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El Bairi K, Haynes HR, Blackley E, Fineberg S, Shear J, Turner S, de Freitas JR, Sur D, Amendola LC, Gharib M, Kallala A, Arun I, Azmoudeh-Ardalan F, Fujimoto L, Sua LF, Liu SW, Lien HC, Kirtani P, Balancin M, El Attar H, Guleria P, Yang W, Shash E, Chen IC, Bautista V, Do Prado Moura JF, Rapoport BL, Castaneda C, Spengler E, Acosta-Haab G, Frahm I, Sanchez J, Castillo M, Bouchmaa N, Md Zin RR, Shui R, Onyuma T, Yang W, Husain Z, Willard-Gallo K, Coosemans A, Perez EA, Provenzano E, Ericsson PG, Richardet E, Mehrotra R, Sarancone S, Ehinger A, Rimm DL, Bartlett JMS, Viale G, Denkert C, Hida AI, Sotiriou C, Loibl S, Hewitt SM, Badve S, Symmans WF, Kim RS, Pruneri G, Goel S, Francis PA, Inurrigarro G, Yamaguchi R, Garcia-Rivello H, Horlings H, Afqir S, Salgado R, Adams S, Kok M, Dieci MV, Michiels S, Demaria S, Loi S. The tale of TILs in breast cancer: A report from The International Immuno-Oncology Biomarker Working Group. NPJ Breast Cancer 2021; 7:150. [PMID: 34853355 PMCID: PMC8636568 DOI: 10.1038/s41523-021-00346-1] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 09/28/2021] [Indexed: 02/08/2023] Open
Abstract
The advent of immune-checkpoint inhibitors (ICI) in modern oncology has significantly improved survival in several cancer settings. A subgroup of women with breast cancer (BC) has immunogenic infiltration of lymphocytes with expression of programmed death-ligand 1 (PD-L1). These patients may potentially benefit from ICI targeting the programmed death 1 (PD-1)/PD-L1 signaling axis. The use of tumor-infiltrating lymphocytes (TILs) as predictive and prognostic biomarkers has been under intense examination. Emerging data suggest that TILs are associated with response to both cytotoxic treatments and immunotherapy, particularly for patients with triple-negative BC. In this review from The International Immuno-Oncology Biomarker Working Group, we discuss (a) the biological understanding of TILs, (b) their analytical and clinical validity and efforts toward the clinical utility in BC, and (c) the current status of PD-L1 and TIL testing across different continents, including experiences from low-to-middle-income countries, incorporating also the view of a patient advocate. This information will help set the stage for future approaches to optimize the understanding and clinical utilization of TIL analysis in patients with BC.
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Affiliation(s)
- Khalid El Bairi
- Department of Medical Oncology, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco.
| | - Harry R Haynes
- Department of Cellular Pathology, Great Western Hospital, Swindon, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| | - Elizabeth Blackley
- Division of Research, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Susan Fineberg
- Department of Pathology, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jeffrey Shear
- Chief Information Officer, WISS & Company, LLP and President J. Shear Consulting, LLC-Ardsley, Ardsley, NY, USA
| | | | - Juliana Ribeiro de Freitas
- Department of Pathology and Legal Medicine, Medical School of the Federal University of Bahia, Salvador, Brazil
| | - Daniel Sur
- Department of Medical Oncology, University of Medicine "I. Hatieganu", Cluj Napoca, Romania
| | | | - Masoumeh Gharib
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Indu Arun
- Department of Histopathology, Tata Medical Center, Kolkata, India
| | - Farid Azmoudeh-Ardalan
- Department of Pathology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Luciana Fujimoto
- Pathology and Legal Medicine, Amazon Federal University, Belém, Brazil
| | - Luz F Sua
- Department of Pathology and Laboratory Medicine, Fundacion Valle del Lili, and Faculty of Health Sciences, Universidad ICESI, Cali, Colombia
| | | | - Huang-Chun Lien
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Pawan Kirtani
- Department of Histopathology, Manipal Hospitals Dwarka, New Delhi, India
| | - Marcelo Balancin
- Department of Pathology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Prerna Guleria
- Army Hospital Research and Referral, Delhi Cantt, New Delhi, India
| | | | - Emad Shash
- Breast Cancer Comprehensive Center, National Cancer Institute, Cairo University, Cairo, Egypt
| | - I-Chun Chen
- Department of Oncology, National Taiwan University Cancer Center, Taipei, Taiwan
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Veronica Bautista
- Department of Pathology, Breast Cancer Center FUCAM, Mexico City, Mexico
| | | | - Bernardo L Rapoport
- The Medical Oncology Centre of Rosebank, Johannesburg, South Africa
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, corner Doctor Savage Road and Bophelo Road, Pretoria, 0002, South Africa
| | - Carlos Castaneda
- Department of Medical Oncology, Instituto Nacional de Enfermedades Neoplásicas, Lima, 15038, Peru
- Faculty of Health Sciences, Universidad Cientifica del Sur, Lima, Peru
| | - Eunice Spengler
- Departmento de Patologia, Hospital Universitario Austral, Pilar, Argentina
| | - Gabriela Acosta-Haab
- Department of Pathology, Hospital de Oncología Maria Curie, Buenos Aires, Argentina
| | - Isabel Frahm
- Department of Pathology, Sanatorio Mater Dei, Buenos Aires, Argentina
| | - Joselyn Sanchez
- Department of Research, Instituto Nacional de Enfermedades Neoplasicas, Lima, 15038, Peru
| | - Miluska Castillo
- Department of Research, Instituto Nacional de Enfermedades Neoplasicas, Lima, 15038, Peru
| | - Najat Bouchmaa
- Institute of Biological Sciences, Mohammed VI Polytechnic University (UM6P), 43 150, Ben-Guerir, Morocco
| | - Reena R Md Zin
- Department of Pathology, Faculty of Medicine, UKM Medical Centre, Kuala Lumpur, Malaysia
| | - Ruohong Shui
- Department of Pathology, Fudan University Cancer Center, Shanghai, China
| | | | - Wentao Yang
- Department of Pathology, Fudan University Cancer Center, Shanghai, China
| | | | - Karen Willard-Gallo
- Molecular Immunology Unit, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - An Coosemans
- Laboratory of Tumour Immunology and Immunotherapy, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Edith A Perez
- Department of Hematology/Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Elena Provenzano
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Paula Gonzalez Ericsson
- Breast Cancer Program, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eduardo Richardet
- Clinical Oncology Unit, Instituto Oncológico Córdoba, Córdoba, Argentina
| | - Ravi Mehrotra
- India Cancer Research Consortium-ICMR, Department of Health Research, New Delhi, India
| | - Sandra Sarancone
- Department of Pathology, Laboratorio QUANTUM, Rosario, Argentina
| | - Anna Ehinger
- Department of Clinical Genetics and Pathology, Skåne University Hospital, Lund University, Lund, Sweden
| | - David L Rimm
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - John M S Bartlett
- Diagnostic Development, Ontario Institute for Cancer Research, Toronto, Canada
- Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, The University of Edinburgh, Edinburgh, UK
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Giuseppe Viale
- Department of Pathology, Istituto Europeo di Oncologia IRCCS, and University of Milan, Milan, Italy
| | - Carsten Denkert
- Institute of Pathology, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg and Philipps-Universität Marburg, Marburg, Germany
| | - Akira I Hida
- Department of Pathology, Matsuyama Shimin Hospital, Matsuyama, Japan
| | - Christos Sotiriou
- Department of Medical Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Stephen M Hewitt
- Laboratory of Pathology, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Sunil Badve
- Department of Pathology and Laboratory Medicine, Indiana University, Indianapolis, USA
| | - William Fraser Symmans
- Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Rim S Kim
- National Surgical Adjuvant Breast and Bowel Project (NSABP)/NRG Oncology, Pittsburgh, PA, USA
| | - Giancarlo Pruneri
- Department of Pathology, RCCS Fondazione Istituto Nazionale Tumori and University of Milan, School of Medicine, Milan, Italy
| | - Shom Goel
- Division of Research, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| | - Prudence A Francis
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- Medical Oncology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | | | - Rin Yamaguchi
- Department of Pathology and Laboratory Medicine, Kurume University Medical Center, Kurume, Fukuoka, Japan
| | - Hernan Garcia-Rivello
- Servicio de Anatomía Patológica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Hugo Horlings
- Division of Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Said Afqir
- Department of Medical Oncology, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco
| | - Roberto Salgado
- Division of Research, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Pathology, GZA-ZNA Hospitals, Antwerp, Belgium
| | - Sylvia Adams
- Perlmutter Cancer Center, New York University Medical School, New York, NY, USA
| | - Marleen Kok
- Divisions of Medical Oncology, Molecular Oncology & Immunology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Maria Vittoria Dieci
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
- Medical Oncology 2, Istituto Oncologico Veneto IOV-IRCCS, Padova, Italy
| | - Stefan Michiels
- Service de Biostatistique et d'Epidémiologie, Gustave Roussy, Oncostat U1018, Inserm, University Paris-Saclay, labeled Ligue Contre le Cancer, Villejuif, France
| | - Sandra Demaria
- Department of Radiation Oncology, Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Sherene Loi
- Division of Research, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
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Gonzalez-Ericsson PI, Stovgaard ES, Sua LF, Reisenbichler E, Kos Z, Carter JM, Michiels S, Le Quesne J, Nielsen TO, Laenkholm AV, Fox SB, Adam J, Bartlett JM, Rimm DL, Quinn C, Peeters D, Dieci MV, Vincent-Salomon A, Cree I, Hida AI, Balko JM, Haynes HR, Frahm I, Acosta-Haab G, Balancin M, Bellolio E, Yang W, Kirtani P, Sugie T, Ehinger A, Castaneda CA, Kok M, McArthur H, Siziopikou K, Badve S, Fineberg S, Gown A, Viale G, Schnitt SJ, Pruneri G, Penault-Llorca F, Hewitt S, Thompson EA, Allison KH, Symmans WF, Bellizzi AM, Brogi E, Moore DA, Larsimont D, Dillon DA, Lazar A, Lien H, Goetz MP, Broeckx G, El Bairi K, Harbeck N, Cimino-Mathews A, Sotiriou C, Adams S, Liu SW, Loibl S, Chen IC, Lakhani SR, Juco JW, Denkert C, Blackley EF, Demaria S, Leon-Ferre R, Gluz O, Zardavas D, Emancipator K, Ely S, Loi S, Salgado R, Sanders M. The path to a better biomarker: application of a risk management framework for the implementation of PD-L1 and TILs as immuno-oncology biomarkers in breast cancer clinical trials and daily practice. J Pathol 2020; 250:667-684. [PMID: 32129476 DOI: 10.1002/path.5406] [Citation(s) in RCA: 120] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/18/2020] [Indexed: 02/05/2023]
Abstract
Immune checkpoint inhibitor therapies targeting PD-1/PD-L1 are now the standard of care in oncology across several hematologic and solid tumor types, including triple negative breast cancer (TNBC). Patients with metastatic or locally advanced TNBC with PD-L1 expression on immune cells occupying ≥1% of tumor area demonstrated survival benefit with the addition of atezolizumab to nab-paclitaxel. However, concerns regarding variability between immunohistochemical PD-L1 assay performance and inter-reader reproducibility have been raised. High tumor-infiltrating lymphocytes (TILs) have also been associated with response to PD-1/PD-L1 inhibitors in patients with breast cancer (BC). TILs can be easily assessed on hematoxylin and eosin-stained slides and have shown reliable inter-reader reproducibility. As an established prognostic factor in early stage TNBC, TILs are soon anticipated to be reported in daily practice in many pathology laboratories worldwide. Because TILs and PD-L1 are parts of an immunological spectrum in BC, we propose the systematic implementation of combined PD-L1 and TIL analyses as a more comprehensive immuno-oncological biomarker for patient selection for PD-1/PD-L1 inhibition-based therapy in patients with BC. Although practical and regulatory considerations differ by jurisdiction, the pathology community has the responsibility to patients to implement assays that lead to optimal patient selection. We propose herewith a risk-management framework that may help mitigate the risks of suboptimal patient selection for immuno-therapeutic approaches in clinical trials and daily practice based on combined TILs/PD-L1 assessment in BC. © 2020 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
| | - Elisabeth S Stovgaard
- Department of Pathology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Luz F Sua
- Department of Pathology and Laboratory Medicine, Fundación Valle del Lili, and Faculty of Health Sciences, Universidad ICESI, Cali, Colombia
| | | | - Zuzana Kos
- Department of Pathology, BC Cancer Agency, Vancouver, Canada
| | - Jodi M Carter
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Stefan Michiels
- Biostatistics and Epidemiology Service, Centre de Recherche en Epidémiologie et Santé des Populations, Gustave Roussy, Université Paris-Sud, Villejuif, France
| | - John Le Quesne
- Leicester Cancer Research Centre, University of Leicester, Leicester, UK
- MRC Toxicology Unit, University of Cambridge, Leicester, UK
| | - Torsten O Nielsen
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | | | - Stephen B Fox
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
| | - Julien Adam
- Department of Pathology, Gustave Roussy, Grand Paris, France
| | - John Ms Bartlett
- Ontario Institute for Cancer Research, Toronto, Canada
- Edinburgh Cancer Research Centre, Institute of Genetics and Molecular Medicine, Edinburgh, UK
| | - David L Rimm
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Cecily Quinn
- Department of Pathology, St Vincent's University Hospital and University College Dublin, Dublin, Ireland
| | - Dieter Peeters
- HistoGeneX NV, Antwerp, Belgium
- AZ Sint-Maarten Hospital, Mechelen, Belgium
| | - Maria V Dieci
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
- Medical Oncology 2, Istituto Oncologico Veneto - IRCCS, Padova, Italy
| | | | - Ian Cree
- International Agency for Research on Cancer (IARC), World Health Organization, Lyon, France
| | - Akira I Hida
- Department of Pathology, Matsuyama Shimin Hospital, Matsuyama, Japan
| | - Justin M Balko
- Breast Cancer Research Program, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Harry R Haynes
- Department of Cellular Pathology, North Bristol NHS Trust, Bristol, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| | - Isabel Frahm
- Department of Pathology, Sanatorio Mater Dei, Buenos Aires, Argentina
| | - Gabriela Acosta-Haab
- Department of Pathology, Hospital de Oncología Maria Curie, Buenos Aires, Argentina
| | - Marcelo Balancin
- Department of Pathology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Enrique Bellolio
- Department of Pathology, Universidad de La Frontera, Temuco, Chile
| | - Wentao Yang
- Department of Pathology, Fudan University Shanghai Cancer Centre, Shanghai, PR China
| | - Pawan Kirtani
- Department of Histopathology, Manipal Hospitals Dwarka, New Delhi, India
| | - Tomoharu Sugie
- Breast Surgery, Kansai Medical University Hospital, Hirakata, Japan
| | - Anna Ehinger
- Department of Clinical Genetics and Pathology, Skane University Hospital, Lund University, Lund, Sweden
| | - Carlos A Castaneda
- Department of Medical Oncology, Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Marleen Kok
- Divisions of Medical Oncology, Tumor Biology & Immunology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Heather McArthur
- Medical Oncology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kalliopi Siziopikou
- Department of Pathology, Breast Pathology Section, Northwestern University, Chicago, IL, USA
| | - Sunil Badve
- Department of Pathology and Laboratory Medicine, Indiana University, Indianapolis, IN, USA
| | - Susan Fineberg
- Department of Pathology, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY, USA
| | - Allen Gown
- PhenoPath Laboratories, Seattle, WA, USA
| | - Giuseppe Viale
- Department of Pathology, Istituto Europeo di Oncologia IRCCS, Milan, Italy
- University of Milan, Milan, Italy
| | - Stuart J Schnitt
- Department of Pathology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Giancarlo Pruneri
- University of Milan, Milan, Italy
- Department of Pathology, IRCCS Fondazione Instituto Nazionale Tumori, Milan, Italy
| | - Frederique Penault-Llorca
- Department of Biology and Pathology, Centre Jean Perrin, Clermont Ferrand, France
- UMR INSERM 1240, Université Clermont Auvergne, Clermont Ferrand, France
| | - Stephen Hewitt
- Experimental Pathology Laboratory, Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | | | | | - William F Symmans
- Department of Pathology, Division of Pathology and Laboratory Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew M Bellizzi
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Edi Brogi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David A Moore
- CRUK Lung Cancer Centre of Excellence, UCL Cancer Institute, and Department of Cellular Pathology, UCLH, London, UK
| | - Denis Larsimont
- Department of Pathology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Deborah A Dillon
- Department of Pathology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Alexander Lazar
- Department of Pathology, Division of Pathology and Laboratory Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Huangchun Lien
- Graduate Institute of Pathology, National Taiwan University, Taipei, Taiwan
| | | | - Glenn Broeckx
- Department of Pathology, University Hospital Antwerp, Edegem, Belgium
| | - Khalid El Bairi
- Cancer Biomarkers Working Group, Faculty of Medicine and Pharmacy, Mohamed Ist University, Oujda, Morocco
| | - Nadia Harbeck
- Breast Center, Department of OB&GYN and CCC (LMU), University of Munich, Munich, Germany
| | - Ashley Cimino-Mathews
- Department of Pathology and Oncology, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Christos Sotiriou
- Department of Medical Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Sylvia Adams
- Perlmutter Cancer Center, New York University Medical School, New York, NY, USA
| | | | | | - I-Chun Chen
- Department of Medical Oncology, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Sunil R Lakhani
- The University of Queensland, Centre for Clinical Research, and Pathology Queensland, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Jonathan W Juco
- Translational Medicine, Merck & Co, Inc, Kenilworth, NJ, USA
| | - Carsten Denkert
- Institute of Pathology, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg and Philipps-Universität Marburg, Marburg, Germany
| | - Elizabeth F Blackley
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Sandra Demaria
- Department of Radiation Oncology, Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | | | - Oleg Gluz
- Johanniter GmbH - Evangelisches Krankenhaus Bethesda Mönchengladbach, West German Study Group, Mönchengladbach, Germany
| | | | | | - Scott Ely
- Translational Medicine, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Sherene Loi
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Division of Research, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Roberto Salgado
- Division of Research, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Pathology, GZA-ZNA Hospitals, Antwerp, Belgium
| | - Melinda Sanders
- Breast Cancer Research Program, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
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