1.Prenatal diagnosis and analysis of fetuses with false-positive NIPT results caused by sex chromosomal abnormalities in pregnant women.
Tingting BAI ; Fengni FAN ; Lihui YANG ; Xiangdong LIN ; Rong QIANG ; Ting JIA ; Rui WANG
Chinese Journal of Medical Genetics 2025;42(5):525-531
OBJECTIVE:
To analyze the results of prenatal diagnosis for fetuses with a high risk for sex chromosome aneuploidies (SCAs) indicated by non-invasive prenatal testing (NIPT), and to assess the influence of maternal chromosomal factors on the results of NIPT.
METHODS:
A retrospective analysis was conducted on the clinical data of 454 pregnant women with a high risk for SCAs indicated by NIPT undergoing invasive prenatal diagnosis at the Medical Genetics Center of Northwest Women's and Children's Hospital from January 2022 to September 2024. The data has included prenatal diagnosis indications, results, pregnancy outcomes, and the chromosomal results of pregnant women.
RESULTS:
Among the 454 women (including 10 with twin pregnancy) with a high risk for SCAs indicated by NIPT, 149 (including 4 twin cases) were diagnosed with SCAs through invasive prenatal diagnosis. These had included 47,XXX (37 cases), 47,XXY (56 cases), 47,XYY (29 cases), 45,X (1 case), 48,XXYY (1 case), mosaicism (20 cases), sex chromosome structural abnormalities (6 cases), and small-scale pathogenic copy number variations (3 cases). 383 pregnant women (including 7 with twin pregnancy) had accepted chromosomal karyotyping analysis. In total 49 cases of SCAs abnormalities were detected. Among them, 41 cases were pregnant women with SCAs but normal fetal chromosomes, which yielded a false positive rate for NIPT caused by maternal factors by 10.7%. In addition, 8 cases (including 1 twin case) had SCAs abnormalities in both the pregnant woman and the fetus. Among the 383 pregnant women, 129 cases (including 3 twin cases) of fetal SCAs were diagnosed, which yielded an overall positive predictive value (PPV) of NIPT for SCAs by 33.7% (129/383). With the 41 false positive cases caused by maternal SCAs abnormalities excluded, the PPV of NIPT for SCAs will be increased to 37.7% (129/342). Among the 454 pregnant women, twin pregnancies have accounted for 2.2% (10/454). Among the confirmed cases of SCAs abnormalities, twin cases accounted for 2.7% (4/149). Among the 383 pregnant women undergoing chromosomal karyotyping, twin cases accounted for 1.8% (7/383). Among the detected cases of chromosomal abnormalities, twin cases accounted for 2.0% (1/49). By calculation, the proportion of singleton pregnant women with a high risk for SCAs indicated by NIPT was approximately 32.1%, and the proportion of twin pregnant women was approximately 38.6%, indicating that twin pregnancies could increase the positive rate of NIPT.
CONCLUSION
NIPT can improve the screening efficiency for SCAs, but its PPV is limited. Therefore, pregnant women with a high risk for SCAs indicated by NIPT need to undergo invasive prenatal diagnosis for a definite diagnosis, and twin pregnancies can increase the positive rate of NIPT. The study confirmed that chromosomal abnormalities in pregnant women can significantly affect the accuracy of NIPT in detecting fetal SCAs. Therefore, when NIPT indicates SCAs abnormalities, it is recommended to simultaneously conduct chromosomal testing on the pregnant women. The combined application of chromosomal karyotyping analysis, fluorescence in situ hybridization, and copy number variation detection techniques can significantly improve the diagnostic accuracy for SCAs, especially for the detection of mosaicisms.
Humans
;
Female
;
Pregnancy
;
Sex Chromosome Aberrations
;
Adult
;
Retrospective Studies
;
False Positive Reactions
;
Prenatal Diagnosis/methods*
;
Noninvasive Prenatal Testing/methods*
;
Aneuploidy
;
Male
;
Sex Chromosome Disorders/genetics*
2.Correlations of immune cell infiltration characteristics with clinicopathological parameters in patients with clear cell renal cell carcinoma.
Huaxuan ZHAO ; Guichao ZHANG ; Jiarong LIU ; Futian MO ; Taoen LI ; Chengyong LEI ; Shidong LÜ
Journal of Southern Medical University 2025;45(6):1280-1288
OBJECTIVES:
To investigate the characteristics of immune cell infiltration in tumor samples from Chinese patients with clear cell renal cell carcinoma (ccRCC) and the correlation of immune cell infiltration with tumor stage and response to immunotherapy.
METHODS:
Tumor samples and clinicopathological data were collected from 154 ccRCC patients treated in Nanfang Hospital, Southern Medical University from October, 2020 to October, 2023. The immune cell types infiltrating the tumor tissues were identified using immunohistochemistry and immunofluorescence staining, and their correlations with the patients' clinicopathological characteristics were analyzed. Patient-derived tumor tissue fragment models (PDTF) models, constructed using tumor tissues from 22 patients, were treated with PD-1 monoclonal antibody, and T cell activation was detected using flow cytometry to assess the patients' responses to immunotherapy.
RESULTS:
In Chinese ccRCC patients included in this study, CD8+ T cells, CD4+ T cells, and CD3+ T cells were the most abundant in the tumor tissues. Higher infiltration levels of CD3+ T cells (P=0.004), PD-1+ T cells (P=0.020), CD68+ T cells (P=0.049), CD79+ T cells (P=0.049), and Tryptase+ cells (P=0.049) were all positively correlated with a larger tumor size (≥5 cm). A higher infiltration level of CD4+ T cells was associated with a lower tumor stage. Patients with higher International Society of Urological Pathology (ISUP) grades had higher infiltration levels of CD3+ T cells (P=0.023), CD8+ T cells (P=0.045), PD-1+ T cells (P=0.014), CD20+ B cells (P=0.020) and CD79+ B cells (P=0.049), and lower levels of Tryptase+ cells (P=0.001). Patients with abundant infiltrating immune cells tended to have better responses to immunotherapy.
CONCLUSIONS
The infiltrating immune cells are heterogeneous in Chinese ccRCC patients, and immune cell infiltration characteristics are closely correlated with clinicopathological parameters of the patients.
Humans
;
Carcinoma, Renal Cell/pathology*
;
Kidney Neoplasms/pathology*
;
Immunotherapy
;
Male
;
Lymphocytes, Tumor-Infiltrating/immunology*
;
Female
;
Middle Aged
;
CD8-Positive T-Lymphocytes/immunology*
;
Aged
;
T-Lymphocytes/immunology*
;
Programmed Cell Death 1 Receptor/immunology*
;
Adult
;
CD4-Positive T-Lymphocytes/immunology*
;
Neoplasm Staging
3.Oligodendrocyte Precursor Cell-Specific HMGB1 Knockout Reduces Immune Cell Infiltration and Demyelination in Experimental Autoimmune Encephalomyelitis Models.
Gyuree KIM ; JiHye SEO ; Bokyung KIM ; Young-Ho PARK ; Hong Jun LEE ; Fuzheng GUO ; Dong-Seok LEE
Neuroscience Bulletin 2025;41(7):1145-1160
Infiltration and activation of peripheral immune cells are critical in the progression of multiple sclerosis and its experimental animal model, experimental autoimmune encephalomyelitis (EAE). This study investigates the role of high mobility group box 1 (HMGB1) in oligodendrocyte precursor cells (OPCs) in modulating pathogenic T cells infiltrating the central nervous system through the blood-brain barrier (BBB) by using OPC-specific HMGB1 knockout (KO) mice. We found that HMGB1 released from OPCs promotes BBB disruption, subsequently allowing increased immune cell infiltration. The migration of CD4+ T cells isolated from EAE-induced mice was enhanced when co-cultured with OPCs compared to oligodendrocytes (OLs). OPC-specific HMGB1 KO mice exhibited lower BBB permeability and reduced immune cell infiltration into the CNS, leading to less damage to the myelin sheath and mitigated EAE progression. CD4+ T cell migration was also reduced when co-cultured with HMGB1 knock-out OPCs. Our findings reveal that HMGB1 secretion from OPCs is crucial for regulating immune cell infiltration and provides insights into the immunomodulatory function of OPCs in autoimmune diseases.
Animals
;
Encephalomyelitis, Autoimmune, Experimental/metabolism*
;
HMGB1 Protein/deficiency*
;
Mice, Knockout
;
Oligodendrocyte Precursor Cells/immunology*
;
Mice, Inbred C57BL
;
CD4-Positive T-Lymphocytes/immunology*
;
Cell Movement
;
Blood-Brain Barrier/immunology*
;
Mice
;
Myelin Sheath/pathology*
;
Disease Models, Animal
;
Coculture Techniques
;
Oligodendroglia/metabolism*
;
Female
;
Cells, Cultured
4.Chromatin landscape alteration uncovers multiple transcriptional circuits during memory CD8+ T-cell differentiation.
Qiao LIU ; Wei DONG ; Rong LIU ; Luming XU ; Ling RAN ; Ziying XIE ; Shun LEI ; Xingxing SU ; Zhengliang YUE ; Dan XIONG ; Lisha WANG ; Shuqiong WEN ; Yan ZHANG ; Jianjun HU ; Chenxi QIN ; Yongchang CHEN ; Bo ZHU ; Xiangyu CHEN ; Xia WU ; Lifan XU ; Qizhao HUANG ; Yingjiao CAO ; Lilin YE ; Zhonghui TANG
Protein & Cell 2025;16(7):575-601
Extensive epigenetic reprogramming involves in memory CD8+ T-cell differentiation. The elaborate epigenetic rewiring underlying the heterogeneous functional states of CD8+ T cells remains hidden. Here, we profile single-cell chromatin accessibility and map enhancer-promoter interactomes to characterize the differentiation trajectory of memory CD8+ T cells. We reveal that under distinct epigenetic regulations, the early activated CD8+ T cells divergently originated for short-lived effector and memory precursor effector cells. We also uncover a defined epigenetic rewiring leading to the conversion from effector memory to central memory cells during memory formation. Additionally, we illustrate chromatin regulatory mechanisms underlying long-lasting versus transient transcription regulation during memory differentiation. Finally, we confirm the essential roles of Sox4 and Nrf2 in developing memory precursor effector and effector memory cells, respectively, and validate cell state-specific enhancers in regulating Il7r using CRISPR-Cas9. Our data pave the way for understanding the mechanism underlying epigenetic memory formation in CD8+ T-cell differentiation.
CD8-Positive T-Lymphocytes/metabolism*
;
Cell Differentiation
;
Chromatin/immunology*
;
Animals
;
Mice
;
Immunologic Memory
;
Epigenesis, Genetic
;
SOXC Transcription Factors/immunology*
;
NF-E2-Related Factor 2/immunology*
;
Mice, Inbred C57BL
;
Gene Regulatory Networks
;
Enhancer Elements, Genetic
5.Exosomal Pparα derived from cancer cells induces CD8 + T cell exhaustion in hepatocellular carcinoma through the miR-27b-3p /TOX axis.
Wenjun ZHONG ; Nianan LUO ; Yafeng CHEN ; Jiangbin LI ; Zhujun YANG ; Rui DONG
Chinese Medical Journal 2025;138(23):3139-3152
BACKGROUND:
Cluster of differentiation 8 positive (CD8 + ) T cells play a crucial role in the response against tumors, including hepatocellular carcinoma (HCC), where their dysfunction is commonly observed. While the association between elevated peroxisome proliferator-activated receptor alpha (PPARα) expression in HCC cells and exosomes and unfavorable prognosis in HCC patients is well-established, the underlying biological mechanisms by which PPARα induces CD8 + T cell exhaustion mediated by HCC exosomes remain poorly understood.
METHODS:
Bioinformatics analyses and dual-luciferase reporter assays were used to investigate the regulation of microRNA-27b-3p ( miR-27b-3p ) and thymocyte selection-associated high mobility group box ( Tox ) by Pparα . In vitro and in vivo experiments were conducted to validate the effects of HCC-derived exosomes, miR-27b-3p overexpression, and Pparα on T cell function. Exosome characterization was confirmed using transmission electron microscopy, Western blotting, and particle size analysis. Exosome tracing was performed using small animal in vivo imaging and confocal microscopy. The expression levels of miR-27b-3p , Pparα , and T cell exhaustion-related molecules ( Tox , Havcr2 , and Pdcd1 ) were detected using quantitative reverse transcription polymerase chain reaction analysis, Western blotting analysis, immunofluorescence staining, and flow cytometry analysis.
RESULTS:
Pparα expression was significantly increased in HCC and negatively correlated with prognosis. It showed a positive correlation with Tox and a negative correlation with miR-27b-3p . The overexpressed Pparα from HCC cells was delivered to CD8 + T cells via exosomes, which absorbed miR-27b-3p both in vitro and in vivo , acting as "miRNA sponges". Further experiments demonstrated that Pparα can inhibit the negative regulation of Tox mediated by miR-27b-3p through binding to its 3'untranslated regions.
CONCLUSIONS
HCC-derived exosomes deliver Pparα to T cells and promote CD8 + T cell exhaustion and malignant progression of HCC via the miR-27b-3p /TOX regulatory axis. The mechanisms underlying T-cell exhaustion in HCC can be utilized for the advancement of anticancer therapies.
MicroRNAs/metabolism*
;
PPAR alpha/genetics*
;
Carcinoma, Hepatocellular/genetics*
;
Humans
;
Liver Neoplasms/genetics*
;
CD8-Positive T-Lymphocytes/immunology*
;
Exosomes/metabolism*
;
Animals
;
Cell Line, Tumor
;
Mice
;
High Mobility Group Proteins/genetics*
;
Male
;
T-Cell Exhaustion
6.Research progress of cytotoxic CD4+ T cell in autoimmune diseases.
Qin ZHANG ; Rui CHI ; Fang GONG
Chinese Journal of Cellular and Molecular Immunology 2025;41(2):161-165
Cytotoxic CD4+ T cells (CD4+ CTLs) represent a novel subset of T cells with cytotoxic effects. They recognize target cells in an antigen-specific manner, relying on class II major histocompatibility complex (MHC-II) interactions. CD4+ CTLs exert cytotoxic effects on target cells by secreting cytotoxic molecules such as granzymes, perforin, and granulysin. Recent studies have revealed their significant roles in various autoimmune diseases. This review focuses on the differentiation, phenotypic characteristics, and roles of CD4+ CTLs in different types of autoimmune disorders, aiming to provide new insights for the prevention and treatment of these diseases.
Humans
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Autoimmune Diseases/immunology*
;
CD4-Positive T-Lymphocytes/immunology*
;
Animals
;
T-Lymphocytes, Cytotoxic/immunology*
;
Perforin/immunology*
;
Granzymes/immunology*
7.Zfp335 regulates the proportion of effector Treg and tumor immunity.
Xiaonan SHEN ; Wenhua LI ; Xiaoxuan JIA ; Biao YANG ; Xin WANG ; Haiyan LIU ; Anjun JIAO ; Lei LEI ; Xiaofeng YANG ; Baojun ZHANG
Chinese Journal of Cellular and Molecular Immunology 2025;41(5):385-390
Objective Zinc finger protein 335 (Zfp335) plays a crucial role in the early development of thymic T cells and the differentiation of peripheral T cell subpopulations. The objective of this study is to investigate the role and underlying mechanisms of Zfp335 in the regulation of regulatory T cell (Treg) within tumor immunity. Methods The Zfp335 gene was specifically knocked out in Treg using tamoxifen (Zfp335fl/fl FOXP3creERT2), and the MC38 tumor model was established. On the 7th day after tumor inoculation, tumor size was observed and measured. Tumor size was monitored and recorded daily starting from day 7 post-inoculation. On day 12, tumors were harvested, and the proportions of CD4+ T cells, CD8+ T cells, and Treg were analyzed by flow cytometry. Additionally, the mitochondrial function of effector regulatory T cell (eTreg) was assessed. Results From day 10 post-tumor inoculation, tumor volume in the Zfp335CKO group was significantly reduced compared to that of the wild-type (WT) group. Furthermore, the infiltration of CD4+ and CD8+ T cells, along with their respective effector cells, was significantly higher in the Zfp335CKO group than in the WT group. The proportions of CD4+ and CD8+ T cells producing interferon-gamma (IFN-γ) and tumor necrosis factor-alpha (TNF-α) were also significantly increased in the Zfp335CKO group compared to that of the WT group. In addition, the percentage of CD8+ T cells secreting granzyme B (GzmB) was significantly higher in the Zfp335CKO group than that in the WT group. In contrast, the proportion of Treg and inducible T cell co-stimulator (ICOS)+ Treg in the Zfp335CKO group was significantly lower than that in the WT group. Finally, the expression level of Mitotracker Deep Red in eTreg from the Zfp335CKO group was significantly reduced compared to that in the WT group. Conclusion During tumorigenesis, the specific deletion of Zfp335 impairs Treg activation, which is related to decreased mitochondrial function in eTreg. In Zfp335CKO mice. Tumors exhibit increased infiltration of effector T cells, accompanied by elevated levels of cytotoxic cytokines, ultimately enhancing resistance to tumor progression.
Animals
;
T-Lymphocytes, Regulatory/metabolism*
;
Mice
;
CD8-Positive T-Lymphocytes/immunology*
;
Neoplasms/genetics*
;
Cell Line, Tumor
;
Mice, Inbred C57BL
;
Mice, Knockout
;
DNA-Binding Proteins/genetics*
;
Female
8.The effects of resveratrol on osteosarcoma cells: Regulation of the interaction between JAK2/STAT3 signaling pathway and tumor immune microenvironment.
Xiaoli WANG ; Guoliang MA ; Ruidong LIU ; Ruixia QI ; Jiudei QI ; Yuguo REN
Chinese Journal of Cellular and Molecular Immunology 2025;41(5):420-427
Objective To investigate the effect of resveratrol on the tumor microenvironment in osteosarcoma. Methods A C57BL/6 xenograft mouse model was established and treated with resveratrol. Single-cell sequencing was performed to analyze changes in the tumor microenvironment. Immunohistochemistry was used to assess immune cell infiltration, while Western blotting was conducted to examine alterations in cellular signaling pathways. Results Resveratrol significantly inhibited the proliferation of LM8 osteosarcoma cells in C57BL/6 mice compared to the control group. Additionally, CD8+ T cell recruitment was enhanced. The Janus kinase 2/signal transducer and activator of transcription 3 (JAK2/STAT3) signaling pathway was notably downregulated in LM8 osteosarcoma cells following resveratrol treatment. Conclusion Resveratrol promotes CD8+ T cell infiltration by inhibiting the JAK2/STAT3 signaling pathway, suggesting its potential as a therapeutic agent in osteosarcoma treatment.
Osteosarcoma/genetics*
;
STAT3 Transcription Factor/genetics*
;
Resveratrol/pharmacology*
;
Animals
;
Janus Kinase 2/genetics*
;
Signal Transduction/drug effects*
;
Tumor Microenvironment/immunology*
;
Cell Line, Tumor
;
Mice, Inbred C57BL
;
Mice
;
Humans
;
Cell Proliferation/drug effects*
;
Bone Neoplasms/metabolism*
;
CD8-Positive T-Lymphocytes/drug effects*
;
Xenograft Model Antitumor Assays
9.The characteristics and clinical values of peripheral T lymphocytic subsets and functional changes in primary biliary cholangitis.
Liming ZHENG ; Jinhan LIU ; Hong LI ; Longgen LIU ; Guojun ZHENG ; Sijia DAI
Chinese Journal of Cellular and Molecular Immunology 2025;41(5):437-443
Objective This study aimed to analyze the characteristics and clinical significance of peripheral lymphocytic subsets and cytokine levels, including interleukin 1β(IL-1β), IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12P70, IL-17A, tumor necrosis factor α(TNF-α), interferon γ(IFN-γ) and IFN-α, in patients with primary biliary cholangitis (PBC), to provide some novel insights into the pathogenesis of PBC. Methods We retrospectively collected clinical features and laboratory data from hospitalized patients who were primarily diagnosed with PBC and from healthy physical examinees at the Third People's Hospital of Changzhou between January 1, 2023, and June 30, 2024. Results A total of 152 PBC patients and 96 healthy controls who met the inclusion and exclusion criteria were enrolled. Significant differences were observed in baseline characteristics and laboratory data between the two groups. After the propensity score matching (PSM) analysis, 61 PBC patients and 61 healthy controls were successfully matched, ensuring that the general characteristics (age and gender) of the two groups were balanced and comparable. Compared to the control group, the proportion of peripheral lymphocytes was significantly higher in the PBC group (31.9% vs. 17.8%), primarily due to an increase in CD4+ T cells (46.77% vs. 41.19%), while CD8+T cells were significantly decreased (19.73% vs. 22.07%). Notably, the proportions of CD4+ programmed cell death 1 (PD-1)+ T and CD8+PD-1+ T cells were elevated, with CD8+PD-1+ T cells showing a significant positive correlation with the severity of liver inflammation (r=0.41). Furthermore, the mitochondrial mass (MM) of CD4+ T cells was significantly increased in PBC patients, whereas no significant changes were observed in the MM of CD8+ T cells or the mitochondrial membrane potential (MMP) of CD3+ T cells. Additionally, the plasma levels of cytokines, such as IL-4, IL-8, IL-10 and IFN-α, were abnormally elevated. The plasma levels of IL-5 and IL-1β were negatively correlated with the stage of liver fibrosis in patients with PBC (r=-0.52). Conclusion The overactivation and proliferation of CD4+ T cells, along with the suppression of CD8+ T cell function and increased PD-1 expression leads to T cell exhaustion, indicating significant immunological alterations in PBC patients. These changes are closely associated with the disease progression. Additionally, cytokines are likely involved in the immune regulation process of PBC and may influence the pathogenic mechanisms of the disease. Regular monitoring of lymphocyte subsets and cytokine levels can help assess the immune status and disease activity in patients with PBC, thereby guiding the individualized treatment strategies.
Humans
;
Male
;
Female
;
Middle Aged
;
Liver Cirrhosis, Biliary/blood*
;
Retrospective Studies
;
T-Lymphocyte Subsets/immunology*
;
Aged
;
Cytokines/blood*
;
Adult
;
CD8-Positive T-Lymphocytes/immunology*
10.Phospholipase Cβ1 (PLCB1) promotes gastric adenocarcinoma metastasis by inducing epithelial mesenchymal transition and inhibiting tumour immune infiltration and is associated with poor patient prognosis.
Lingping YUE ; Junfeng CHEN ; Qianqian GAO
Chinese Journal of Cellular and Molecular Immunology 2025;41(5):444-449
Objective To investigate whether PLCB1 expression leads to gastric adenocarcinoma metastasis and poor prognosis, and to preliminarily analyze its mechanism. Methods 122 gastric adenocarcinoma patients and their adjacent non-cancerous tissues were selected, and tissue microarray technology was used to detect the expression levels of PLCB1, epithelial cadherin(E-cadherin), vimentin and CD8+ T cells by immunohistochemistry, and scored by two pathologists. According to the immunohistochemical score of PLCB1, the patients were divided into PLCB1 high expression group (IHC>90) and PLCB1 low expression group (IHC≤90). The clinical pathological characteristics, epithelial mesenchymal transition(EMT)-related proteins and CD8+ T cells expression differences between the two groups were compared. The overall survival of the patients was collected, and COX regression analysis and Kaplan-Meier curve were used to evaluate the relationship between PLCB1 expression level and prognosis. Results PLCB1 was highly expressed in 55 cases of gastric adenocarcinoma tissues, while only 12 cases in adjacent non-cancerous tissues. The tumor invasion depth, lymph node metastasis degree and TNM stage of the PLCB1 high expression group were higher than those of the PLCB1 low expression group. Chi-square test showed that PLCB1 expression level was negatively correlated with E-cadherin (r=-0.339), positively correlated with vimentin (r=0.211), and negatively correlated with CD8+ T cells (r=-0.343). Kaplan-Meier curve analysis showed that the overall survival and disease-free survival of gastric adenocarcinoma patients with high PLCB1 expression were significantly reduced. Multivariate COX regression analysis showed that except for lymph node metastasis, tumor invasion depth, TNM stage, E-cadherin and vimentin were also independent prognostic factors for gastric adenocarcinoma patients. Conclusion PLCB1 is highly expressed in gastric adenocarcinoma, and is closely related to tumor aggressiveness and prognosis. PLCB1 may induce EMT and inhibit CD8+ T cell infiltration to affect gastric adenocarcinoma metastasis and immune response.
Humans
;
Stomach Neoplasms/genetics*
;
Epithelial-Mesenchymal Transition
;
Male
;
Female
;
Middle Aged
;
Prognosis
;
Adenocarcinoma/genetics*
;
Cadherins/metabolism*
;
Aged
;
Adult
;
CD8-Positive T-Lymphocytes/immunology*
;
Vimentin/metabolism*
;
Lymphatic Metastasis
;
Neoplasm Metastasis

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