Identification of MET fusions in solid tumors: A multicenter, large scale study in China.

MET amplification and exon 14 skipping are well known as oncogenic drivers in multiple cancer types. However, MET fusions in most cancer types are poorly defined. To explore the profile and analyze the characteristics of MET fusions, a large-cohort study was conducted to screen MET fusions in clinical samples (n = 10 882) using DNA-based NGS. A total of 37 potentially functional MET fusions containing the intact tyrosine kinase domain (TKD) of MET were identified in 36 samples. Further, 15 novel MET fusions were identified in five cancer types, and the incidence of novel MET fusions accounted for 40.5% (15/37). Brain cancer had the highest incidence of MET fusion, with PTPRZ1-MET as the most common fusion (37.0%). All MET breakpoints in brain cancer (n = 27) were also located in intron 1, while those in lung cancer (n = 4) occurred in intron 1, intron 11, intron 14 and exon 14, respectively. The positive consistency of the common fusion group was 100% (11/11), while that of the rare fusion group was 53.8% (7/13). In conclusion, we provided a comprehensive genomic landscape of MET rearrangement and updated the MET fusions database for clinical test. In addition, we revealed that DNA-based NGS might serve as the clinical test for common MET fusions; however, rare MET fusions must be validated by both DNA-based NGS and RNA-based NGS. Prospective trials are necessary to confirm the treatment efficacy of MET inhibitors.

MFAP2 aggravates tumor progression through activating FOXM1/ß-catenin-mediated glycolysis in ovarian cancer.

Ovarian cancer is one of the most common gynecological tumors that seriously endanger the health and quality of life of women. Microfibril-associated protein 2 (MFAP2) has been demonstrated to play crucial roles in the development of multiple tumors. However, the function of MFAP2 in ovarian cancer remains unclear. In this study, we found that MFAP2 was upregulated in ovarian cancer and cells and was positively correlated with FOXM1 and glycolysis-related genes. The results of Cell Count Kit-8, colony formation, and flow cytometry assays indicated that MFAP2 promoted cell proliferation. In addition, MFAP2 promotes cell proliferation, glucose uptake, lactate production; increases ATP levels, extracellular acidification ratio, and oxygen consumption ratio in ovarian cancer cells and increases the expression of glycolytic proteins. Further mechanistic analysis suggests that MFAP2 promotes FOXM1/ß-catenin-mediated glycolysis signaling in ovarian cancer cells. Knockdown of MFAP2 inhibits ovarian cancer xenograft tumor growth and expression of Ki-67, MFAP2, FOXM1, GLUT1, HK2, and ß-catenin in mice. In conclusion, MFAP2 promotes cell proliferation and glycolysis by modulating the FOXM1/ß-catenin signaling pathway in ovarian cancer, which may offer a fresh insight into the treatment of ovarian cancer in the glycolysis pathway.

Next Generation Sequencing Reveals Pathogenic and Actionable Genetic Alterations of Soft Tissue Sarcoma in Chinese Patients: A Single Center Experience.

Background: Next generation sequencing (NGS) has systematically investigated the genomic landscape of soft tissue sarcoma (STS) in Western patients, but few reports have described the utility of NGS in identifying pathogenic and targetable mutations in Asian patients. Methods: We review our single center experience of identifying the genomic profile and feasible genetic mutations in 65 Chinese patients with STS by NGS. Results: On average, 3.35 mutations were identified per patient (range, 0-28), and at least one mutation could be detected in 95.4% (62/65) of patients. TP53, MDM2, CDK4, KDR, and NF1 were the most frequent mutation genes in Chinese STS patients. Actionable mutations were discovered in 36.9% (24/65) of patients, and clinical benefit was achieved in 4 patients treated with corresponding molecular targeted therapies. Conclusions: Our study describes the mutation profile of Chinese STS patients by a single center experience. Some patients have achieved improved clinical outcomes by adopting treatment based on the results of genetic testing. NGS may affect clinical decision-making as a routine clinical test for patients with STS.

Ginsenoside Rg3 suppresses ovarian cancer cell proliferation and invasion by inhibiting the expression of lncRNA H19.

Ovarian cancer (OC) is the most malignant disease of the female reproductive system and accounts for a large proportion of gynecological cancer-related deaths. Emerging evidence has indicated that ginsenoside Rg3, one of the tetracyclic triterpenoid saponins in ginseng, plays crucial roles in regulating cancer progression, yet its role and mechanisms in regulating the proliferation and invasion of OC are still elusive. In this study, the cell viability, proliferation, migration and invasion of OC were assessed by using methyl thiazol tetrazolium (MTT), colony formation, wound healing and Transwell assays, respectively. The protein levels of E-cadherin and N-cadherin were analyzed by Western blot assay. The expression of long noncoding RNA (lncRNA) H19 was analyzed by quantitative real-time polymerase chain reaction (RT-qPCR). The results revealed that ginsenoside Rg3 significantly inhibited the viability of OC cells (SKOV3 and A2780) in a concentration­dependent manner. Ginsenoside Rg3 (50 µg/ml) had almost no significant effect on the activity of human ovarian epithelial cells (HOSEpiCs). Thus, this dose was selected for the subsequent experiments. Furthermore, Rg3 markedly decreased the colony formation, migration and invasion of OC cells. In addition, the expression of N-cadherin was downregulated, and the expression of E-cadherin was upregulated with Rg3 treatment. Moreover, lncRNA H19 was upregulated in OC cells, and Rg3 negatively regulated H19 expression in a concentration-dependent manner. In terms of the mechanism, knockdown of H19 inhibited cell proliferation, migration and invasion, while overexpression of H19 reversed the inhibitory effect of Rg3 on the OC cells. In conclusion, ginsenoside Rg3 suppresses the proliferation, migration and invasion of OC cells by partially inhibiting the expression of lncRNA H19.

Benchmarking the Human Leukocyte Antigen Typing Performance of Three Assays and Seven Next-Generation Sequencing-Based Algorithms.

With the great progress made recently in next generation sequencing (NGS) technology, sequencing accuracy and throughput have increased, while the cost for data has decreased. Various human leukocyte antigen (HLA) typing algorithms and assays have been developed and have begun to be used in clinical practice. In this study, we compared the HLA typing performance of three HLA assays and seven NGS-based HLA algorithms and assessed the impact of sequencing depth and length on HLA typing accuracy based on 24 benchmarked samples. The algorithms HISAT-genotype and HLA-HD showed the highest accuracy at both the first field and the second field resolution, followed by HLAscan. Our internal capture-based HLA assay showed comparable performance with whole exome sequencing (WES). We found that the minimal depth was 100X for HISAT-genotype and HLA-HD to obtain more than 90% accuracy at the third field level. The top three algorithms were quite robust to the change of read length. Thus, we recommend using HISAT-genotype and HLA-HD for NGS-based HLA genotyping because of their higher accuracy and robustness to read length. We propose that a minimal sequence depth for obtaining more than 90% HLA typing accuracy at the third field level is 100X. Besides, targeting capture-based NGS HLA typing may be more suitable than WES in clinical practice due to its lower sequencing cost and higher HLA sequencing depth.

Heat maps present the spatial distribution of human papillomavirus infection in Zhejiang Province, China.

Determining the spatial distribution of human papillomavirus (HPV) and performing accurate public health analyses helps to distinguish areas of healthcare that require further research, and enables therapeutic techniques and approaches in healthcare to be focused more accurately. A total of 4,560 women were enrolled in the present study. Flow-through hybridization and gene chip assays were used to detect the genotypes of HPV infection. Heat maps were then generated to present the spatial distribution of HPV infections in Zhejiang Province according to genotype. Of the exfoliated cervical cell samples from the 4,560 women, HPV was detected in 1,886 samples. HPV-16, -58, -52 and -18 were the most prevalently identified genotypes in the population included in the present study. HPV-16 and -58 infections were mainly distributed in the northern and central regions of Zhejiang Province, such as in Hangzhou and Shaoxing, where the prevalence was higher than that in the southern regions (P<0.05). HPV-18 infection was widespread throughout Zhejiang Province, but had a much lower infection rate in Ningbo and Huzhou (P<0.05). High infection rates of HPV-52 were mainly detected in Hangzhou and the eastern coastal areas of Wenzhou, with a relatively low rate of infection in the center of the province (P<0.05). In conclusion, HPV-16, -58, -52 and -18 were the four most prevalent HPV genotypes observed in Zhejiang Province. Heat maps were created to display the spatial distribution of HPV infection according to genotype, which varied by geographical regions. The results indicate that for individuals in Ningbo or Wenzhou, bivalent or quadrivalent vaccines may be suitable, but for those in Hangzhou and Shaoxing, nonavalent vaccines are strongly recommended.

Lesion Segmentation in Ultrasound Using Semi-Pixel-Wise Cycle Generative Adversarial Nets.

Breast cancer is the most common invasive cancer with the highest cancer occurrence in females. Handheld ultrasound is one of the most efficient ways to identify and diagnose the breast cancer. The area and the shape information of a lesion is very helpful for clinicians to make diagnostic decisions. In this study we propose a new deep-learning scheme, semi-pixel-wise cycle generative adversarial net (SPCGAN) for segmenting the lesion in 2D ultrasound. The method takes the advantage of a fully convolutional neural network (FCN) and a generative adversarial net to segment a lesion by using prior knowledge. We compared the proposed method to a fully connected neural network and the level set segmentation method on a test dataset consisting of 32 malignant lesions and 109 benign lesions. Our proposed method achieved a Dice similarity coefficient (DSC) of 0.92 while FCN and the level set achieved 0.90 and 0.79 respectively. Particularly, for malignant lesions, our method increases the DSC (0.90) of the fully connected neural network to 0.93 significantly (p 0.001). The results show that our SPCGAN can obtain robust segmentation results. The framework of SPCGAN is particularly effective when sufficient training samples are not available compared to FCN. Our proposed method may be used to relieve the radiologists' burden for annotation.

Mutational profiling of melanomas in patients from the southeast coast of China.

BACKGROUND: Melanoma is one of the most lethal cancers in China, and the genomic landscape of melanoma in the Asian population is different from Caucasians. METHODS: To better understand the genomic profile of distinct kinds of melanomas in China, we used an NGS platform to analysis of 62 melanomas from the southeast coast of China. RESULTS: The recurrently mutated genes are BRAF (29%), RAS (29%), CTNNB1 (11.3%), KIT (9.7%) and NF1 (8.1%) in the whole group. Among the different types of melanoma, cutaneous melanoma has a high frequency of BRAF mutation (70.6%), NRAS (57.1%) is the top one gene found in the mucosal group. For acral melanoma, except for the RAS family, CTNNB1 mutation (13.2%) first found to be frequently mutated in our cohort and patients with CTNNB1 activating mutation. These results may be related to a more reduced response to immunotherapy, according to the earlier report. CONCLUSIONS: Our study profiled the mutational landscape of melanoma in patients from the southeast coast of China. In addition to the most frequently mutated genes (BRAF, RAS, KIT) reported in other studies, we found some new recurrent gene mutations, such as CTNNB1 mutation in acral melanoma, that had not been reported in other studies.

Inhibition of Euchromatic Histone Lysine Methyltransferase 2 (EHMT2) Suppresses the Proliferation and Invasion of Cervical Cancer Cells.

EHMT2 (euchromatic histone lysine methyltransferase 2), a histone methyltransferase, has been shown to be involved in multiple human cancers. In this study, we determined mRNA and protein expression of EHMT2 in cervical cancer cells and normal cervical epithelial cells. EHMT2 was inhibited with short hairpin RNA (shEHMT2) in cervical cancer cells. Cell viability, colony proliferation, apoptosis, adhesion, and invasion assays and Western blot were performed to assess the function of EHMT2. As a result, EHMT2 was upregulated in human cervical cancer cells compared to normal cervical epithelial cells. Suppression of EHMT2 expression impairs cell proliferation and induces apoptosis. Furthermore, EHMT2 silencing inhibited cell adhesion and invasion. Finally, knockdown of EHMT2 resulted in a reduction of the expression of the tumorigenic proteins Bcl-2, Mcl-1, and Survivin and in an increase in the expression of the anti-malignant protein E-cadherin. In conclusion, our data suggest that EHMT2 plays a key role in cell proliferation and metastatic capacity in cervical cancer cells and could serve as a potential therapeutic target.

Myricetin induces apoptosis and enhances chemosensitivity in ovarian cancer cells.

Ovarian cancer is the most lethal type of gynecological cancer and is the fifth leading cause of cancer-associated mortality in females globally. The majority of patients with ovarian cancer suffer from recurrent, progressive disease, due to the acquisition of a resistance phenotype towards various conventional chemotherapy drugs. Although paclitaxel has been demonstrated to be effective against ovarian tumors, there have been reports of the development of a resistant phenotype against Taxol® treatment. The multidrug resistance (MDR)-1/P-glycoprotein has previously been demonstrated to be associated with the acquisition of paclitaxel resistance in certain ovarian tumors. Therefore, the screening of novel drug candidates able to target MDR-1 in ovarian cancer cells and increase the sensitivity to Taxol® is required in order to improve the treatment of this disease. In the present study, the underlying mechanisms by which the dietary flavonoid myricetin enhances the cytotoxic potential of paclitaxel in ovarian cancer cells, was investigated. It was observed that myricetin induced significant cytotoxicity in A2780 and OVCAR3 ovarian cancer cells, with the IC50 value obtained at 25 µM. Myricetin treatment also resulted in the induction of apoptosis in the two cell lines, accompanied by the modulation of certain pro- and anti-apoptotic markers. It was also determined that the pre-incubation of ovarian cancer cells with a lower dose of myricetin was able to increase the cytotoxicity of paclitaxel, due to the significant downregulation of MDR-1 in these cells.

Clear Cell Carcinoma of the Uterine Cervix: A Clinical and Pathological Analysis of 47 Patients Without Intrauterine Diethylstilbestrol Exposure.

OBJECTIVES: The aim of this study was to summarize the clinical and pathological characteristics and to conduct prognosis analysis of patients who were diagnosed with clear cell carcinoma of the uterine cervix (CCCUC) and without a history of exposure to diethylstilbestrol. METHODS: We performed a retrospective review of all the patients with CCCUC who were diagnosed and treated at Zhejiang Cancer Hospital between 1998 and 2014. Charts were reviewed for clinical and pathological characteristics, and prognosis analysis was conducted. RESULTS: A total of 47 patients were included. Median age was 52 years. No patient had a history of exposure to diethylstilbestrol. The International Federation of Gynecology and Obstetrics stage distribution was 55.3% (n = 26) stage I, 40.4% (n = 19) stage II, 2.1% (n = 1) stage III, and 2.1% (n = 1) stage IV. Forty-two patients (89.4%) underwent radical hysterectomy and pelvic lymphadenectomy. Pathological examination revealed deep cervical stromal invasion (greater than two thirds) in 20 patients (48.4%), pelvic lymph node (PLN) metastasis in 10 patients (23.8%), lymphovascular space involvement in 9 patients (21.4%), and ovarian metastasis in 1 patient (2.4%). Advanced tumor stage (IIB-IV), larger tumor size (>4 cm), and PLN metastasis had negative effects on progression-free survival (PFS) and overall survival (OS) (P < 0.05). Adjuvant radiation therapy alone or concurrent chemoradiation therapy after radical surgery did not affect PFS or OS in patients with risk factors (P > 0.05). CONCLUSIONS: International Federation of Gynecology and Obstetrics stage, tumor size, and PLN status were prognostic factors for both PFS and OS in patients with CCCUC. The long-term effects of adjuvant radiation therapy or concurrent chemoradiation therapy may be limited for CCCUC patients with risk factors. Future larger case series or clinical trials are required to confirm these findings.

Xiaoaiping combined with cisplatin can inhibit proliferation and invasion and induce cell cycle arrest and apoptosis in human ovarian cancer cell lines.

PURPOSE: The aim of the present study was utilizing Xiaoaiping as a single agent or combined with cisplatin to study its effect on the ovarian cancer cells (HO-8910 and HO-8910PM cells) in tumor cell proliferation, cell apoptosis, cell cycle distribution and cell invasion and migration. METHODS: Both HO-8910 and HO-8910PM cell lines were treated with Xiaoaiping injection, cisplatin or combination. Effects on the cell viability and apoptosis induction were estimated using the Cell counting Kit-8 assay and Annexin V-FITC/Propidium Iodide staining. The distribution of cells in different phases of the cell cycle was assayed using flow cytometry analysis. The effects of Xiaoaiping on the inhibition of cell invasion and migration were researched with Transwell cell migration. RESULTS: Both Xiaoaiping and cisplatin significantly decreased the HO-8910 cell survival versus control arm. Combination treatment showed a higher cytotoxicity to cells in vitro than Xiaoaiping and cisplatin alone. An increase in the G0/G1 phase fraction in HO-8910 cells treated with either Xiaoaiping or cisplatin alone was evident when compared to the fraction in control arm. Compared to the effects of treatment with either agent alone, combination treatment significantly increased the fraction of cells in G0/G1 phase. The HO-8910 cell lines treated with cisplatin demonstrated a significant increase of apoptotic cell rate compared to untreated cell lines. The rate of apoptosis in combined treatment group was significantly higher than that of the single agent treatment groups. A significant reduction in the number of invading cells was observed for Xiaoaiping-treated HO-8910 cells compared with the control group. However, cisplatin did not significantly induce the migration of cells versus untreated cells. Combination of Xiaoaiping and cisplatin significantly suppressed cell invasion and migration versus single-drug treatment in HO-8910 cells. The results of HO-8910PM cells were similar with HO-8910 cells in all tests. CONCLUSIONS: In summary, our results showed that Xiaoaiping as a single agent or combined with cisplatin could induce cell cycle arrest, cause apoptosis and necrosis in ovarian cancer cells, and inhibit cell invasion and migration. The present study also laid a foundation for further investigation involving molecular mechanism. Above all, it may provide a novel therapeutic regimen for ovarian cancer.

Impact of carboplatin plus paclitaxel combined with endostar against A375 melanoma cells: An in vitro and in vivo analysis.

PURPOSE: The aim of the present study was to investigate the efficacy of carboplatin plus paclitaxel (CP) combined with endostar against A375 melanoma cells in vitro and in vivo. METHODS: Effects on the cell viability and apoptosis induction were estimated with the Cell counting Kit-8 assay and Annexin V-FITC/Propidium Iodide staining. Fifty female BALB/c-nude mice with subcutaneous injection of A375 cells were randomized to be treated with normal saline, dacarbazine alone, dacarbazine plus endostar, carboplatin plus paclitaxel, and CP plus endostar. Tumor volume of mice was monitored after injection and survival time was adopted for survival analysis. RESULTS: CP plus endostar significantly decreased the cell survival rate compared with CP (P<0.01). Combination of CP and endostar showed higher cytotoxicity to A375 cells in vitro than endostar plus dacarbazine (P<0.01). The percentage of apoptotic cells in A375 cells treated with CP plus endostar was appreciably higher when compared to CP group (P<0.05). The mean relative tumor size in CP group was definitely larger (p<0.05) than CP plus endostar group. In addition, the mean survival time in CP plus endostar group was notably elevated compared with the CP group (P<0.05). CONCLUSIONS: Our data indicated that treatment with CP plus endostar significantly reduced cell growth and induced a high rate of apoptotic cells in the A375 melanoma cell line. CP and endostar exhibited synergistic anti-tumor activities in A375 melanoma cells in vitro. CP plus endostar suppressed the growth of xenograft tumors and prolonged the survival time of mice with xenograft tumors. Combination of CP and endostar may be a promising treatment for melanoma.

[Inhibitory effect of a Chinese medicine Xiaoaiping combined with cisplatin on the proliferation, invasion and apoptosis in ovarian cancer HO-8910 PM cells in vitro and in vivo].

OBJECTIVE: To explore the effect of a Chinese medicine, Xiaoaiping, in combination with cisplatin on the proliferation, invasion and apoptosis in human ovarian cancer HO-8910PM cells in vitro and vivo. METHODS: CCK-8 assay was used to detect the inhibitoty effect of Xiaoaiping alone or in combination with cisplatin on the proliferation of human ovarian cancer HO-8910PM cells. Flow cytometry was used to detect the apoptosis and cell cycle distribution. Transwell migration test was used to assay the effect of drugs on the cell invasive capability. Changes of the tumor volume in nude mice were observed to evaluate the antitumor effects in vivo. RESULTS: CCK-8 assay Xiaoaiping alone or combined with cisplatin could inhibit the proliferation of HO-8910PM cells with a dose-dependent manner. The inhibition rates of Xiaoaiping combined with cisplatin were (53.4±3.0)%, significantly increased than those with single drug (P<0.05). Flow cytometry showed that G0/G1 fraction was increased respectively from (64.2±1.6)% to (74.1±1.6)% and (68.6±1.6)%. The percentages of apoptotic cells were increased from (2.2±1.6)% to (16.1±1.6)%, (35.6±1.6)% after treated with Xiaoaiping, Cisplatin and combination drugs (P<0.05 for all). Transwell chamber with matrigel assay showed that number of cells penetrating through membrane in HO-8910PM cells was (89.2±20.7)/HPF in the drug combination group, significantly less than that in the control group(187.2±24.6)/HPF, Xiaoaiping(141.8±13.7 )/HPF or cisplatin group (155.8±19.4)/HPF (P<0.01 for all). The inhibition rate of drug combination group in the nude mouse transplanted tumors, compared with that of single Xiaoaiping and cisplatin group, was increased significantly (59.0% vs. 23.4% and 34.2%), (P<0.01 for both). CONCLUSION: The results of our in vitro and vivo experiments indicate that Xiaoaiping can inhibit cell proliferation, increase G0/G1 arrest, promote apoptosis, inhibit cell migration of human ovarian cancer HO-8910 PM cells, and can synergistically enhance the antitumor activity of cisplatine.

[Clinicopathologic characteristics and risk factors for lung metastasis after radical hysterectomy in early-stage cervical cancer].

OBJECTIVE: To discuss the clinicopathologic characteristics and risk factors for lung metastasis of early-stage cervical cancer after radical hysterectomy. METHODS: The complete clinicopathologic data of patients with lung metastasis of cervical cancer after radical surgery from January 2008 to December 2013 admitted in Zhejiang Cancer Hospital were retrospectively analyzed by univariate and multivariate analysis. RESULTS: (1) There were 38 cases of early cervical cancer suffered from lung metastasis after radical hysterectomy during the period. The median age at diagnosis of cervical cancer was 46 years, the average lung metastasis time was 13 months after operation, 50.0% (19/38) cases occurred in the first year. Thirty-one cases were squamous cell carcinoma and 7 cases were non-squamous cell carcinoma. (2) Univariate analysis showed that age, clinical stage, manner of tumor growth, tumor grade, perineuronal invasion, para-aortic lymph node metastasis were not significant effect on postoperative lung metastasis (all P>0.05). But tumor size, histologic types, depth of stromal invasion, uterine body infiltration, lympho-vascular space invasion,pelvic lymph node metastasis, positive margin and abnormal tumor markers were significantly correlated with postoperative lung metastasis (all P<0.05). Multivariate analysis showed that only tumor size, histologic types and pelvic lymph node metastasis were independent risk factors for lung metastasis of cervical cancer (P<0.05). CONCLUSIONS: Patients of early-stage cervical cancer with lung metastasis mostly occurs within 1 year after radical hysterectomy. Local large tumor lesions (tumor size >4 cm), non-squamous cell carcinoma and pelvic lymph node metastasis were more likely to have lung metastasis.

[Splenectomy in epithelial ovarian cancer: analysis of 32 cases].

OBJECTIVE: To investigate the clinicopathologic features, the complications of splenectomy and the survival of epithelial ovarian cancer patients with splenic metastasis. METHODS: A retrospective study was performed of 32 patients with epithelial ovarian cancer who underwent splenectomy for tumor cytoreduction at Zhejiang Cancer Hospital between Jan 1998 and Jun 2006. RESULTS: Of 32 patients, 23 patients (72%) were serous adenocarcinoma and 9 were non-serous adenocarcinoma. According to pathological grade, none was of G1, 11 were of G2, 21 were of G3. Postoperatively, 20 patients were left with no residual tumor, 7 were with < or = 2 cm and 5 were with > 2 cm residual tumor. Postoperative complications developed in 8 patients (25%), including subphrenic abscess, wound infection, gastric perforation, gastrorrhagia, phlebothrombosis, and bowel obstruction. The median follow up was 38 months, estimated 2-year and 5-year overall survival were 70% and 36%. Univariate analysis revealed that histological grade, residual tumor and courses of chemotherapy were influencing factors of the survival (P < 0.05), but multivariate analysis indicated that only residual tumor and courses of chemotherapy independently influenced survival (P < 0.05). CONCLUSIONS: In epithelial ovarian cancer patients with splenic metastasis, low grade serous adenocarcinoma is most common. Splenectomy as part of cytoreductive surgery is associated with modest morbidity and mortality. Residual tumor and courses of chemotherapy are independent factors associated with the prognosis of the patients.