Primary malignant lymphoma of the breast: clinicopathological study of nine cases

Primary lymphoma of the breast is rare, accounting for 1.7-2.2% of extranodal lymphomas and 0.38-0.7% of non-Hodgkin's lymphomas (NHL). The aim of this study was to evaluate the clinicopathological features and treatment outcomes of patients with primary breast lymphomas (PBL). We conducted a retrospective review of the NHL cases diagnosed at Korea Cancer Center Hospital between 1989 and 2002. Nine (0.9%) of the 1,050 cases fulfilled the criteria for PBL. All patients were women (median age, 45 years) and usually presented with breast masses that had recently become enlarged. Six cases involved the breast alone (stage IE), whereas 3 cases also involved the ipsilateral axillary lymph nodes (stage IIE). Histopathologic studies revealed a diffuse large B cell lymphoma in 7 cases, marginal zone B cell lymphoma in 1 case, and small lymphocytic lymphoma in 1 case. Immunohistochemical analysis revealed a B-cell phenotype in all cases. There was no uniform approach to the treatment of PBL. Modified radical mastectomy and chemotherapy was performed in 4 cases, modified radical mastectomy and chemoradiotherapy was performed in 1 case, chemoradiotherapy alone, modified radical mastectomy alone, chemotherapy alone, and radiotherapy alone were performed in 1 case each. All cases achieved complete remission, but median overall survival was 12 months, showing very poor prognosis irrespective of the type of treatment modality.     

Primary breast lymphoma: an uncommon but curable disease

Primary malignant breast lymphoma (PBL) is a rare disease with an incidence of 0.04-0.5% of all malignant breast neoplasms. The majority of cases are B-cell lymphomas and the most common histologic type is diffuse large B-cell lymphoma (DLCL). In this study, we report our experience with three cases of PBL. The treatment was the same currently indicated for early stage aggressive NHL, i.e. anthracycline based chemotherapy followed by the involved field radiation therapy. Unfortunately, two patients underwent mastectomy to carry out correct diagnosis. The three patients are alive without any evidence of relapse after 24, 67 and 135 months of follow-up. Considering that aggressive NHL is very sensitive to chemotherapy, mastectomy should be avoided to preserve the quality of life of these patients, once surgery does not change the good prognosis of PBL.     

Primary breast lymphoma

Primary breast lymphoma (PBL) is a rare form of localized extranodal lymphoma. Few reports are available in the literature concerning its treatment and outcome. Of the 34 cases of PBL seen at our institution over a 25-year period, 20 consecutive cases were treated with CHOP or CHOP-like chemotherapy regimen and had adequate biopsy specimens for histological review. All these 20 PBL were of B-cell origin including one case of Burkitt lymphoma, and 2 cases of low-grade histologic type. Sixteen of the 20 patients achieved a complete remission (CR) and 2 achieved a partial remission (PR) (>75% tumor regression). Two patients had progressive disease while on therapy. With a median follow-up period of 80 months, 6 patients relapsed. Median time to relapse from diagnosis was 23 months (range, 3-41 months). Two of the relapses involved the central nervous system (CNS): isolated CNS relapse in one case and associated with other relapse sites in 1 case. The two patients who achieved a PR after chemotherapy also had disease progression to the CNS, 4 and 8 months after the end of CHOP chemotherapy. All 4 patients died of their disease 3, 6, 10 and 13 months after CNS involvement. Of the 16 centroblastic diffuse large B-cell lymphoma (DLCL), 3 had CNS disease at relapse. Three (15%) of our study patients developed a controlateral breast relapse. Twelve of the initial 20 patients were alive, including 11 with a persistent CR, 6 patients died of their lymphoma and 2 of unrelated diseases. In conclusion, we observed a high incidence of CNS relapse in this group of localized extranodal lymphoma, strongly suggesting that CNS prophylaxis should be associated with systemic chemotherapy in localized PLB.     

Primary breast lymphoma. An immunohistologic study of 20 new cases

Primary malignant lymphomas of the breast (PBL) are uncommon. The authors report the clinical, histologic, and immunoperoxidase findings on 20 cases recorded at the Alberta Cancer Registry over the last 23 years. These cases were then added to material on 257 cases abstracted from the literature and analyzed. It was found that there are two clinicopathologic types of PBL. The first affects pregnant or lactating women with bilateral, diffuse disease, is rapidly fatal, and corresponds histologically to a Burkitt's-type lymphoma. The second is unilateral at presentation and afflicts a broad age range, but primarily older women. This has a variable course only part of which is predicted by histologic grade and stage. Tumor size, treatment, and side of presentation were not found to be significant prognostic factors. Histologically, these tumors can be grouped into large cell B-cell lymphomas, monocytoid B-cell lymphomas (MBCL), and undifferentiated, some of which may be T-cell. Evidence suggesting that the MBCL of breast are the equivalent of the malignant lymphomas of the mucosa-associated lymphoid tissues (MALT) is reviewed. The breast is a hormone-dependent member of the MALT and therefore it is interesting that two of these tumors were strongly positive for estrogen receptors.     

Primary Malignant Lymphoma of the Breast： a Study of 15 Cases and Review of the Chinese Literature

OBJECTIVE To study the clinical features and significant prognostic factors for primary breast lymphoma (PBL).METHODS A retrospective clinical analysis of 15 patients with PBL and a statistical analysis of 134 cases with PBL were performed.RESULTS All 15 patients, but one, were female with a median age of 42years. None were diagnosed with PBL preoperatively. Pathological studyshowed that all cases were non-Hodgkin‘s lymphoma with the DLCL type(53.3%). The right breast was affected in 10 patients, the left in 4 and both inone. A statistical analysis showed that the size of tumors and treatmentpattern (single or multi-modality) were significant prognostic factors inpredicting the survival time, but the location of the tumor at initialpresentation and the age of the patients were not.CONCLUSION Most PBLs are NHL. The right breast is more frequently involved. The correct diagnosis depends mostly on postoperative pathology. The size of the tumor and the modality of treatment are significant prognostic factors.     

Clinical Analysis of 21 Cases of Primary Breast Malignant Lymphoma

OBJECTIVE To explore the clinico-pathological characteristics, diagnosis, treatment, and prognosis factors for primary breast malignant lymphoma (PBL). METHODS The clinical data from 21 cases of PBL were retrospectively analysed. RESULTS There were 19 females and 2 males with a median age of 37 years. All cases had diffuse non-Hodgkin lymphoma from B-cell lineage. The overall 5-year survival rate was 62.50% for the whole group and 81.82% for stage Ⅰ and Ⅱ diseases. CONCLUSION The prognosis of PBL is related to the stage and treatment modality. Operation combined with chemoradiotherapy is the best treatment method. Local resection should be the first surgical treatment.     

Localized non-Hodgkin's lymphoma of the breast

Chart review identified 18 patients seen at Memorial Hospital from 1970 to 1984 with primary non-Hodgkin's lymphoma localized to the breast. Sixteen involved the breast alone (Stage IE), whereas two also involved ipsilateral axillary lymph nodes (Stage IIE). None had B symptoms. Histologic subtypes included 11 diffuse histiocytic, 4 diffuse poorly differentiated, 2 diffuse mixed and one nodular mixed. Thirteen patients (72%) are alive with 55 months median follow-up (11 months-14 years). Three patients died with recurrent disease at less than 2 years, one recurred at 4 years and died 6 years after diagnosis, and one died at 30 months without clinical evidence of disease. Seven (39%) have remained continuously disease-free (11 months-11 years; median, 54 months). Of the clinical Stage I patients, 1 of 3 treated with mastectomy alone recurred in the scar, whereas 1 of 12 treated with irradiation alone recurred locally. Thus, radiation therapy alone achieved good local control, although distant relapses remain a problem in these clinically staged patients. Overall, the outcome of clinically localized non-Hodgkin's lymphoma of the breast is similar to that for localized lymphoma in other sites.     

Analysis of differential therapeutic strategies for primary breast lymphoma: two case reports

Primary breast lymphoma (PBL) is a rare form of extranodal non-Hodgkin’s lymphoma (NHL), whose own specific biological characteristics still need to be fully defined. No significant prognostic factor has been found and the optimal therapeutic strategy is uncertain. However, an intensified systemic therapy has been advocated to prevent relapse, even in patients who show a complete response to local treatment. We report two cases of primary diffuse large B-cell breast lymphoma, review the literature about this topic, and discuss treatment options. We conclude that differential therapeutic strategies based on the risk of relapse associated with the International Prognostic Index (IPI) are a reasonable way to approach PBL, and can avoid undue toxicity deriving from treatment.     

原发性乳腺淋巴瘤27例临床分析并文献复习

背景与目的:原发性乳腺淋巴瘤(primary breast lymphoma,PBL)发病率低,预后较差.本研究旨在分析该病例的临床和病理特征,从而探讨PBL的合理治疗模式.方法:收集并回顾性分析1976年到2005年间在中山大学肿瘤防治中心诊断为PBL,并接受治疗的27例患者的临床资料和治疗情况.结果:27例中有26例女性和1例男性患者;年龄12～84岁;90%的患者为Ⅰ E期或ⅡE期.按照WHO 2001淋巴瘤病理分类系统,有22例B细胞性淋巴瘤(17例弥漫大B细胞性淋巴瘤,2例黏膜相关性淋巴瘤,1例边缘区淋巴瘤,2例未能分类),3例外周T细胞性淋巴瘤,2例患者的病理类型未能分类.初始治疗时有20例患者接受了综合治疗,其中8例患者为根治术加术后化疗,12例患者为肿物切除术后加全身化疗,两组的5年生存率分别为23.0%和58.0%(P=0.006);其余有5例患者仅接受全身化疗,2例患者仅接受肿物切除手术.24例患者在初始治疗后取得完全缓解,1例患者部分缓解,2例患者疾病进展.随访时间1个月～10年,中位随访时间38个月.全组患者的5年总生存率和无病生存率分别是47.0%和23.0%;其中20例中高度恶性淋巴瘤患者(17例弥漫大B细胞性淋巴瘤和3例外周T细胞性淋巴瘤)的5年总生存率和无病生存率分别是48.0%和27.0%;随访中有16例复发,部位见于同侧乳腺6例、对侧乳腺4例、中枢神经系统(central nervous system,CNS)3例、骨髓1例和淋巴结侵犯2例.结论:PBL的病理类型以中高度恶性淋巴瘤为主;根治性手术在其治疗中作用有限,肿物切除术加术后化疗和放疗的效果较好.PBL患者易发生CNS复发,在随访中应定期进行颅脑CT或MR检查.     

Primary bone lymphoma: a new and detailed characterization of 28 patients in a single-institution study

BACKGROUND: The incidence of primary bone lymphoma (PBL) is so rare that many of its aspects remain unknown. A number of studies have been reported from Western countries, but only a few reports are available from Asia. METHODS: We retrospectively analyzed 28 consecutive patients diagnosed with PBL initially treated at our hospital between 1995 and 2004. All patients underwent chemotherapy with half receiving radiotherapy as their initial treatment. A log-rank test was used in a univariate analysis to identify factors affecting overall survival. RESULTS: Fifteen (54%) patients were male and 13 (46%) female with a median age of 47 (range: 5-81). Although 19 (68%) patients had diffuse large B-cell lymphoma (DLBCL), other histopathological subtypes (three B-lymphoblastic lymphoma, two anaplastic large cell lymphoma, two indolent B-cell lymphoma, one NK/T-cell lymphoma (NTCL) and one Hodgkin lymphoma) were also included. The pelvis was the most frequently involved site (54%). While 68% of patients had stage IV disease, none of them showed bone marrow involvement at their initial diagnosis. Despite 61% high intermediate-risk and high-risk patients based on the International Prognostic Index, the estimated 3-year overall and progression-free survival rates were 84% and 77%, respectively. Only 'histopathological subtype (immunoblastic variant of DLBCL or NTCL versus others)' and 'response to initial treatment (progression versus remission)' were factors significantly affecting overall survival. CONCLUSIONS: Although the total number of patients was relatively small, the detailed clinical data analyses presented here revealed several new characteristics of PBL and some aspects that may be unique to Japanese patients.     

原发乳腺淋巴瘤14例临床分析并文献回顾

目的：探讨原发乳腺淋巴瘤（primary breast lymphoma,PBL）的治疗方法及预后。方法：对军事医学科学院附属医院淋巴瘤科2005-07-15-2011-01-20收治的14例PBL患者的临床特征、病理特点、治疗方法及预后进行回顾性分析。结果：14例PBL均为女性,中位年龄48岁;ⅠE及ⅡE期各7例;病理类型均为B细胞淋巴瘤。其中3例行患侧全乳切除并腋窝淋巴结清除术,9例行乳腺肿物切除术,2例行乳腺肿物核芯针穿刺活检术。10例接受化放疗,4例单纯化疗,4例同时行中枢预防性鞘内注射;其中一线化疗完全缓解率为86%。中位随访53.5个月,7例复发,3例死亡;5年无进展生存率为39%,5年总生存率为72%。结论：全乳切除未使PBL患者获益。乳腺肿物切除明确病理、以蒽环类为主的化疗联合受累野放疗可为适宜的选择。由于PBL中枢复发率较高,故建议中枢预防鞘内注射。     

Prognostic factors for pleural lymphoma patients.

Prognostic factors in 47 patients with pleural lymphocytic lymphoma developing in chronic tuberculous pyothorax were evaluated using Cox's proportional hazards model. There were 41 men and six women, aged 44-80 (median 61) years. Approximately 70% of the patients had localized disease in Stages I and II, and 30% advanced disease in Stages III and IV. Histologically, 27 patients had the diffuse large, immunoblastic type and 12 had others. In the other seven patients, histological subtyping of the lymphocytic lymphoma was impossible because of degenerative or necrotic changes in the histologic specimens. A diagnosis of lymphocytic lymphoma of B-cell type was made in one case using combined cytologic and surface maker findings on a cell suspension. In addition, immunologic and immunohistochemical studies revealed another 40 cases to be proven B-cell lymphomas. Poor performance status and elevated levels of BUN and GPT were significantly associated with shortened survival in a Cox's proportional hazards model. A poor performance status and high levels of serum BUN and GPT suggested a marked deterioration in a patient's condition. When compared with previous literature describing prognostic factors in patients with B-cell lymphomas and with lymphocytic lymphomas with unfavorable histologies or associated with long-standing inflammations, the only common prognostic factors was performance status. The significance of primary site in predicting survival from lymphocytic lymphoma is discussed.     

Primary gastrointestinal lymphoma in Japan: a clinicopathologic analysis of 455 patients with special reference to its time trends

BACKGROUND: An optimal treatment modality for patients with primary gastrointestinal lymphoma has not yet been established. This study aimed to elucidate the clinicopathologic features of this disease and the influence of therapeutic modalities on the prognosis in Japanese patients METHODS: The clinicopathologic features of 455 patients with primary gastrointestinal lymphoma were investigated retrospectively regarding treatment modalities and time trends. RESULTS: This study comprised 342 patients (75%) with gastric lymphoma, 96 patients (22%) with intestinal lymphoma, and 17 patients (4%) with both gastric and intestinal lymphoma. Two hundred thirty-one (51%) patients were classified as having low-grade B-cell lymphoma including 200 marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) type, 185 (41%) patients were classified as having high-grade B-cell lymphoma including 76 diffuse large cell lymphoma plus MALT lymphoma, and 39 (9%) patients were classified as having T-cell lymphoma. The frequency of nonsurgical treatment, including Helicobacter pylori eradication, chemotherapy, and radiation, increased during the latest decade. Patients who received nonsurgical treatment showed a better overall survival than those treated by surgery, but event-free survival did not differ between two groups. Cox multivariate analysis revealed that early stage, younger age, gastric localization, B-cell phenotype, and absence of B symptoms were independent prognostic factors for better overall and event-free survivals. Mucosa-associated lymphoid tissue-derived lymphoma was also an independent prognostic factor for event-free survival, but not for overall survival. CONCLUSIONS: Nonsurgical treatment may be an optimal therapeutic modality for patients with primary gastrointestinal lymphoma.     

Malignant lymphoma in patients with rheumatic diseases other than Sjogren's syndrome: a clinicopathologic study of five cases and a review of the Japanese literature

We conducted clinicopathologic and immunohistochemical analysis of five patients with malignant lymphoma complicating rheumatic diseases other than Sjogren's syndrome, and reviewed 26 cases of similar lesions reported in the Japanese literature over a 17-year period. All five patients were women ranging in age from 31 to 74 years (mean 55 years). Two of them fulfilled the diagnostic criteria for systemic lupus erythematosus, two for dermatomyositis and one for progressive systemic sclerosis. The use of immunosuppressive drugs before the onset of malignant lymphoma was recorded in four patients. All the biopsied or resected specimens showed non-Hodgkin's lymphoma of B-cell phenotype. Three were nodal in origin (one diffuse mixed, one diffuse large cell and one immunoblastic) and two were extranodal (one low-grade B-cell lymphoma of mucosa-associated lymphoid tissue and one diffuse large cell). In three of four cases examined, Epstein-Barr virus-encoded small RNAs were identified in a small to large number of the lymphoma cells by in situ hybridization. Our study showed that the clinicopathological features of malignant lymphomas complicating rheumatic disease in Japan were similar to those in England and the USA. Furthermore, our findings suggested no evidence for a causative association between iatrogenic immunosuppression due to methotrexate therapy and the development of EBV-related lymphoid neoplasms.      

Diffuse large B-cell lymphomas with plasmablastic differentiation

Recent evidence suggests that diffuse large B-cell lymphoma (DLBCL) with plasmablastic differentiation represents a clinically heterogeneous spectrum with different clinicopathologic characteristics representing distinct entities. Subtypes of DLBCL with plasmablastic features and terminal B-cell differentiation include plasmablastic lymphoma (PBL) of oral mucosa type; PBL with plasmacytic differentiation; primary effusion lymphoma (PEL); KSHV-positive solid lymphoma/extracavitary PEL/HHV-8 associated DLBCL; and DLBCL expressing ALK. In contrast, PBL associated with multicentric Castleman disease, DLBCL with secretory differentiation, pyothorax-associated lymphoma, and atypical Burkitt lymphoma with plasmacytoid differentiation have morphologic appearances of plasma cell differentiation but maintain a mature B-cell (CD20 positive) phenotype. These tumors as well as extramedullary plasmablastic tumors secondary to multiple myeloma or plasmacytomas are included in the differential diagnosis. In this review, we discuss recently described clinicopathologic insights, case observations, and recently reported molecules involved in terminal B-cell or plasma cell differentiation and their possible roles in disease pathogenesis.     

乳腺非何杰金淋巴瘤8例临床病理及免疫表型分析

本文对6例原发及2例继发乳腺NHL进行报道分析。临床易误诊为乳腺癌．在部分病例镜下可见到淋巴上皮病损。本组组织学类型大多为高度恶性。免疫级化示：原发组6例中4例为B细胞性，1例为T细胞性．1例来定；继发2例均为B细胞性。本研究示：原发与继发乳腺NHL主要靠临床区别，组织学形态难以鉴别；至少部分乳腺NHL与粘膜相关淋巴组织有关；年轻妇女乳腺NHL预后差。     

Matched-pair analysis comparing the outcomes of primary breast and nodal diffuse large B-cell lymphoma in patients treated with rituximab plus chemotherapy

Primary breast diffuse large B-cell lymphoma (DLBCL) is an extremely rare presentation of non-Hodgkin's lymphoma that has been associated with poorer clinical outcomes compared with nodal DLBCL in the pre-rituximab era. The aim of this study was to investigate the impact of rituximab on clinical outcomes in patients with primary breast DLBCL. Data from 25 female patients with primary breast DLBCL receiving rituximab plus chemotherapy were matched to 75 female patients (1:3) with nodal DLBCL by following five established prognostic factors (age, Ann Arbor stage, Eastern Cooperative Oncology Group performance status, serum lactate dehydrogenase level and B symptoms). Overall survival (OS) was similar between primary breast and nodal DLBCL groups (3-year OS rate, 82.2% vs. 90.7%, respectively; p = 0.345). In the analysis of immunohistochemically defined prognostic subgroups, 19 of 20 available cases in the primary breast DLBCL group displayed a non-germinal center (GC) phenotype. Compared with patterns of recurrence, extranodal progression in the breast or central nervous system (CNS) was significantly higher in the primary breast DLBCL group than in the nodal DLBCL group (p < 0.001). Additionally, the stage-modified International Prognostic Index was the only independent prognostic factor for OS in this population. This suggests that clinical outcomes of primary breast DLBCL might no longer be inferior to those of nodal DLBCL in the rituximab era, which might be associated with the intrinsic biologic characteristics of the non-GC phenotype. However, despite including rituximab, extranodal progression in the breast or CNS was problematic. This study was registered at www.clinicaltrials.gov as no. NCT01266668.     

Primary salivary gland lymphoma among Japanese: A clinicopathological study of 30 cases

To clarify the clinicopathological findings of primary salivary gland lymphoma as defined by the World Health Organization (WHO) classification, 30 Japanese patients with this disease were studied. The male to female ratio was 1:1.7 and median patient age was 57 years. The parotid gland (n = 22) was involved most frequently, followed by the submandibular gland (n = 5) and minor salivary gland (n = 3). Twenty-four (80%) cases demonstrated Stage IE, whereas only six (20%) had Stage IIE-1. None of the 30 cases had "B" symptoms or a poor performance status. The 5-year overall survival of 31 cases was 96% and 5-year failure-free survival was 77%. Histologically, 15 cases were mucosa-associated lymphoid tissue (MALT) lymphoma, seven were follicular lymphoma (FL), and six were diffuse large B-cell lymphoma (DLBCL) + MALT lymphoma and only two were DLBCL without a MALT lymphoma component. MALT lymphoma is the most frequent type of primary salivary gland lymphoma. However, FL comprised 20% of primary salivary gland lymphoma. The majority of the primary salivary gland DLBCL appear to arise from MALT type lymphoma. When appropriate therapy for histologic subtype is used, outcome of the primary salivary gland B-cell lymphoma appears excellent whether histologically indolent or aggressive.     

Extranodal non-Hodgkin's lymphoma of the head and neck. A clinicopathologic study in the Kyoto-Nara area of Japan

The clinicopathologic features of 114 Japanese patients with extranodal non-Hodgkin's lymphoma of the head and neck region were analyzed. The median age was 60.5 years and the male:female ratio was 1.5:1. The most common site of involvement was Waldeyer's ring, followed by the oral cavity, thyroid gland, paranasal sinuses, nasal cavity, and larynx. Seventy-five percent of the patients were in Stage I or Stage II at admission. Histologically, diffuse lymphoma accounted for 94% and follicular lymphoma for 6% of cases. The histologic grade according to the Working Formulation System of the National Cancer Institute was low in 11%, intermediate in 75%, and high in 14% of cases. Immunohistochemical study showed that the majority of the cases were of B-cell type and only 13 cases (11%) were of the T-cell type. Peripheral T-cell lymphomas (eight cases) mainly occurred in the nasopharynx and nasal cavity, whereas four of five thymic T-cell lymphomas were found in the palatine tonsil. The over-all 5-year survival rate was 54%, and the factors affecting survival were sex, histologic grade, T/B phenotype, clinical stage, and the site of initial presentation. Five-year survival with nasal cavity and Waldeyer's ring lymphoma was 24% and 46%, respectively. The poor prognosis of lymphomas at these sites might result from the predominance of T-cell lymphoma, the paucity of low grade lymphoma, and the relatively high incidence of cases that were in an advanced stage at presentation. In Stage II, patients treated with combined therapy tended to have a better 5-year survival rate than those treated with radiotherapy alone.     

Diffuse large B-cell lymphoma involving the breast. A report of four cases

Non-Hodgkin lymphoma of the breast is an uncommon form of lymphoma occurring either primary disease (PBL) or part of systemic involvement. We report the clinical outcome of 4 consecutive cases with CD20+ diffuse large B-cell lymphoma (DLBCL) of the breast, in the attempt to further clarify the management of this disease. The median age was 53 years (39-61), stages were IIE (n=2), IIIE (n=1), and IV (n=1); IPI scores were 0 (n=2), 2 (n=2). Two cases were PBL, and 2 were secondary involvement of the breast. Two stage IIE patients received MACOP-B, radiation therapy was given to one of them and both achieved CR. The stage IIIE patient treated with MACOP-B plus Rituximab was in PR at the beginning of the Rituximab and achieved CR at the end of the treatment. The 61-year-old stage IV patient and bilateral involvement received P-VNBEC as first line treatment, achieving PR; she was then treated with 4 cycles of MACOP-B plus Rituximab obtaining CR. After a median follow-up of 40 months (31-50) all patients are alive and in CR. No CNS prophylaxis was given and no incidence of CNS relapse was observed. In our experience DLBCL of the breast shows chemosensitivity to MA-COP-B regimen but the intensification with Rituximab seems to be effective especially in the advanced stages. Further and comparative studies are required to confirm the validity of our results.