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Wen H, Deng G, Shi X, Liu Z, Lin A, Cheng Q, Zhang J, Luo P. Body mass index, weight change, and cancer prognosis: a meta-analysis and systematic review of 73 cohort studies. ESMO Open 2024; 9:102241. [PMID: 38442453 PMCID: PMC10925937 DOI: 10.1016/j.esmoop.2024.102241] [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: 08/21/2023] [Revised: 11/19/2023] [Accepted: 01/09/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Identifying the association between body mass index (BMI) or weight change and cancer prognosis is essential for the development of effective cancer treatments. We aimed to assess the strength and validity of the evidence of the association between BMI or weight change and cancer prognosis by a systematic evaluation and meta-analysis of relevant cohort studies. METHODS We systematically searched the PubMed, Web of Science, EconLit, Embase, Food Sciences and Technology Abstracts, PsycINFO, and Cochrane databases for literature published up to July 2023. Inclusion criteria were cohort studies with BMI or weight change as an exposure factor, cancer as a diagnostic outcome, and data type as an unadjusted hazard ratio (HR) or headcount ratio. Random- or fixed-effects models were used to calculate the pooled HR along with the 95% confidence interval (CI). RESULTS Seventy-three cohort studies were included in the meta-analysis. Compared with normal weight, overweight or obesity was a risk factor for overall survival (OS) in patients with breast cancer (HR 1.37, 95% CI 1.22-1.53; P < 0.0001), while obesity was a protective factor for OS in patients with gastrointestinal tumors (HR 0.67, 95% CI 0.56-0.80; P < 0.0001) and lung cancer (HR 0.67, 95% CI 0.48-0.92; P = 0.01) compared with patients without obesity. Compared with normal weight, underweight was a risk factor for OS in patients with breast cancer (HR 1.15, 95% CI 0.98-1.35; P = 0.08), gastrointestinal tumors (HR 1.54, 95% CI 1.32-1.80; P < 0.0001), and lung cancer (HR 1.28, 95% CI 1.22-1.35; P < 0.0001). Compared with nonweight change, weight loss was a risk factor for OS in patients with gastrointestinal cancer. CONCLUSIONS Based on the results of the meta-analysis, we concluded that BMI, weight change, and tumor prognosis were significantly correlated. These findings may provide a more reliable argument for the development of more effective oncology treatment protocols.
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Affiliation(s)
- H Wen
- Department of Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong; The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong
| | - G Deng
- Department of Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong; The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong
| | - X Shi
- Department of Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong; The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong
| | - Z Liu
- State Key Laboratory of Proteomics, Beijing Proteome Research Center, National Center for Protein Sciences (Beijing), Beijing Institute of Lifeomics, Beijing; Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
| | - A Lin
- Department of Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong.
| | - Q Cheng
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Hunan, China.
| | - J Zhang
- Department of Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong.
| | - P Luo
- Department of Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong.
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Vick LV, Canter RJ, Monjazeb AM, Murphy WJ. Multifaceted effects of obesity on cancer immunotherapies: Bridging preclinical models and clinical data. Semin Cancer Biol 2023; 95:88-102. [PMID: 37499846 PMCID: PMC10836337 DOI: 10.1016/j.semcancer.2023.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/04/2023] [Accepted: 07/24/2023] [Indexed: 07/29/2023]
Abstract
Obesity, defined by excessive body fat, is a highly complex condition affecting numerous physiological processes, such as metabolism, proliferation, and cellular homeostasis. These multifaceted effects impact cells and tissues throughout the host, including immune cells as well as cancer biology. Because of the multifaceted nature of obesity, common parameters used to define it (such as body mass index in humans) can be problematic, and more nuanced methods are needed to characterize the pleiotropic metabolic effects of obesity. Obesity is well-accepted as an overall negative prognostic factor for cancer incidence, progression, and outcome. This is in part due to the meta-inflammatory and immunosuppressive effects of obesity. Immunotherapy is increasingly used in cancer therapy, and there are many different types of immunotherapy approaches. The effects of obesity on immunotherapy have only recently been studied with the demonstration of an "obesity paradox", in which some immune therapies have been demonstrated to result in greater efficacy in obese subjects despite the direct adverse effects of obesity and excess body fat acting on the cancer itself. The multifactorial characteristics that influence the effects of obesity (age, sex, lean muscle mass, underlying metabolic conditions and drugs) further confound interpretation of clinical data and necessitate the use of more relevant preclinical models mirroring these variables in the human scenario. Such models will allow for more nuanced mechanistic assessment of how obesity can impact, both positively and negatively, cancer biology, host metabolism, immune regulation, and how these intersecting processes impact the delivery and outcome of cancer immunotherapy.
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Affiliation(s)
- Logan V Vick
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Robert J Canter
- Department of Surgery, Division of Surgical Oncology, University of California Davis Comprehensive Cancer Center, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Arta M Monjazeb
- Department of Radiation Oncology, University of California Davis Comprehensive Cancer Center, University of California School of Medicine, Sacramento, CA, USA
| | - William J Murphy
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, CA, USA; Department of Internal Medicine, Division of Malignant Hematology, Cellular Therapy and Transplantation, University of California Davis School of Medicine, Sacramento, CA, USA.
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Li Z, Shen G, Shi M, Zheng Y, Guan Y, Xin Y, Wang M, Zhao F, Ren D, Zhao J. Association between high body mass index and prognosis of patients with early-stage breast cancer: A systematic review and meta-analysis. CANCER PATHOGENESIS AND THERAPY 2023; 1:205-215. [PMID: 38327841 PMCID: PMC10846319 DOI: 10.1016/j.cpt.2023.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 03/10/2023] [Accepted: 03/28/2023] [Indexed: 02/09/2024]
Abstract
Background A high body mass index (BMI) can indicate overweight or obesity and is a crucial risk factor for breast cancer survivors. However, the association between high BMI and prognosis in early-stage breast cancer (EBC) remains unclear. We aimed to assess the effects of high BMI on the prognosis of patients with EBC. Methods The PubMed, Embase, and Cochrane Library databases and proceedings of major oncological conferences related to the effects of BMI on the prognosis of breast cancer were searched up to November 2021. Fixed- and random-effects models were used for meta-analyses. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) for disease-free survival (DFS) and overall survival (OS) were extracted from the included literature. Results Twenty retrospective cohort studies with 33,836 patients with EBC were included. Overweight patients had worse DFS (HR: 1.16, 95% CI: 1.05-1.27, P = 0.002) and OS (HR: 1.20; 95% CI: 1.09-1.33, P < 0.001). Obesity also had adverse effects on DFS (HR: 1.17, 95% CI: 1.07-1.29, P = 0.001) and OS (HR: 1.30, 95% CI: 1.17-1.45, P < 0.001). Likewise, patients with high BMI had worse DFS (HR: 1.16, 95% CI: 1.08-1.26, P < 0.001) and OS (HR: 1.25, 95% CI: 1.14-1.39, P < 0.001). In subgroup analyses, overweight had adverse effects on DFS (HR: 1.11, 95% CI: 1.04-1.18, P = 0.001) and OS (HR: 1.18, 95% CI: 1.11-1.26, P < 0.001) in multivariate analyses, whereas the relationship that overweight had negative effects on DFS (HR: 1.21, 95% CI: 0.99-1.48, P = 0.058) and OS (HR: 1.39, 95% CI: 0.92-2.10, P = 0.123) was not statistically significant in univariate analysis. By contrast, obesity had adverse effects on DFS (HR: 1.21, 95% CI: 1.06-1.38, P = 0.004 and HR: 1.14, 95% CI: 1.08-1.22, P < 0.001) and OS (HR: 1.33, 95% CI: 1.15-1.54, P < 0.001 and HR: 1.23, 95% CI: 1.15-1.31, P < 0.001) in univariate and multivariate analyses, respectively. Conclusions Compared with normal weight, increased body weight (overweight, obesity, and high BMI) led to worse DFS and OS in patients with EBC. Once validated, these results should be considered in the development of prevention programs.
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Affiliation(s)
| | | | | | - Yonghui Zheng
- Breast Disease Diagnosis and Treatment Center of the Affiliated Hospital of Qinghai University and the Affiliated Cancer Hospital of Qinghai University, Xining, Qinghai 810000, China
| | - Yumei Guan
- Breast Disease Diagnosis and Treatment Center of the Affiliated Hospital of Qinghai University and the Affiliated Cancer Hospital of Qinghai University, Xining, Qinghai 810000, China
| | - Yuanfang Xin
- Breast Disease Diagnosis and Treatment Center of the Affiliated Hospital of Qinghai University and the Affiliated Cancer Hospital of Qinghai University, Xining, Qinghai 810000, China
| | - Miaozhou Wang
- Breast Disease Diagnosis and Treatment Center of the Affiliated Hospital of Qinghai University and the Affiliated Cancer Hospital of Qinghai University, Xining, Qinghai 810000, China
| | - Fuxing Zhao
- Breast Disease Diagnosis and Treatment Center of the Affiliated Hospital of Qinghai University and the Affiliated Cancer Hospital of Qinghai University, Xining, Qinghai 810000, China
| | - Dengfeng Ren
- Breast Disease Diagnosis and Treatment Center of the Affiliated Hospital of Qinghai University and the Affiliated Cancer Hospital of Qinghai University, Xining, Qinghai 810000, China
| | - Jiuda Zhao
- Breast Disease Diagnosis and Treatment Center of the Affiliated Hospital of Qinghai University and the Affiliated Cancer Hospital of Qinghai University, Xining, Qinghai 810000, China
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Zheng A, Zhang L, Ji Z, Fan L, Jin F. Oncotype DX for Comprehensive Treatment in Male Breast Cancer: A Case Report and Literature Review. Am J Mens Health 2020; 13:1557988319847856. [PMID: 31068065 PMCID: PMC6509981 DOI: 10.1177/1557988319847856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Male breast cancer (MBC) is uncommon in clinical practice. Using the 21-gene assay to facilitate decision-making on comprehensive treatment of MBC is rarely reported. This study reports the case of a 53-year-old man with left breast cancer. Modified radical mastectomy was performed. Endocrine treatment was chosen for the patient according to the result of the 21-gene assay, a recommended genomic test of breast cancer. The patient remained in good health without evidence of recurrence at 18-month follow-up. This case provides a reference mode for the comprehensive management of early-stage, estrogen receptor–expressing and lymph node–negative MBC patients.
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Affiliation(s)
- Ang Zheng
- 1 Department of Breast Surgery, The First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Lin Zhang
- 2 NingBo Huamei Hospital, University of Chinese Academy of Sciences, People's Republic of China
| | - Ziyao Ji
- 3 Department of Ultrasound, The First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Lijuan Fan
- 1 Department of Breast Surgery, The First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Feng Jin
- 1 Department of Breast Surgery, The First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
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Limon-Miro AT, Lopez-Teros V, Astiazaran-Garcia H. Dietary Guidelines for Breast Cancer Patients: A Critical Review. Adv Nutr 2017; 8:613-623. [PMID: 28710147 PMCID: PMC5502868 DOI: 10.3945/an.116.014423] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Current dietary guidelines for breast cancer patients (BCPs) fail to address adequate dietary intakes of macro- and micronutrients that may improve patients' nutritional status. This review includes information from the PubMed and Biomed Central databases over the last 15 y concerning dietary guidelines for BCPs and the potential impact of a personalized, nutrient-specific diet on patients' nutritional status during and after antineoplastic treatment. Results indicated that BCPs should receive a nutritional assessment immediately after diagnosis. In addition, they should be encouraged to pursue and maintain a healthy body weight [body mass index (BMI; in kg/m2) 20-24.9], preserving their lean mass and avoiding an increase in fat mass. Therefore, after nutritional status diagnosis, a conservative energy restriction of 500-1000 kcal/d could be considered in the dietary intervention when appropriate. Based on the reviewed information, we propose a personalized nutrition intervention for BCPs during and after antineoplastic treatment. Specifications in the nutritional therapy should be based on the patients' nutritional status, dietary habits, schedule, activities, and cultural preferences. BCPs' daily energy intake should be distributed as follows: <30% fat/d (mainly monounsaturated and polyunsaturated fatty acids), ∼55% carbohydrates (primarily whole foods such as oats, brown rice, and fruits), and 1.2-1.5 g protein ⋅ kg-1 ⋅ d-1 to avoid sarcopenic obesity. Findings suggest that 5-9 servings/d of fruits (∼150 g/serving) and vegetables (∼75 g/serving) should be encouraged. Garlic and cruciferous vegetables must also be part of the nutrition therapy. Adequate dietary intakes of food-based macro- and micronutrients rich in β-carotene and vitamins A, E, and C can both prevent deterioration in BCPs' nutritional status and improve their overall health and prognosis.
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Affiliation(s)
- Ana Teresa Limon-Miro
- Department of Nutrition, Research Center for Food and Development, Hermosillo, Sonora, Mexico; and
| | - Veronica Lopez-Teros
- Department of Chemical and Biological Sciences, University of Sonora, Hermosillo, Sonora, Mexico
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Benderli Cihan Y. Is Height of Prognostic Significance in Breast Cancer Cases? Asian Pac J Cancer Prev 2017; 18:589-591. [PMID: 28440607 PMCID: PMC5464469 DOI: 10.22034/apjcp.2017.18.3.589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective: The objective of this study was to investigate the correlation of height with prognosis and other prognostic factors in Turkish breast cancer cases. Materials and Methods: We retrospectively reviewed a total of 393 women aged between 26 and 88 years, diagnosed with stage 1-3 invasive ductal breast cancer, treated and followed-up in Kayseri Education and Research Hospital. Findings: The mean age at admission was 55.7 years; 77.6% were aged under 65, 56.7% were postmenopausal, 97.4% had undergone modified radical mastectomy, 47.3% were AJCC stage II, 36.8% N0, 46.0% grade II, 95.4% had received chemotherapy, 81.1% radiotherapy and 71.5% hormonotherapy. Height was under 151 cm in 20.8 %, 151-160 cm in 57.3 % and over 161 in 21.9 %. Follow-up duration differed between 0.3 and 195.3 months. Mean overal survival (OS) was 125.0 (65.6-184.3) months and progression free survival was 91.5 (37.7-145.2) months, with a tendency for better survival in taller individuals but no signficant variation between height groups. The 5 and 10-year OS rates were 74.5% and 56.4%, and PFS rates were 64.5% and 49.2%. Regarding association of height with other prognostic factors, a significant correlation was found between height and AJCC stage (p= 0.011) and estrogen status (ER) (p= 0.043). Conclusion: In conclusion, overal survival was found to be longer in patients with a height between 151 and 160 cm than those under 151 cm and over 161 cm. The reason for not obtaining significant results might be a relatively small number of patients and lack of the evaluation of clinical and pathologic characteristics together with anthropometric measurements in the patient population. Further studies are warranted to clarify any association.
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Affiliation(s)
- Yasemin Benderli Cihan
- Kayseri Education and Research Hospital, Department of Radiation Oncology, Turkey.
edu.tr
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Bongiovanni A, Riva N, Ricci M, Liverani C, La Manna F, De Vita A, Foca F, Mercatali L, Severi S, Amadori D, Ibrahim T. First-line chemotherapy in patients with metastatic gastroenteropancreatic neuroendocrine carcinoma. Onco Targets Ther 2015; 8:3613-9. [PMID: 26664145 PMCID: PMC4671803 DOI: 10.2147/ott.s91971] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background and aim To investigate the efficacy of platinum-based chemotherapy in patients with metastatic gastroenteropancreatic neuroendocrine carcinoma (mGEP-NEC) and define predictive and prognostic factors. Methods Twenty mGEP-NEC patients were treated with cisplatin or carboplatin/etoposide between April 2010 and October 2014. Both large-cell and small-cell histologies were included. Cisplatin 25 mg/m2 was administered on days 1–3 followed by etoposide 100 mg/m2 on days 1–3 every 21 days. Carboplatin 300 mg/m2 was administered on day 1 followed by etoposide 100 mg/m2 on days 1–3. Results Of the 19 evaluable patients, 13 obtained a partial response, four showed stable disease, and two progressed. Median overall survival (mOS) was 13.5 months and median progression-free survival (mPFS) was 10.9 months. Gallium-68 positron emission tomography/computerizsed tomography-positive patients had a higher, albeit not significantly, OS than those with negative results (75% vs 34.3% at 18 months; P=0.06). mPFS was 19.3 and 6.3 months (P<0.01) in mGEP-NEC patients with Ki67 ≤55% or >55%, respectively. mOS was 8.1 months in the latter group but was not reached in the Ki67 ≤55% group (P-value =0.039). Patients with a lower body mass index (BMI) had a better prognosis in terms of both OS and PFS. Patients with BMI ≥25 had a mOS of 11.7 months (P=0.0293) and a mPFS of 6.2 months (P=0.0057). Conclusion Platinum-based chemotherapy showed good efficacy in mGEP-NEC patients. Those with Ki67 ≤55%, positive Gallium-68 positron emission tomography/computerized tomography and BMI <25 had a better prognosis.
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Affiliation(s)
- Alberto Bongiovanni
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Nada Riva
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Marianna Ricci
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Chiara Liverani
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Federico La Manna
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Alessandro De Vita
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Flavia Foca
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Laura Mercatali
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Stefano Severi
- Nuclear Medicine Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Dino Amadori
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Toni Ibrahim
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
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Azim HA, Abdal-Kader YSED, Mousa MM, Malek RA, Abdalmassih MK, Ibrahim NY. Taxane-based regimens as adjuvant treatment for breast cancer: a retrospective study in egyptian cancer patients. Asian Pac J Cancer Prev 2015; 16:65-9. [PMID: 25640392 DOI: 10.7314/apjcp.2015.16.1.65] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate the impact of adding taxanes to anthracycline-based regimens in the adjuvant setting in localized young female breast cancer patients on the overall survival (OS) and the disease free survival (DFS). MATERIALS AND METHODS This retrospective study included all female breast cancer patients who were candidates for adjuvant chemotherapy presenting to Kasr Al Ainy centre of clinical oncology and Cairo oncology centre (Cairo Cure) in the period from January 2005 till December 2010. RESULTS Our study included 865 patients, 732 of whom received anthracycline based regimens and 133 taxane based regimens. The mean age of patients was 39 years. After a median follow up of 50 months the median DFS was 48.4 months. Survival analysis indicated that the tumor size (>5cm vs. <5cm) p=0.001), nodal involvement (Yes vs. No) p=0.0001) and pathology (invasive lobular vs. ductal) p=0.048) affected DFS. As regards hormonal status, ER, PR and HER 2neu positive patients had longer DFS (p=0.001, 0.003, 0.106). On multivariate analysis DFS was affected by tumor size and lymph node involvement (p=0.014, 0.007). Subgroup analysis showed improvement in arms treated with taxanes in terms of DFS with positive Her2neu, ER and PR, but this was not statistically significant. CONCLUSIONS Adding adjuvant taxanes to anthracyclines is beneficial for treatment of localized breast cancer among all subgroups, especially higher risk groups .The type of adjuvant chemotherapy regimens and tumor characteristics have direct effects on DFS.
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Affiliation(s)
- Hamdy Abdel Azim
- Clinical Oncology Department, Kasr Al-Ainy Center of Clinical Oncology and Nuclear Medicine, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt E-mail :
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