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Brisuda A, Horňák J, Žemličková B, Háček J, Babjuk M. Intravesical thermochemotherapy in the treatment of high-risk and very high-risk non-muscle-invasive urothelial bladder cancer: a single-arm study. Int Urol Nephrol 2024; 56:2243-2250. [PMID: 38329573 PMCID: PMC11190016 DOI: 10.1007/s11255-023-03924-3] [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: 09/14/2023] [Accepted: 12/19/2023] [Indexed: 02/09/2024]
Abstract
AIM Intravesical thermochemotherapy, also known as HIVEC (Hyperthermic Intra-VEsical Chemotherapy), represents an alternative adjuvant topical treatment for non-muscle-invasive urothelial bladder cancer (NMIBC). High-risk (HR) and very HR tumors carry a substantial risk of recurrence and progression. In this study, we present our own results using HIVEC as an alternative to unavailable Bacillus Calmette-Guérin (BCG) vaccine in the treatment of such groups of patients. METHODS During the period of November 2014-June 2022, a total of 47 patients with HR and very HR NMIBC underwent treatment with HIVEC after transurethral resection. They were given an induction of 6 instillations with/without a maintenance. The aim was to evaluate the time to recurrence, event-free survival (recurrence or progression), as measured by Kaplan-Meier analysis, the effect of maintenance treatment and other factors on survival (log-rank test and multivariable Cox regression analysis), and complications. RESULTS The median follow-up for patients who did not experience an event was 32 months. The median time to HR (high grade and/or T1 tumor) recurrence in those who recurred was 15 months. The survival rate without HR recurrence at 12, 24, and 48 months was 84, 70, and 59%, respectively. Progression was detected in 10.6% of patients, which translated to 89% of patients living without progression after 24 months. Maintenance treatment (defined as more than six instillations) and presence of CIS significantly correlated with risk of HR recurrence (Hazard ratio 0.34 and 3.12, respectively). One female patient underwent salvage cystectomy due to contractory bladder, and 19.1% of patients experienced transient lower urinary tract symptoms. CONCLUSION Based on our experience, HIVEC represents an adequate and safe alternative treatment for HR and very HR NMIBC in situations where BCG is not available or radical cystectomy is not an option for the patient. However, high-quality data from prospective randomized studies are still lacking, and thus, thermochemotherapy should still be regarded as an experimental treatment modality.
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Affiliation(s)
- Antonín Brisuda
- 2nd Faculty of Medicine, Charles University, V Úvalu 84, 150 06, Prague 5, Czech Republic.
| | - Jakub Horňák
- 2nd Faculty of Medicine, Charles University, V Úvalu 84, 150 06, Prague 5, Czech Republic
| | - Barbora Žemličková
- 2nd Faculty of Medicine, Charles University, V Úvalu 84, 150 06, Prague 5, Czech Republic
| | - Jaromír Háček
- 2nd Faculty of Medicine, Charles University, V Úvalu 84, 150 06, Prague 5, Czech Republic
| | - Marek Babjuk
- 2nd Faculty of Medicine, Charles University, V Úvalu 84, 150 06, Prague 5, Czech Republic
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Magalhães JC, Sousa M, Basto R, Fraga T, Gomes I, Fernandes C, Mariano M, Paulo J, Madeira P, Sousa G. Adjuvant Hyperthermic Intravesical Chemotherapy in Intermediate- and High-Risk Non-muscle Invasive Bladder Cancer. Cureus 2023; 15:e45672. [PMID: 37745737 PMCID: PMC10512434 DOI: 10.7759/cureus.45672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 09/26/2023] Open
Abstract
INTRODUCTION Non-muscle invasive bladder cancer (NMIBC) is a frequently diagnosed neoplasm, which is typically managed with transurethral resection of bladder tumor (TURBT) eventually followed by intravesical therapies. Bacillus Calmette-Guérin (BCG) is used as first-line adjuvant treatment in high- (HR) and intermediate-risk (IR) NMIBC, although, in the latter, mitomycin C (MMC) may also be used. Multiple limitations to the use of BCG encouraged the search for therapeutic alternatives. In this context, hyperthermic intravesical chemotherapy with MMC (HIVEC-MMC) emerged as a promising therapy in the adjuvant setting for NMIBC. The aim of our study was to evaluate the tolerability, compliance, and survival outcomes of HIVEC-MMC in patients with IR- and HR-NMIBC. MATERIAL AND METHODS This was a single-center retrospective analysis of IR- and HR- NMIBC patients who received HIVEC-MMC after TURBT between August 2018 and August 2022. Levels of risk stratification were defined using the European Association of Urology (EAU) criteria. The protocol consisted of four weekly HIVEC-MMC instillations (induction) followed by six monthly instillations (maintenance). The primary outcomes were to evaluate the tolerability and compliance with the HIVEC-MMC protocol and secondary outcomes were disease-free survival (DFS) and overall survival (OS). For the purpose of statistical analysis, methods of descriptive statistics, survival analysis (Kaplan-Meier estimation), and multivariate analysis (Cox regression, and binary logistic regression) were used. RESULTS Fifty-seven patients were enrolled with a median age of 67.9 (34.4-83.5) years old. In this cohort, 40 patients (70.2%) had primary tumors. At the time of referral for HIVEC-MMC, the majority of the patients had IR-NMIBC (n= 33, 57.9%). A total of 41 patients (71.9%) completed the HIVEC-MMC protocol. Disease recurrence and adverse events (AEs) were the most common reasons to stop the protocol. After a median follow-up of 31 months (95% CI, 5.0-54.0), 32 patients (61.4%) were disease-free, 22 (38.6%) experienced recurrent disease and six patients (10.5%) died, although only one death was directly attributable to bladder cancer. The median DFS was 42 months (95% CI, 28.0-56.0). Completion of the HIVEC-MMC maintenance phase protocol stood as a predictive factor for DFS (44 months, 95% CI 29.1-58.9 vs. 14 months, 95% CI 0.0-29.6, p < 0.001; HR 4.48, 95% CI 1.65-12.15). The median OS was not reached; the 24- and 48-month OS were 92.6% and 82.7%, respectively. EAU risk group, ECOG-PS, and completion of HIVEC protocol were found to be significant predictive factors of OS but lost their significance on multivariate analysis. However, if we exclude those who experienced recurrence during the maintenance phase protocol, treatment completion had a significant positive impact on OS (HR: 42.8, 95% CI 1.75-1045.072, p= 0.021). CONCLUSIONS Our study suggests that HIVEC is a secure and well-tolerated treatment with promising efficacy data, making this therapeutic approach a feasible option in IR- and HR-NMIBC patients, mainly in those who cannot tolerate or have contraindications to BCG therapy, but also as an alternative during BCG shortages.
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Affiliation(s)
- Joana C Magalhães
- Medical Oncology, Instituto Português de Oncologia de Coimbra Francisco Gentil, E.P.E., Coimbra, PRT
| | - Maria Sousa
- Medical Oncology, Centro Hospitalar Universitário do Porto, Porto, PRT
| | - Raquel Basto
- Medical Oncology, Centro Hospitalar Vila Nova de Gaia/Espinho, Gaia, PRT
| | - Teresa Fraga
- Medical Oncology, Instituto Português de Oncologia de Coimbra Francisco Gentil, E.P.E., Coimbra, PRT
| | - Inês Gomes
- Medical Oncology, Instituto Português de Oncologia de Coimbra Francisco Gentil, E.P.E., Coimbra, PRT
| | - Catarina Fernandes
- Medical Oncology, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Mónica Mariano
- Medical Oncology, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Judy Paulo
- Medical Oncology, Instituto Português de Oncologia de Coimbra Francisco Gentil, E.P.E., Coimbra, PRT
| | - Pedro Madeira
- Medical Oncology, Instituto Português de Oncologia de Coimbra Francisco Gentil, E.P.E., Coimbra, PRT
| | - Gabriela Sousa
- Medical Oncology, Instituto Português de Oncologia de Coimbra Francisco Gentil, E.P.E., Coimbra, PRT
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Zeng N, Xu MY, Sun JX, Liu CQ, Xu JZ, An Y, Zhong XY, Ma SY, He HD, Xia QD, Wang SG. Hyperthermia intravesical chemotherapy acts as a promising alternative to bacillus Calmette-Guérin instillation in non-muscle-invasive bladder cancer: a network meta-analysis. Front Oncol 2023; 13:1164932. [PMID: 37251942 PMCID: PMC10213538 DOI: 10.3389/fonc.2023.1164932] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Introduction With the shortage of bacillus Calmette-Guérin (BCG) vaccine, it is important to find an alternative to BCG instillation, which is the most commonly used adjuvant treatment for non-muscle-invasive bladder cancer (NMIBC) patients after transurethral resection of bladder tumor treatment (TURBt) to delay tumor recurrence. Hyperthermia intravesical chemotherapy (HIVEC) with mitomycin C (MMC) is a potential treatment choice. We aim to compare HIVEC with BCG instillation for the preventive efficacy of bladder tumor recurrence and progression. Methods A network meta-analysis (NMA) was taken with MMC instillation and TURBt as the attached comparators. Randomized controlled trials (RCTs) with NIMBC patients after TURBt were included. Articles with pure BCG unresponsive patients and combined therapies were excluded. The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO, CRD42023390363). Results It was found that HIVEC had a non-significant 22% relative reduction in bladder tumor recurrence compared with BCG instillation [HIVEC vs. BCG: HR 0.78, 95% credible interval (CrI) 0.55-1.08] and a nonsignificant higher risk of bladder tumor progression (BCG vs. HIVEC: HR 0.77, 95% CrI 0.22-3.03). Discussion HIVEC is a potential alternative to BCG, and it is expected to be the standard therapy for NMIBC patients after TURBt during the global shortage of BCG. Systematic Review Registration PROSPERO identifier, CRD42023390363.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Qi-Dong Xia
- *Correspondence: Qi-Dong Xia, ; Shao-Gang Wang,
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Kostyev F, Bondar O, Chystiakov R, Lysenko V, Stavnychyi O, Varbanets V. The impact of different adjuvant intravesical therapy methods on tumor biology in patients with high-risk non-muscle-invasive bladder cancer. Cent European J Urol 2022; 74:496-502. [PMID: 35083068 PMCID: PMC8771141 DOI: 10.5173/ceju.2021.0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 08/25/2021] [Accepted: 10/04/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction Expression level of the cell proliferation marker Ki-67 correlates with the degree of differentiation of tumor cells and stage in primary patients with non-muscle-invasive bladder cancer (NMIBC), but the marker is currently not used in assessing the efficacy of adjuvant intravesical therapy and risk stratification in patients with recurrent bladder tumors. Material and methods A retroprospective study included 107 patients with high-risk NMIBC; the patients were divided into 2 groups. The first group included patients who received adjuvant therapy after transurethral resection of the bladder using the Bacillus Calmette-Guérin (BCG) vaccine (BCG therapy group; n = 54), the second group consisted of patients who received hyperthermic intravesical chemotherapy (HIVEC® therapy group; n = 53) using the device for local hyperthermia Combat BRS HIVEC®. Results Tumor recurrences were recorded in 21 (39%) patients receiving intravesical BCG therapy and in 9 (17%) patients after intravesical hyperthermic chemotherapy (p = 0.012). The expression level of Ki-67 in primary tumors did not differ; in recurrent tumors it was significantly different in both groups (32.05 ±13.80 vs 11.00 ± 6.86). The frequency of recurrence-free survival (RFS) in patients receiving chemohyperthermia was significantly higher than in patients after the BCG therapy (log-rank test result: p = 0.048). Conclusions Assessment of Ki-67 expression in recurrent tumors can be a criterion for the effectiveness of intravesical bladder-preserving treatment. The use of hyperthermic chemotherapy can reduce the number of radical cystectomies in a separate group of patients with NMIBC.
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Affiliation(s)
- Fedir Kostyev
- Odessa National Medical University, Department of Urology and Nephrology, Odessa, Ukraine
| | - Oleksandr Bondar
- Odessa National Medical University, Department of Urology and Nephrology, Odessa, Ukraine
| | - Roman Chystiakov
- Odessa National Medical University, Department of Urology and Nephrology, Odessa, Ukraine
| | - Viktoria Lysenko
- Odessa National Medical University, Department of Urology and Nephrology, Odessa, Ukraine
| | - Oleksiy Stavnychyi
- Odessa National Medical University, Department of Urology and Nephrology, Odessa, Ukraine
| | - Valeria Varbanets
- Odessa National Medical University, Department of Urology and Nephrology, Odessa, Ukraine
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Plata A, Guerrero-Ramos F, Garcia C, González-Díaz A, Gonzalez-Valcárcel I, de la Morena JM, Díaz-Goizueta FJ, del Álamo JF, Gonzalo V, Montero J, Sousa-Escandón A, León J, Pontones JL, Delgado F, Adriazola M, Pascual Á, Calleja J, Ruano A, Martínez-Piñeiro L, Angulo JC. Long-Term Experience with Hyperthermic Chemotherapy (HIVEC) Using Mitomycin-C in Patients with Non-Muscle Invasive Bladder Cancer in Spain. J Clin Med 2021; 10:jcm10215105. [PMID: 34768625 PMCID: PMC8584886 DOI: 10.3390/jcm10215105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 12/23/2022] Open
Abstract
(1) Background: Intravesical mitomycin-C (MMC) combined with hyperthermia is increasingly used in non-muscle invasive bladder cancer (NMIBC), especially in the context of a relative BCG shortage. We aim to determine real-world data on the long-term treatment outcomes of adjunct hyperthermic intravesical chemotherapy (HIVEC) with MMC and a COMBAT® bladder recirculation system (BRS); (2) Methods: A prospective observational trial was performed on patients with NMIBC treated with HIVEC using BRS in nine academic institutions in Spain between 2012–2020 (HIVEC-E). Treatment effectiveness (recurrence, progression and overall mortality) was evaluated in patients treated with HIVEC MMC 40mg in the adjuvant setting, with baseline data and a clinical follow-up, that comprise the Full Analysis Set (FAS). Safety, according to the number and severity of adverse effects (AEs), was evaluated in the safety (SAF) population, composed by patients with at least one adjunct HIVEC MMC instillation; (3) Results: The FAS population (n = 502) received a median number of 8.78 ± 3.28 (range 1–20) HIVEC MMC instillations. The median follow-up duration was 24.5 ± 16.5 (range 1–81) months. Its distribution, based on EAU risk stratification, was 297 (59.2%) for intermediate and 205 (40.8%) for high-risk. The figures for five-year recurrence-free and progression-free survival were 50.37% (53.3% for intermediate and 47.14% for high-risk) and 89.83% (94.02% for intermediate and 84.23% for high-risk), respectively. A multivariate analysis identified recurrent tumors (HR 1.83), the duration of adjuvant HIVEC therapy <4 months (HR 1.72) and that high-risk group (HR 1.47) were at an increased risk of recurrence. Independent factors of progression were high-risk (HR 3.89), recurrent tumors (HR 3.32) and the induction of HIVEC therapy without maintenance (HR 2.37). The overall survival was determined by patient age at diagnosis (HR 3.36) and the treatment duration (HR 1.82). The SAF population (n = 592) revealed 406 (68.58%) patients without AEs and 186 (31.42%) with at least one AE: 170 (28.72%) of grade 1–2 and 16 (2.7%) of grade 3–4. The most frequent AEs were dysuria (10%), pain (7.1%), urgency (5.7%), skin rash (4.9%), spasms (3.7%) and hematuria (3.6%); (4) Conclusions: HIVEC using BRS is efficacious and well tolerated. A longer treatment duration, its use in naïve patients and the intermediate-risk disease are independent determinants of success. Furthermore, a monthly maintenance of adjunct MMC HIVEC diminishes the progression rate of NMIBC.
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Affiliation(s)
- Ana Plata
- Urology Department, Hospital Universitario de Canarias, Carretera Ofra s/n, 38320 San Cristóbal de La Laguna, Spain; (A.P.); (C.G.)
| | - Félix Guerrero-Ramos
- Urology Department, Hospital Universitario 12 de Octubre, Avenida de Córdoba s/n, 28041 Madrid, Spain; (F.G.-R.); (A.G.-D.)
| | - Carlos Garcia
- Urology Department, Hospital Universitario de Canarias, Carretera Ofra s/n, 38320 San Cristóbal de La Laguna, Spain; (A.P.); (C.G.)
| | - Alejandro González-Díaz
- Urology Department, Hospital Universitario 12 de Octubre, Avenida de Córdoba s/n, 28041 Madrid, Spain; (F.G.-R.); (A.G.-D.)
| | - Ignacio Gonzalez-Valcárcel
- Urology Department, Hospital Universitario Infanta Sofía, Paseo de Europa 34, San Sebastián de los Reyes, 28702 Madrid, Spain; (I.G.-V.); (J.M.d.l.M.)
| | - José Manuel de la Morena
- Urology Department, Hospital Universitario Infanta Sofía, Paseo de Europa 34, San Sebastián de los Reyes, 28702 Madrid, Spain; (I.G.-V.); (J.M.d.l.M.)
| | | | - Julio Fernández del Álamo
- Urology Department, Hospital Universitario de Torrejón, Mateo Inurria, s/n, Torrejón de Ardoz, 28850 Madrid, Spain;
| | - Victoria Gonzalo
- Urology Department, Hospital Universitario de Burgos, Avenida Islas Baleares 3, 09006 Burgos, Spain; (V.G.); (J.M.)
| | - Javier Montero
- Urology Department, Hospital Universitario de Burgos, Avenida Islas Baleares 3, 09006 Burgos, Spain; (V.G.); (J.M.)
| | - Alejandro Sousa-Escandón
- Urology Department, Hospital Comarcal de Monforte, Rúa Corredoira s/n, 27400 Monforte de Lemos, Spain; (A.S.-E.); (J.L.)
| | - Juan León
- Urology Department, Hospital Comarcal de Monforte, Rúa Corredoira s/n, 27400 Monforte de Lemos, Spain; (A.S.-E.); (J.L.)
| | - Jose Luis Pontones
- Urology Department, Hospital Universitario La Fe, Avinguda de Fernando Abril Martorell 106, 46026 Valencia, Spain; (J.L.P.); (F.D.)
| | - Francisco Delgado
- Urology Department, Hospital Universitario La Fe, Avinguda de Fernando Abril Martorell 106, 46026 Valencia, Spain; (J.L.P.); (F.D.)
| | - Miguel Adriazola
- Urology Department, Hospital General Rio Carrión, Avenida Donantes de Sangre s/n, 34005 Palencia, Spain; (M.A.); (Á.P.)
| | - Ángela Pascual
- Urology Department, Hospital General Rio Carrión, Avenida Donantes de Sangre s/n, 34005 Palencia, Spain; (M.A.); (Á.P.)
| | - Jesús Calleja
- Urology Department, Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal 3, 47003 Valladolid, Spain; (J.C.); (A.R.)
| | - Ana Ruano
- Urology Department, Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal 3, 47003 Valladolid, Spain; (J.C.); (A.R.)
| | - Luis Martínez-Piñeiro
- Urology Department, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain;
| | - Javier C. Angulo
- Urology Department, Hospital Universitario Getafe, Carretera de Toledo, Km 12.500, Getafe, 28905 Madrid, Spain;
- Clinical Department, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Carretera de Toledo, Km 12.500, Getafe, 28905 Madrid, Spain
- Correspondence: ; Tel.: +34-699497569
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You C, Li X, Du Y, Wang H, Zhang X, Wei T, Wang A. Application of intra-arterial chemotherapy in high-risk non-muscle invasive bladder cancer: a systematic review and meta-analysis. PeerJ 2021; 9:e12248. [PMID: 34692255 PMCID: PMC8485834 DOI: 10.7717/peerj.12248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/13/2021] [Indexed: 12/09/2022] Open
Abstract
Background To summarize the current evidence on the effects of intra-arterial chemotherapy (IAC) on high-risk non-muscle invasive bladder cancer (NMIBC) and compare oncology results with intravesical chemotherapy (IVC). Methods We performed a systematic review and cumulative meta-analysis of the primary outcomes of interest by a systematical search of multiple scientific databases in February 2021. The mean difference (MD) and odds ratio (OR) were calculated for continuous and dichotomous variables respectively, with 95% confidence intervals (CIs). The hazard radio (HR) with 95% CIs was used for overall survival (OS), recurrence-free survival (RFS) and progression-free survival (PFS). Results A total of six studies with 866 patients were included. For IAC combined with IVC versus IVC alone, statistically significant differences were found regarding tumor recurrence rate (OR: 0.51, 95% CI [0.36∼0.72], p = 0.0001), tumor progression rate (OR: 0.47, 95% CI [0.30∼0.72], p = 0.0006), tumor-specific death rate (OR: 0.49, 95% CI [0.25∼0.99], p = 0.05), PFS (HR: 0.47, 95% CI [0.23∼0.96], p = 0.04) and RFS (HR: 0.60, 95% CI [0.41∼0.87], p = 0.007). No significant difference between two groups was found for time to first recurrence (MD: 3.27, 95% CI [−2.37∼8.92], p = 0.26) and OS (HR: 1.20, 95% CI [0.44∼3.32], p = 0.72). For IAC alone versus IVC, There was no statistical difference in the terms of tumor-specific death rate (OR: 0.67, 95% CI [0.29∼1.53], p = 0.34), RFS (HR: 0.90, 95% CI [0.56∼1.46], p = 0.68) and PFS (HR: 0.71, 95% CI [0.32∼1.55], p = 0.39). Adverse events mainly included nausea/vomiting (36.3%), hypoleukemia (19.4%), neutropenia (16.0%), increased creatinine (9.9%), increased alanine aminotransferase (18.7%), and thrombocytopenia (9.9%). Conclusion The IAC combined with IVC is a safe and effective treatment for high risk NMIBC, with lower rates of recurrence, progression, tumor-specific death, PFS and RFS, and with minor and tolerable events. The effectiveness of the IAC alone is parallel to the IVC alone.
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Affiliation(s)
- Chengyu You
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Xianhui Li
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Yuelin Du
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Hui Wang
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Xiaojun Zhang
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Tangqiang Wei
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Anguo Wang
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
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