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ÖZDAŞ T, ÖZDAŞ S, CANATAR İ, ÇOŞKUN E, ŞENYURT EB, GÖRGÜLÜ O. CRM1 expression: association with high prognostic value in laryngeal cancer. Turk J Med Sci 2023; 53:909-923. [PMID: 38031942 PMCID: PMC10760544 DOI: 10.55730/1300-0144.5655] [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: 07/18/2022] [Revised: 08/18/2023] [Accepted: 02/03/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Laryngeal cancer is a very common malignant tumor of the head and neck. While laryngeal cancer does not show any obvious early symptoms, it tends to have a poor prognosis in advanced clinical stages. Chromosome region maintenance 1 (CRM1) mediates the nuclear export of some RNAs, major and tumor suppressor proteins and has been associated with the pathogenesis of many tumors. However, the clinicopathological significance of CRM1 gene expression in laryngeal cancer has not been clarified yet. Therefore, this study aims to detect the expression of CRM1 in laryngeal cancer and to investigate its relationship with clinicopathological parameters and prognosis. METHODS CRM1 expression in matched tumor and normal tissues obtained from 43 laryngeal cancer patients were evaluated intracellular for protein and mRNA levels by immunohistochemical staining (IHC), western-blot, and quantitative real-time RT-PCR (qRT-PCR), respectively. RESULTS IHC, western-blot, and qRT-PCR analyses showed that CRM1 expression was significantly increased in laryngeal cancer tissue compared to normal tissue. Increased expression of CRM1 has been associated with poor prognostic clinicopathological features, including advanced tumor stage, increased tumor invasion, larger tumor size, positive lymph node metastasis, distant metastasis, and invasive histological type by IHC, western-blot, and qRT-PCR. Kaplan-Meier survival analysis showed that patients with high expression of CRM1 exhibited lower overall survival compared to those with low expression (Log-rank = 7.16, p = 0.007). According to the The Cancer Genome Atlas (TCGA) datasets, elevated CRM1 expression in head and neck cancer including cases of squamous cell laryngeal origin is associated with advanced tumor stage and histological grade (p > 0.05, for all). DISCUSSION Consequently, CRM1 plays an important role in laryngeal cancer and may serve as an indicator and prognostic factor for poor overall survival in laryngeal cancer patients.
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Affiliation(s)
- Talih ÖZDAŞ
- Department of Otorhinolaryngology, Adana City Training and Research Hospital, Health Science University, Adana,
Turkiye
| | - Sibel ÖZDAŞ
- Department of Bioengineering, Faculty of Engineering Sciences, Adana Alparslan Türkeş Science and Technology University, Adana,
Turkiye
| | - İpek CANATAR
- Department of Bioengineering, Faculty of Engineering Sciences, Adana Alparslan Türkeş Science and Technology University, Adana,
Turkiye
| | - Erdal ÇOŞKUN
- Genomics Team, Microsoft Research, Redmond, WA,
USA
| | - Elif Burcu ŞENYURT
- Department of Otorhinolaryngology, Adana City Training and Research Hospital, Health Science University, Adana,
Turkiye
| | - Orhan GÖRGÜLÜ
- Department of Otorhinolaryngology, Adana City Training and Research Hospital, Health Science University, Adana,
Turkiye
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Vazquez-Guillen JM, Palacios-Saucedo GC, Alanis-Valdez AY, Huerta-Escobedo A, Zavala-Pompa A, Rivera-Morales LG, Martinez-Torres AC, Gonzalez-Villasana V, Serna-Hernandez JC, Hernandez-Martinez SJ, Castelan-Maldonado EE, Montalvo-Bañuelos MS, Alonso-Tellez CA, Sanchez-Fresno EC, Tamez-Guerra RS, Rodriguez-Padilla C. p16 INK4a and pRb expression in laryngeal squamous cell carcinoma with and without infection by EBV or different genotypes of HPV: a retrospective study. Infect Agent Cancer 2023; 18:43. [PMID: 37434200 DOI: 10.1186/s13027-023-00514-x] [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: 06/14/2022] [Accepted: 05/24/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Laryngeal squamous cell carcinoma (LSCC) represents one of the principal tumors of the head and neck. Human papillomavirus (HPV) and Epstein-Barr virus (EBV) are considered risk factors for the development and the clinical prognosis of LSCC. High levels of p16INK4a are suggested as a surrogate marker of HPV or EBV infection in some head and neck tumors but in LSCC is still controversial. Furthermore, pRb expression may be considered an additional biomarker but it has not been clearly defined. This work aimed to compare the expression of pRb and p16INK4a as possible biomarkers in tumor tissues with and without infection by EBV or different genotypes of HPV from patients with LSCC. METHODS Tumor samples from 103 patients with LSCC were previously investigated for the presence and genotypes of HPV using the INNO-LiPA line probe assay and for the infection of EBV by qPCR. p16 INK4a and pRb expression was assessed by immunohistochemistry. RESULTS Of the 103 tumor samples, expression of p16INK4a was positive in 55 (53.4%) and of this, 32 (56.1%) were positive for HPV whereas 11 (39.3%) were EBV positive but both without a significantly difference (p > 0.05). pRb expression was positive in 78 (75.7%) and a higher frequency of this expression was observed in HPV negative samples (87.0%) (p = 0.021) and in high-risk HPV negative samples (85.2%) (p = 0.010). No difference was observed when comparing pRb expression and EBV infection status (p > 0.05). CONCLUSION Our results support the suggestion that p16INK4a is not a reliable surrogate marker for identifying HPV or EBV infection in LSCC. On the other hand, most of our samples had pRb expression, which was more frequent in tumors without HPV, suggesting that pRb could indicate HPV negativity. However, more studies with a larger number of cases are required, including controls without LSCC and evaluating other molecular markers to determine the real role of p16INK4a and pRb in LSCC.
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Affiliation(s)
- Jose Manuel Vazquez-Guillen
- Laboratorio de Inmunologia y Virologia, Facultad de Ciencias Biologicas, Universidad Autonoma de Nuevo Leon, San Nicolas de los Garza, Nuevo Leon, Mexico
| | - Gerardo C Palacios-Saucedo
- Division de Investigacion, Departamento de Otorrinolaringologia y Departamento de Anatomia Patologica, Unidad Medica de Alta Especialidad, Hospital de Especialidades No. 25, Instituto Mexicano del Seguro Social, Monterrey, Nuevo Leon, Mexico.
| | - Alondra Yamileth Alanis-Valdez
- Laboratorio de Inmunologia y Virologia, Facultad de Ciencias Biologicas, Universidad Autonoma de Nuevo Leon, San Nicolas de los Garza, Nuevo Leon, Mexico
| | - Andrea Huerta-Escobedo
- Laboratorio de Inmunologia y Virologia, Facultad de Ciencias Biologicas, Universidad Autonoma de Nuevo Leon, San Nicolas de los Garza, Nuevo Leon, Mexico
| | - Angel Zavala-Pompa
- Laboratorio Medicina Diagnostica S.A. de C.V., Monterrey, Nuevo Leon, Mexico
| | - Lydia Guadalupe Rivera-Morales
- Laboratorio de Inmunologia y Virologia, Facultad de Ciencias Biologicas, Universidad Autonoma de Nuevo Leon, San Nicolas de los Garza, Nuevo Leon, Mexico
| | - Ana Carolina Martinez-Torres
- Laboratorio de Inmunologia y Virologia, Facultad de Ciencias Biologicas, Universidad Autonoma de Nuevo Leon, San Nicolas de los Garza, Nuevo Leon, Mexico
| | - Vianey Gonzalez-Villasana
- Departamento de Biologia Celular y Genetica, Facultad de Ciencias Biologicas, Universidad Autonoma de Nuevo Leon, San Nicolas de los Garza, Nuevo Leon, Mexico
| | - Julio Cesar Serna-Hernandez
- Division de Investigacion, Departamento de Otorrinolaringologia y Departamento de Anatomia Patologica, Unidad Medica de Alta Especialidad, Hospital de Especialidades No. 25, Instituto Mexicano del Seguro Social, Monterrey, Nuevo Leon, Mexico
| | - Silvia Judith Hernandez-Martinez
- Division de Investigacion, Departamento de Otorrinolaringologia y Departamento de Anatomia Patologica, Unidad Medica de Alta Especialidad, Hospital de Especialidades No. 25, Instituto Mexicano del Seguro Social, Monterrey, Nuevo Leon, Mexico
| | - Edmundo Erbey Castelan-Maldonado
- Division de Investigacion, Departamento de Otorrinolaringologia y Departamento de Anatomia Patologica, Unidad Medica de Alta Especialidad, Hospital de Especialidades No. 25, Instituto Mexicano del Seguro Social, Monterrey, Nuevo Leon, Mexico
| | - Martha Socorro Montalvo-Bañuelos
- Departamento de Foniatria, Hospital General de Zona No. 6, Instituto Mexicano del Seguro Social, San Nicolas de los Garza, Nuevo Leon, Mexico
| | - Cesar Alejandro Alonso-Tellez
- Division de Investigacion, Departamento de Otorrinolaringologia y Departamento de Anatomia Patologica, Unidad Medica de Alta Especialidad, Hospital de Especialidades No. 25, Instituto Mexicano del Seguro Social, Monterrey, Nuevo Leon, Mexico
| | - Ethel Corinthia Sanchez-Fresno
- Division de Investigacion, Departamento de Otorrinolaringologia y Departamento de Anatomia Patologica, Unidad Medica de Alta Especialidad, Hospital de Especialidades No. 25, Instituto Mexicano del Seguro Social, Monterrey, Nuevo Leon, Mexico
| | - Reyes S Tamez-Guerra
- Laboratorio de Inmunologia y Virologia, Facultad de Ciencias Biologicas, Universidad Autonoma de Nuevo Leon, San Nicolas de los Garza, Nuevo Leon, Mexico
| | - Cristina Rodriguez-Padilla
- Laboratorio de Inmunologia y Virologia, Facultad de Ciencias Biologicas, Universidad Autonoma de Nuevo Leon, San Nicolas de los Garza, Nuevo Leon, Mexico
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Melariri H, Els T, Oyedele O, Suttle TK, Bermosky KT, De Freitas A, Murtaza A, Moosajee M, Melariri PE. Prevalence of locoregional recurrence and survival post-treatment of head and neck cancers in Africa: a systematic review and meta-analysis. EClinicalMedicine 2023; 59:101964. [PMID: 37125401 PMCID: PMC10139903 DOI: 10.1016/j.eclinm.2023.101964] [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: 01/18/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 05/02/2023] Open
Abstract
Background Recurrent cancers of the head and neck are associated with poor survival outcome. Yet, their burden in Africa is not reliably known. We therefore aimed to estimate the prevalence of recurrence and the 5-year overall survival among patients treated for head and neck cancers (HNC) in Africa. Method In this systematic review and meta-analysis, we searched four electronic databases (Pubmed, CINAHL, MEDLINE, and Web of Science) and the grey literature for studies reporting the prevalence of HNC recurrence and 5-year overall survival post treatment, published between January 1, 2002, and December 31, 2022. We contacted corresponding authors of relevant studies. Searches were extended to reference lists of review articles and other relevant sources for potentially eligible studies. Each record was assessed for inclusion or exclusion by two independent reviewers. Records with individual-level data on recurrence and survival conducted in Africa were included while exclusion was based on the study design and availability of relevant data. Data were independently extracted by three reviewers from eligible studies, and summary estimates were sought. Our primary outcomes were recurrence and 5-year overall survival of patients who have been treated for HNC, and our secondary outcomes included risk factors, tumor site, squamous cell histology, clinical stage of tumor, and treatment options received. Only records selected for primary outcomes were assessed for secondary outcome data extraction. Random-effects meta-analysis was conducted for each outcome. Meta-regression models were used in addressing sample heterogeneity among the studies. Protocol for this study was registered with PROSPERO, CRD42022372307. Findings This systematic review and meta-analysis returned 3998 records, yielding 28 included studies after exclusion. Eighteen studies reported on the prevalence of HNC recurrence while 24 articles reported on the 5-year overall survival. Of the pooled total study population, 7199 (70.5%) of 10,218 patients were males while 2603 (25.5%) were females. We found that the prevalence of HNC recurrence was 15.4% (I2 = 96.2%; 95% CI: 9.5-22.3; n = 3214; k = 18), and the 5-year overall survival was 54.4% (I2 = 99.5%; 95% CI: 40.1-68.4; n = 9798; k = 24). We also found that the prevalence of smoking and alcohol consumption as risk factors for HNC were 42.6% (I2 = 98.8%; 95% CI: 25.2-61.0; n = 4374; k = 15) and 35.8% (I2 = 98.9%; 95% CI: 21.7-51.4; n = 4110; k = 11) respectively. The pooled current prevalence for advanced HNC (clinical stages III-IV) was 80.0% (I2 = 99.2%; 95% CI: 68.6-89.5; n = 7624; k = 18) compared to 12.2% (I2 = 96.4%; 95% CI: 6.2-19.8; n = 7624; k = 18) in early disease (clinical stages I-II). Interpretation The results showed significantly high prevalence of cancer recurrence, poor 5-year overall survival and very high prevalence of advanced cancers at time of diagnosis. This study provides robust evidence for strategies towards prompt diagnosis and appropriate management of HNC to improve patients' outcome in the African continent. Funding This study was not supported by any funding.
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Affiliation(s)
- Herbert Melariri
- Department of Otorhinolaryngology, Port Elizabeth Provincial Hospital, Gqeberha, South Africa
- Corresponding author. Department of Otorhinolaryngology, Port Elizabeth Provincial Hospital, Buckingham Road, Mount Croix, Gqeberha, South Africa.
| | - Timothy Els
- Department of Otorhinolaryngology, Port Elizabeth Provincial Hospital, Gqeberha, South Africa
| | - Opeoluwa Oyedele
- Department of Computing, Mathematical, and Statistical Sciences, School of Science, University of Namibia, Windhoek, Namibia
- Department of Environmental Health, Faculty of Health Sciences, Nelson Mandela University, Gqeberha, South Africa
| | - Tessa K. Suttle
- Department of Otorhinolaryngology, Port Elizabeth Provincial Hospital, Gqeberha, South Africa
| | - Kim Theresa Bermosky
- Department of Otorhinolaryngology, Port Elizabeth Provincial Hospital, Gqeberha, South Africa
| | - Adelaide De Freitas
- Department of Radiation Oncology, Livingstone Tertiary Hospital, Gqeberha, South Africa
| | - Amir Murtaza
- Department of Otorhinolaryngology, Port Elizabeth Provincial Hospital, Gqeberha, South Africa
| | - Mohamed Moosajee
- Department of Otorhinolaryngology, Port Elizabeth Provincial Hospital, Gqeberha, South Africa
| | - Paula E. Melariri
- Faculty of Health Sciences, Nelson Mandela University, Gqeberha, South Africa
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Zhou LQ, Hu Y, Xiao HJ. The prognostic significance of survivin expression in patients with HNSCC: a systematic review and meta-analysis. BMC Cancer 2021; 21:424. [PMID: 33863308 PMCID: PMC8052826 DOI: 10.1186/s12885-021-08170-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 04/07/2021] [Indexed: 12/16/2022] Open
Abstract
Background Survivin has been recently identified as a promising novel therapeutic target and prognostic marker in different types of cancer. Here we conducted a comprehensive meta-analysis to better clarify they the precise prognostic and diagnostic value of survivin in head and neck squamous cell carcinoma (HNSCC). Methods Database of PubMed (Medline), Embase, and Web of Science were systematically searched for related published literature up to September 2020. Pooled hazards ratios (HR) and related 95% confidence intervals (CI) were used to estimate the association of survivin expression and survival outcomes in HNSCC patients. Results Twenty eight studies with 4891 patients were finally included in this meta-analysis, the pooled analysis indicated that the survivin expression was significantly correlated with poorer overall survival (OS) (HR, 2.02; 95% CI, 1.65–2.47, P < 0.001), and poorer disease-free survival (DFS)/ disease-specific survival (DSS) (HR = 2.03, 95%CI: 1.64–2.52, P < 0.001; HR = 1.92, 95%CI: 1.41–2.60, P < 0.001, receptively). Similar results were observed in subgroup analysis stratified by different cancer types, such as laryngeal squamous cell carcinoma (LSCC) (HR = 1.35, 95%CI: 1.05–1.74, P < 0.001), oral squamous cell carcinomas (OSCC) (HR = 2.45, 95%CI: 1.89–3.17, P < 0.001), nasopharyngeal carcinoma (NPC) (HR = 2.53, 95%CI: 1.76–3.62, P < 0.001) and HNSCC (HR = 1.52, 95%CI: 1.25–1.86, P < 0.001). Furthermore, ethnicity-stratified analysis indicated that survivin was significantly associated with poorer OS among both Asian and Non- Asian HNSCC patients (HR = 2.16, 95%CI: 1.76–2.66; HR = 1.56, 95%CI: 1.33–1.82, respectively). Conclusions Our results suggested that survivin is predictors of worse prognosis in HNSCC patients. Hence, survivin is a potential therapeutic target for HNSCC. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08170-3.
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Affiliation(s)
- Liu-Qing Zhou
- Department of Otorhinolaryngology, Union Hospital, Ongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yao Hu
- Department of Otorhinolaryngology, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430000, China
| | - Hong-Jun Xiao
- Department of Otorhinolaryngology, Union Hospital, Ongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Ben Elhadj M, Fourati A, El Amine O, Goucha A, El May A, El May MV, Mokni Baizig N. Prevalence and Prognostic Value of HPV among Tunisian Patients with Laryngeal Cancer and Relationship between DNA HPV and p16, IGF-1R, Survivin, p53 Expressions. Ann Otol Rhinol Laryngol 2020; 129:863-871. [PMID: 32364419 DOI: 10.1177/0003489420918280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Tobacco and alcohol are the main etiological factors common to laryngeal cancers. However, the Human Papilloma Virus (HPV) constitutes an alternative risk factor according to several studies. In Tunisia, despite the annual increasing incidence of laryngeal squamous cell carcinoma (LSCC), the prevalence and prognostic significance of HPV have never been explored.In this study, we sought to highlight HPV DNA in 70 biopsies of laryngeal cancer, and to analyze the status of HPV infection in association with p53, p16, survivin, and IGF-1R expressions. METHODS HPV high risk (HPV HR) DNA was detected in tumors by in situ hybridization. However, the expression of p53, p16, survivin and IGF-1R were stained by immunohistochemistry test. The correlations of HPV status with clinicopathological parameters, overall survival, disease-free survival and proteins expressions were statistically evaluated. RESULTS HPV HR DNA was detected in 39 out of 70 (55.71%) laryngeal tumors. HPV+ patients have a better overall survival (P = .081) and long disease-free-survival (P = .016) with a low rate of recurrence (P = .006) than HPV- patients. No significant correlations were found between HPV HR status and clinicopathological parameters (all P > .005). Moreover, HPV+ tumors were not associated with expression of p53, p16 and survivin. However, HPV HR status correlates with weak to moderate IGF-1R expression (P = .043). CONCLUSION The substantial detection of HPV HR in LSCC tumors suggest that this virus plays an important part in laryngeal cancer in Tunisia. It is a good prognostic factor. In addition, HPV infection could act to block the pathway of IGF-1R expression.
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Affiliation(s)
- Mariem Ben Elhadj
- Departement of Immuno-Histo-Cytology, Salah Azaiez Cancer Institute, Tunis, Tunisia.,Research unit 17/ES/13 Faculty of Medicine, Tunis, Tunisia, University of Tunis El Manar, Tunisia
| | - Asma Fourati
- Departement of Immuno-Histo-Cytology, Salah Azaiez Cancer Institute, Tunis, Tunisia.,Research unit 17/ES/13 Faculty of Medicine, Tunis, Tunisia, University of Tunis El Manar, Tunisia
| | - Olfa El Amine
- Departement of Immuno-Histo-Cytology, Salah Azaiez Cancer Institute, Tunis, Tunisia
| | - Aida Goucha
- Departement of Immuno-Histo-Cytology, Salah Azaiez Cancer Institute, Tunis, Tunisia
| | - Ahmed El May
- Departement of Immuno-Histo-Cytology, Salah Azaiez Cancer Institute, Tunis, Tunisia
| | - Michèle-Veronique El May
- Research unit 17/ES/13 Faculty of Medicine, Tunis, Tunisia, University of Tunis El Manar, Tunisia
| | - Nehla Mokni Baizig
- Departement of Immuno-Histo-Cytology, Salah Azaiez Cancer Institute, Tunis, Tunisia.,Research unit 17/ES/13 Faculty of Medicine, Tunis, Tunisia, University of Tunis El Manar, Tunisia
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Ben Elhadj M, Goucha A, Fourati A, Adouni O, Dhambri S, Hsairi M, El May MV, Mokni Baizig N. The Prognostic Significance of IGF-1R and the Predictive Risk Value of Circulating IGF-1 in Tunisian Patients with Laryngeal Carcinoma. Cancer Invest 2020; 38:289-299. [PMID: 32308049 DOI: 10.1080/07357907.2020.1758711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The aim was to evaluate the clinical impact of IGF-1/IGF-1R in Tunisian laryngeal carcinoma. A high IGF-1R immunohistochemical expression was found in our series (81.43%). A tendency toward an association between IGF-1R expression and lymph node metastasis was found (p = 0.068). Patients with positive IGF-1R expression showed a short disease free survival (p = 0.053) and a high recurrence rate. Furthermore, circulating IGF-1 levels sera, detected by ELISA, were higher among patients compared to controls (p < 0.001). IGF-1R might have a prognostic significance and could be a factor of tumor recurrence. However, high levels of IGF-1 increase the risk of developing of LSCC disease.
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Affiliation(s)
- Mariem Ben Elhadj
- Departement of Immuno-Histo-Cytology, Salah Azaiez Cancer Institute, Tunis, Tunisia.,Research unit 17/ES/13 Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - Aida Goucha
- Departement of Immuno-Histo-Cytology, Salah Azaiez Cancer Institute, Tunis, Tunisia
| | - Asma Fourati
- Departement of Immuno-Histo-Cytology, Salah Azaiez Cancer Institute, Tunis, Tunisia.,Research unit 17/ES/13 Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - Olfa Adouni
- Departement of Immuno-Histo-Cytology, Salah Azaiez Cancer Institute, Tunis, Tunisia
| | - Sawsen Dhambri
- Departement of ORL, Salah Azaiez Cancer Institute, Tunis, Tunisia
| | - Mohamed Hsairi
- Departement of Epidemiology, Salah Azaiez Cancer Institute, Tunis, Tunisia
| | | | - Nehla Mokni Baizig
- Departement of Immuno-Histo-Cytology, Salah Azaiez Cancer Institute, Tunis, Tunisia.,Research unit 17/ES/13 Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
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