tumorsMalignant tumoursMalignant tumours2224-50572587-6813Rosoncoweb10.18027/2224-5057-2023-13-2-2tumors-1115Research ArticleОРИГИНАЛЬНЫЕ ИССЛЕДОВАНИЯORIGINAL REPORTSДинамика изменений тумор-ассоциированных макрофагов у пациентов с первичной меланомой кожи в зависимости от способа хирургического леченияDynamics of changes in tumor-associated macrophages in patients with primary skin melanoma depending on the method of surgical treatmentЯргунинС. А.YarguninS.  A.

Яргунин Сергей А. – кандидат медицинских наук, заведующий 6-м онкологическим отделением, врач-онколог.

Краснодар

Sergey A. Yargunin - MD, PhD, Oncologist, Department of General Oncology, Clinical Oncology Dispensary No. 1.

Krasnodar

syargya@yandex.ruРешетовИ. В.ReshetovI.  V.

Решетов Игорь В. – доктор медицинских наук, академик РАН, директор Института кластерной онкологии им. проф. Л.Л. Левшина, ФГАОУ ВО «ПМГМУ им. И.М. Сеченова Минздрава России» (Сеченовский Университет), кафедра онкологии, радиотерапии и пластической хирургии, Академия постдипломного образования ФГБУ ФНКЦ ФМБА России, кафедра онкологии и пластической хирургии.

Москва

Igor V. Reshetov - MD, PhD, DSc, Oncologist, Academician of the Russian Academy of Sciences, Director of the Institute of Cluster Oncology named after prof. L.L. Levshina of I.M. Sechenov First Moscow State Medical University (Sechenov University), Department of Oncology, Radiotherapy and Plastic Surgery, Academy of Postgraduate Education Federal Scientific and Practical Center of the Federal Medical and Biological Agency of Russia, Department of Oncology and Plastic Surgery.

Moscow

reshetoviv@mail.ruШойхетЯ. Н.ShoikhetYa.  N.

Шойхет Яков Н. - доктор медицинских наук, член-корреспондент РАН, заведующий кафедрой госпитальной хирургии.

Барнаул

Yakov N. Shoikhet - MD, PhD, DSc, Corresponding Member, Russian Academy of Medical Sciences, Head Department of Hospital Surgery, Altay State Medical University.

Barnaul

starok100@mail.ruПятаковС. Н.PyatakovS.  N.

Пятаков Станислав Н. - доктор медицинских наук, заместитель главного врача по медицинской части.

Сочи

Stanislav N. Pyatakov - Deputy Chief Physician for the Medical Department of the City Hospital No. 4.

Sochi

spyatakov@inbox.ruГБУЗ «Краснодарский онкологический диспансер № 1» Минздрава Краснодарского краяРоссияClinical Oncology Dispensary No. 1Russian FederationФГАОУ ВО «Первый МГМУ им. И.М. Сеченова Минздрава России» (Сеченовский университет)РоссияI.M. Sechenov First Moscow State Medical University (Sechenov University)Russian FederationФГБОУ ВО «Алтайский государственный медицинский университет» Минздрава РоссииРоссияAltay State Medical UniversityRussian FederationГБУЗ «Городская больница № 4 города Сочи» Минздрава Краснодарского краяРоссияState Hospital №4Russian Federation2023250420231321228Copyright © Яргунин С.А., Решетов И.В., Шойхет Я.Н., Пятаков С.Н., 20232023Яргунин С.А., Решетов И.В., Шойхет Я.Н., Пятаков С.Н.Yargunin S.A., Reshetov I.V., Shoikhet Y.N., Pyatakov S. .Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.malignanttumors.org/jour/article/view/1115Актуальность

Актуальность: Несмотря на кажущийся радикальный характер оперативных вмешательств у пациентов с первичной меланомой кожи, частота локорегионарного рецидивирования и метастазирования остается высокой. Малоизученным является вопрос о влиянии хирургического лечения на эволюцию микроокружения меланомы.

Цель

Цель: оценить влияние динамики поляризации в тумор-ассоциированных макрофагах у пациентов в первичных меланомах кожи 0-IIa стадий и в последующих метастатических поражениях при использовании различных способов устранения операционного дефекта на выживаемость больных с меланомой кожи.

Материалы и методы

Материалы и методы: проводилось исследование Post-Hoc, в котором использованы данные о 128 пациентах с меланомой кожи 0-IIa стадий, которые не были подвергнуты адъювантной терапии после оперативного вмешательства, рандомизированных на 2 группы: основную (с применением пластического закрытия послеоперационного дефекта тканей) и группу сравнения (с линейным ушиванием дефекта тканей). Разделение на группы производилось на основании добровольного информированного согласия пациента на выполнение того или иного типа оперативного вмешательства. Исследована динамика рецепторов макрофагов с коллагеновой структурой CD68 и CD163 в образцах тканей у пациентов с первичной МК и в метастазах у прогрессирующей категории пациентов. Изучена 5-летняя выживаемость без прогрессирования и общая выживаемость пациентов.

Результаты

Результаты: выявлено, что у пациентов с первичной меланомой кожи 0-IIa стадий пластическое замещение дефекта тканей, по сравнению с обычным ушиванием может приводить к уменьшению плотности в интрастромальном распространении провоспалительных макрофагов CD68 операционного очага, а также менее частой поляризации ТАМ-клеток в М2 сторону и миграции в интрастромальный компонент опухоли, более частому смешанному их содержанию, что в итоге улучшает выживаемость у данной категории пациентов.

Выводы

Выводы: пластический способ закрытия операционного дефекта у пациентов с первичной меланомой кожи 0-IIa стадий может влиять на поляризацию ТАМ-клеток. Пластическое замещение дефекта тканей после удаления опухоли позволяет улучшить пятилетние результаты выживаемости (выживаемости без прогрессирования на 22,6% (р = 0,003) и общей выживаемости на 13,1% (р = 0,029).

Summary

Summary: Skin melanoma is one of the deadliest among human skin tumors, and surgery remains the first and main method in its combined treatment. Despite the seemingly radical nature of surgical interventions in patients with primary skin melanoma, the frequency of locoregional recurrence and metastasis remains high. The question of the impact of surgical treatment on the evolution of the melanoma microenvironment remains unclear.

Aim

Aim: to investigate the dynamics of polarization in tumor-associated macrophages in patients with primary skin melanoma of stage 0-IIa and in subsequent metastatic lesions to assess the impact of postoperative ischemia on survival of patients.

Results

Results: it was found that in patients with primary skin melanoma of stage 0-IIa plastic replacement of a tissue defect, compared with conventional suturing, can lead to a decrease in the density in the intrastromal distribution of pro-inflammatory CD68 + macrophages in the surgical focus, as well as less frequent polarization of TAM cells in the M2 direction and migration to the intrastromal component of the tumor, their more frequent mixed content, which, as a result, affects the survival of this category of patients for the better.

Conclusions

Conclusions: plastic closing a surgical defect in patients with primary skin melanoma of stage 0-IIa may affect the duration of postoperative ischemia and the polarization of TAM cells. Plastic replacement of a tissue defect after tumor removal improves five-year survival rates (PFS by 22,6 % (p = 0.003) and OS by 13,1% (p = 0.029).

меланома кожихирургическое лечениепластическое замещение дефекта тканеймикроокружение опухоливыживаемость без прогрессированияобщая выживаемостьskin melanomasurgical treatmentplastic replacement of tissue defectstumor microenvironmentprogression-free survivaloverall survivalReferencesBakker A., Maertens K.J., Van Son M.J., Van Loey N. E. Psychological consequences of pediatric burns from a child and family perspective: a review of the empirical literature. Clin Psychol Rev. 2013 Apr; 33 (3): 361-71. https://doi.org/10.1016/j.cpr.2012.12.006.Bakker A., Maertens K.J., Van Son M.J., Van Loey N. E. Psychological consequences of pediatric burns from a child and family perspective: a review of the empirical literature. Clin Psychol Rev. 2013 Apr; 33 (3): 361-71. https://doi.org/10.1016/j.cpr.2012.12.006.Salmi S., Siiskonen H., Sironen, R., Tyynela-Korhonen K., Hirschovits - Gerz B., Valkonen M. et al. The number and localization of CD68 + and CD163 + macrophages in different stages of cutaneous melanoma. Melanoma Research: June 2019 — Volume 29 — Issue 3-p 237-247. https://doi.org/10.1097/CMR.0000000000000522.Salmi S., Siiskonen H., Sironen, R., Tyynela-Korhonen K., Hirschovits - Gerz B., Valkonen M. et al. The number and localization of CD68 + and CD163 + macrophages in different stages of cutaneous melanoma. Melanoma Research: June 2019 — Volume 29 — Issue 3-p 237-247. https://doi.org/10.1097/CMR.0000000000000522.Simiczyjew A., Dratkiewicz E., Mazurkiewicz J., Ziętek M., Matkowski R., Nowak D. The Influence of Tumor Microenvironment on Immune Escape of Melanoma. Int J Mol Sci. 2020 Nov 7; 21 (21): 8359. PMID: 33171792. https://doi.org/10.3390/ijms21218359.Simiczyjew A., Dratkiewicz E., Mazurkiewicz J., Ziętek M., Matkowski R., Nowak D. The Influence of Tumor Microenvironment on Immune Escape of Melanoma. Int J Mol Sci. 2020 Nov 7; 21 (21): 8359. PMID: 33171792. https://doi.org/10.3390/ijms21218359.Chanmee T., Ontong P., Konno K., Itano N. Tumor-associated macrophages as major players in the tumor microenvironment. Cancers (Basel). 2014 Aug 13; 6 (3): 1670-90. https://doi.org/10.3390/cancers6031670.Chanmee T., Ontong P., Konno K., Itano N. Tumor-associated macrophages as major players in the tumor microenvironment. Cancers (Basel). 2014 Aug 13; 6 (3): 1670-90. https://doi.org/10.3390/cancers6031670.Piaggio F., Kondylis V., Pastorino F., Di Paolo D., Perri P., Cossu I. et al. A novel liposomal clodronate depletes tumor-associated macrophages in primary and metastatic melanoma: anti-angiogenic and anti-tumor effects. J. Control Release. 2016 Feb 10; 223: 165-177. https://doi.org/10.1016/j.jconrel.2015.12.037.Piaggio F., Kondylis V., Pastorino F., Di Paolo D., Perri P., Cossu I. et al. A novel liposomal clodronate depletes tumor-associated macrophages in primary and metastatic melanoma: anti-angiogenic and anti-tumor effects. J. Control Release. 2016 Feb 10; 223: 165-177. https://doi.org/10.1016/j.jconrel.2015.12.037.Falleni M.; Savi, F., Tosi D., Agape E., Cerri, A., Moneghini L., Bulfamante G. P. M1 and M2 macrophages' clinico-pathological significance in cutaneous melanoma. Melanoma Res. 2017 Jun; 27 (3): 200-210. https://doi.org/10.1097/CMR.0000000000000352.Falleni M.; Savi, F., Tosi D., Agape E., Cerri, A., Moneghini L., Bulfamante G. P. M1 and M2 macrophages' clinico-pathological significance in cutaneous melanoma. Melanoma Res. 2017 Jun; 27 (3): 200-210. https://doi.org/10.1097/CMR.0000000000000352.Georgescu S. R., Tampa M., Mitran C. I., Mitran M. I., Caruntu C., Caruntu A. et al. Tumor Microenvironments in Organs, Tumour Microenvironment in Skin Carcinogenesis. In Tumor Microenvironments in Organs; Springer: Cham, Switzerland, 2020; pp. 123-142. ISBN 9783030362133. https://doi.org/10.1007/978-3-030-36214-0_10.Georgescu S. R., Tampa M., Mitran C. I., Mitran M. I., Caruntu C., Caruntu A. et al. Tumor Microenvironments in Organs, Tumour Microenvironment in Skin Carcinogenesis. In Tumor Microenvironments in Organs; Springer: Cham, Switzerland, 2020; pp. 123-142. ISBN 9783030362133. https://doi.org/10.1007/978-3-030-36214-0_10.Pieniazek M., Matkowski R., Donizy P. Macrophages in skin melanoma-the key element in melanomagenesis. Oncol Lett. 2018 Apr; 15 (4): 5399-5404. https://doi.org/10.3892/ol.2018.8021.Pieniazek M., Matkowski R., Donizy P. Macrophages in skin melanoma-the key element in melanomagenesis. Oncol Lett. 2018 Apr; 15 (4): 5399-5404. https://doi.org/10.3892/ol.2018.8021.Smith M. P., Sanchez-laorden B., Brien K. O., Brunton H., Young H., Dhomen N., et al. The immune-microenvironment confers resistance to MAP kinase pathway inhibitors through macrophage-derived TNFa. Cancer Discov. 2014 Oct; 4 (10): 1214-1229. https://doi.org/10.1158/2159-8290.CD-13-1007.Smith M. P., Sanchez-laorden B., Brien K. O., Brunton H., Young H., Dhomen N., et al. The immune-microenvironment confers resistance to MAP kinase pathway inhibitors through macrophage-derived TNFa. Cancer Discov. 2014 Oct; 4 (10): 1214-1229. https://doi.org/10.1158/2159-8290.CD-13-1007.Noy R., Pollard J. W. Tumor-associated macrophages: from mechanisms to therapy. Immunity 2014; 41: 49-61. PMID: 25035953. PMCID: PMC4137410. https://doi.org/10.1016/j.immuni.2014.06.010.Noy R., Pollard J. W. Tumor-associated macrophages: from mechanisms to therapy. Immunity 2014; 41: 49-61. PMID: 25035953. PMCID: PMC4137410. https://doi.org/10.1016/j.immuni.2014.06.010.Caux C., Ramos R. N., Prendergast G. C., Bendriss-Vermare N., Menetrier-Caux C. A Milestone Review on How Macrophages Affect Tumor Growth. Cancer Res. 2016 Nov 15; 76 (22): 6439-6442. https://doi.org/10.1158/0008-5472.CAN-16-2631.Caux C., Ramos R. N., Prendergast G. C., Bendriss-Vermare N., Menetrier-Caux C. A Milestone Review on How Macrophages Affect Tumor Growth. Cancer Res. 2016 Nov 15; 76 (22): 6439-6442. https://doi.org/10.1158/0008-5472.CAN-16-2631.Quail D. F., Joyce J. A. Microenvironmental regulation of tumor progression and metastasis. Nat Med. 2013 Nov; 19 (11): 1423-37. https://doi.org/10.1038/nm.3394.Quail D. F., Joyce J. A. Microenvironmental regulation of tumor progression and metastasis. Nat Med. 2013 Nov; 19 (11): 1423-37. https://doi.org/10.1038/nm.3394.Ersek B., Sillo P., Cakir U., Molnar V., Bencsik A., Mayer B. et al. Melanoma-associated fibroblasts impair CD8 + T cell function and modify expression of immune checkpoint regulators via increased arginase activity. Cell Mol Life Sci. 2021 Jan; 78 (2): 661-673. https://doi.org/10.1007/s00018-020-03517-8.Ersek B., Sillo P., Cakir U., Molnar V., Bencsik A., Mayer B. et al. Melanoma-associated fibroblasts impair CD8 + T cell function and modify expression of immune checkpoint regulators via increased arginase activity. Cell Mol Life Sci. 2021 Jan; 78 (2): 661-673. https://doi.org/10.1007/s00018-020-03517-8.Ziani L., Safta-Saadoun T. B., Gourbeix J., Cavalcanti A., Robert C., Favre G. et al. Melanoma-associated fibroblasts decrease tumor cell susceptibility to NK cell-mediated killing through matrix-metalloproteinases secretion. Onco-target. 2017 Mar 21; 8 (12): 19780-19794. https://doi.org/10.18632/oncotarget.15540.Ziani L., Safta-Saadoun T. B., Gourbeix J., Cavalcanti A., Robert C., Favre G. et al. Melanoma-associated fibroblasts decrease tumor cell susceptibility to NK cell-mediated killing through matrix-metalloproteinases secretion. Onco-target. 2017 Mar 21; 8 (12): 19780-19794. https://doi.org/10.18632/oncotarget.15540.Díaz F. E., Dantas E., Geffner J. Unravelling the Interplay between Extracellular Acidosis and Immune Cells. Mediators Inflamm. 2018 Dec 30; 2018: 1218297. https://doi.org/10.1155/2018/1218297.Díaz F. E., Dantas E., Geffner J. Unravelling the Interplay between Extracellular Acidosis and Immune Cells. Mediators Inflamm. 2018 Dec 30; 2018: 1218297. https://doi.org/10.1155/2018/1218297.Bohme I., Bosserhoff A. Extracellular acidosis triggers a senescence-like phenotype in human melanoma cells. Pigment Cell Melanoma Res. 2020 Jan; 33 (1): 41-51. https://doi.org/10.1111/pcmr.12811.Bohme I., Bosserhoff A. Extracellular acidosis triggers a senescence-like phenotype in human melanoma cells. Pigment Cell Melanoma Res. 2020 Jan; 33 (1): 41-51. https://doi.org/10.1111/pcmr.12811.Marzagalli M., Ebelt N. D., Manuel E. R. Unraveling the crosstalk between melanoma and immune cells in the tumor microenvironment. Semin Cancer Biol. 2019 Dec; 59: 236-250. https://doi.org/10.1016/j.semcancer.2019.08.002.Marzagalli M., Ebelt N. D., Manuel E. R. Unraveling the crosstalk between melanoma and immune cells in the tumor microenvironment. Semin Cancer Biol. 2019 Dec; 59: 236-250. https://doi.org/10.1016/j.semcancer.2019.08.002.Tan S., Khumalo N., Bayat A. Understanding Keloid Pathobiology From a Quasi-Neoplastic Perspective: Less of a Scar and More of a Chronic Inflammatory Disease With Cancer-Like Tendencies. Front Immunol. 2019 Aug 7; 10: 1810. https://doi.org/10.3389/fimmu.2019.01810.Tan S., Khumalo N., Bayat A. Understanding Keloid Pathobiology From a Quasi-Neoplastic Perspective: Less of a Scar and More of a Chronic Inflammatory Disease With Cancer-Like Tendencies. Front Immunol. 2019 Aug 7; 10: 1810. https://doi.org/10.3389/fimmu.2019.01810.Das S., Skobe M. Lymphatic vessel activation in cancer. Ann N Y Acad Sci. 2008; 1131: 235-41. https://doi.org/10.1196/annals.1413.021.Das S., Skobe M. Lymphatic vessel activation in cancer. Ann N Y Acad Sci. 2008; 1131: 235-41. https://doi.org/10.1196/annals.1413.021.Rutkowski J. M., Moya M., Johannes J., Goldman J., Swartz M. A. Secondary lymphedema in the mouse tail: lymphatic hyperplasia, VEGF-C upregulation, and the protective role of MMP-9. Microvasc Res. 2006 Nov; 72 (3): 161-71. https://doi.org/10.1016/j.mvr.2006.05.009.Rutkowski J. M., Moya M., Johannes J., Goldman J., Swartz M. A. Secondary lymphedema in the mouse tail: lymphatic hyperplasia, VEGF-C upregulation, and the protective role of MMP-9. Microvasc Res. 2006 Nov; 72 (3): 161-71. https://doi.org/10.1016/j.mvr.2006.05.009.Zampell J. C., Yan A., Elhadad S., Avraham T., Weitman E., Mehrara B. J. CD4 (+) cells regulate fibrosis and lymphangiogenesis in response to lymphatic fluid stasis. PLoS One. 2012; 7 (11): e49940. https://doi.org/10.1371/journal.pone.0049940.Zampell J. C., Yan A., Elhadad S., Avraham T., Weitman E., Mehrara B. J. CD4 (+) cells regulate fibrosis and lymphangiogenesis in response to lymphatic fluid stasis. PLoS One. 2012; 7 (11): e49940. https://doi.org/10.1371/journal.pone.0049940.Backs J., Song K., Bezprozvannaya S., Chang S., Olson E. N. CaM kinase II selectively signals to histone deacetylase 4 during cardiomyocyte hypertrophy. J Clin Invest. 2006 Jul; 116 (7): 1853-64. https://doi.org/10.1172/JCI27438.Backs J., Song K., Bezprozvannaya S., Chang S., Olson E. N. CaM kinase II selectively signals to histone deacetylase 4 during cardiomyocyte hypertrophy. J Clin Invest. 2006 Jul; 116 (7): 1853-64. https://doi.org/10.1172/JCI27438.Humphrey J. D., Dufresne E. R., Schwartz M. A. Mechanotransduction and extracellular matrix homeostasis. Nat Rev Mol Cell Biol. 2014 Dec; 15 (12): 802-12. https://doi.org/10.1038/nrm3896.Humphrey J. D., Dufresne E. R., Schwartz M. A. Mechanotransduction and extracellular matrix homeostasis. Nat Rev Mol Cell Biol. 2014 Dec; 15 (12): 802-12. https://doi.org/10.1038/nrm3896.Salica J. P., Guerrieri D., Maffia P., Croxatto J., Chuluyan H. E., Gallo J. E. Transglutaminase binding fusion protein linked to SLPI reduced corneal inflammation and neovascularization. BMC Ophthalmol. 2015 Feb 4; 15: 12. https://doi.org/10.1186/1471-2415-15-12.Salica J. P., Guerrieri D., Maffia P., Croxatto J., Chuluyan H. E., Gallo J. E. Transglutaminase binding fusion protein linked to SLPI reduced corneal inflammation and neovascularization. BMC Ophthalmol. 2015 Feb 4; 15: 12. https://doi.org/10.1186/1471-2415-15-12.Bald T., Quast T., Landsberg J., Rogava M., Glodde N., Lopez-Ramos D. et al. Ultraviolet-radiation-induced inflammation promotes angiotropism and metastasis in melanoma. Nature. 2014 Mar 6; 507 (7490): 109-13. https://doi.org/10.1038/nature13111.Bald T., Quast T., Landsberg J., Rogava M., Glodde N., Lopez-Ramos D. et al. Ultraviolet-radiation-induced inflammation promotes angiotropism and metastasis in melanoma. Nature. 2014 Mar 6; 507 (7490): 109-13. https://doi.org/10.1038/nature13111.Roh-Johnson M., Shah A. N., Stonick J. A. et al. Macrophage-Dependent Cytoplasmic Transfer during Melanoma Invasion In Vivo. Dev Cell. 2017 Dec 4; 43 (5): 549-562. e6. https://doi.org/10.1016/j.devcel.2017.11.003.Roh-Johnson M., Shah A. N., Stonick J. A. et al. Macrophage-Dependent Cytoplasmic Transfer during Melanoma Invasion In Vivo. Dev Cell. 2017 Dec 4; 43 (5): 549-562. e6. https://doi.org/10.1016/j.devcel.2017.11.003.Harrell M. I., Iritani B. M., Ruddell A. Tumor-induced sentinel lymph node lymphangiogenesis and increased lymph flow precede melanoma metastasis. Am J Pathol. 2007 Feb; 170 (2): 774-86. https://doi.org/10.2353/ajpath.2007.060761.Harrell M. I., Iritani B. M., Ruddell A. Tumor-induced sentinel lymph node lymphangiogenesis and increased lymph flow precede melanoma metastasis. Am J Pathol. 2007 Feb; 170 (2): 774-86. https://doi.org/10.2353/ajpath.2007.060761.Abouelkheir G. R., Upchurch B. D., Rutkowski J. M. Lymphangiogenesis: fuel, smoke, or extinguisher of inflammation's fire? Exp Biol Med (Maywood). 2017 Apr; 242 (8): 884-895. https://doi.org/10.1177/1535370217697385.Abouelkheir G. R., Upchurch B. D., Rutkowski J. M. Lymphangiogenesis: fuel, smoke, or extinguisher of inflammation's fire? Exp Biol Med (Maywood). 2017 Apr; 242 (8): 884-895. https://doi.org/10.1177/1535370217697385.Sund B. New developments in wound care. vol. 86. PJB. PJB Publications: London 1: 255 (Clinical Report CBS 836), 2000. https://doi.org/10.1136/bmj.326.7380.88.Sund B. New developments in wound care. vol. 86. PJB. PJB Publications: London 1: 255 (Clinical Report CBS 836), 2000. https://doi.org/10.1136/bmj.326.7380.88.Van der Auwera I., Cao Y., Tille J. C., Pepper M. S., Jackson D. G., Fox S. B. et al. First international consensus on the methodology of lymphangiogenesis quantification in solid human tumours. Br J Cancer. 2006 Dec 18; 95 (12): 1611-25. https://doi.org/10.1038/sj.bjc.6603445.Van der Auwera I., Cao Y., Tille J. C., Pepper M. S., Jackson D. G., Fox S. B. et al. First international consensus on the methodology of lymphangiogenesis quantification in solid human tumours. Br J Cancer. 2006 Dec 18; 95 (12): 1611-25. https://doi.org/10.1038/sj.bjc.6603445.Behan F. C., Lo C. H., Sizeland A., Pham T., Findlay M. Keystone island flap reconstruction of parotid defects. Plast Reconstr Surg. 2012 Jul; 130 (1): 36e-41e. https://doi.org/10.1097/PRS.0b013e3182547f55.Behan F. C., Lo C. H., Sizeland A., Pham T., Findlay M. Keystone island flap reconstruction of parotid defects. Plast Reconstr Surg. 2012 Jul; 130 (1): 36e-41e. https://doi.org/10.1097/PRS.0b013e3182547f55.Tiainen S., Tumelius R., Rilla K., Hamalainen K., Tammi M., Tammi R., Kosma V.- M., Oikari S., Auvinen P. High numbers of macrophages, especially M2-like (CD163-positive), correlate with hyaluronan accumulation and poor outcome in breast cancer. Histopathology. 2015 May; 66 (6): 873-83. doi:10.1111/his.12607. Epub 2015 Jan 15.Tiainen S., Tumelius R., Rilla K., Hamalainen K., Tammi M., Tammi R., Kosma V.- M., Oikari S., Auvinen P. High numbers of macrophages, especially M2-like (CD163-positive), correlate with hyaluronan accumulation and poor outcome in breast cancer. Histopathology. 2015 May; 66 (6): 873-83. doi:10.1111/his.12607. Epub 2015 Jan 15.

The authors declare that there are no conflicts of interest present.