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Sun J, Xia Y, Shen F, Cheng S. Chinese expert consensus on the diagnosis and treatment of hepatocellular carcinoma with microvascular invasion (2024 edition). Hepatobiliary Surg Nutr 2025; 14:246-266. [PMID: 40342785 PMCID: PMC12057508 DOI: 10.21037/hbsn-24-359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 10/10/2024] [Indexed: 05/11/2025]
Abstract
Background Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in China. Surgical resection is the preferred treatment for HCC, but the postoperative recurrence and metastasis rates are high. Current evidence shows that microvascular invasion (MVI) is an independent risk factor for postoperative recurrence and metastasis, but there are still many controversies about the diagnosis, classification, prediction, and treatment of MVI worldwide. Methods Systematic literature reviews to identify knowledge gaps and support consensus statements and a modified Delphi method to develop evidence- and expert-based guidelines and finalization of the clinical consensus statements based on recommendations from a panel of experts. Results After many discussions and revisions, the Chinese Association of Liver Cancer of the Chinese Medical Doctor Association organized domestic experts in related fields to form the "Chinese expert consensus on the diagnosis and treatment of hepatocellular carcinoma with microvascular invasion (2024 edition)" which included eight recommendations to better guide the prediction, diagnosis and treatment of HCC patients with MVI. The MVI pathological grading criteria as outlined in the "Guidelines for Pathological Diagnosis of Primary Liver Cancer" and the Eastern Hepatobiliary Surgery Hospital (EHBH) nomogram for predicting MVI are highly recommended. Conclusions We present an expert consensus on the diagnosis and treatment of MVI and potentially improve recurrence-free survival (RFS) and overall survival (OS) for HCC patients with MVI.
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Affiliation(s)
- Juxian Sun
- Department of Hepatic Surgery VI, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Yong Xia
- Department of Hepatic Surgery IV, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Feng Shen
- Department of Hepatic Surgery IV, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Shuqun Cheng
- Department of Hepatic Surgery VI, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
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Cai C, Wang L, Tao L, Zhu H, Ren Y, Li D, Li D. Imaging-Based Prediction of Ki-67 Expression in Hepatocellular Carcinoma: A Retrospective Study. Cancer Med 2025; 14:e70562. [PMID: 39964132 PMCID: PMC11834164 DOI: 10.1002/cam4.70562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 11/04/2024] [Accepted: 12/20/2024] [Indexed: 02/21/2025] Open
Abstract
AIM This study aims to develop a non-invasive, preoperative predictive model for Ki-67 expression in HCC patients using enhanced computed tomography (CT) and clinical indicators to improve patient outcomes. METHODS This retrospective study analyzed 595 post-curative hepatectomy HCC patients. Patients were categorized into high (> 20%) and low (≤ 20%) Ki-67 expression groups based on cellular proliferation levels. Radiomic features were extracted from enhanced CT scans and combined with clinical parameters to develop a predictive model for Ki-67 expression. RESULTS Key clinical factors impacting Ki-67 expression in HCC included alpha-fetoprotein (AFP), non-smooth tumor margin, ill-defined pseudo-capsule, and peritumoral star node. From 1441 initially extracted radiomic features, 16 key features were selected using Lasso regression. These features were used to develop a radiomics model, which, when combined with clinical data, yielded an integrated predictive model with high accuracy. The combined model achieved an area under the curve (AUC) of 0.854 in the training group and 0.839 in the validation group. A nomogram based on this model was constructed, and its predictive accuracy was validated through calibration curves and decision curve analysis. A risk scorecard model was also constructed as a practical tool for clinicians to assess the risk level of high Ki-67 expression, facilitating personalized treatment planning. Survival analysis demonstrated significant differences in 3-year overall survival (OS) and progression-free survival (PFS) rates between patients with high and low Ki-67 expression, indicating the model's strong prognostic capability. CONCLUSIONS This study successfully developed a comprehensive model that integrates radiomic and clinical data for the preoperative prediction of Ki-67 expression in HCC patients.
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Affiliation(s)
- Chiyu Cai
- Department of Hepatobiliary and Pancreatic SurgeryZhengzhou University People's HospitalZhengzhouChina
| | - Liancai Wang
- Department of Hepatobiliary and Pancreatic SurgeryZhengzhou University People's HospitalZhengzhouChina
| | - Lianyuan Tao
- Department of Hepatobiliary and Pancreatic SurgeryZhengzhou University People's HospitalZhengzhouChina
| | - Hengli Zhu
- Department of Hepatobiliary and Pancreatic SurgeryZhengzhou University People's HospitalZhengzhouChina
| | - Yongnian Ren
- Department of Hepatobiliary and Pancreatic SurgeryZhengzhou University People's HospitalZhengzhouChina
| | - Deyu Li
- Department of Hepatobiliary and Pancreatic SurgeryZhengzhou University People's HospitalZhengzhouChina
| | - Dongxiao Li
- Department of Digestive DiseasesZhengzhou University People's HospitalZhengzhouChina
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Chang YS, Tsai MJ, Tsai CJ, Wang CC, Lin CC, Yen YH, Hung CH, Kuo YH, Huang DS, Tai WC, Hu TH, Tsai MC. A new model based on preoperative AFP, albumin, and tumor burden score for predicting microvascular invasion in early-stage HCC. Am J Cancer Res 2024; 14:4979-4988. [PMID: 39553207 PMCID: PMC11560811 DOI: 10.62347/zgrj7827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 09/03/2024] [Indexed: 11/19/2024] Open
Abstract
Microscopic vascular invasion (MVI) has been demonstrated as a strong risk factor associated with tumor recurrence and poor overall survival among hepatocellular carcinoma (HCC) patients after resection, but the preoperative prediction of MVI is still challenging. We aimed to build and validate a novel model to predict MVI in the preoperative setting. We retrospectively collected 857 patients with Barcelona Clinic Liver Cancer (BCLC) stage 0 or A HCC who underwent primary resection at Kaohsiung Chang Gung Hospital between January 2001 and June 2016. The patients were randomized into derivation (n = 648) and validation groups (n = 209). Logistic regression analysis was used to screen out independent risk factors for MVI and further constructed a predictive model for MVI. Prediction performance was compared by the area under the receiver operating characteristic curve (AUC). The multivariable logistic regression analysis of the training cohort found that alpha-fetoprotein (AFP) ≥ 20 ng/mL (OR = 1.96, 95% CI: 1.41-2.73, P < 0.001), albumin < 3.5 g/dL (OR = 1.48, 95% CI: 1.06-2.05, P = 0.019) and tumor burden score (TBS) ≥ 8.6 (OR = 2.54, 95% CI: 1.49-4.35, P = 0.001) to be independent risk factors for MVI. The three factors were chosen to build a model for prediction of MVI. The AUC for the training and validation group was 0.619 (95% CI: 0.575-0.663) and 0.642 (95% CI: 0.562-0.722), respectively, and the calibration plot showed good performance of the prediction model, with a low mean absolute error at 0.01. In conclusion, the new model comprised AFP, albumin, and TBS that can predict risk of MVI for early-stage HCC.
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Affiliation(s)
- Yuan-Sheng Chang
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
| | - Mu-Jung Tsai
- School of Medicine, Kaohsiung Medical University HospitalKaohsiung, Taiwan
| | - Chieh-Jui Tsai
- Kaohsiung Municipal Kaohsiung Senior High SchoolKaohsiung, Taiwan
| | - Chih-Chi Wang
- Division of General Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
| | - Chih-Che Lin
- Division of General Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
| | - Yi-Hao Yen
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
| | - Chao-Hung Hung
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
| | - Yuan-Hung Kuo
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
| | - Ding-Sen Huang
- Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
| | - Wei-Chen Tai
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
| | - Tsung-Hui Hu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
| | - Ming-Chao Tsai
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-sen UniversityKaohsiung, Taiwan
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Zhang WH, Zhao Y, Zhang CR, Huang JC, Lyu SC, Lang R. Preoperative systemic inflammatory response index as a prognostic marker for distal cholangiocarcinoma after pancreatoduodenectomy. World J Gastrointest Surg 2024; 16:2910-2924. [PMID: 39351557 PMCID: PMC11438816 DOI: 10.4240/wjgs.v16.i9.2910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Revised: 08/05/2024] [Accepted: 08/13/2024] [Indexed: 09/18/2024] Open
Abstract
BACKGROUND The relationship between preoperative inflammation status and tumorigenesis as well as tumor progression is widely acknowledged. AIM To assess the prognostic significance of preoperative inflammatory biomarkers in patients with distal cholangiocarcinoma (dCCA) who underwent pancreatoduodenectomy (PD). METHODS This single-center study included 216 patients with dCCA after PD between January 1, 2011, and December 31, 2022. The individuals were categorized into two sets based on their systemic inflammatory response index (SIRI) levels: A low SIRI group (SIRI < 1.5, n = 123) and a high SIRI group (SIRI ≥ 1.5, n = 93). Inflammatory biomarkers were evaluated for predictive accuracy using receiver operating characteristic curves. Both univariate and multivariate Cox proportional hazards analyses were performed to estimate SIRI for overall survival (OS) and recurrence-free survival (RFS). RESULTS The study included a total of 216 patients, with 58.3% being male and a mean age of 65.6 ± 9.6 years. 123 patients were in the low SIRI group and 93 were in the high SIRI group after PD for dCCA. SIRI had an area under the curve value of 0.674 for diagnosing dCCA, showing better performance than other inflammatory biomarkers. Multivariate analysis indicated that having a SIRI greater than 1.5 independently increased the risk of dCCA following PD, leading to lower OS [hazard ratios (HR) = 1.868, P = 0.006] and RFS (HR = 0.949, P < 0.001). Additionally, survival analysis indicated a significantly better prognosis for patients in the low SIRI group (P < 0.001). CONCLUSION It is determined that a high SIRI before surgery is a significant risk factor for dCCA after PD.
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Affiliation(s)
- Wen-Hui Zhang
- Department of Hepatobiliary Surgery, Beijing Chao-Yang Hospital Affiliated to Capital Medical University, Beijing 100020, China
| | - Yu Zhao
- Department of Urology Surgery, Beijing Chao-Yang Hospital Affiliated to Capital Medical University, Beijing 100020, China
| | - Cheng-Run Zhang
- Department of Hepatobiliary Surgery, Beijing Chao-Yang Hospital Affiliated to Capital Medical University, Beijing 100020, China
| | - Jin-Can Huang
- Department of Hepatobiliary Surgery, Beijing Chao-Yang Hospital Affiliated to Capital Medical University, Beijing 100020, China
| | - Shao-Cheng Lyu
- Department of Hepatobiliary Surgery, Beijing Chao-Yang Hospital Affiliated to Capital Medical University, Beijing 100020, China
| | - Ren Lang
- Department of Hepatobiliary Surgery, Beijing Chao-Yang Hospital Affiliated to Capital Medical University, Beijing 100020, China
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Zhang Y, Yang C, Sheng R, Dai Y, Zeng M. Preoperatively Identify the Microvascular Invasion of Hepatocellular Carcinoma with the Restricted Spectrum Imaging. Acad Radiol 2023; 30 Suppl 1:S30-S39. [PMID: 37442719 DOI: 10.1016/j.acra.2023.06.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/07/2023] [Accepted: 06/14/2023] [Indexed: 07/15/2023]
Abstract
RATIONALE AND OBJECTIVES To noninvasively and preoperatively identify the microvascular invasion (MVI) of hepatocellular carcinoma (HCC) with the restricted spectrum imaging (RSI). MATERIALS AND METHODS 62 patients were included into this prospective study and underwent the RSI examination with a 3.0-T scanner. Mono-exponential diffusion-weighted imaging-derived apparent diffusion coefficient (ADC) and RSI-derived metrics including f1 (fraction of restricted diffusion), f2 (fraction of hindered diffusion), f3 (fraction of free diffusion), and f1f2 (the multiply of f1 and f2) were calculated. Univariate and multivariate logistic regression were used to select the independent risk factors. Nomogram-based model was constructed with the selected indexes. Receiver operative characteristics analysis and calibration curve were used to evaluate the diagnostic accuracy. RESULTS MVI-positive HCC showed significantly higher f1 and lower ADC values (ADC: 1.549 ± 0.228 ×10-3 vs 1.365 ± 0.239 ×10-3 mm2/s, P = .003; f1: 0.1633 ± 0.0341 vs 0.2221 ± 0.0491, P < .001). Tumor size and f1 were selected as independent risk factors for MVI. The nomogram-based model was then constructed with tumor size and f1. Nomogram-based model (area under ROC curve [AUC]= 0.856) yielded the best diagnostic accuracy followed by f1 (AUC=0.842) and ADC (AUC=0.708). The AUC of both the f1 and nomogram model were significantly higher than that of ADC. CONCLUSION RSI-derived metrics can be utilized to noninvasively and efficiently identify the MVI of HCC. Considering the importance of MVI as a significant prognostic factor for HCC, the utilization of RSI has the potential to assist in prognostic prediction and clinical management.
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Affiliation(s)
- Yunfei Zhang
- Shanghai Institute of Medical Imaging, Fudan University, Shanghai, China (Y.Z., R.S., M.Z.); Department of Radiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China (Y.Z., C.Y., R.S., M.Z.)
| | - Chun Yang
- Department of Radiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China (Y.Z., C.Y., R.S., M.Z.)
| | - Ruofan Sheng
- Shanghai Institute of Medical Imaging, Fudan University, Shanghai, China (Y.Z., R.S., M.Z.); Department of Radiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China (Y.Z., C.Y., R.S., M.Z.)
| | - Yongming Dai
- School of Biomedical Engineering, ShanghaiTech Univerisity, Shanghai, China (Y.D.)
| | - Mengsu Zeng
- Shanghai Institute of Medical Imaging, Fudan University, Shanghai, China (Y.Z., R.S., M.Z.); Department of Radiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China (Y.Z., C.Y., R.S., M.Z.).
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Forlemu AN, Nana Sede Mbakop R, Bandaru P, Gayam V, Moparty H, Sempokuya T, Pradhan F, Reddy M, Olivera M. Liver Segment Disposition of Hepatocellular Carcinoma Predicts Microvascular Invasion. Int J Hepatol 2023; 2023:5727701. [PMID: 37292454 PMCID: PMC10247321 DOI: 10.1155/2023/5727701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/24/2023] [Accepted: 05/03/2023] [Indexed: 06/10/2023] Open
Abstract
Background Hepatocellular carcinoma (HCC) is a leading cause of cancer morbidity and mortality. Findings of microvascular invasion (MVI) in patients with HCC have emerged as an important prognostic factor for poor survival after tumor resection. Aim This study evaluated the relation between MVI and HCC within various anatomical Couinaud's segments of the liver. Method A multicenter retrospective review of HCC records was conducted from 2012 to 2017. HCC cases were identified using ICD-9 and 10 codes 155, C22.0, and C22.8. HCC patients who underwent liver transplants were included in this study. Liver segment of the location of HCC was obtained from radiographic records, and MVI information was obtained from pathology reports. Segmental distributions of HCC in MVI versus non-MVI groups were compared using Wilcoxon rank sum tests. p value was set at <0.05. Results We analyzed 120 HCC patients who underwent liver transplantation. The mean age of our cohort was 57 years, and the most common etiology of liver disease was hepatitis C at 58.3%. The median HCC size was 3.1 cm, and MVI was present in 23.3% of the explanted specimens. MVI was 2 to 3 times significantly higher in patients with HCC affecting segments 2 and 3 and segments 4b and 5 (p = 0.01). Moreover, median survival was significantly lower in patients with MVI versus those without MVI (50 vs. 137 months, p < 0.05). Conclusion MVI was significantly higher in HCC tumors located in liver segments 2 and 3 and 4b and 5, and survival was lower in patients with MVI compared with those without.
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Affiliation(s)
- Arnold Nongmoh Forlemu
- Department of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | | | - Praneeth Bandaru
- Department of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Vijay Gayam
- Department of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Hamsika Moparty
- Department of Internal Medicine, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Tomoki Sempokuya
- Department of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Faruq Pradhan
- Department of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Madhavi Reddy
- Department of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Marco Olivera
- Department of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
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Xia F, Zhang Q, Ndhlovu E, Zheng J, Gao H, Xia G. A nomogram for preoperative prediction of microvascular invasion in ruptured hepatocellular carcinoma. Eur J Gastroenterol Hepatol 2023; 35:591-599. [PMID: 36966771 DOI: 10.1097/meg.0000000000002535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
BACKGROUND AND AIM Microvascular invasion (MVI) is defined as the presence of micrometastatic cancer cell emboli in hepatic vessels, including small vessels, and at present, researchers believe that is an important factor for early postoperative recurrence and survival. Here, we developed and validated a preoperative predictive model for the presence of MVI in patients with ruptured hepatocellular carcinoma (rHCC). METHODS We retrospectively collected data for 210 rHCC patients who underwent staged hepatectomy at Wuhan Tongji Hospital, and 91 patients who underwent staged hepatectomy at Zhongshan People's Hospital between January 2010 and March 2021. Then, the former was used as the training cohort and the latter was used as the validation cohort. Logistic regression was used to screen for variables associated with MVI, and these variables were used to construct nomograms. We used R software to assess the discrimination, calibration ability, as well as clinical efficacy of nomograms. RESULTS Multivariate logistic regression analysis identified four risk factors independently associated with MVI: max tumor length [odds ratio (OR) = 1.385; 95% confidence interval (CI), 1.072-1.790], number of tumors (OR = 2.182; 95% CI, 1.129-5.546), direct bilirubin (OR = 1.515; 95% CI, 1.189-1.930), and alpha-fetoprotein (cutoff = 400 ng/mL) (OR = 2.689; 95% CI, 3.395-13.547). Nomograms were built from the four variables and they were tested for discrimination and calibration, and the results were good. CONCLUSION We developed and validated a preoperative predictive model for the presence of MVI in patients with ruptured HCC. This model can help clinicians identify patients at risk of MVI and make better treatment options.
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Affiliation(s)
- Feng Xia
- Department of Hepatic Surgery, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei
| | - Qiao Zhang
- Department of Emergency Medicine, Zhongshan People's Hospital Affiliated to Guangdong Medical University
| | - Elijah Ndhlovu
- Department of Hepatic Surgery, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei
| | - Jun Zheng
- Department of Science and Education, Shenzhen Baoan District People's Hospital, Guangdong
| | - Hengyi Gao
- Department of Hepatobiliary and Pancreatic Surgery, Shenzhen Longhua District People's Hospital, Guangdong
| | - Guobing Xia
- Department of Hepatobiliary and Pancreatic Surgery, Huangshi Central Hospital of Edong Healthcare Group, Hubei Polytechnic University, Huangshi, Hubei, China
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Ling Q. Commentary: A preoperative model for predicting microvascular invasion and assisting in prognostic stratification in liver transplantation for HCC regarding empirical criteria. Transl Oncol 2021; 14:101234. [PMID: 34626954 PMCID: PMC8512638 DOI: 10.1016/j.tranon.2021.101234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/29/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Qi Ling
- Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; NHC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, China; Alibaba-Zhejiang University Joint Research Center of Future Digital Healthcare, Hangzhou, China.
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