1
|
Asmundo L, Rizzetto F, Sgrazzutti C, Carbonaro LA, Mazzarelli C, Centonze L, Rutanni D, De Carlis L, Vanzulli A. Computed Tomography and Magnetic Resonance Imaging Signs of Chronic Liver Rejection: A Case-Control Study. J Comput Assist Tomogr 2024; 48:26-34. [PMID: 37422693 DOI: 10.1097/rct.0000000000001511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
OBJECTIVE In liver transplantation, chronic rejection is still poorly studied. This study aimed to investigate the role of imaging in its recognition. METHODS This study is a retrospective observational case-control series. Patients with histologic diagnosis of chronic liver transplant rejection were selected; the last imaging examination (computed tomography or magnetic resonance imaging) before the diagnosis was evaluated. At least 3 controls were selected for each case; radiological signs indicative of altered liver function were analyzed. χ 2 Test with Yates correction was used to compare the rates of radiologic signs in the case and control groups, also considering whether patients suffered chronic rejection within or after 12 months. Statistical significance was set at P < 0.050. RESULTS A total of 118 patients were included in the study (27 in the case group and 91 in the control group). Periportal edema was appreciable in 19 of 27 cases (70%) and in 6 of 91 controls (4%) ( P < 0.001); ascites and hepatomegaly were present in 14 of 27 cases (52%) and 12 of 27 cases (44%), respectively, and in 1 of 91 controls (1%) ( P < 0.001); splenomegaly was present in 13 of 27 cases (48%) and in 8 of 91 controls (10%) ( P < 0.001); and biliary tract dilatation was present in 13 of 27 cases (48%) and in 11 of 91 patients controls (5%) ( P < 0.001). In the controls, periportal edema was significantly less frequent beyond 12 months after transplant (1% vs 11%; P = 0.020); the other signs after 12 months were not significant. CONCLUSIONS The identification of periportal edema, biliary dilatation, ascites, and hepatosplenomegaly can serve as potential warning signs of ongoing chronic liver rejection. It is especially important to investigate periportal edema if it is present 1 year or more after orthotopic liver transplantation.
Collapse
Affiliation(s)
- Luigi Asmundo
- From the Postgraduate School in Radiodiagnostic, University of Milan
| | | | | | | | - Chiara Mazzarelli
- Department of Hepatology and Gastroenterology Unit, ASST Grande Ospedale
| | | | - Davide Rutanni
- From the Postgraduate School in Radiodiagnostic, University of Milan
| | | | | |
Collapse
|
2
|
Centonze L, De Carlis R, Vella I, Carbonaro L, Incarbone N, Palmieri L, Sgrazzutti C, Ficarelli A, Valsecchi MG, Dello Iacono U, Lauterio A, Bernasconi D, Vanzulli A, De Carlis L. From LI-RADS Classification to HCC Pathology: A Retrospective Single-Institution Analysis of Clinico-Pathological Features Affecting Oncological Outcomes after Curative Surgery. Diagnostics (Basel) 2022; 12:160. [PMID: 35054327 PMCID: PMC8775107 DOI: 10.3390/diagnostics12010160] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/08/2022] [Accepted: 01/09/2022] [Indexed: 02/08/2023] Open
Abstract
Background: The latest Liver Imaging Reporting and Data System (LI-RADS) classification by the American College of Radiology has been recently endorsed in the American Association for the Study of Liver Disease (AASLD) guidelines for Hepatocellular carcinoma (HCC) management. Although the LI-RADS protocol has been developed as a diagnostic algorithm, there is some evidence concerning a possible correlation between different LI-RADS classes and specific pathological features of HCC. We aimed to investigate such radiological/pathological correlation and the possible prognostic implication of LI-RADS on a retrospective cohort of HCC patients undergoing surgical resection. Methods: We performed a retrospective analysis of the pathological characteristics of resected HCC, exploring their distribution among different LI-RADS classes and analyzing the risk factors for recurrence-free, overall and cancer-specific survival Results: LI-RADS-5 (LR-5) nodules showed a higher prevalence of microvascular invasion (MVI), satellitosis and capsule infiltration, as well as higher median values of alpha-fetoprotein (αFP) compared to LI-RADS-3/4 (LR-3/4) nodules. MVI, αFP, satellitosis and margin-positive (R1) resection resulted as independent risk factors for recurrence-free survival, while LI-RADS class did not exert any significant impact. Focusing on overall survival, we identified patient age, Eastern Cooperative Oncology Group performance status (ECOG-PS), Model for End Stage Liver Disease (MELD) score, αFP, MVI, satellitosis and R1 resection as independent risk factors for survival, without any impact of LI-RADS classification. Last, MELD score, log10αFP, satellitosis and R1 resection resulted as independent risk factors for cancer-specific survival, while LI-RADS class did not exert any significant impact. Conclusions: Our results suggest an association of LR-5 class with unfavorable pathological characteristics of resected HCC; tumor histology and underlying patient characteristics such as age, ECOG-PS and liver disease severity exert a significant impact on postoperative oncological outcomes.
Collapse
Affiliation(s)
- Leonardo Centonze
- Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, 20161 Milan, Italy; (R.D.C.); (I.V.); (N.I.); (L.P.); (A.F.); (A.L.); (L.D.C.)
| | - Riccardo De Carlis
- Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, 20161 Milan, Italy; (R.D.C.); (I.V.); (N.I.); (L.P.); (A.F.); (A.L.); (L.D.C.)
| | - Ivan Vella
- Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, 20161 Milan, Italy; (R.D.C.); (I.V.); (N.I.); (L.P.); (A.F.); (A.L.); (L.D.C.)
| | - Luca Carbonaro
- Department of Diagnostic and Interventional Radiology, Niguarda Ca’ Granda Hospital, 20161 Milan, Italy; (L.C.); (C.S.); (U.D.I.); (A.V.)
| | - Niccolò Incarbone
- Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, 20161 Milan, Italy; (R.D.C.); (I.V.); (N.I.); (L.P.); (A.F.); (A.L.); (L.D.C.)
| | - Livia Palmieri
- Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, 20161 Milan, Italy; (R.D.C.); (I.V.); (N.I.); (L.P.); (A.F.); (A.L.); (L.D.C.)
| | - Cristiano Sgrazzutti
- Department of Diagnostic and Interventional Radiology, Niguarda Ca’ Granda Hospital, 20161 Milan, Italy; (L.C.); (C.S.); (U.D.I.); (A.V.)
| | - Alberto Ficarelli
- Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, 20161 Milan, Italy; (R.D.C.); (I.V.); (N.I.); (L.P.); (A.F.); (A.L.); (L.D.C.)
| | - Maria Grazia Valsecchi
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre—B4, School of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy; (M.G.V.); (D.B.)
| | - Umberto Dello Iacono
- Department of Diagnostic and Interventional Radiology, Niguarda Ca’ Granda Hospital, 20161 Milan, Italy; (L.C.); (C.S.); (U.D.I.); (A.V.)
| | - Andrea Lauterio
- Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, 20161 Milan, Italy; (R.D.C.); (I.V.); (N.I.); (L.P.); (A.F.); (A.L.); (L.D.C.)
| | - Davide Bernasconi
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre—B4, School of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy; (M.G.V.); (D.B.)
| | - Angelo Vanzulli
- Department of Diagnostic and Interventional Radiology, Niguarda Ca’ Granda Hospital, 20161 Milan, Italy; (L.C.); (C.S.); (U.D.I.); (A.V.)
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, 20161 Milan, Italy; (R.D.C.); (I.V.); (N.I.); (L.P.); (A.F.); (A.L.); (L.D.C.)
- School of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy
| |
Collapse
|
3
|
D'Amico G, Maruzzelli L, Airoldi A, Petridis I, Tosetti G, Rampoldi A, D'Amico M, Miraglia R, De Nicola S, La Mura V, Solcia M, Volpes R, Perricone G, Sgrazzutti C, Vanzulli A, Primignani M, Luca A, Malizia G, Federico A, Dallio M, Andriulli A, Iacobellis A, Addario L, Garcovich M, Gasbarrini A, Chessa L, Salerno F, Gobbo G, Merli M, Ridola L, Baroni GS, Tarantino G, Caporaso N, Morisco F, Pozzoni P, Colli A, Belli LS. Performance of the model for end-stage liver disease score for mortality prediction and the potential role of etiology. J Hepatol 2021; 75:1355-1366. [PMID: 34333100 DOI: 10.1016/j.jhep.2021.07.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 07/02/2021] [Accepted: 07/16/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND & AIMS Although the discriminative ability of the model for end-stage liver disease (MELD) score is generally considered acceptable, its calibration is still unclear. In a validation study, we assessed the discriminative performance and calibration of 3 versions of the model: original MELD-TIPS, used to predict survival after transjugular intrahepatic portosystemic shunt (TIPS); classic MELD-Mayo; and MELD-UNOS, used by the United Network for Organ Sharing (UNOS). We also explored recalibrating and updating the model. METHODS In total, 776 patients who underwent elective TIPS (TIPS cohort) and 445 unselected patients (non-TIPS cohort) were included. Three, 6 and 12-month mortality predictions were calculated by the 3 MELD versions: discrimination was assessed by c-statistics and calibration by comparing deciles of predicted and observed risks. Cox and Fine and Grey models were used for recalibration and prognostic analyses. RESULTS In the TIPS/non-TIPS cohorts, the etiology of liver disease was viral in 402/188, alcoholic in 185/130, and non-alcoholic steatohepatitis in 65/33; mean follow-up±SD was 25±9/19±21 months; and the number of deaths at 3-6-12 months was 57-102-142/31-47-99, respectively. C-statistics ranged from 0.66 to 0.72 in TIPS and 0.66 to 0.76 in non-TIPS cohorts across prediction times and scores. A post hoc analysis revealed worse c-statistics in non-viral cirrhosis with more pronounced and significant worsening in the non-TIPS cohort. Calibration was acceptable with MELD-TIPS but largely unsatisfactory with MELD-Mayo and -UNOS whose performance improved much after recalibration. A prognostic analysis showed that age, albumin, and TIPS indication might be used to update the MELD. CONCLUSIONS In this validation study, the performance of the MELD score was largely unsatisfactory, particularly in non-viral cirrhosis. MELD recalibration and candidate variables for an update to the MELD score are proposed. LAY SUMMARY While the discriminative performance of the model for end-stage liver disease (MELD) score is credited to be fair to good, its calibration, the correspondence of observed to predicted mortality, is still unsettled. We found that application of 3 different versions of the MELD in 2 independent cirrhosis cohorts yielded largely imprecise mortality predictions particularly in non-viral cirrhosis. Thus, we propose a recalibration and suggest candidate variables for an update to the model.
Collapse
Affiliation(s)
- Gennaro D'Amico
- Gatroenterology Unit, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy; Gastroenterology Unit, Clinica La Maddalena, Palermo, Italy.
| | - Luigi Maruzzelli
- Radiology Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Aldo Airoldi
- Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy
| | - Ioannis Petridis
- Hepatology Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Giulia Tosetti
- Gastroenterology and Hepatology Unit Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy
| | | | - Mario D'Amico
- Radiology Unit, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy; Radiology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Roberto Miraglia
- Radiology Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Stella De Nicola
- Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy
| | - Vincenzo La Mura
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Luigi Villa, Milan, Italy
| | - Marco Solcia
- Interventional Radiology Unit, ASST GOM Niguarda, Milan, Italy
| | - Riccardo Volpes
- Hepatology Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | | | - Cristiano Sgrazzutti
- University of Milan, Department of Oncology and Hemato-oncology and Radiology, Department ASST Niguarda, Milan, Italy
| | - Angelo Vanzulli
- University of Milan, Department of Oncology and Hemato-oncology and Radiology, Department ASST Niguarda, Milan, Italy
| | - Massimo Primignani
- Gastroenterology and Hepatology Unit Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy
| | - Angelo Luca
- Radiology Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Giuseppe Malizia
- Gatroenterology Unit, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Alessandro Federico
- Hepato-Gastroenterology Unit, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Marcello Dallio
- Hepato-Gastroenterology Unit, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Angelo Andriulli
- Department of Gastroenterology and Endoscopy, Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Angelo Iacobellis
- Department of Gastroenterology and Endoscopy, Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | | | - Matteo Garcovich
- Department of Internal Medicine and Gastroenterology, Policlinico Gemelli, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine and Gastroenterology, Policlinico Gemelli, Rome, Italy
| | - Luchino Chessa
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | | | - Giulia Gobbo
- Internal Medicine Unit, IRCCS Policlinico San Donato, Milano, Italy
| | - Manuela Merli
- Gastroenterology and Hepatology Unit, Department of Translational and Precision Medicine, Università Sapienza, Roma, Italy
| | - Lorenzo Ridola
- Gastroenterology Unit, ASL Latina, Department of Translational and Precision Medicine, "Sapienza" University of Rome, Italy
| | | | - Giuseppe Tarantino
- Liver Injury and Transplant Unit, Polytechnic University of Marche, Ancona, Italy
| | - Nicola Caporaso
- Gastroenterology Unit, Federico II University, Naples, Italy
| | | | - Pietro Pozzoni
- General Medicine Unit,Presidio Ospedaliero, Azienda Socio Sanitaria Territoriale di Lecco, Lecco, Italy
| | - Agostino Colli
- General Medicine Unit,Presidio Ospedaliero, Azienda Socio Sanitaria Territoriale di Lecco, Lecco, Italy
| | | |
Collapse
|
4
|
Centonze L, Di Sandro S, Lauterio A, De Carlis R, Sgrazzutti C, Ciulli C, Vella I, Vicentin I, Incarbone N, Bagnardi V, Vanzulli A, De Carlis L. A retrospective single-centre analysis of the oncological impact of LI-RADS classification applied to Metroticket 2.0 calculator in liver transplantation: every nodule matters. Transpl Int 2021; 34:1712-1721. [PMID: 34448275 DOI: 10.1111/tri.13983] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 12/29/2022]
Abstract
Although the diagnostic value of Liver Imaging Reporting and Data System (LI-RADS) protocol is well recognized in clinical practice, its role in liver transplant (LT) setting is under-explored. We sought to evaluate the oncological impact of LI-RADS classification applied to Metroticket 2.0 calculator in a single-centre retrospective cohort of transplanted hepatocellular carcinoma (HCC) patients, exploring which LI-RADS subclasses need to be considered in order to grant the best Metroticket 2.0 performance. The most recent pre-LT imaging of 245 patients undergoing LT for HCC between 2005 and 2015 was retrospectively and blindly reviewed, classifying all nodules according to LI-RADS protocol. Metroticket 2.0 accuracy was subsequently tested incorporating all vital nodules identified during multi-disciplinary team (MDT) meetings attended before LI-RADS reclassification of the latest pre-LT imaging, LR-5 and LR-treatment-viable (LR-TR-V), LR-4/5 and LR-TR-V, and LR-3/4/5 and LR-TR-V nodules respectively. Considering their extremely low probability for harbouring HCC, LR-1 and LR-2 nodules were not considered in this analysis. Incorporation of all HCCs identified during MDT meetings attended before LI-RADS reclassification of the latest pre-LT imaging resulted in a Metroticket 2.0 c-index of 0.72, [95% confidence interval (CI) 0.64-0.80]. Metroticket 2.0 c-index dropped to 0.60 [95% CI: 0.48-0.72] when LI-RADS-5 and LI-RADS-TR-V (P = 0.0089) or LI-RADS-5, LI-RADS-4 and LI-RADS-TR-V (P = 0.0068) nodules were entered in the calculator. Conversely, addition of LI-RADS-3 HCCs raised the Metroticket 2.0 c-index to 0.65 [95% CI: 0.54-0.86], resulting in a not statistically significant diversion from the original performance (0.72 vs. 0.65; P = 0.08). Exclusion of LR-3 and LR-4 nodules from Metroticket 2.0 calculator resulted in a significant drop in its accuracy. Every nodule with an intermediate-to-high probability of harbouring HCC according to LI-RADS protocol seems to contribute to tumour burden and should be entered in the Metroticket 2.0 calculator in order to grant appropriate performance.
Collapse
Affiliation(s)
- Leonardo Centonze
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Stefano Di Sandro
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy.,Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Lauterio
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Riccardo De Carlis
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | | | - Cristina Ciulli
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy.,School of Medicine, University of Milan-Bicocca, Milan, Italy
| | - Ivan Vella
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Ilaria Vicentin
- Advanced Technologies Department, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Niccolò Incarbone
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy.,School of Medicine, University of Milan-Bicocca, Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Angelo Vanzulli
- Advanced Technologies Department, Niguarda Ca' Granda Hospital, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy.,School of Medicine, University of Milan-Bicocca, Milan, Italy
| |
Collapse
|
5
|
Reginelli A, Vanzulli A, Sgrazzutti C, Caschera L, Serra N, Raucci A, Urraro F, Cappabianca S. Vascular microinvasion from hepatocellular carcinoma: CT findings and pathologic correlation for the best therapeutic strategies. Med Oncol 2017; 34:93. [PMID: 28401484 DOI: 10.1007/s12032-017-0949-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 04/04/2017] [Indexed: 12/13/2022]
Abstract
Recurrence of HCC reduces survival rates in patients treated with surgery, and one of the most relevant risk factors for tumour recurrence is microvascular invasion (mVI). The identification of mVI on preoperative examinations could improve surgical planning's and techniques so as to reduce the risk of tumour recurrence. During our study, we have revised 101 CT examinations of the liver performed on patients diagnosed with solitary HCC who had surgical treatment and pathological analysis of the specimens for mVI in order to detect CT signs which could be reliable in mVI prediction. On CT examinations, the tumours were evaluated for margins, capsule, size, contrast enhancement, halo sign and Thad. From our statistical analysis, we found out that irregularity in tumour margins and defects in peritumoural capsule are the most significant characteristics predicting mVI in HCC. Every report on CT examinations performed on surgical candidate patients should include suggestions about mVI probability in order to tailor procedures, reduce tumour recurrence risk and improve survival rates.
Collapse
Affiliation(s)
- Alfonso Reginelli
- Department of Internal and Experimental Medicine, Second University of Naples, Naples, Italy.
| | - Angelo Vanzulli
- Niguarda Cancer Center - ASST Grande Ospedale Metropolitano, University of Milano, Niguarda, Milan, Italy
| | - Cristiano Sgrazzutti
- Niguarda Cancer Center - ASST Grande Ospedale Metropolitano, University of Milano, Niguarda, Milan, Italy
| | - Luca Caschera
- Niguarda Cancer Center - ASST Grande Ospedale Metropolitano, University of Milano, Niguarda, Milan, Italy
| | - Nicola Serra
- Department of Internal and Experimental Medicine, Second University of Naples, Naples, Italy
| | - Antonio Raucci
- Department of Internal and Experimental Medicine, Second University of Naples, Naples, Italy
| | - Fabrizio Urraro
- Department of Internal and Experimental Medicine, Second University of Naples, Naples, Italy
| | - Salvatore Cappabianca
- Department of Internal and Experimental Medicine, Second University of Naples, Naples, Italy
| |
Collapse
|