | - Barbara Altieri
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, 97080 Wuerzburg, Germany;
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