1
|
Mohan N, V J, Prahladan A, K R. Impact of incorporating Magnetic Resonance Imaging in FIGO Staging of Primary Carcinoma Cervix: Experience from a tertiary cancer center. Asia Pac J Clin Oncol 2021; 18:465-472. [PMID: 34818450 DOI: 10.1111/ajco.13636] [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: 04/01/2021] [Accepted: 06/20/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND International Federation of Gynaecology and Obstetrics (FIGO) staging of carcinoma cervix, although essentially clinical, acknowledges the benefits of MRI. The impact of incorporating MRI in staging of cervical cancer and the discordance between clinical-and MRI-based FIGO staging is not well studied, especially in low- and middle-income countries. AIM We aim to study the role and accuracy of MRI in staging carcinoma cervix, its correlation with clinical FIGO and histopathological staging with emphasis on how it can change treatment plan. METHODS Retrospective observational cohort study (n = 193) where MRI details of different staging parameters of the study subjects were compared with clinical FIGO staging and histopathology to assess correlation and agreement between them. Change of clinical FIGO stage and hence treatment plan brought about by incorporating MRI was assessed. RESULTS MRI had a tumor detection rate of 94.3%, overall staging accuracy of 78.3% and very strong correlation with histopathology (Spearman's coefficient of rank correlation, r = 0.886). Clinical FIGO and MRI had agreement only in 52.8% cases (r = 0.61). Incorporating MRI changed the clinical stage in 47.2% patients and subsequently modified primary treatment plan in 23.3%. CONCLUSION MRI is highly accurate in evaluating carcinoma cervix and has good correlation with histopathology. Our data shows low agreement between MRI and clinical FIGO staging. Thus, incorporating MRI in FIGO staging has considerable impact in altering treatment decisions and should be offered to all patients for staging carcinoma cervix.
Collapse
Affiliation(s)
- Neha Mohan
- Department of Imageology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - Jiji V
- Department of Imageology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - Anil Prahladan
- Department of Imageology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - Ramachandran K
- Department of Imageology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| |
Collapse
|
2
|
Dundr P, Cibula D, Němejcová K, Tichá I, Bártů M, Jakša R. Pathologic Protocols for Sentinel Lymph Nodes Ultrastaging in Cervical Cancer. Arch Pathol Lab Med 2019; 144:1011-1020. [PMID: 31869245 DOI: 10.5858/arpa.2019-0249-ra] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Ultrastaging of sentinel lymph nodes (SLNs) is a crucial aspect in the approach to SLN processing. No consensual protocol for pathologic ultrastaging has been approved by international societies to date. OBJECTIVE.— To provide a review of the ultrastaging protocol and all its aspects related to the processing of SLNs in patients with cervical cancer. DATA SOURCES.— In total, 127 publications reporting data from 9085 cases were identified in the literature. In 24% of studies, the information about SLN processing is entirely missing. No ultrastaging protocol was used in 7% of publications. When described, the differences in all aspects of SLN processing among the studies and institutions are substantial. This includes grossing of the SLN, which is not completely sliced and processed in almost 20% of studies. The reported protocols varied in all aspects of SLN processing, including the thickness of slices (range, 1-5 mm), the number of levels (range, 0-cut out until no tissue left), distance between the levels (range, 40-1000 μm), and number of sections per level (range, 1-5). CONCLUSIONS.— We found substantial differences in protocols used for SLN pathologic ultrastaging, which can impact sensitivity for detection of micrometastases and even small macrometastases. Since the involvement of pelvic lymph nodes is the most important negative prognostic factor, such profound discrepancies influence the referral of patients to adjuvant radiotherapy and could potentially cause treatment failure. It is urgent that international societies agree on a consensual protocol before SLN biopsy without pelvic lymphadenectomy is introduced into routine clinical practice.
Collapse
Affiliation(s)
- Pavel Dundr
- From Institute of Pathology (Drs Dundr, Němejcová, Tichá, Bártů, and Jakša) and Gynecologic Oncology Center, Department of Obstetrics and Gynecology (Dr Cibula), First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - David Cibula
- From Institute of Pathology (Drs Dundr, Němejcová, Tichá, Bártů, and Jakša) and Gynecologic Oncology Center, Department of Obstetrics and Gynecology (Dr Cibula), First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Kristýna Němejcová
- From Institute of Pathology (Drs Dundr, Němejcová, Tichá, Bártů, and Jakša) and Gynecologic Oncology Center, Department of Obstetrics and Gynecology (Dr Cibula), First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Ivana Tichá
- From Institute of Pathology (Drs Dundr, Němejcová, Tichá, Bártů, and Jakša) and Gynecologic Oncology Center, Department of Obstetrics and Gynecology (Dr Cibula), First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Michaela Bártů
- From Institute of Pathology (Drs Dundr, Němejcová, Tichá, Bártů, and Jakša) and Gynecologic Oncology Center, Department of Obstetrics and Gynecology (Dr Cibula), First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Radek Jakša
- From Institute of Pathology (Drs Dundr, Němejcová, Tichá, Bártů, and Jakša) and Gynecologic Oncology Center, Department of Obstetrics and Gynecology (Dr Cibula), First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| |
Collapse
|
3
|
Bataille B, Escande A, Le Tinier F, Parent A, Bogart E, Collinet P, Bresson L, Narducci F, Leblanc E, Lemaire AS, Taieb S, Lartigau E, Mirabel X, Cordoba A. Outcomes of pre-operative brachytherapy followed by hysterectomy for early cervical cancer. Int J Gynecol Cancer 2019; 30:181-186. [PMID: 31871113 DOI: 10.1136/ijgc-2019-000617] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 09/24/2019] [Accepted: 09/25/2019] [Indexed: 12/09/2022] Open
Abstract
OBJECTIVE The standard of care for early cervical cancer is radical hysterectomy; however, consideration of pre-operative brachytherapy has been explored. We report our experience using pre-operative brachytherapy plus Wertheim-type hysterectomy to treat early stage cervical cancer. METHODS This single-center study evaluated consecutive patients with histologically proven node-negative early stage cervical cancer (International Federation of Gynecology and Obstetrics 2009 stage IB1-IIB) that was treated using pre-operative brachytherapy and hysterectomy. Pre-brachytherapy staging was performed using magnetic resonance imaging (MRI) and pelvic lymph node assessment was performed using lymphadenectomy. The tumor and cervical tissues were treated using brachytherapy (total dose 60 Gy) followed by Wertheim-type hysterectomy. The study included patients from January 2000 to December 2013. RESULTS A total of 80 patients completed a median follow-up of 6.7 years (range 5.4-8.5). The surgical specimens revealed a pathological complete response for 61 patients (76%). Patients with incomplete responses generally had less than 1 cm residual tumor at the cervix, and only one patient had lymphovascular space involvement. The estimated 5-year rates were 88% for overall survival (95% CI 78% to 94%) and 82% for disease-free survival (95% CI 71% to 89%). Toxicities were generally mild-to-moderate, including 26 cases (33%) of grade 2 late toxicity and 10 cases (13%) of grade 3 late toxicity. Univariate analyses revealed that poor disease-free survival was associated with overweight status (≥25 kg/m2, HR 3.05, 95% CI 1.20 to 7.76, p=0.019) and MRI tumor size >3 cm (HR 3.05, 95% CI 1.23 to 7.51, p=0.016). CONCLUSIONS Pre-operative brachytherapy followed by Wertheim-type hysterectomy may be safe and effective for early stage cervical cancer, although poorer outcomes were associated with overweight status and MRI tumor size >3 cm.
Collapse
Affiliation(s)
- Benoit Bataille
- Radiation Oncology and Brachytherapy Department, Centre Oscar Lambret, Lille, France
| | - Alexandre Escande
- Radiation Oncology and Brachytherapy Department, Centre Oscar Lambret, Lille, France
| | - Florence Le Tinier
- Radiation Oncology and Brachytherapy Department, Centre Oscar Lambret, Lille, France
| | - Audrey Parent
- Methodology and Biostatistics Department, Centre Oscar Lambret, Lille, France
| | - Emilie Bogart
- Methodology and Biostatistics Department, Centre Oscar Lambret, Lille, France
| | - Pierre Collinet
- Gynecological Surgery Department, Hopital Jeanne de Flandre, Lille, Hauts-de-France, France
| | - Lucie Bresson
- Gynecological Surgery Department, Centre Oscar Lambret, Lille, France
| | - Fabrice Narducci
- Gynecological Surgery Department, Centre Oscar Lambret, Lille, France
| | - Eric Leblanc
- Gynecological Surgery Department, Centre Oscar Lambret, Lille, France
| | | | - Sophie Taieb
- Medical Imaging Department, Centre Oscar Lambret, Lille, France
| | - Eric Lartigau
- Radiation Oncology and Brachytherapy Department, Centre Oscar Lambret, Lille, France
| | - Xavier Mirabel
- Radiation Oncology and Brachytherapy Department, Centre Oscar Lambret, Lille, France
| | - Abel Cordoba
- Radiation Oncology and Brachytherapy Department, Centre Oscar Lambret, Lille, France
| |
Collapse
|
4
|
Sozzi G, Berretta R, Fiengo S, Ferreri M, Giallombardo V, Finazzo F, Messana D, Capozzi VA, Colacurci N, Scambia G, Chiantera V. Integrated pre-surgical diagnostic algorithm to define extent of disease in cervical cancer. Int J Gynecol Cancer 2019; 30:16-20. [PMID: 31645425 DOI: 10.1136/ijgc-2019-000665] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/22/2019] [Accepted: 08/26/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Survival of patients with cervical cancer is strongly associated with the local extent of the primary disease. The aim of the study was to develop an integrated diagnostic algorithm, including ultrasonography (USG), magnetic resonance imaging (MRI), and examination under anesthesia, to define the local extent of disease in patients with newly diagnosed cervical cancer. METHODS Patients with biopsy proven cervical cancer who underwent primary surgery from January 2013 to December 2018 in four participating centers were recruited. Patients who underwent USG, MRI, and examination under anesthesia prior to surgery were included in the study. Those for whom complete data were not available were excluded. Data regarding tumor size, parametrial invasion, and vaginal involvement obtained by USG, MRI, and examination under anesthesia were retrieved and compared with final histology. Specificity and sensitivity of the three methods were calculated for each parameter and the methods were compared with each other. An integrated pre-surgical algorithm was constructed considering the accuracy of each diagnostic method for each parameter. RESULTS A total of 79 consecutive patients were included in the study. Median age was 53 years (range 28-87) and median body mass index was 24.6 kg/m2 (range 16-43). Fifty-five (69.6%) patients had squamous carcinoma, 18 (22.8%) patients had adenocarcinoma, and six (7.6%) patients had other histological subtypes. A statistically significant difference among the three methods was found for detecting tumor size (p=0.002 for tumors >2 cm and p=0.006 for tumors >4 cm) and vaginal involvement (p=0.01). There was no difference in detection of parametrial invasion between USG, MRI, and examination under anesthesia (p=0.26). Furthermore, regarding tumor size assessment, USG was found to be the significantly better method (p<0.01 for tumors >2 cm and p=0.02 for tumors >4 cm). Examination under anesthesia was the most accurate method for detection of vaginal involvement (p=0.01). Examination under anesthesia and MRI had higher accuracy than USG for identification of parametrial invasion. Application of the algorithm provided the correct definition of local extent of disease in 77.2% of patients (p=0.04). USG was the most accurate method to determine tumor size, while examination under anesthesia was found to be more accurate in prediction of vaginal involvement. CONCLUSION Our integrated diagnostic algorithm allows a higher accuracy in defining the local extent of disease and may be used as a tool to determine the therapeutic approach in women with cervical cancer.
Collapse
Affiliation(s)
- Giulio Sozzi
- Department of Gynecologic Oncology, ARNAS Civico Di Cristina Benfratelli, Palermo, Italy .,University of Palermo, Palermo, Italy
| | - Roberto Berretta
- Department of Gynecology and Obstetrics, University Hospital of Parma, Parma, Italy
| | - Stefania Fiengo
- Department of Woman, Child and General and Special Surgery, University of Campania Luigi Vanvitelli, Napoli, Italy
| | - Marco Ferreri
- Department of Gynecologic Oncology, University of Palermo, Palermo, Italy
| | | | - Francesca Finazzo
- Department of Radiology, ARNAS Civico Di Cristina Benfratelli, Palermo, Italy
| | - Domenico Messana
- Department of Radiology, ARNAS Civico Di Cristina Benfratelli, Palermo, Italy
| | - Vito Andrea Capozzi
- Department of Gynecology and Obstetrics, University Hospital of Parma, Parma, Italy
| | - Nicola Colacurci
- Department of Woman, Child and General and Special Surgery, University of Campania Luigi Vanvitelli, Napoli, Italy
| | - Giovanni Scambia
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Vito Chiantera
- Department of Gynecologic Oncology, ARNAS Civico Di Cristina Benfratelli, Palermo, Italy.,University of Palermo, Palermo, Italy
| |
Collapse
|
5
|
Cheng-Yen Lai J, Lai KJ, Yi-Yung Yu E, Hung ST, Chu CY, Wang KL. Sentinel lymphatic mapping among women with early-stage cervical cancer: A systematic review. Taiwan J Obstet Gynecol 2019; 57:636-643. [PMID: 30342642 DOI: 10.1016/j.tjog.2018.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2018] [Indexed: 11/26/2022] Open
Abstract
The presence of pelvic lymph node metastases is without doubt the most significant prognostic factor that determines recurrences and survival of women with early-stage cervical cancer. To avoid the underdiagnosis of lymph node metastasis, pelvic lymphadenectomy procedure is routinely performed with radical hysterectomy procedure. However, the pelvic lymphadenectomy procedure may not be necessary in most of these women due to the relatively low incidence of pelvic lymph node metastasis. The removal of large numbers of pelvic lymph nodes could also render non-metastatic irreversible damages for these women, including vessel, nerve, or ureteral injuries; formation of lymphocysts; and lymphedema. Over the past decades, the concept of sentinel lymph node biopsy has emerged as a popular and widespread surgical technique for the evaluation of the pelvic lymph node status in gynecologic malignancies. The histological status of sentinel lymph node should be representative for all other lymph nodes in the regional drainage area. If metastasis is non-existent in the sentinel lymph node, the likelihood of metastatic spread in the remaining regional lymph nodes is very low. Further lymphadenectomy is therefore not necessary for a patient with negative sentinel lymph nodes. Since the uterine cervix has several lymphatic drainage pathways, it is a challenging task to assess the distribution pattern of sentinel lymph nodes in women with early-stage cervical cancer. This review article will adapt the methodology proposed in these studies to systematically review sentinel lymphatic mapping among women with early-stage cervical cancer.
Collapse
Affiliation(s)
- Jerry Cheng-Yen Lai
- Department of Medical Research, Taitung MacKay Memorial Hospital, Taitung, Taiwan
| | - Kuan-Ju Lai
- Department of Pathology, Taitung MacKay Memorial Hospital, Taitung, Taiwan
| | - Edward Yi-Yung Yu
- Department of Radiology, Taitung MacKay Memorial Hospital, Taitung, Taiwan
| | - Sho-Ting Hung
- Department of Radiology, Taitung MacKay Memorial Hospital, Taitung, Taiwan
| | - Chia-Ying Chu
- Department of Pathology, Taitung MacKay Memorial Hospital, Taitung, Taiwan
| | - Kung-Liahng Wang
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan; Department of Nursing, MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan; Department of Obstetrics and Gynecology, Taitung MacKay Memorial Hospital, Taitung, Taiwan; Department of Obstetrics and Gynecology, MacKay Medical College, New Taipei City, Taiwan.
| |
Collapse
|
6
|
Dappa E, Elger T, Hasenburg A, Düber C, Battista MJ, Hötker AM. The value of advanced MRI techniques in the assessment of cervical cancer: a review. Insights Imaging 2017; 8:471-481. [PMID: 28828723 PMCID: PMC5621992 DOI: 10.1007/s13244-017-0567-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/18/2017] [Accepted: 07/18/2017] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To assess the value of new magnetic resonance imaging (MRI) techniques in cervical cancer. METHODS We searched PubMed and MEDLINE and reviewed articles published from 1990 to 2016 to identify studies that used MRI techniques, such as diffusion weighted imaging (DWI), intravoxel incoherent motion (IVIM) and dynamic contrast enhancement (DCE) MRI, to assess parametric invasion, to detect lymph node metastases, tumour subtype and grading, and to detect and predict tumour recurrence. RESULTS Seventy-nine studies were included. The additional use of DWI improved the accuracy and sensitivity of the evaluation of parametrial extension. Most studies reported improved detection of nodal metastases. Functional MRI techniques have the potential to assess tumour subtypes and tumour grade differentiation, and they showed additional value in detecting and predicting treatment response. Limitations included a lack of technical standardisation, which limits reproducibility. CONCLUSIONS New advanced MRI techniques allow improved analysis of tumour biology and the tumour microenvironment. They can improve TNM staging and show promise for tumour classification and for assessing the risk of tumour recurrence. They may be helpful for developing optimised and personalised therapy for patients with cervical cancer. TEACHING POINTS • Conventional MRI plays a key role in the evaluation of cervical cancer. • DWI improves tumour delineation and detection of nodal metastases in cervical cancer. • Advanced MRI techniques show promise regarding histological grading and subtype differentiation. • Tumour ADC is a potential biomarker for response to treatment.
Collapse
Affiliation(s)
- Evelyn Dappa
- Department of Diagnostic and Interventional Radiology, Johannes Gutenberg-University Medical Centre, Langenbeckstr. 1, 55131, Mainz, Germany.
| | - Tania Elger
- Department of Gynaecology and Obstetrics, Johannes Gutenberg-University Medical Centre, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Annette Hasenburg
- Department of Gynaecology and Obstetrics, Johannes Gutenberg-University Medical Centre, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Christoph Düber
- Department of Diagnostic and Interventional Radiology, Johannes Gutenberg-University Medical Centre, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Marco J Battista
- Department of Gynaecology and Obstetrics, Johannes Gutenberg-University Medical Centre, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Andreas M Hötker
- Department of Diagnostic and Interventional Radiology, Johannes Gutenberg-University Medical Centre, Langenbeckstr. 1, 55131, Mainz, Germany
| |
Collapse
|
7
|
Kadkhodayan S, Hasanzadeh M, Treglia G, Azad A, Yousefi Z, Zarifmahmoudi L, Sadeghi R. Sentinel node biopsy for lymph nodal staging of uterine cervix cancer: a systematic review and meta-analysis of the pertinent literature. Eur J Surg Oncol 2014; 41:1-20. [PMID: 25454828 DOI: 10.1016/j.ejso.2014.09.010] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 09/15/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We reviewed the available literature on the accuracy of sentinel node mapping in the lymph nodal staging of uterine cervical cancers. METHODS MEDLINE and Scopus were searched by using "sentinel AND (cervix OR cervical)" as key words. Studies evaluating the accuracy of sentinel node mapping in the lymph nodal staging of uterine cervical cancers were included if enough data could be extracted for calculation of detection rate and/or sensitivity. RESULTS Sixty-seven studies were included in the systematic review. Pooled detection rate was 89.2% [95% CI: 86.3-91.6]. Pooled sensitivity was 90% [95% CI: 88-92]. Sentinel node detection rate and sensitivity were related to mapping method (blue dye, radiotracer, or both) and history of pre-operative neoadjuvant chemotherapy. Sensitivity was higher in patients with bilaterally detected pelvic sentinel nodes compared to those with unilateral sentinel nodes. Lymphatic mapping could identify sentinel nodes outside the routine lymphadenectomy limits. CONCLUSION Sentinel node mapping is an accurate method for the assessment of lymph nodal involvement in uterine cervical cancers. Selection of a population with small tumor size and lower stage will ensure the lowest false negative rate. Lymphatic mapping can also detect sentinel nodes outside of routine lymphadenectomy areas providing additional histological information which can improve the staging. Further studies are needed to explore the impact of sentinel node mapping in fertility sparing surgery and in patients with history of neoadjuvant chemotherapy.
Collapse
Affiliation(s)
- S Kadkhodayan
- Women's Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - M Hasanzadeh
- Women's Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - G Treglia
- Department of Nuclear Medicine and PET/CT Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - A Azad
- Women's Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Z Yousefi
- Women's Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - L Zarifmahmoudi
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - R Sadeghi
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
| |
Collapse
|
8
|
A comparative analysis of clinical and molecular factors with the stage of cervical cancer in a Brazilian cohort. PLoS One 2013; 8:e57810. [PMID: 23505442 PMCID: PMC3591395 DOI: 10.1371/journal.pone.0057810] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 01/26/2013] [Indexed: 11/19/2022] Open
Abstract
Cell cycle protein expression plays an important role in the pathophysiology of cervical cancer. However, few studies have attempted to correlate the use of these biomarkers with the clinical progression of the tumor.
Collapse
|