Pub Date : 2024-04-01DOI: 10.4274/ejbh.galenos.2024.2024-1-11
S. Dwivedi, Amiy Arnav, Varun Kumar Agarwal, S. K. Deshpande, Rohit Sharma, Naresh Saidha
Objective The most dreaded long-term complication of axillary lymph node dissection remains upper arm lymphedema. Our study has strategized the three most common identified causes of post treatment arm lymphedema, i.e., obesity, radiation, and neoadjuvant chemotherapy and tried to identify the histopathological and clinical or surgical factors which can predict arm lymphedema. Materials and Methods This is a prospective observational study was conducted at a tertiary care referral centre in India, with strict inclusion criteria of BMI <30 kg/m2, age <75 years, presence of metastatic axillary node proven by FNAC, received anthracycline based neoadjuvant chemotherapy and postoperative nodal irradiation, and completed 24 months of regular follow-up. Results Total of 70 patients were included in the study. The mean age of the patients was 50.3 years (±12.9). lymphovascular invasion, total number of lymph nodes removed from level III, total number of days drain was left in situ and maximum drain output were found to be significantly (p<0.05) associated with arm lymphedema. Conclusion In patients undergoing modified radical mastectomy with level III dissection, and postoperative irradiation, the incidence of unilateral arm lymphedema is significantly influenced by several clinicopathological factors like the total number of lymph nodes removed in level III, higher maximal drain output, prolonged duration of drain placement and the presence of lymphovascular invasion.
目的腋窝淋巴结清扫术后最可怕的长期并发症仍然是上臂淋巴水肿。我们的研究针对治疗后手臂淋巴水肿最常见的三个原因，即肥胖、放疗和新辅助化疗进行了分析、肥胖、放疗和新辅助化疗，并试图找出可预测手臂淋巴水肿的组织病理学、临床或手术因素。材料和方法这是一项前瞻性观察研究，在印度的一家三级医疗转诊中心进行，严格的纳入标准是体重指数小于 30 kg/m2、年龄小于 75 岁、经 FNAC 证实存在转移性腋窝结节、接受过以蒽环类为基础的新辅助化疗和术后结节照射，并完成了 24 个月的定期随访。研究发现，淋巴管侵犯、III级淋巴结切除总数、引流管留在原位的总天数和最大引流管输出量与手臂淋巴水肿有显著相关性（P<0.05）。结论 在接受改良根治性乳房切除术并进行 III 层清扫和术后照射的患者中，单侧手臂淋巴水肿的发生率受多个临床病理学因素的显著影响，如 III 层淋巴结清除总数、最大引流管输出量较高、引流管放置时间较长以及存在淋巴管侵犯。
{"title":"Predictors of Unilateral Arm Lymphedema in Non-obese Locoregionally Advanced Breast Cancer Patients Undergoing Neoadjuvant Chemotherapy, Modified Radical Mastectomy, and Postoperative Irradiation.","authors":"S. Dwivedi, Amiy Arnav, Varun Kumar Agarwal, S. K. Deshpande, Rohit Sharma, Naresh Saidha","doi":"10.4274/ejbh.galenos.2024.2024-1-11","DOIUrl":"https://doi.org/10.4274/ejbh.galenos.2024.2024-1-11","url":null,"abstract":"Objective\u0000The most dreaded long-term complication of axillary lymph node dissection remains upper arm lymphedema. Our study has strategized the three most common identified causes of post treatment arm lymphedema, i.e., obesity, radiation, and neoadjuvant chemotherapy and tried to identify the histopathological and clinical or surgical factors which can predict arm lymphedema.\u0000\u0000\u0000Materials and Methods\u0000This is a prospective observational study was conducted at a tertiary care referral centre in India, with strict inclusion criteria of BMI <30 kg/m2, age <75 years, presence of metastatic axillary node proven by FNAC, received anthracycline based neoadjuvant chemotherapy and postoperative nodal irradiation, and completed 24 months of regular follow-up.\u0000\u0000\u0000Results\u0000Total of 70 patients were included in the study. The mean age of the patients was 50.3 years (±12.9). lymphovascular invasion, total number of lymph nodes removed from level III, total number of days drain was left in situ and maximum drain output were found to be significantly (p<0.05) associated with arm lymphedema.\u0000\u0000\u0000Conclusion\u0000In patients undergoing modified radical mastectomy with level III dissection, and postoperative irradiation, the incidence of unilateral arm lymphedema is significantly influenced by several clinicopathological factors like the total number of lymph nodes removed in level III, higher maximal drain output, prolonged duration of drain placement and the presence of lymphovascular invasion.","PeriodicalId":93996,"journal":{"name":"European journal of breast health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140357119","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-01DOI: 10.4274/ejbh.galenos.2024.2024-1-10
Gotfrida Marandu, Kija Malale, Rose Laisser, Joseph Mwanga, Paul Alikado Sabuni, P. Rambau
Objective Despite facing unique barriers, Catholic nuns in Tanzania require accessible breast health promotion. This study explores interventions to empower nuns through knowledge, improved attitudes, and positive practices, ultimately promoting well-being and early detection for better breast cancer outcomes. Materials and Methods A quasi-experimental design study guided by the Health Belief Model was conducted to monitor the implementation of a breast health intervention program aimed at increasing breast cancer screening knowledge among 385 Catholic nuns aged 20 to over 60 years old within Lake Zone, Tanzania. Data were collected at two-time points: pre-intervention (baseline) and implementation phase intervention (after three months). The intervention consisted of a 2-hour educational session. Participants had opportunities to ask questions and provide feedback. Results The breast health promotion intervention was well-received by Catholic nuns, with 339 (88%) expressing strong motivation to learn and promote awareness. The training effectively increased knowledge and positive attitudes towards breast cancer screening. Researcher assistants successfully delivered the program, and 354 (92%) of participants expressed interest in continued education and support. The intervention addressed cultural barriers and empowered nuns to take charge of their health, though some challenges remain meanwhile 158 (41%) had limited prior knowledge, 81 (21%) hesitated to discuss breast health due to religious beliefs, and some faced difficulty applying the learnings. Conclusion Overall, the breast health promotion intervention had a positive outcome on the Catholic nuns' awareness and knowledge of breast health. However, addressing the identified barriers and challenges is crucial to further enhance the intervention's effectiveness and sustainability.
{"title":"Evaluation of Breast Health Promotion Intervention Among Catholic Nuns in Lake Zone 'Tanzania.","authors":"Gotfrida Marandu, Kija Malale, Rose Laisser, Joseph Mwanga, Paul Alikado Sabuni, P. Rambau","doi":"10.4274/ejbh.galenos.2024.2024-1-10","DOIUrl":"https://doi.org/10.4274/ejbh.galenos.2024.2024-1-10","url":null,"abstract":"Objective\u0000Despite facing unique barriers, Catholic nuns in Tanzania require accessible breast health promotion. This study explores interventions to empower nuns through knowledge, improved attitudes, and positive practices, ultimately promoting well-being and early detection for better breast cancer outcomes.\u0000\u0000\u0000Materials and Methods\u0000A quasi-experimental design study guided by the Health Belief Model was conducted to monitor the implementation of a breast health intervention program aimed at increasing breast cancer screening knowledge among 385 Catholic nuns aged 20 to over 60 years old within Lake Zone, Tanzania. Data were collected at two-time points: pre-intervention (baseline) and implementation phase intervention (after three months). The intervention consisted of a 2-hour educational session. Participants had opportunities to ask questions and provide feedback.\u0000\u0000\u0000Results\u0000The breast health promotion intervention was well-received by Catholic nuns, with 339 (88%) expressing strong motivation to learn and promote awareness. The training effectively increased knowledge and positive attitudes towards breast cancer screening. Researcher assistants successfully delivered the program, and 354 (92%) of participants expressed interest in continued education and support. The intervention addressed cultural barriers and empowered nuns to take charge of their health, though some challenges remain meanwhile 158 (41%) had limited prior knowledge, 81 (21%) hesitated to discuss breast health due to religious beliefs, and some faced difficulty applying the learnings.\u0000\u0000\u0000Conclusion\u0000Overall, the breast health promotion intervention had a positive outcome on the Catholic nuns' awareness and knowledge of breast health. However, addressing the identified barriers and challenges is crucial to further enhance the intervention's effectiveness and sustainability.","PeriodicalId":93996,"journal":{"name":"European journal of breast health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140352762","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-01DOI: 10.4274/ejbh.galenos.2024.2023-12-5
Tuba Kayan Tapan, Filiz Çelebi, Kourosh Yaghouti, F. Ağaçayak, Serkan Ilgün, G. Soybir, G. Alço, N. Ak, Ç. Ordu, E. Özkurt, Ç. Ünal, Sevgi Kurt, Alper Öztürk, Z. İyigün, T. Duymaz, V. Özmen
Objective Differences in individual muscle/fat volumes may change the effectiveness of chemotherapy. In this study, the relationship between trunkal muscle and fat volume and body mass index (BMI) obtained before receiving neoadjuvant chemotherapy (NCT) in patients with breast cancer and complete pathological response (pCR) was investigated. Materials and Methods The volumes of psoas, abdominal and paraspinal muscles, and trunkal subcutaneous and visceral fat were calculated using CoreSlicer AI 2.0 opensource program from the F-18 fluorodeoxyglucose positron emission tomography/computed tomography (CT) and CT images before NCT and postoperative pCR rates to NCT were recorded. Muscle/fat volumes and BMI prior to NCT were compared in terms of pathological pCR rates. Patients were followed up regularly for recurrence and survival. Results Ninety-three patients were included with median (range) values for age, BMI, and body weights of 48 (28-72) years, 27 (16.8-51.6) kg/m2, and 71.94 (43-137) kg, respectively. The median follow-up time was 18.6 (6.7-59.6) months. No significant correlation was found between total muscle or fat volumes of patients with and without pCR. BMI [26.2 (16.8-51.6) kg/m2 vs. 24.6 (20.3-34.3) kg/m2, p = 0.03] and pCR rates in patients with low right-psoas muscle volume [11.74 (7.03-18.51) vs. 10.2 (6.71-13.36), p = 0.025] were significantly greater. A significant relationship was found between right psoas muscle volume and disease-free survival (DFS) (11.74 cm3 (7.03-18.51) vs. 10.2 cm3 (6.71-13.36), p = 0.025). However, no significant relationship was detected between total muscle-fat volume, BMI and overall survival and DFS (p>0.05). Conclusion This is the first published study investigating the relationship between the pCR ratio and body muscle and fat volume measured by CoreSlicer AI 2.0 in patients with breast cancer who received NCT. No correlation was found between the pCR ratio and total muscle plus fat volume. However, these results need to be validated with larger patient series.
{"title":"The Relationship of Pathological Response and Visceral Muscle and Fat Volume in Women With Breast Cancer Who Received Neoadjuvant Chemotherapy.","authors":"Tuba Kayan Tapan, Filiz Çelebi, Kourosh Yaghouti, F. Ağaçayak, Serkan Ilgün, G. Soybir, G. Alço, N. Ak, Ç. Ordu, E. Özkurt, Ç. Ünal, Sevgi Kurt, Alper Öztürk, Z. İyigün, T. Duymaz, V. Özmen","doi":"10.4274/ejbh.galenos.2024.2023-12-5","DOIUrl":"https://doi.org/10.4274/ejbh.galenos.2024.2023-12-5","url":null,"abstract":"Objective\u0000Differences in individual muscle/fat volumes may change the effectiveness of chemotherapy. In this study, the relationship between trunkal muscle and fat volume and body mass index (BMI) obtained before receiving neoadjuvant chemotherapy (NCT) in patients with breast cancer and complete pathological response (pCR) was investigated.\u0000\u0000\u0000Materials and Methods\u0000The volumes of psoas, abdominal and paraspinal muscles, and trunkal subcutaneous and visceral fat were calculated using CoreSlicer AI 2.0 opensource program from the F-18 fluorodeoxyglucose positron emission tomography/computed tomography (CT) and CT images before NCT and postoperative pCR rates to NCT were recorded. Muscle/fat volumes and BMI prior to NCT were compared in terms of pathological pCR rates. Patients were followed up regularly for recurrence and survival.\u0000\u0000\u0000Results\u0000Ninety-three patients were included with median (range) values for age, BMI, and body weights of 48 (28-72) years, 27 (16.8-51.6) kg/m2, and 71.94 (43-137) kg, respectively. The median follow-up time was 18.6 (6.7-59.6) months. No significant correlation was found between total muscle or fat volumes of patients with and without pCR. BMI [26.2 (16.8-51.6) kg/m2 vs. 24.6 (20.3-34.3) kg/m2, p = 0.03] and pCR rates in patients with low right-psoas muscle volume [11.74 (7.03-18.51) vs. 10.2 (6.71-13.36), p = 0.025] were significantly greater. A significant relationship was found between right psoas muscle volume and disease-free survival (DFS) (11.74 cm3 (7.03-18.51) vs. 10.2 cm3 (6.71-13.36), p = 0.025). However, no significant relationship was detected between total muscle-fat volume, BMI and overall survival and DFS (p>0.05).\u0000\u0000\u0000Conclusion\u0000This is the first published study investigating the relationship between the pCR ratio and body muscle and fat volume measured by CoreSlicer AI 2.0 in patients with breast cancer who received NCT. No correlation was found between the pCR ratio and total muscle plus fat volume. However, these results need to be validated with larger patient series.","PeriodicalId":93996,"journal":{"name":"European journal of breast health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140354739","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-01DOI: 10.4274/ejbh.galenos.2024.2023-12-10
M. Ozsen, K. Şenol, Ş. Tolunay, M. S. Gokgoz, T. Evrensel
Objective Neuroendocrine neoplasms of primary breast tumors are rare compared to locations, such as the respiratory system and gastrointestinal system, where they are frequently observed. The diagnostic criteria for primary neuroendocrine tumors of the breast have been changed since first description. Morphological and immunohistochemical features helpful in their diagnosis, which vary due to the heterogeneous nature of these tumors, are highlighted in this retrospective study. The purpose was to determine specific histopathological features that can identify neuroendocrine morphology in primary breast tumors. Materials and Methods Cases diagnosed with invasive breast carcinoma from resection materials in a single center between 2011 and 2022 and in which neuroendocrine markers were investigated were included. Demographic information, initial histopathological diagnosis, presence of tumor in another organ, tumor location, size and surgical details of the cases were obtained from the hospital database and pathology reports. The slides were re-evaluated in terms of tumor growth pattern, cribriformity, tubule formation, nuclear features, prominence of nucleoli, palisading and basal location of nuclei, presence of grooves, cytoplasmic features and evidence of cytoplasmic border. Results The presence of basally located nuclei, absence of tubule formation, inconspicuous nucleoli, fine nuclear chromatin, granular cytoplasm and inconspicuous cytoplasmic borders were frequent findings in tumors with neuroendocrine features (p<0.05). These features may help differentiate primary breast tumors with neuroendocrine features from other breast carcinomas. Conclusion The histopathological features that are different from the specific features seen in classical neuroendocrine tumors, the absence of specific clinical and radiological findings, the inability to study neuroendocrine markers in every laboratory and the need to prove that the breast tumor is not a metastasis all create diagnostic difficulties for primary breast neuroendocrine neoplasms. We believe that the results of this study may help diagnose and identify more specific histomorphological features that help determine neuroendocrine morphology in primary breast tumors.
{"title":"Histopathological Features Predicting Neuroendocrine Morphology in Primary Breast Tumors: A Retrospective Analysis.","authors":"M. Ozsen, K. Şenol, Ş. Tolunay, M. S. Gokgoz, T. Evrensel","doi":"10.4274/ejbh.galenos.2024.2023-12-10","DOIUrl":"https://doi.org/10.4274/ejbh.galenos.2024.2023-12-10","url":null,"abstract":"Objective\u0000Neuroendocrine neoplasms of primary breast tumors are rare compared to locations, such as the respiratory system and gastrointestinal system, where they are frequently observed. The diagnostic criteria for primary neuroendocrine tumors of the breast have been changed since first description. Morphological and immunohistochemical features helpful in their diagnosis, which vary due to the heterogeneous nature of these tumors, are highlighted in this retrospective study. The purpose was to determine specific histopathological features that can identify neuroendocrine morphology in primary breast tumors.\u0000\u0000\u0000Materials and Methods\u0000Cases diagnosed with invasive breast carcinoma from resection materials in a single center between 2011 and 2022 and in which neuroendocrine markers were investigated were included. Demographic information, initial histopathological diagnosis, presence of tumor in another organ, tumor location, size and surgical details of the cases were obtained from the hospital database and pathology reports. The slides were re-evaluated in terms of tumor growth pattern, cribriformity, tubule formation, nuclear features, prominence of nucleoli, palisading and basal location of nuclei, presence of grooves, cytoplasmic features and evidence of cytoplasmic border.\u0000\u0000\u0000Results\u0000The presence of basally located nuclei, absence of tubule formation, inconspicuous nucleoli, fine nuclear chromatin, granular cytoplasm and inconspicuous cytoplasmic borders were frequent findings in tumors with neuroendocrine features (p<0.05). These features may help differentiate primary breast tumors with neuroendocrine features from other breast carcinomas.\u0000\u0000\u0000Conclusion\u0000The histopathological features that are different from the specific features seen in classical neuroendocrine tumors, the absence of specific clinical and radiological findings, the inability to study neuroendocrine markers in every laboratory and the need to prove that the breast tumor is not a metastasis all create diagnostic difficulties for primary breast neuroendocrine neoplasms. We believe that the results of this study may help diagnose and identify more specific histomorphological features that help determine neuroendocrine morphology in primary breast tumors.","PeriodicalId":93996,"journal":{"name":"European journal of breast health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140355385","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-01DOI: 10.4274/ejbh.galenos.2024.2023-12-13
Alexander Mundinger, Carolin Mundinger
Artificial Intelligence (AI) is defined as the simulation of human intelligence by a digital computer or robotic system and has become a hype in current conversations. A subcategory of AI is deep learning, which is based on complex artificial neural networks that mimic the principles of human synaptic plasticity and layered brain architectures, and uses large-scale data processing. AI-based image analysis in breast screening programmes has shown non-inferior sensitivity, reduces workload by up to 70% by pre-selecting normal cases, and reduces recall by 25% compared to human double reading. Natural language programs such as ChatGPT (OpenAI) achieve 80% and higher accuracy in advising and decision making compared to the gold standard: human judgement. This does not yet meet the necessary requirements for medical products in terms of patient safety. The main advantage of AI is that it can perform routine but complex tasks much faster and with fewer errors than humans. The main concerns in healthcare are the stability of AI systems, cybersecurity, liability and transparency. More widespread use of AI could affect human jobs in healthcare and increase technological dependency. AI in senology is just beginning to evolve towards better forms with improved properties. Responsible training of AI systems with meaningful raw data and scientific studies to analyse their performance in the real world are necessary to keep AI on track. To mitigate significant risks, it will be necessary to balance active promotion and development of quality-assured AI systems with careful regulation. AI regulation has only recently included in transnational legal frameworks, as the European Union's AI Act was the first comprehensive legal framework to be published, in December 2023. Unacceptable AI systems will be banned if they are deemed to pose a clear threat to people's fundamental rights. Using AI and combining it with human wisdom, empathy and affection will be the method of choice for further, fruitful development of tomorrow's senology.
{"title":"Artificial Intelligence in Senology - Where Do We Stand and What Are the Future Horizons?","authors":"Alexander Mundinger, Carolin Mundinger","doi":"10.4274/ejbh.galenos.2024.2023-12-13","DOIUrl":"https://doi.org/10.4274/ejbh.galenos.2024.2023-12-13","url":null,"abstract":"Artificial Intelligence (AI) is defined as the simulation of human intelligence by a digital computer or robotic system and has become a hype in current conversations. A subcategory of AI is deep learning, which is based on complex artificial neural networks that mimic the principles of human synaptic plasticity and layered brain architectures, and uses large-scale data processing. AI-based image analysis in breast screening programmes has shown non-inferior sensitivity, reduces workload by up to 70% by pre-selecting normal cases, and reduces recall by 25% compared to human double reading. Natural language programs such as ChatGPT (OpenAI) achieve 80% and higher accuracy in advising and decision making compared to the gold standard: human judgement. This does not yet meet the necessary requirements for medical products in terms of patient safety. The main advantage of AI is that it can perform routine but complex tasks much faster and with fewer errors than humans. The main concerns in healthcare are the stability of AI systems, cybersecurity, liability and transparency. More widespread use of AI could affect human jobs in healthcare and increase technological dependency. AI in senology is just beginning to evolve towards better forms with improved properties. Responsible training of AI systems with meaningful raw data and scientific studies to analyse their performance in the real world are necessary to keep AI on track. To mitigate significant risks, it will be necessary to balance active promotion and development of quality-assured AI systems with careful regulation. AI regulation has only recently included in transnational legal frameworks, as the European Union's AI Act was the first comprehensive legal framework to be published, in December 2023. Unacceptable AI systems will be banned if they are deemed to pose a clear threat to people's fundamental rights. Using AI and combining it with human wisdom, empathy and affection will be the method of choice for further, fruitful development of tomorrow's senology.","PeriodicalId":93996,"journal":{"name":"European journal of breast health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140355953","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-01DOI: 10.4274/ejbh.galenos.2024.2023-12-12
Dogan S. Polat, Y. Xi, Keith Hulsey, Matthew Lewis, B. Dogan
Objective Breast cancer clinical stage and nodal status are the most clinically significant drivers of patient management, in combination with other pathological biomarkers, such as estrogen receptor (ER), progesterone receptor or human epidermal growth factor receptor 2 (HER2) receptor status and tumor grade. Accurate prediction of such parameters can help avoid unnecessary intervention, including unnecessary surgery. The objective was to investigate the role of magnetic resonance imaging (MRI) radiomics for yielding virtual prognostic biomarkers (ER, HER2 expression, tumor grade, molecular subtype, and T-stage). Materials and Methods Patients with primary invasive breast cancer who underwent dynamic contrast-enhanced (DCE) breast MRI between July 2013 and July 2016 in a single center were retrospectively reviewed. Age, N-stage, grade, ER and HER2 status, and Ki-67 (%) were recorded. DCE images were segmented and Haralick texture features were extracted. The Bootstrap Lasso feature selection method was used to select a small subset of optimal texture features. Classification of the performance of the final model was assessed with the area under the receiver operating characteristic curve (AUC). Results Median age of patients (n = 209) was 49 (21-79) years. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the model for differentiating N0 vs N1-N3 was: 71%, 79%, 76%, 74%, 75% [AUC = 0.78 (95% confidence interval (CI) 0.72-0.85)], N0-N1 vs N2-N3 was 81%, 59%, 24%, 95%, 62% [AUC = 0.74 (95% CI 0.63-0.85)], distinguishing HER2(+) from HER2(-) was 79%, 48%, 34%, 87%, 56% [AUC = 0.64 (95% CI 0.54-0.73)], high nuclear grade (grade 2-3) vs low grade (grades 1) was 56%, 88%, 96%, 29%, 61% [AUC = 0.71 (95% CI 0.63-0.80)]; and for ER (+) vs ER(-) status the [AUC=0.67 (95% CI 0.59-0.76)]. Radiomics performance in distinguishing triple-negative vs other molecular subtypes was [0.60 (95% CI 0.49-0.71)], and Luminal A [0.66 (95% CI 0.56-0.76)]. Conclusion Quantitative radiomics using MRI contrast texture shows promise in identifying aggressive high grade, node positive triple negative breast cancer, and correlated well with higher nuclear grades, higher T-stages, and N-positive stages.
{"title":"Radiomics Analysis of Contrast-Enhanced Breast MRI for Optimized Modelling of Virtual Prognostic Biomarkers in Breast Cancer.","authors":"Dogan S. Polat, Y. Xi, Keith Hulsey, Matthew Lewis, B. Dogan","doi":"10.4274/ejbh.galenos.2024.2023-12-12","DOIUrl":"https://doi.org/10.4274/ejbh.galenos.2024.2023-12-12","url":null,"abstract":"Objective\u0000Breast cancer clinical stage and nodal status are the most clinically significant drivers of patient management, in combination with other pathological biomarkers, such as estrogen receptor (ER), progesterone receptor or human epidermal growth factor receptor 2 (HER2) receptor status and tumor grade. Accurate prediction of such parameters can help avoid unnecessary intervention, including unnecessary surgery. The objective was to investigate the role of magnetic resonance imaging (MRI) radiomics for yielding virtual prognostic biomarkers (ER, HER2 expression, tumor grade, molecular subtype, and T-stage).\u0000\u0000\u0000Materials and Methods\u0000Patients with primary invasive breast cancer who underwent dynamic contrast-enhanced (DCE) breast MRI between July 2013 and July 2016 in a single center were retrospectively reviewed. Age, N-stage, grade, ER and HER2 status, and Ki-67 (%) were recorded. DCE images were segmented and Haralick texture features were extracted. The Bootstrap Lasso feature selection method was used to select a small subset of optimal texture features. Classification of the performance of the final model was assessed with the area under the receiver operating characteristic curve (AUC).\u0000\u0000\u0000Results\u0000Median age of patients (n = 209) was 49 (21-79) years. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the model for differentiating N0 vs N1-N3 was: 71%, 79%, 76%, 74%, 75% [AUC = 0.78 (95% confidence interval (CI) 0.72-0.85)], N0-N1 vs N2-N3 was 81%, 59%, 24%, 95%, 62% [AUC = 0.74 (95% CI 0.63-0.85)], distinguishing HER2(+) from HER2(-) was 79%, 48%, 34%, 87%, 56% [AUC = 0.64 (95% CI 0.54-0.73)], high nuclear grade (grade 2-3) vs low grade (grades 1) was 56%, 88%, 96%, 29%, 61% [AUC = 0.71 (95% CI 0.63-0.80)]; and for ER (+) vs ER(-) status the [AUC=0.67 (95% CI 0.59-0.76)]. Radiomics performance in distinguishing triple-negative vs other molecular subtypes was [0.60 (95% CI 0.49-0.71)], and Luminal A [0.66 (95% CI 0.56-0.76)].\u0000\u0000\u0000Conclusion\u0000Quantitative radiomics using MRI contrast texture shows promise in identifying aggressive high grade, node positive triple negative breast cancer, and correlated well with higher nuclear grades, higher T-stages, and N-positive stages.","PeriodicalId":93996,"journal":{"name":"European journal of breast health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140355463","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-01DOI: 10.4274/ejbh.galenos.2024.2024-1-7
Almila Nazli Korucu, N. Inandiklioğlu
Despite advances in diagnosis and treatment, breast cancer is still one of the three most common cancers in the world and a significant cause of morbidity and mortality. Lipids play a role in many basic physiological pathways in cells, from regulating cell homeostasis to energy expenditure. As in many types of cancer, changes in lipid metabolism and their relationship have been reported in breast cancer. The STARD3 gene encodes a member of the subfamily of lipid trafficking proteins. It is a sterol-binding protein that mediates the transport of cholesterol from the endoplasmic reticulum to endosomes. It has been shown that STARD3 is correlated with human epidermal growth factor receptor 2 (HER2) amplification since it has the same localization as HER2 in the chromosome. In this review, we aimed to emphasize that investigating lipid metabolism together with the STARD3 biomarker has great potential not only for subtype-specific strategies but also for patient-specific strategies.
{"title":"Is STARD3 A New Biomarker for Breast Cancer?","authors":"Almila Nazli Korucu, N. Inandiklioğlu","doi":"10.4274/ejbh.galenos.2024.2024-1-7","DOIUrl":"https://doi.org/10.4274/ejbh.galenos.2024.2024-1-7","url":null,"abstract":"Despite advances in diagnosis and treatment, breast cancer is still one of the three most common cancers in the world and a significant cause of morbidity and mortality. Lipids play a role in many basic physiological pathways in cells, from regulating cell homeostasis to energy expenditure. As in many types of cancer, changes in lipid metabolism and their relationship have been reported in breast cancer. The STARD3 gene encodes a member of the subfamily of lipid trafficking proteins. It is a sterol-binding protein that mediates the transport of cholesterol from the endoplasmic reticulum to endosomes. It has been shown that STARD3 is correlated with human epidermal growth factor receptor 2 (HER2) amplification since it has the same localization as HER2 in the chromosome. In this review, we aimed to emphasize that investigating lipid metabolism together with the STARD3 biomarker has great potential not only for subtype-specific strategies but also for patient-specific strategies.","PeriodicalId":93996,"journal":{"name":"European journal of breast health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140356119","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-01DOI: 10.4274/ejbh.galenos.2024.2023-12-8
L. C. Ward, Belinda Thompson, K. Gaitatzis, Louise A. Koelmeyer
Objective Breast cancer related lymphedema (BCRL) may be assessed through objective measurement of limb swelling with common techniques including volumetric measurement using a tape measure or perometry, and measurement of extracellular water using bioimpedance spectroscopy (BIS). This study aimed to evaluate the performance of a stand-on BIS device for detection of BCRL, introduce a novel graphical method to compare volumetric and BIS methods alongside traditional specificity and sensitivity analysis, and determine and compare BIS thresholds with those published previously. Materials and Methods Female participants with indocyanine green lymphography confirmed unilateral arm lymphedema (n = 197) and healthy controls (n = 267) were assessed using a cross-sectional study design. BIS and volumetric measures were obtained in a single session. Results The BIS lymphedema index (L-Dex) method had a significantly higher sensitivity than the excess volume approach (area under the curve = 0.832 vs. 0.649, p = 0.0001). A threshold of L-Dex 6.5 had a higher true positive rate (70.6%) than L-Dex 10 (68.5%) although false positive rate increased from 0.4% to 2.6%. A threshold of 5% excess volume improved the true positive rate (68.5%) compared with 10% excess volume (49.7%) however the false positive rate increased to an unacceptable 47%. The L-Dex ranges in this study were not significantly different from previously published ranges. Conclusion BIS was superior for identifying BCRL compared with volume measurements, reaffirming the value of this technique. However, it is recommended that BIS be used in conjunction with comprehensive evaluation of symptoms and clinical presentation. The proposed graphical method provides a simple and easily interpretable approach to compare and define concordance between the two commonly used methods for BCRL assessment namely limb volume and BIS L-Dex indices. The existing BIS (L-Dex) thresholds for presence of BCRL were also validated.
目的乳腺癌相关淋巴水肿（BCRL）可通过客观测量肢体肿胀来进行评估，常用的技术包括使用卷尺或周径测量法进行体积测量，以及使用生物阻抗光谱法（BIS）测量细胞外水分。本研究旨在评估站立式 BIS 设备在检测 BCRL 方面的性能，引入一种新颖的图形方法，与传统的特异性和灵敏度分析方法一起比较体积测量法和 BIS 方法，并确定和比较 BIS 阈值与之前公布的阈值。材料和方法采用横断面研究设计，对患有吲哚菁绿淋巴造影术证实的单侧手臂淋巴水肿的女性参与者（n = 197）和健康对照组（n = 267）进行评估。结果BIS淋巴水肿指数（L-Dex）法的灵敏度明显高于过量体积法（曲线下面积 = 0.832 vs. 0.649，p = 0.0001）。尽管假阳性率从 0.4% 上升到 2.6%，但 L-Dex 6.5 临界值的真阳性率（70.6%）高于 L-Dex 10 临界值（68.5%）。与超量 10%（49.7%）相比，超量 5%的阈值提高了真阳性率（68.5%），但假阳性率却增加到令人无法接受的 47%。本研究中的 L-Dex 范围与之前公布的范围没有明显差异。结论与容积测量相比，BIS 在识别 BCRL 方面更具优势，再次证明了该技术的价值。不过，建议在使用 BIS 时结合症状和临床表现的综合评估。所提出的图形方法提供了一种简单且易于解释的方法，用于比较和确定 BCRL 评估的两种常用方法（即肢体体积和 BIS L-Dex 指数）之间的一致性。现有的 BIS（L-Dex）阈值也对 BCRL 的存在进行了验证。
{"title":"Comparison of Volume Measurements and Bioimpedance Spectroscopy Using A Stand-on Device for Assessment of Unilateral Breast Cancer-Related Lymphedema.","authors":"L. C. Ward, Belinda Thompson, K. Gaitatzis, Louise A. Koelmeyer","doi":"10.4274/ejbh.galenos.2024.2023-12-8","DOIUrl":"https://doi.org/10.4274/ejbh.galenos.2024.2023-12-8","url":null,"abstract":"Objective\u0000Breast cancer related lymphedema (BCRL) may be assessed through objective measurement of limb swelling with common techniques including volumetric measurement using a tape measure or perometry, and measurement of extracellular water using bioimpedance spectroscopy (BIS). This study aimed to evaluate the performance of a stand-on BIS device for detection of BCRL, introduce a novel graphical method to compare volumetric and BIS methods alongside traditional specificity and sensitivity analysis, and determine and compare BIS thresholds with those published previously.\u0000\u0000\u0000Materials and Methods\u0000Female participants with indocyanine green lymphography confirmed unilateral arm lymphedema (n = 197) and healthy controls (n = 267) were assessed using a cross-sectional study design. BIS and volumetric measures were obtained in a single session.\u0000\u0000\u0000Results\u0000The BIS lymphedema index (L-Dex) method had a significantly higher sensitivity than the excess volume approach (area under the curve = 0.832 vs. 0.649, p = 0.0001). A threshold of L-Dex 6.5 had a higher true positive rate (70.6%) than L-Dex 10 (68.5%) although false positive rate increased from 0.4% to 2.6%. A threshold of 5% excess volume improved the true positive rate (68.5%) compared with 10% excess volume (49.7%) however the false positive rate increased to an unacceptable 47%. The L-Dex ranges in this study were not significantly different from previously published ranges.\u0000\u0000\u0000Conclusion\u0000BIS was superior for identifying BCRL compared with volume measurements, reaffirming the value of this technique. However, it is recommended that BIS be used in conjunction with comprehensive evaluation of symptoms and clinical presentation. The proposed graphical method provides a simple and easily interpretable approach to compare and define concordance between the two commonly used methods for BCRL assessment namely limb volume and BIS L-Dex indices. The existing BIS (L-Dex) thresholds for presence of BCRL were also validated.","PeriodicalId":93996,"journal":{"name":"European journal of breast health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140355746","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-01DOI: 10.4274/ejbh.galenos.2024.2023-11-3
Juan Alors-Ruiz, Salomé Sanz-Viedma, Francisco Javier Fernández-Garcia, F. Sendra-Portero
Objective High rates of negative sentinel lymph node biopsy (SLNB) in clinically node-negative (cN0) breast cancer (BC) after neoadjuvant chemotherapy (NAC) have been described. These results are associated with triple-negative (TNBC) and human epidermal growth factor receptor 2 (HER2+) subtypes achieving pathologic complete response (pCR). This study evaluates predictive variables and survival in order to assess the possible omission of SLNB after NAC. Materials and Methods Prospective study of women with cN0 BC treated with NAC and subsequent surgery, between April 2010 and May 2021. SLNB technique included, performing axillary lymphadenectomy in the absence of detection or SLNB-positivity. Multivariable logistic regression was used for analysis of NAC-response and SLNB-results in molecular subtypes: HR-/HER2+, TNBC, HR+/HER2- and HR+/HER2+. Kaplan-Meyer and log-rank were used for survival analysis. Results A total of 179 patients (50.5±10.1 years) were included. Of these, 39.7% achieved pCR (ypT0/Tis). HR-negative subtypes had higher pCR rates (HR-/HER2+: 59.4%; TNBC: 53.4%), with no cases of SLNB-positive. With residual disease, HR-/HER2+ and TNBC showed low rates of SLNB-positivity (6.7% and 10.3%) versus HR+ (HR+/HER2+: 20%; HR+/HER2-: 44%; p<0.001). Multivariable analysis identified independent predictors of SLNB-negativity (p<0.0001) to be: HR- [odds ratio (OR)=0.15; 95% confidence interval (CI): 0.06-0.37; p = 0.0001], HER2+ (OR=0.34; 95% CI: 0.14-0.81; p = 0.015) and high-grade Nottingham (OR=0.42; 95% CI: 0.18-0.99; p = 0.048). Disease-free survival showed worse outcomes with SLNB-positivity (p<0.0001), HR+/HER2- (p = 0.0277), larger tumor size (p = 0.002) and residual disease after NAC (p<0.0001). Conclusion Patient selection based on NAC response, molecular subtype, and survival outcomes is a priority for establishing individualized therapeutic strategies after NAC. Molecular subtypes with higher pCR rates and lower rates of SLNB-positivity could benefit from non-invasive strategies that include omission of SLNB.
{"title":"Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in cN0 Breast Cancer: Impact of HER2-Positive Status on Survival.","authors":"Juan Alors-Ruiz, Salomé Sanz-Viedma, Francisco Javier Fernández-Garcia, F. Sendra-Portero","doi":"10.4274/ejbh.galenos.2024.2023-11-3","DOIUrl":"https://doi.org/10.4274/ejbh.galenos.2024.2023-11-3","url":null,"abstract":"Objective\u0000High rates of negative sentinel lymph node biopsy (SLNB) in clinically node-negative (cN0) breast cancer (BC) after neoadjuvant chemotherapy (NAC) have been described. These results are associated with triple-negative (TNBC) and human epidermal growth factor receptor 2 (HER2+) subtypes achieving pathologic complete response (pCR). This study evaluates predictive variables and survival in order to assess the possible omission of SLNB after NAC.\u0000\u0000\u0000Materials and Methods\u0000Prospective study of women with cN0 BC treated with NAC and subsequent surgery, between April 2010 and May 2021. SLNB technique included, performing axillary lymphadenectomy in the absence of detection or SLNB-positivity. Multivariable logistic regression was used for analysis of NAC-response and SLNB-results in molecular subtypes: HR-/HER2+, TNBC, HR+/HER2- and HR+/HER2+. Kaplan-Meyer and log-rank were used for survival analysis.\u0000\u0000\u0000Results\u0000A total of 179 patients (50.5±10.1 years) were included. Of these, 39.7% achieved pCR (ypT0/Tis). HR-negative subtypes had higher pCR rates (HR-/HER2+: 59.4%; TNBC: 53.4%), with no cases of SLNB-positive. With residual disease, HR-/HER2+ and TNBC showed low rates of SLNB-positivity (6.7% and 10.3%) versus HR+ (HR+/HER2+: 20%; HR+/HER2-: 44%; p<0.001). Multivariable analysis identified independent predictors of SLNB-negativity (p<0.0001) to be: HR- [odds ratio (OR)=0.15; 95% confidence interval (CI): 0.06-0.37; p = 0.0001], HER2+ (OR=0.34; 95% CI: 0.14-0.81; p = 0.015) and high-grade Nottingham (OR=0.42; 95% CI: 0.18-0.99; p = 0.048). Disease-free survival showed worse outcomes with SLNB-positivity (p<0.0001), HR+/HER2- (p = 0.0277), larger tumor size (p = 0.002) and residual disease after NAC (p<0.0001).\u0000\u0000\u0000Conclusion\u0000Patient selection based on NAC response, molecular subtype, and survival outcomes is a priority for establishing individualized therapeutic strategies after NAC. Molecular subtypes with higher pCR rates and lower rates of SLNB-positivity could benefit from non-invasive strategies that include omission of SLNB.","PeriodicalId":93996,"journal":{"name":"European journal of breast health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140356433","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-01DOI: 10.4274/ejbh.galenos.2024.2023-12-2
Murat Kaya, A. Abuaisha, Ilknur Suer, S. Emiroğlu, Fahrunnisa Abanoz, S. Palanduz, K. Çefle, S. Ozturk
Objective Recent research suggests curcumin extracted from the turmeric plant may inhibit the proliferation of cancer cells by controlling the expression of microRNAs (miRNAs). The effect of phenolic curcumin on miR-638-5p and potential target gene expressions in the triple negative breast cancer (TNBC) cell line MDA-MB-231 was investigated in this study. Materials and Methods GSE154255 and GSE40525 datasets were downloaded and analyzed using GEO2R to identify dysregulated miRNAs in TNBC. To find differently expressed genes in breast cancer (BRCA), The Cancer Genome Atlas Program data was examined. Utilizing in silico tools, KEGG, GO, and other enrichment analyses were performed. The databases miRNet, miRTarBase v8.0, and TarBase v.8 were used for miRNA and mRNA matching. Real-time quantitative reverse transcription polymerase chain reaction was used to examine the levels of miRNA and its targets in miRNA mimic transfected/curcumin-treated MDA-MB-231 cultures and controls. The cell viability detection kit-8 method was used to assess cell viability, and the scratch assay was used to conduct migration assessment. Results Bioinformatics analysis showed that miR-638-5p was significantly reduced in TNBC patients. Experimental results showed that miR-638-5p was upregulated in MDA-MB-231 treated with curcumin, while the potential target genes of miR-638-5p, CFL1, SIX4, MAZ, and CDH1 were downregulated. Mimic miR-638-5p transfection inhibited MDA-MB-231 cell proliferation and reduced migration and expression of CFL1, SIX4, and MAZ genes was decreased in mimic miR-638-5p transfected cells. Conclusion These findings suggest that curcumin exerts its anticancer effects on MDA-MB-231 cells by modulating the expression of miR-638-5p and its possible target genes.
{"title":"Turmeric Inhibits MDA-MB-231 Cancer Cell Proliferation, Altering miR-638-5p and Its Potential Targets.","authors":"Murat Kaya, A. Abuaisha, Ilknur Suer, S. Emiroğlu, Fahrunnisa Abanoz, S. Palanduz, K. Çefle, S. Ozturk","doi":"10.4274/ejbh.galenos.2024.2023-12-2","DOIUrl":"https://doi.org/10.4274/ejbh.galenos.2024.2023-12-2","url":null,"abstract":"Objective\u0000Recent research suggests curcumin extracted from the turmeric plant may inhibit the proliferation of cancer cells by controlling the expression of microRNAs (miRNAs). The effect of phenolic curcumin on miR-638-5p and potential target gene expressions in the triple negative breast cancer (TNBC) cell line MDA-MB-231 was investigated in this study.\u0000\u0000\u0000Materials and Methods\u0000GSE154255 and GSE40525 datasets were downloaded and analyzed using GEO2R to identify dysregulated miRNAs in TNBC. To find differently expressed genes in breast cancer (BRCA), The Cancer Genome Atlas Program data was examined. Utilizing in silico tools, KEGG, GO, and other enrichment analyses were performed. The databases miRNet, miRTarBase v8.0, and TarBase v.8 were used for miRNA and mRNA matching. Real-time quantitative reverse transcription polymerase chain reaction was used to examine the levels of miRNA and its targets in miRNA mimic transfected/curcumin-treated MDA-MB-231 cultures and controls. The cell viability detection kit-8 method was used to assess cell viability, and the scratch assay was used to conduct migration assessment.\u0000\u0000\u0000Results\u0000Bioinformatics analysis showed that miR-638-5p was significantly reduced in TNBC patients. Experimental results showed that miR-638-5p was upregulated in MDA-MB-231 treated with curcumin, while the potential target genes of miR-638-5p, CFL1, SIX4, MAZ, and CDH1 were downregulated. Mimic miR-638-5p transfection inhibited MDA-MB-231 cell proliferation and reduced migration and expression of CFL1, SIX4, and MAZ genes was decreased in mimic miR-638-5p transfected cells.\u0000\u0000\u0000Conclusion\u0000These findings suggest that curcumin exerts its anticancer effects on MDA-MB-231 cells by modulating the expression of miR-638-5p and its possible target genes.","PeriodicalId":93996,"journal":{"name":"European journal of breast health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140354666","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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