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Jo W, Won T, Daoud A, Čiháková D. Immune checkpoint inhibitors associated cardiovascular immune-related adverse events. Front Immunol 2024; 15:1340373. [PMID: 38375475 PMCID: PMC10875074 DOI: 10.3389/fimmu.2024.1340373] [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: 11/17/2023] [Accepted: 01/19/2024] [Indexed: 02/21/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) are specialized monoclonal antibodies (mAbs) that target immune checkpoints and their ligands, counteracting cancer cell-induced T-cell suppression. Approved ICIs like cytotoxic T-lymphocyte antigen-4 (CTLA-4), programmed death-1 (PD-1), its ligand PD-L1, and lymphocyte activation gene-3 (LAG-3) have improved cancer patient outcomes by enhancing anti-tumor responses. However, some patients are unresponsive, and others experience immune-related adverse events (irAEs), affecting organs like the lung, liver, intestine, skin and now the cardiovascular system. These cardiac irAEs include conditions like myocarditis, atherosclerosis, pericarditis, arrhythmias, and cardiomyopathy. Ongoing clinical trials investigate promising alternative co-inhibitory receptor targets, including T cell immunoglobulin and mucin domain-containing protein 3 (Tim-3) and T cell immunoreceptor with immunoglobulin and ITIM domain (TIGIT). This review delves into the mechanisms of approved ICIs (CTLA-4, PD-1, PD-L1, and LAG-3) and upcoming options like Tim-3 and TIGIT. It explores the use of ICIs in cancer treatment, supported by both preclinical and clinical data. Additionally, it examines the mechanisms behind cardiac toxic irAEs, focusing on ICI-associated myocarditis and atherosclerosis. These insights are vital as ICIs continue to revolutionize cancer therapy, offering hope to patients, while also necessitating careful monitoring and management of potential side effects, including emerging cardiac complications.
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Affiliation(s)
- Wonyoung Jo
- Department of Biomedical Engineering, Johns Hopkins University, Whiting School of Engineering, Baltimore, MD, United States
| | - Taejoon Won
- Department of Pathobiology, University of Illinois Urbana-Champaign, College of Veterinary Medicine, Urbana, IL, United States
| | - Abdel Daoud
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, United States
| | - Daniela Čiháková
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Pathology, Johns Hopkins University, School of Medicine, Baltimore, MD, United States
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Chan A, Torelli S, Cheng E, Batchelder R, Waliany S, Neal J, Witteles R, Nguyen P, Cheng P, Zhu H. Immunotherapy-Associated Atherosclerosis: A Comprehensive Review of Recent Findings and Implications for Future Research. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023; 25:715-735. [PMID: 38213548 PMCID: PMC10776491 DOI: 10.1007/s11936-023-01024-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2023] [Indexed: 01/13/2024]
Abstract
Purpose of the Review Even as immune checkpoint inhibitors (ICIs) have transformed the lifespan of many patients, they may also trigger acceleration of long-term cardiovascular disease. Our review aims to examine the current landscape of research on ICI-mediated atherosclerosis and address key questions regarding its pathogenesis and impact on patient management. Recent Findings Preclinical mouse models suggest that T cell dysregulation and proatherogenic cytokine production are key contributors to plaque development after checkpoint inhibition. Clinical data also highlight the significant burden of atherosclerotic cardiovascular disease (ASCVD) in patients on immunotherapy, although the value of proactively preventing and treating ASCVD in this population remains an open area of inquiry. Current treatment options include dietary/lifestyle modification and traditional medications to manage hypertension, hyperlipidemia, and diabetes risk factors; no current targeted therapies exist. Summary Early identification of high-risk patients is crucial for effective preventive strategies and timely intervention. Future research should focus on refining screening tools, elucidating targetable mechanisms driving ICI atherosclerosis, and evaluating long-term cardiovascular outcomes in cancer survivors who received immunotherapy. Moreover, close collaboration between oncologists and cardiologists is essential to optimize patient outcomes.
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Affiliation(s)
- Antonia Chan
- Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Stefan Torelli
- Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Evaline Cheng
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Ryan Batchelder
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Sarah Waliany
- Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Joel Neal
- Department of Medicine, Division of Oncology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA USA
| | - Ronald Witteles
- Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Patricia Nguyen
- Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA USA
- Stanford Cardiovascular Institute and Department of Medicine, Stanford University, 240 Pasteur Drive, Rm 3500, Biomedical Innovations Building, Stanford, CA 94304 USA
| | - Paul Cheng
- Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA USA
- Stanford Cardiovascular Institute and Department of Medicine, Stanford University, 240 Pasteur Drive, Rm 3500, Biomedical Innovations Building, Stanford, CA 94304 USA
| | - Han Zhu
- Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA USA
- Stanford Cardiovascular Institute and Department of Medicine, Stanford University, 240 Pasteur Drive, Rm 3500, Biomedical Innovations Building, Stanford, CA 94304 USA
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Dougan M. Gastrointestinal mucosal toxicities from immune checkpoint inhibitors: Current understanding and future directions. Immunol Rev 2023; 318:11-21. [PMID: 37455375 DOI: 10.1111/imr.13239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
Immune checkpoint inhibitor (ICI) therapy has revolutionized the field of oncology over the past decade, leading to durable remissions in some patients but also producing a wide spectrum of treatment-limiting inflammatory toxicities that are referred to as immune-related adverse events (irAEs). Although irAEs can involve any organ system in the body, they most commonly affect the barrier tissues, including the gastrointestinal tract with colitis and enterocolitis affecting a significant fraction of patients on ICIs. We are beginning to understand the mechanisms that drive ICI colitis, with early experiments indicating a role for CD8+ resident memory T cells (TRMs) in the gut, which become activated and differentiate into cytotoxic cells in response to ICI therapy. The risk factors that define who will develop ICI colitis are not understood and substantial efforts are underway to identify potential biomarkers for risk of this and other toxicities. Optimal management of ICI colitis is also an area of active investigation. Current standard treatments are based largely on small, retrospective analyses, and while drugs like systemic glucocorticoids or the TNFα inhibitor infliximab do appear to be highly active in ICI colitis, the impact of these therapies on antitumor responses is poorly understood. As discussed in this review, future work will have to define the immune mechanisms driving ICI colitis in more detail and in comparison to antitumor responses in order to identify candidate pathways that can be targeted to improve ICI colitis without interfering in antitumor immunity. Studying these interventions will require randomized, controlled trials with both tumor and colitis endpoints, a goal that will necessitate collaboration across institutions and funding agencies. We are at a point where such collaborative trials are feasible, and have the potential to greatly improve the care of patients with ICI colitis as well as other irAEs.
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Affiliation(s)
- Michael Dougan
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Drobni ZD, Gongora C, Taron J, Suero-Abreu GA, Karady J, Gilman HK, Supraja S, Nikolaidou S, Leeper N, Merkely B, Maurovich-Horvat P, Foldyna B, Neilan TG. Impact of immune checkpoint inhibitors on atherosclerosis progression in patients with lung cancer. J Immunother Cancer 2023; 11:e007307. [PMID: 37433718 DOI: 10.1136/jitc-2023-007307] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Patients with lung cancer face a heightened risk of atherosclerosis-related cardiovascular events. Despite the strong scientific rationale, there is currently a lack of clinical evidence examining the impact of immune checkpoint inhibitors (ICIs) on the advancement of atherosclerosis in patients with lung cancer. The objective of our study was to investigate whether there is a correlation between ICIs and the accelerated progression of atherosclerosis among individuals with lung cancer. METHODS In this case-control (2:1 matched by age and gender) study, total, non-calcified, and calcified plaque volumes were measured in the thoracic aorta using sequential contrast-enhanced chest CT scans. Univariate and multivariate rank-based estimation regression models were developed to estimate the effect of ICI therapy on plaque progression in 40 cases (ICI) and 20 controls (non-ICI). RESULTS The patients had a median age of 66 years (IQR: 58-69), with 50% of them being women. At baseline, there were no significant differences in plaque volumes between the groups, and their cardiovascular risk profiles were similar. However, the annual progression rate for non-calcified plaque volume was 7 times higher in the ICI group compared with the controls (11.2% vs 1.6% per year, p=0.001). Conversely, the controls showed a greater progression in calcified plaque volume compared with the ICI group (25% vs 2% per year, p=0.017). In a multivariate model that considered cardiovascular risk factors, the use of an ICI was associated with a more substantial progression of non-calcified plaque volume. Additionally, individuals treated with combination ICI therapy exhibited greater plaque progression. CONCLUSIONS ICI therapy was associated with more non-calcified plaque progression. These findings underscore the importance of conducting studies aimed at identifying the underlying mechanisms responsible for plaque advancement in patients undergoing ICI treatment. TRIAL REGISTRATION NUMBER NCT04430712.
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Affiliation(s)
- Zsofia Dora Drobni
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Massachusetts General Hospital Department of Radiology, Boston, Massachusetts, USA
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Carlos Gongora
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jana Taron
- Department of Radiology, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Giselle A Suero-Abreu
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Julia Karady
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Massachusetts General Hospital Department of Radiology, Boston, Massachusetts, USA
| | - Hannah K Gilman
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Massachusetts General Hospital Department of Radiology, Boston, Massachusetts, USA
| | - Sama Supraja
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Massachusetts General Hospital Department of Radiology, Boston, Massachusetts, USA
| | - Sofia Nikolaidou
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Massachusetts General Hospital Department of Radiology, Boston, Massachusetts, USA
| | - Nicolas Leeper
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - Borek Foldyna
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Massachusetts General Hospital Department of Radiology, Boston, Massachusetts, USA
| | - Tomas G Neilan
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Massachusetts General Hospital Department of Radiology, Boston, Massachusetts, USA
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Suero-Abreu GA, Zanni MV, Neilan TG. Atherosclerosis With Immune Checkpoint Inhibitor Therapy: Evidence, Diagnosis, and Management: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2022; 4:598-615. [PMID: 36636438 PMCID: PMC9830225 DOI: 10.1016/j.jaccao.2022.11.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 11/13/2022] [Indexed: 12/24/2022] Open
Abstract
As the clinical applications of immune checkpoint inhibitors (ICIs) expand, our knowledge of the potential adverse effects of these drugs continues to broaden. Emerging evidence supports the association between ICI therapy with accelerated atherosclerosis and atherosclerotic cardiovascular (CV) events. We discuss the biological plausibility and the clinical evidence supporting an effect of inhibition of these immune checkpoints on atherosclerotic CV disease. Further, we provide a perspective on potential diagnostic and pharmacological strategies to reduce atherosclerotic risk in ICI-treated patients. Our understanding of the pathophysiology of ICI-related atherosclerosis is in its early stages. Further research is needed to identify the mechanisms linking ICI therapy to atherosclerosis, leverage the insight that ICI therapy provides into CV biology, and develop robust approaches to manage the expanding cohort of patients who may be at risk for atherosclerotic CV disease.
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Affiliation(s)
| | - Markella V. Zanni
- Metabolism Unit, Division of Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tomas G. Neilan
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA,Cardiovascular Imaging Research Center, Department of Radiology and Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,Address for correspondence: Dr Tomas G. Neilan, Cardio-Oncology Program and Cardiovascular Imaging Research Center (CIRC), Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, Massachusetts 02114, USA. @TomasNeilan
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Neurotoxicity and safety of the rechallenge of immune checkpoint inhibitors: a growing issue in neuro-oncology practice. Neurol Sci 2022; 43:2339-2361. [DOI: 10.1007/s10072-022-05920-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
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Vuong JT, Stein-Merlob AF, Nayeri A, Sallam T, Neilan TG, Yang EH. Immune Checkpoint Therapies and Atherosclerosis: Mechanisms and Clinical Implications: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79:577-593. [PMID: 35144750 PMCID: PMC8983019 DOI: 10.1016/j.jacc.2021.11.048] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 09/27/2021] [Accepted: 11/08/2021] [Indexed: 12/31/2022]
Abstract
Immune checkpoint inhibitor therapy has revolutionized the treatment of advanced malignancies in recent years. Numerous reports have detailed the myriad of possible adverse inflammatory effects of immune checkpoint therapies, including within the cardiovascular system. However, these reports have been largely limited to myocarditis. The critical role of inflammation and adaptive immunity in atherosclerosis has been well characterized in preclinical studies, and several emerging clinical studies indicate a potential role of immune checkpoint targeting therapies in the development and exacerbation of atherosclerosis. In this review, we provide an overview of the role of T-cell immunity in atherogenesis and describe the molecular effects and clinical associations of both approved and investigational immune checkpoint therapy on atherosclerosis. We also highlight the role of cholesterol metabolism in oncogenesis and discuss the implications of these associations on future treatment and monitoring of atherosclerotic cardiovascular disease in the oncologic population receiving immune checkpoint therapy.
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Affiliation(s)
- Jacqueline T Vuong
- Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Ashley F Stein-Merlob
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Arash Nayeri
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Tamer Sallam
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Tomas G Neilan
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eric H Yang
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA; UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA.
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Živković SA, Al-Lahham T. Neurologic Complications of Immune Checkpoint Inhibitors. Neurology 2022. [DOI: 10.17925/usn.2022.18.1.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The clinical use of cancer immunotherapy with immune checkpoint inhibitors has transformed the management of cancer and added another effective treatment option for different types of malignancies. The blockade of immune checkpoint pathways triggers an enhanced immune response leading to cancer regression but may also lead to autoimmune toxicities or immune-related adverse events, which may involve skin, endocrine, respiratory, gastrointestinal or neurologic manifestations. Clinically relevant neurologic complications involving the central and/or peripheral nervous system affect up to 1% of patients treated with immune checkpoint inhibitors and may be associated with significant morbidity and mortality. Common neurologic complications include aseptic meningitis and encephalitis, hypophysitis, myasthenia, myositis and neuropathies. Neurologic immune-related adverse events after immune checkpoint inhibition should be distinguished from cancer progression or other complications of cancer therapy (e.g. infections). The treatment of neurologic complications may include holding or withdrawing cancer immunotherapy, anti-inflammatory and immunosuppressive therapies with corticosteroids and steroid-sparing agents, immunomodulation with intravenous immune globulin or plasmapheresis and symptomatic treatment (e.g. antiepileptic medications, pain medications).
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Zhang L, Wang H, Tian J, Sui L, Chen X. Concomitant Statins and the Survival of Patients with Non-Small-Cell Lung Cancer Treated with Immune Checkpoint Inhibitors: A Meta-Analysis. Int J Clin Pract 2022; 2022:3429462. [PMID: 35855055 PMCID: PMC9276478 DOI: 10.1155/2022/3429462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/17/2022] [Accepted: 05/28/2022] [Indexed: 11/17/2022] Open
Abstract
Statins are suggested to improve cancer survival by possible anti-inflammatory effect. However, it remains unclear if concomitant use of statins could improve the efficacy of immune checkpoint inhibitors (ICIs) in patients with non-small-cell lung cancer (NSCLC). Accordingly, a meta-analysis was performed to systematically evaluate the effect of concomitant statins in NSCLC patients receiving ICIs. Relevant studies were obtained by literature search in PubMed, Embase, and Web of Science databases. A conservative random-effect model was used to combine the results. Eight cohorts including 2382 patients were included. The programmed death-1/ligand-1 inhibitors were used in seven studies; while the cytotoxic T-lymphocyte-associated protein 4 inhibitors were used in the other study. It was shown that concomitant use of statin did not significantly affect the progression-free survival (PFS, hazard ratio (HR): 0.86, 95% confidence interval (CI): 0.70 to 1.07, P=0.17; I 2 = 62%) or overall survival (OS, HR: 0.86, 95% CI: 0.74 to 1.01, P=0.07; I 2 = 29%) of NSCLC patients receiving ICIs. Subgroup analyses showed consistent results in studies with univariate or multivariate analytic models (P for subgroup analysis = 0.97 and 0.38 for the outcome of PFS and OS, respectively). In conclusion, concomitant use of statin seemed to have no significant influence on the survival of patients with NSCLC who were treated with ICIs.
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Affiliation(s)
- Lei Zhang
- Department of Oncology, The Hospital of Shunyi District of Beijing, Beijing 101300, China
| | - Hong Wang
- Department of Oncology, The Hospital of Shunyi District of Beijing, Beijing 101300, China
| | - Jizheng Tian
- Department of Oncology, The Hospital of Shunyi District of Beijing, Beijing 101300, China
| | - Lili Sui
- Department of Oncology, The Hospital of Shunyi District of Beijing, Beijing 101300, China
| | - Xiaoyan Chen
- Department of Oncology, The Hospital of Shunyi District of Beijing, Beijing 101300, China
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