1
|
Dubey AK, Kaur I, Madaan R, Raheja S, Bala R, Garg M, Kumar S, Lather V, Mittal V, Pandita D, Gundamaraju R, Singla RK, Sharma R. Unlocking the potential of oncology biomarkers: advancements in clinical theranostics. Drug Metab Pers Ther 2024; 39:5-20. [PMID: 38469723 DOI: 10.1515/dmpt-2023-0056] [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: 06/30/2023] [Accepted: 01/11/2024] [Indexed: 03/13/2024]
Abstract
INTRODUCTION Cancer biomarkers have revolutionized the field of oncology by providing valuable insights into tumor changes and aiding in screening, diagnosis, prognosis, treatment prediction, and risk assessment. The emergence of "omic" technologies has enabled biomarkers to become reliable and accurate predictors of outcomes during cancer treatment. CONTENT In this review, we highlight the clinical utility of biomarkers in cancer identification and motivate researchers to establish a personalized/precision approach in oncology. By extending a multidisciplinary technology-based approach, biomarkers offer an alternative to traditional techniques, fulfilling the goal of cancer therapeutics to find a needle in a haystack. SUMMARY AND OUTLOOK We target different forms of cancer to establish a dynamic role of biomarkers in understanding the spectrum of malignancies and their biochemical and molecular characterization, emphasizing their prospective contribution to cancer screening. Biomarkers offer a promising avenue for the early detection of human cancers and the exploration of novel technologies to predict disease severity, facilitating maximum survival and minimum mortality rates. This review provides a comprehensive overview of the potential of biomarkers in oncology and highlights their prospects in advancing cancer diagnosis and treatment.
Collapse
Affiliation(s)
- Ankit Kumar Dubey
- Joint Laboratory of Artificial Intelligence for Critical Care Medicine, Department of Critical Care Medicine and Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, 34753 Sichuan University , Chengdu, P.R. China
- iGlobal Research and Publishing Foundation, New Delhi, India
| | - Ishnoor Kaur
- Chitkara College of Pharmacy, 154025 Chitkara University Punjab , Rajpura, India
| | - Reecha Madaan
- Chitkara College of Pharmacy, 154025 Chitkara University Punjab , Rajpura, India
| | - Shikha Raheja
- Jan Nayak Ch. Devi Lal Memorial College of Pharmacy, Sirsa, Haryana, India
| | - Rajni Bala
- Chitkara College of Pharmacy, 154025 Chitkara University Punjab , Rajpura, India
| | - Manoj Garg
- Amity Institute of Molecular Medicine & Stem Cell Research, 77282 Amity University, Sector-125 , Noida, India
| | - Suresh Kumar
- Department of Pharmaceutical Sciences and Drug Research, 429174 Punjabi University Patiala , Patiala, India
| | - Viney Lather
- Amity Institute of Pharmacy, 77282 Amity University , Noida, India
| | - Vineet Mittal
- Department of Pharmaceutical Sciences, 29062 Maharshi Dayanand University , Rohtak, Haryana, India
| | - Deepti Pandita
- Department of Pharmaceutics, Delhi Pharmaceutical Sciences and Research University, PushpVihar, 633274 Govt. of NCT of Delhi , New Delhi, India
- Centre for Advanced Formulation and Technology (CAFT), Delhi Pharmaceutical Sciences and Research University, PushpVihar, Govt. of NCT of Delhi, New Delhi, India
| | - Rohit Gundamaraju
- ER Stress and Mucosal Immunology Lab, School of Health Sciences, 8785 University of Tasmania , Launceston, Tasmania, Australia
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Rajeev K Singla
- Joint Laboratory of Artificial Intelligence for Critical Care Medicine, Department of Critical Care Medicine and Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, 34753 Sichuan University , Chengdu, P.R. China
- School of Pharmaceutical Sciences, 34753 Lovely Professional University , Phagwara, Punjab, India
| | - Rohit Sharma
- Department of Rasa Shastra and Bhaishajya Kalpana, Faculty of Ayurveda, Institute of Medical Sciences, 80095 Banaras Hindu University , Varanasi, Uttar Pradesh, India
| |
Collapse
|
2
|
Ki-67 Index Provides Long-Term Survival Information for Early-Stage HER2-Low-Positive Breast Cancer: A Single-Institute Retrospective Analysis. JOURNAL OF ONCOLOGY 2022; 2022:4364151. [PMID: 36147446 PMCID: PMC9489376 DOI: 10.1155/2022/4364151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/14/2022] [Accepted: 08/05/2022] [Indexed: 11/30/2022]
Abstract
Aim It has been reported that more than half of breast cancer (BC) could be identified as HER2-low-positive, which might be a distinct subtype. But the results are controversial. We aim to compare the survival outcomes between HER2-low-positive and HER2-0 BC with Asian women based on HR status or Ki-67 index. Methods Between January 2009 and December 2017, HER2-nonamplified BC in our single institute was identified. Patients were classified as HER2-low and HER2-0 cohort. Clinical characteristics were compared between these two groups and survival outcomes were calculated by the Kaplan–Meier method. We also performed subgroup analysis according to Ki-67 index and hormone-receptor (HR) status. Results Of the 2,230 included patients, 536 presented with HER2-0, and 1,694 with HER2-low positive. After a median follow-up of 85 months (range: 1–152 months), the 8-year OS, BCSS, and RFS of the overall cohort were 91%, 95%, and 89%, respectively. In comparison with the HER2-0 cohort, majority of HER2-low-expression BC concurrently presented with HR positive (82.3% vs. 69%, P < 0.001). There was no significant survival difference between the two groups in terms of OS, BCSS, and RFS (all p > 0.05). We then performed subgroup analysis according to HR status and Ki-67 index (<14% vs. ≥14%). Our results indicated that there was no significant survival difference between HER2-low-positive and HER2-0 tumors regardless of HR status (p > 0.05), while OS (p=0.026) and BCSS (p=0.052) of HER2-0 BC with high Ki-67 index were significantly poorer than that of HER2-low positive with high Ki-67, but not for RFS (p=0.17). Conclusion Among early stage HER2-nonamplified BC, no significant survival difference could be found between HER2-low positive and HER2-0 cohort regardless of HR status. Survival outcomes of HER2-low positive with high Ki-67 seem to be poorer than that of HER2-0 tumors with high Ki-67 index.
Collapse
|
3
|
Comparison of Genomic Profiling Data with Clinical Parameters: Implications for Breast Cancer Prognosis. Cancers (Basel) 2022; 14:cancers14174197. [PMID: 36077734 PMCID: PMC9454811 DOI: 10.3390/cancers14174197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/24/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Around 20 years ago, genomic profiling of breast carcinomas identified tumor subtypes with clinical implications and opened the door for a better understanding of breast cancer biology. The commercialization of multigene tests had a significant impact on clinical practice, and yet, controversy exists as to which methodology is best to inform the choice of therapy and existing recommendations are inconsistent and often driven by cost-effectiveness. Here we report data from a cohort of breast cancer patients in which pathological and molecular subtyping are directly compared in a clinical setting. The findings show that some patients with genomic low-risk tumors could receive unnecessary systemic therapy if only following the classical clinical parameters, while others could remain under-treated. This study suggests that to design precise treatment regimens for patients with early breast cancer, the conventional clinicopathological classification should be complemented with the robust prognostic information provided by molecular subtyping. Abstract Precise prognosis is crucial for selection of adjuvant therapy in breast cancer. Molecular subtyping is increasingly used to complement immunohistochemical and pathological classification and to predict recurrence. This study compares both outcomes in a clinical setting. Molecular subtyping (MammaPrint®, TargetPrint®, and BluePrint®) and pathological classification data were compared in a cohort of 143 breast cancer patients. High risk clinical factors were defined by a value of the proliferation factor Ki67 equal or higher than 14% and/or high histological grade. The results from molecular classification were considered as reference. Core needle biopsies were found to be comparable to surgery samples for molecular classification. Discrepancies were found between molecular and pathological subtyping of the samples, including misclassification of HER2-positive tumors and the identification of a significant percentage of genomic high risk T1N0 tumors. In addition, 20% of clinical low-risk tumors showed genomic high risk, while clinical high-risk samples included 42% of cases with genomic low risk. According to pathological subtyping, a considerable number of breast cancer patients would not receive the appropriate systemic therapy. Our findings support the need to determine the molecular subtype of invasive breast tumors to improve breast cancer management.
Collapse
|
4
|
Nishimura R, Osako T, Okumura Y, Nakano M, Otsuka H, Fujisue M, Arima N. Triple Negative Breast Cancer: An Analysis of the Subtypes and the Effects of Menopausal Status on Invasive Breast Cancer. J Clin Med 2022; 11:jcm11092331. [PMID: 35566456 PMCID: PMC9103495 DOI: 10.3390/jcm11092331] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/23/2022] [Accepted: 04/21/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Triple negative breast cancer (TNBC) is a subtype of breast cancer which lacks hormone receptor (HR) expression and HER2 gene amplification and is the most aggressive subtype, with a heterogeneous genetic profile. The aim of this retrospective study was to evaluate the clinical significance of menopausal status in breast cancer cases with TNBC. Methods: Primary breast cancer patients who underwent curative surgery were enrolled in this retrospective study. A total of 5153 invasive breast cancer cases with Stage I–III were analyzed. The distribution of cases according to the menopausal status and subtypes was investigated and the clinicopathological characteristics and prognosis were compared between pre- and postmenopausal TNBC patients. Results: TNBC was frequently seen in postmenopausal patients and Luminal B and Luminal/HER2 subtypes were more common in premenopausal patients. There was no difference in DFS in the Luminal A/B and HER2 subtypes, but a significant difference was seen in the TNBC patients. Premenopausal patients with TNBC frequently had an overexpression of the p53 protein, a significantly higher Ki-67 index value, and a higher nuclear grade. A multivariate analysis revealed that menopausal status, nodal status, and tumor size were significant factors for DFS in TNBC cases. Conclusion: Menopausal status significantly correlates with breast cancer subtypes. TNBC was often seen in postmenopausal patients and these patients tend to have more favorable factors and a better DFS than premenopausal patients. These findings suggest that menopausal status is an important factor for evaluating biology and prognosis in TNBC cases.
Collapse
Affiliation(s)
- Reiki Nishimura
- Department of Breast Oncology, Kumamoto Shinto General Hospital, Kumamoto 862-8655, Japan; (T.O.); (Y.O.); (M.N.); (H.O.); (M.F.)
- Correspondence:
| | - Tomofumi Osako
- Department of Breast Oncology, Kumamoto Shinto General Hospital, Kumamoto 862-8655, Japan; (T.O.); (Y.O.); (M.N.); (H.O.); (M.F.)
| | - Yasuhiro Okumura
- Department of Breast Oncology, Kumamoto Shinto General Hospital, Kumamoto 862-8655, Japan; (T.O.); (Y.O.); (M.N.); (H.O.); (M.F.)
| | - Masahiro Nakano
- Department of Breast Oncology, Kumamoto Shinto General Hospital, Kumamoto 862-8655, Japan; (T.O.); (Y.O.); (M.N.); (H.O.); (M.F.)
| | - Hiroko Otsuka
- Department of Breast Oncology, Kumamoto Shinto General Hospital, Kumamoto 862-8655, Japan; (T.O.); (Y.O.); (M.N.); (H.O.); (M.F.)
| | - Mamiko Fujisue
- Department of Breast Oncology, Kumamoto Shinto General Hospital, Kumamoto 862-8655, Japan; (T.O.); (Y.O.); (M.N.); (H.O.); (M.F.)
| | - Nobuyuki Arima
- Department of Pathology, Kumamoto Shinto General Hospital, Kumamoto 862-8655, Japan;
| |
Collapse
|
5
|
Ki-67 and breast cancer prognosis: does it matter if Ki-67 level is examined using preoperative biopsy or postoperative specimen? Breast Cancer Res Treat 2022; 192:343-352. [PMID: 35025005 PMCID: PMC8926964 DOI: 10.1007/s10549-022-06519-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 01/04/2022] [Indexed: 11/17/2022]
Abstract
Purpose This study aimed to identify the association between Ki-67 level and the prognosis of patients with breast cancer, regardless of the timing of Ki-67 testing (using preoperative biopsy vs. postoperative specimen). Methods A total of 4177 patients underwent surgery between January 2008 and December 2016. Immunohistochemical Ki-67 levels, using either preoperative (1673) or postoperative (2831) specimens, were divided into four groups using cutoff points of 10%, 15%, and 20%. Results Groups with higher-Ki-67 levels, in both the pre- and postoperative periods, showed significantly larger tumor size, higher grade, more frequent hormone receptor-negativity and human epidermal growth factor receptor 2 overexpression, and active adjuvant treatments than groups with lower-Ki-67 levels. High-Ki-67 levels were also significantly associated with poor survival, irrespective of the timing of specimen examination. Conclusion Despite the problems associated with Ki-67, Ki-67 level is an important independent prognostic factor, regardless of the timing of Ki-67 testing, i.e., preoperative or postoperative testing.
Collapse
|
6
|
Cao L, Sugumar K, Keller E, Li P, Rock L, Simpson A, Freyvogel M, Montero AJ, Shenk R, Miller ME. Neoadjuvant Endocrine Therapy as an Alternative to Neoadjuvant Chemotherapy Among Hormone Receptor-Positive Breast Cancer Patients: Pathologic and Surgical Outcomes. Ann Surg Oncol 2021; 28:5730-5741. [PMID: 34342757 PMCID: PMC8330206 DOI: 10.1245/s10434-021-10459-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/22/2021] [Indexed: 12/22/2022]
Abstract
Background Neoadjuvant chemotherapy (NCT) is considered more effective in downstaging hormone receptor-positive (HR+) breast cancer than neoadjuvant endocrine therapy (NET), particularly in node-positive disease. This study compared breast and axillary response and survival after NCT and NET in HR+ breast cancer. Methods Based on American College of Surgeons Oncology Group (ACOSOG) Z1031 criteria, women age 50 years or older with cT2-4 HR+ breast cancer who underwent NET or NCT and surgery were identified in the National Cancer Database 2010–2016. Chi-square and logistic regression analysis determined differences between the NCT and NET groups and therapy response, including downstaging and pathologic complete response (pCR, ypT0/is and ypN0). Results Of 19,829 patients, 14,025 (70.7%) received NCT and 5804 (29.3%) received NET. The NET patients were older (mean age, 68.9 vs. 60.3; P < 0.001) and had greater comorbidity (1+ Charlson–Deyo score, 21% vs. 16%; P < 0.001). Therapy achieved T downstaging (any) for 58% of the patients with NCT versus 40.5% of the patients with NET, and in-breast pCR was achieved for 9.3% of the NCT versus 1.3% of the NET patients (P < 0.001). Approximately half of the mastectomy procedures could have been potentially avoided for the patients with in-breast pCR (53.6% of the NCT and 43.8% of the NET patients). For the cN+ patients, N downstaging (any) was 29% for the NCT patients versus 18.3% for the NET patients (P < 0.001), and nodal pCR was achieved for 20.3% of the NCT versus 13.5% of the NET patients (P < 0.001). Among those with nodal pCR, axillary lymph node dissection (ALND) still was performed for 56% of the patients after NCT and 45% of the patients after NET. Conclusions Although the response rates after NCT were higher, NET achieved both T and N downstaging and pCR. Neoadjuvant endocrine therapy can be used to de-escalate surgery for patients who cannot tolerate NCT or when chemotherapy may not be effective based on genomic testing. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10459-3.
Collapse
Affiliation(s)
- Lifen Cao
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA
| | - Kavin Sugumar
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA
| | - Eleanor Keller
- University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Pamela Li
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA
| | - Lisa Rock
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA
| | - Ashley Simpson
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA
| | - Mary Freyvogel
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA
| | - Alberto J Montero
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Robert Shenk
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA
| | - Megan E Miller
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA. .,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA.
| |
Collapse
|
7
|
Yarso KY, Bellynda M, Azmiardi A, Wasita B, Heriyanto DS, Astuti I, Hakimi M, Aryandono T. Chemotherapy Negates the Effect of SDF1 mRNA to Distant Metastasis and Poor Overall Survival in Breast Cancer Patients. Asian Pac J Cancer Prev 2021; 22:757-766. [PMID: 33773539 PMCID: PMC8286657 DOI: 10.31557/apjcp.2021.22.3.757] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE Investigate the effect of SDF1a, nuclear, and cytoplasmic CXCR4 breast cancer tissue on metastasis and overall survival in patients with complete-chemotherapy and no-chemotherapy. METHODS Cohort ambidirectional design was employed with survival analysis that followed the patient's diagnosis until obtaining the outcome, distant metastasis, or death. We analyzed samples in three groups (all-patient, no-chemotherapy, and complete-chemotherapy groups). Breast cancer cell nuclear and cytoplasm expressions of CXCR4 protein were examined using immunohistochemistry. Amplification of mRNA SDF1a of breast cancer tissue was examined using rtPCR on 131 samples from the same initial paraffin block. RESULTS In the distant metastasis and Overall Survival (OS) analysis, there was no correlation between cytoplasmic and nuclear CXCR4 in all-patient, no-chemotherapy, and complete-chemotherapy groups. SDF1a was significantly correlated to shorter distant metastasis and poor OS in the all-patient (p=0.004 and p=0.04, respectively) and no-chemotherapy group (p=0.008 and p=0.026, respectively). However, in the complete-chemotherapy group, SDF1a was not correlated to either metastasis (p=0.527) or OS (p=0.993), advanced stage demonstrated a strong association on shorter distant metastatic in no-chemotherapy (p=0.021) and complete-chemotherapy group (p=0.004) and also poor OS in both groups (p=0.006 and p=0.002, respectively). The hormone receptor showed a protective effect on the no-chemotherapy group's OS (p= 0.019). Meanwhile, not undergoing chemotherapy was associated with poor OS in the all-patient group (p= 0.011). CONCLUSION SDF1a mRNA amplification has a significant correlation with the occurrence of metastasis and OS in all-patient and no-chemotherapy group. Undergoing chemotherapy negates the effect of SDF1a for distant metastasis and OS.
Collapse
Affiliation(s)
- Kristanto Yuli Yarso
- Department of Surgery, Oncology Division, Medical Faculty, Sebelas Maret University, Indonesia
| | - Monica Bellynda
- Department of Surgery, Medical Faculty, Sebelas Maret University, Indonesia
| | - Akhmad Azmiardi
- Department of Public Health, Faculty of Public Health, Veteran Bangun Nusantara Sukoharjo University, Indonesia
| | - Brian Wasita
- Department of Anatomical Pathology, Medical Faculty, Sebelas Maret University, Indonesia
| | - Didik Setyo Heriyanto
- Department of Anatomical Pathology, Medical Faculty, Gadjah Mada University, Indonesia
| | - Indwiani Astuti
- Department of Pharmacology and Therapy, Medical Faculty, Gadjah Mada University, Indonesia
| | - Mohammad Hakimi
- Department of Obstetrics and Gynecology, Medical Faculty, Gadjah Mada University, Indonesia
| | - Teguh Aryandono
- Department of Surgery, Oncology Division, Medical Faculty, Gadjah Mada University, Indonesia
| |
Collapse
|
8
|
Chen Y, Wang J, Zhang X, Yang W, Chen H, Bao B, Qiu Y, Tian L. Correlation between apparent diffusion coefficient and pathological characteristics of patients with invasive breast cancer. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:143. [PMID: 33569445 PMCID: PMC7867890 DOI: 10.21037/atm-20-7746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background There is insufficient research on the correlation between the apparent diffusion coefficient and clinicopathological characteristics of breast cancer patients. The present study is to investigate the correlation between the apparent diffusion coefficient and pathological characteristics of patients with invasive breast cancer. Methods From January 2019 to September 2020, 122 cases of invasive breast cancer and 21 cases of benign tumors were retrospectively enrolled. The apparent diffusion coefficient was compared between the two groups, and the correlation between the apparent diffusion coefficient and the pathological characteristics of the patients with invasive breast cancer were analyzed. Results Compared with the benign tumor group, the apparent diffusion coefficient in the invasive breast cancer group was significantly lower (0.89±0.17 vs. 1.47±0.27 10−3 mm2/s, P=0.000). Using the apparent diffusion coefficient to diagnose patients with invasive breast cancer, the area under receiver operating characteristic (ROC) curve was 0.966±0.021 [95% confidence interval (CI): 0.924–1.000, P=0.000], and the best diagnostic cut-off value was 1.16 (10−3 mm2/s), with sensitivity and specificity of 0.905 and 0.902, respectively. The apparent diffusion coefficient was used to diagnose vascular tumor thrombus in patients with invasive breast cancer. The area under the ROC curve was 0.641±0.068 (95% CI: 0.508–0.774, P=0.047), and the best diagnostic threshold was 0.835 (10−3 mm2/s), with sensitivity and specificity of 0.676 and 0.650, respectively. The apparent diffusion coefficient in patients with high expression of Ki-67 (%) was significantly reduced (0.87±0.17 vs. 1.00±0.16 10−3 mm2/s, P=0.000). The apparent diffusion coefficient was not significantly correlated with age, menopause, lesion size, estrogen receptor, progesterone receptor, or lymph node metastasis in patients with invasive breast cancer (P>0.05). Conclusions In patients with invasive breast cancer the apparent diffusion coefficient was significantly reduced. It was able to differentiate invasive breast cancer and vascular tumor thrombus, and was also related to Ki-67 (%) high expression.
Collapse
Affiliation(s)
- Yuhui Chen
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jiandong Wang
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xiuxiu Zhang
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Wuyao Yang
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Hongye Chen
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Baoshi Bao
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yue Qiu
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Lin Tian
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
9
|
Egeland NG, Jonsdottir K, Lauridsen KL, Skaland I, Hjorth CF, Gudlaugsson EG, Hamilton-Dutoit S, Lash TL, Cronin-Fenton D, Janssen EAM. Digital Image Analysis of Ki-67 Stained Tissue Microarrays and Recurrence in Tamoxifen-Treated Breast Cancer Patients. Clin Epidemiol 2020; 12:771-781. [PMID: 32801916 PMCID: PMC7383278 DOI: 10.2147/clep.s248167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/05/2020] [Indexed: 12/17/2022] Open
Abstract
Purpose The proliferation marker Ki-67 has been used as a prognostic marker to separate low- and high-risk breast cancer subtypes and guide treatment decisions for adjuvant chemotherapy. The association of Ki-67 with response to tamoxifen therapy is unclear. High-throughput automated scoring of Ki-67 might enable standardization of quantification and definition of clinical cut-off values. We hypothesized that digital image analysis (DIA) of Ki-67 can be used to evaluate proliferation in breast cancer tumors, and that Ki-67 may be associated with tamoxifen resistance in early-stage breast cancer. Patients and Methods Here, we apply DIA technology from Visiopharm using a custom designed algorithm for quantifying the expression of Ki-67, in a case–control study nested in the Danish Breast Cancer Group clinical database, consisting of stages I, II, or III breast cancer patients of 35–69 years of age, diagnosed during 1985–2001, in the Jutland peninsula, Denmark. We assessed DIA-Ki-67 score on tissue microarrays (TMAs) from breast cancer patients in a case–control study including 541 ER-positive and 300 ER-negative recurrent cases and their non-recurrent controls, matched on ER-status, cancer stage, menopausal status, year of diagnosis, and county of residence. We used logistic regression to estimate odds ratios and associated 95% confidence intervals to determine the association of Ki-67 expression with recurrence risk, adjusting for matching factors, chemotherapy, type of surgery, receipt of radiation therapy, age category, and comorbidity. Results Ki-67 was not associated with increased risk of recurrence in tamoxifen-treated patients (ORadj =0.72, 95% CI 0.54, 0.96) or ER-negative patients (ORadj =0.85, 95% CI 0.54, 1.34). Conclusion Our findings suggest that Ki-67 digital image analysis in TMAs is not associated with increased risk of recurrence among tamoxifen-treated ER-positive breast cancer or ER-negative breast cancer patients. Overall, our findings do not support an increased risk of recurrence associated with Ki-67 expression.
Collapse
Affiliation(s)
- Nina Gran Egeland
- Department of Pathology, Stavanger University Hospital, Stavanger, Norway.,Department of Chemistry, Bioscience and Environmental Engineering, University of Stavanger, Stavanger, Norway
| | - Kristin Jonsdottir
- Department of Pathology, Stavanger University Hospital, Stavanger, Norway
| | | | - Ivar Skaland
- Department of Pathology, Stavanger University Hospital, Stavanger, Norway
| | - Cathrine F Hjorth
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Timothy L Lash
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Epidemiology, Rollins School of Public Health and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Emiel A M Janssen
- Department of Pathology, Stavanger University Hospital, Stavanger, Norway.,Department of Chemistry, Bioscience and Environmental Engineering, University of Stavanger, Stavanger, Norway
| |
Collapse
|
10
|
Martí C, Sánchez-Méndez JI. Neoadjuvant endocrine therapy for luminal breast cancer treatment: a first-choice alternative in times of crisis such as the COVID-19 pandemic. Ecancermedicalscience 2020; 14:1027. [PMID: 32368252 PMCID: PMC7192402 DOI: 10.3332/ecancer.2020.1027] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Indexed: 01/09/2023] Open
Abstract
The epidemiological emergency caused by CoV-2 (COVID-19) has changed priorities in breast cancer management. In those places where the pandemic has had the greatest effect, it is of paramount importance for most patients to be at home, reducing or postponing their attendance at clinics, as well as avoiding surgeries. In this scenario, neoadjuvant endocrine treatment could be an appropriate alternative treatment for hormone receptor positive breast cancer (luminal-like tumours) in order to minimise hospital admissions and to delay elective surgeries. Accordingly, we present a simple protocol that can be applied to most cases of luminal-like breast cancer and is appropriate for the majority of secondary or tertiary medical centres, or even primary care.
Collapse
Affiliation(s)
- Covadonga Martí
- Breast Cancer Unit, Hospital Universitario La Paz, 28046 Madrid, Spain
- Gynaecology Department, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - José I Sánchez-Méndez
- Breast Cancer Unit, Hospital Universitario La Paz, 28046 Madrid, Spain
- Gynaecology Department, Hospital Universitario La Paz, 28046 Madrid, Spain
| |
Collapse
|
11
|
Zati zehni A, Jacob SN, Mumm JN, Heidegger HH, Ditsch N, Mahner S, Jeschke U, Vilsmaier T. Hormone Receptor Expression in Multicentric/Multifocal versus Unifocal Breast Cancer: Especially the VDR Determines the Outcome Related to Focality. Int J Mol Sci 2019; 20:ijms20225740. [PMID: 31731733 PMCID: PMC6888644 DOI: 10.3390/ijms20225740] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 11/12/2019] [Indexed: 12/21/2022] Open
Abstract
The aim of this study was to evaluate the prognostic impact that hormone receptor (HR) expressions have on the two different breast cancer (BC) entities—multifocal versus unifocal BC. As the prognosis determining aspects, we investigated the overall survival (OS) and disease-free survival (DFS) by univariate and multivariate analysis. To underline the study’s conclusions, we additionally considered the histopathological grading and the tumor node metastasis (TNM) staging. A retrospective analysis was performed on survival-related events in a series of 320 breast cancer patients treated at the Department of Gynecology and Obstetrics at the Ludwig Maximillian University in Munich between 2000 and 2002. All three steroid receptors analyzed by immunohistochemistry, namely, the estrogen receptor (ER), the progesterone receptor (PR), and the vitamin D receptor (VDR), showed a significantly positive influence on the course of the disease, but only for the unifocal breast tumor patients. The prognosis of patients with multifocal breast cancer was either not affected by estrogen and/or progesterone receptor expression or even involved a worse etiopathology for the vitamin D receptor-positive patients. The estrogen receptor in unifocal breast cancer and the vitamin D receptor in multifocal breast cancer were especially identified as an independent prognostic marker for overall survival, when adjusted for age, grading, and staging. Altogether, our results strengthen the need to further investigate the behavior of the hormone receptors in breast cancer and understand why they have different effects on each focality type. Moreover, the studies for an adopted vitamin D supplementation due to breast cancer focality type must be enlarged to fully comprehend the remarkable and interesting role played by the vitamin D receptor.
Collapse
Affiliation(s)
- Alaleh Zati zehni
- Department of Obstetrics and Gynecology, Ludwig Maximilian University of Munich (LMU), Maistraße 11, 80337 Munich, Germany (H.H.H.); (S.M.); (T.V.)
| | - Sven-Niclas Jacob
- Department of General, Visceral, Transplant, Vascular and Thoracic Surgery, LMU, Marchioninistraße 15, 81377 Munich, Germany;
| | - Jan-Niclas Mumm
- Department of Urology, LMU Munich, University Hospital, Marchioninistraße 15, 81377 Munich, Germany;
| | - Helene Hildegard Heidegger
- Department of Obstetrics and Gynecology, Ludwig Maximilian University of Munich (LMU), Maistraße 11, 80337 Munich, Germany (H.H.H.); (S.M.); (T.V.)
| | - Nina Ditsch
- Department of Obstetrics and Gynecology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany;
| | - Sven Mahner
- Department of Obstetrics and Gynecology, Ludwig Maximilian University of Munich (LMU), Maistraße 11, 80337 Munich, Germany (H.H.H.); (S.M.); (T.V.)
| | - Udo Jeschke
- Department of Obstetrics and Gynecology, Ludwig Maximilian University of Munich (LMU), Maistraße 11, 80337 Munich, Germany (H.H.H.); (S.M.); (T.V.)
- Department of Obstetrics and Gynecology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany;
- Correspondence: ; Tel.: +49-8214-0016-5505
| | - Theresa Vilsmaier
- Department of Obstetrics and Gynecology, Ludwig Maximilian University of Munich (LMU), Maistraße 11, 80337 Munich, Germany (H.H.H.); (S.M.); (T.V.)
| |
Collapse
|
12
|
Viale G, Hanlon Newell AE, Walker E, Harlow G, Bai I, Russo L, Dell'Orto P, Maisonneuve P. Ki-67 (30-9) scoring and differentiation of Luminal A- and Luminal B-like breast cancer subtypes. Breast Cancer Res Treat 2019; 178:451-458. [PMID: 31422497 PMCID: PMC6797656 DOI: 10.1007/s10549-019-05402-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 08/07/2019] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Ki-67 labeling index assessed by immunohistochemical assays has been shown useful in assessing the risk of recurrence for estrogen receptor (ER)-positive HER2-negative breast cancers (BC) and distinguishing Luminal A-like from Luminal B-like tumors. We aimed to assess the performance of the Ventana CONFIRM anti-Ki-67 (30-9) Rabbit Monoclonal Primary Antibody. METHODS We constructed a case-cohort design based on a random sample (n = 679) of all patients operated on for a first primary, non-metastatic, ER-positive, HER2-negative BC at the European Institute of Oncology (IEO) Milan, Italy during 1998-2002 and all additional patients (n = 303) operated during the same period, who developed an event (metastasis in distant organs or death due to BC as primary event) and were not included in the previous subset. Multivariable Cox proportional hazards regression with inverse subcohort sampling probability weighting was used to evaluate the risk of event according to Ki-67 (30-9) and derived intrinsic molecular subtype, using previously defined cutoff values, i.e., respectively 14% and 20%. RESULTS Ki-67 was < 14% in 318 patients (32.4%), comprised between 14 and 19% in 245 patients (24.9%) and ≥ 20 in 419 patients (42.7%). At multivariable analysis, the risk of developing distant disease was 1.88 (95% CI 1.20-2.93; P = 0.006) for those with Ki-67 comprised between 14 and 19%, and 3.06 (95% CI 1.93-4.84; P < 0.0001) for those with Ki-67 ≥ 20% compared to those with Ki-67 < 14%. Patients with Luminal B-like BC had an approximate twofold risk of developing distant disease (HR = 1.91; 95% CI 1.35-2.71; P = 0.0003) than patients with Luminal A-like BC defined using Ki-67 (30-9). CONCLUSIONS Ki-67 evaluation using the 30-9 rabbit monoclonal primary antibody was able to stratify patients with ER-positive HER2-negative BC into prognostically distinct groups. Ki-67 assessment, with strict adherence to the international recommendations, should be included among the clinically useful biological parameters for the best treatment of patients with BC.
Collapse
Affiliation(s)
- Giuseppe Viale
- Department of Pathology, IEO European Institute of Oncology IRCCS, Milan, Italy.,University of Milan, Milan, Italy
| | | | | | - Greg Harlow
- Ventana Medical Systems, Inc., Tucson, AZ, USA.
| | - Isaac Bai
- Ventana Medical Systems, Inc., Tucson, AZ, USA
| | - Leila Russo
- Department of Pathology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Patrizia Dell'Orto
- Department of Pathology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Patrick Maisonneuve
- Division of Epidemiology and Biostatistics, IEO European Institute of Oncology IRCCS, Milan, Italy
| |
Collapse
|
13
|
Wang W, Lin L, Fei X, Hong J, Gao W, Zhu S, Wu J, Huang O, He J, Li Y, Zhu L, Chen W, Chen X, Shen K. 21-Gene recurrence score influences the chemotherapy decision for patients with breast cancer of different luminal subtypes. Oncol Lett 2019; 18:4346-4356. [PMID: 31579428 DOI: 10.3892/ol.2019.10766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 07/18/2019] [Indexed: 12/20/2022] Open
Abstract
Luminal subtypes and the 21-gene recurrence score (RS) are important factors in the decision-making process for adjuvant chemotherapy in patients with hormonal receptor (HR)-positive/human epidermal growth factor receptor 2 (HER2)-negative breast cancer. However, their effect on adjuvant chemotherapy decisions in the real world has not been thoroughly investigated, particularly for patients of the luminal A-like subtype with a high RS or the luminal B-like subtype with a low RS. The present study, a total of 772 HR+/HER2- patients who underwent 21-gene testing, were included in a retrospective analysis. The impact of clinicopathological factors and the 21-gene RS on chemotherapy recommendation was analyzed in the whole population and for patients of different luminal subgroups. The results revealed that chemotherapy was highly recommended for patients of younger age, with larger tumor size, node involvement, higher grade, luminal B-like subtype and higher RS. A high RS was identified to be the most important impact factor for chemotherapy recommendation among all patients [odds ratio (OR), 62.54; 95% CI, 25.58-152.92], the luminal A-like group (OR, 435.05; 95% CI, 29.90-6331.06) and the luminal B-like group (OR, 57.20; 95% CI, 22.42-145.96). For patients of the luminal A-like subtype with a high RS or patients of the luminal B-like subtype with low RS, the 21-gene RS was demonstrated to be the most important independent factor for chemotherapy recommendation, with an adjusted OR of 134.52 (95% CI, 10.39-1741.89). In conclusion, luminal subtypes and the 21-gene RS were found to be associated with chemotherapy recommendation for HR+/HER2- patients. For patients with a discordant luminal subtype and 21-gene RS risk, the 21-gene RS score was found to be the most important factor that influences chemotherapy decision, which warrants further clinical evaluation.
Collapse
Affiliation(s)
- Wei Wang
- Department of Breast Surgery, Comprehensive Breast Health Center, Shanghai Jiaotong University School of Medicine, Shanghai 200025, P.R. China
| | - Lin Lin
- Department of Clinical Laboratory, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, P.R. China
| | - Xiaochun Fei
- Department of Pathology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, P.R. China
| | - Jin Hong
- Department of Breast Surgery, Comprehensive Breast Health Center, Shanghai Jiaotong University School of Medicine, Shanghai 200025, P.R. China
| | - Weiqi Gao
- Department of Breast Surgery, Comprehensive Breast Health Center, Shanghai Jiaotong University School of Medicine, Shanghai 200025, P.R. China
| | - Siji Zhu
- Department of Breast Surgery, Comprehensive Breast Health Center, Shanghai Jiaotong University School of Medicine, Shanghai 200025, P.R. China
| | - Jiayi Wu
- Department of Breast Surgery, Comprehensive Breast Health Center, Shanghai Jiaotong University School of Medicine, Shanghai 200025, P.R. China
| | - Ou Huang
- Department of Breast Surgery, Comprehensive Breast Health Center, Shanghai Jiaotong University School of Medicine, Shanghai 200025, P.R. China
| | - Jianrong He
- Department of Breast Surgery, Comprehensive Breast Health Center, Shanghai Jiaotong University School of Medicine, Shanghai 200025, P.R. China
| | - Yafen Li
- Department of Breast Surgery, Comprehensive Breast Health Center, Shanghai Jiaotong University School of Medicine, Shanghai 200025, P.R. China
| | - Li Zhu
- Department of Breast Surgery, Comprehensive Breast Health Center, Shanghai Jiaotong University School of Medicine, Shanghai 200025, P.R. China
| | - Weiguo Chen
- Department of Breast Surgery, Comprehensive Breast Health Center, Shanghai Jiaotong University School of Medicine, Shanghai 200025, P.R. China
| | - Xiaosong Chen
- Department of Breast Surgery, Comprehensive Breast Health Center, Shanghai Jiaotong University School of Medicine, Shanghai 200025, P.R. China
| | - Kunwei Shen
- Department of Breast Surgery, Comprehensive Breast Health Center, Shanghai Jiaotong University School of Medicine, Shanghai 200025, P.R. China
| |
Collapse
|
14
|
Sato N, Masuda N, Morimoto T, Ueno T, Kanbayashi C, Kaneko K, Yasojima H, Saji S, Sasano H, Morita S, Ohno S, Toi M. Neoadjuvant exemestane or exemestane plus docetaxel and cyclophosphamide tailored by clinicopathological response to 12 weeks' exemestane exposure in patients with estrogen receptor-positive breast cancer: A multicenter, open-label, phase II study. Cancer Med 2019; 8:5468-5481. [PMID: 31361400 PMCID: PMC6745863 DOI: 10.1002/cam4.2423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/28/2019] [Accepted: 07/03/2019] [Indexed: 12/21/2022] Open
Abstract
Our aim was to investigate the efficacy and safety of initial neoadjuvant endocrine therapy with exemestane alone followed by tailored treatment, either continued exemestane monotherapy or exemestane plus docetaxel–cyclophosphamide (TC) combination therapy, in postmenopausal patients with primary invasive estrogen receptor–positive, human epidermal growth factor receptor 2–negative, stage I‐IIIA breast cancer and Ki67 labeling index ≤30%. In this open‐label phase II study, patients initially received exemestane 25 mg/d for 12 weeks. Responders were defined as patients who achieved complete response (CR), partial response (PR) with Ki67 labeling index ≤5% after treatment, or stable disease with Ki67 labeling index ≤5% both before and after treatment. For the subsequent 12 weeks, exemestane monotherapy was continued for responders (group A), whereas nonresponders received exemestane plus four cycles of TC (docetaxel 75 mg/m2 and cyclophosphamide 600 mg/m2 every 3 weeks) (group B). Clinical response rate (ie the proportion of patients with CR or PR) at 24 weeks was the primary endpoint. Of 64 patients provisionally enrolled between December 2010 and May 2016, 58 (median age 60 years) started the study treatment. Five patients discontinued treatment in the initial exemestane monotherapy period, and 39 completed the study treatment. Clinical response rates at 8‐12 and 24 weeks were 71% (10/14, 95% confidence interval [CI] 41.9%‐91.6%) and 57% (8/14, 95% CI 28.9%‐82.3%), respectively, in group A, and 16% (4/25, 95% CI 4.5%‐36.1%) and 56% (14/25, 95% CI 34.9%‐75.6%), respectively, in group B. Grade ≥3 adverse events were reported in 8% (1/15) and 53% (20/38) in group A and group B, respectively. The tailored treatment maintained the favorable clinical response to exemestane alone in responders and improved clinical response in nonresponders. Trial number UMIN000004752 (UMIN Clinical Trials Registry).
Collapse
Affiliation(s)
- Nobuaki Sato
- Department of Breast Oncology, Niigata Cancer Center Hospital, Niigata, Japan
| | - Norikazu Masuda
- Department of Surgery, Breast Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Takashi Morimoto
- Department of Breast Surgery, Yao Municipal Hospital, Osaka, Japan
| | - Takayuki Ueno
- Breast Surgical Oncology, Breast Oncology Center, Cancer Institute Hospital, Tokyo, Japan
| | - Chizuko Kanbayashi
- Department of Breast Oncology, Niigata Cancer Center Hospital, Niigata, Japan
| | - Koji Kaneko
- Department of Breast Oncology, Niigata Cancer Center Hospital, Niigata, Japan
| | - Hiroyuki Yasojima
- Department of Surgery, Breast Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Shigehira Saji
- Department of Medical Oncology, Fukushima Medical University, Fukushima, Japan
| | | | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shinji Ohno
- Breast Oncology Center, Cancer Institute Hospital, Tokyo, Japan
| | - Masakazu Toi
- Department of Surgery (Breast Surgery), Graduate School of Medicine, Kyoto University, Kyoto, Japan
| |
Collapse
|