Moreover, the lymphocyte count in dead cases was significantly lower than that of critical cases who recovered, at almost every time point in the critical groups. Kang MK, Lee YR, Song JE, Kweon YO, Tak WY, Jang SY, Park JG, Park SY. Epub 2022 Apr 27. National Library of Medicine In the present study, we specifically aimed to predict the presence of v-HLNs on 18F-FDG PET/CT after COVID-19 vaccination and to investigate their relationships to lymphocyte counts, with a special focus on a subgroup of BC patients. J Am Acad Dermatol 2017;77:100920. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). The messenger RNA vaccine had been given to 233 (90%). In particular, there are no case reports of lymphedema in a healthy patient following vaccination. 2021 May 1;46(5):396-401. doi: 10.1097/RLU.0000000000003648. Therefore, it is possible that a person could be infected with the virus that causes COVID-19 just before or just after vaccination and then get sick because the vaccine did not have enough time to provide protection. A particular subset of these cells, called monocytes, have been found to show strikingly abnormal features as a result of the respiratory infection. Study flow chart. . eCollection 2022. Unauthorized use of these marks is strictly prohibited. An age of no more than 50 y (odds ratio [OR], 2.2; 95% CI, 1.0-4.5), the absence of lymphopenia (OR, 2.2; 95% CI, 1.1-4.3), and less than a 30-d interval from the last vaccine injection to the 18F-FDG PET/CT (OR, 2.6; 95% CI, 1.3-5.6) were independent factors for v-HLNs on multivariate analysis. For this reason, everyone who receives a COVID-19 vaccine is monitored by their vaccination provider for at least 15 minutes. The sample size (n = 7) was too small to allow a statistical analysis or to draw any conclusion. Absolute Lymphocyte Count After COVID-19 Vaccination Is Associated with Vaccine-Induced Hypermetabolic Lymph Nodes on, DOI: https://doi.org/10.2967/jnumed.121.263082, Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine, Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine, Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK, COVID-19 vaccine BNT162b1 elicits human antibody and TH1 T cell responses, A single immunization with nucleoside-modified mRNA vaccines elicits strong cellular and humoral immune responses against SARS-CoV-2 in mice, Lymphocyte egress from thymus and peripheral lymphoid organs is dependent on S1P receptor 1, The spleen in local and systemic regulation of immunity, Assessing immune response upon systemic RNA vaccination on [, Lymph node activation by PET/CT following vaccination with licensed vaccines for human papillomaviruses, In vivo imaging of the immune response upon systemic RNA cancer vaccination by FDG-PET, Hypermetabolic lymphadenopathy following administration of BNT162b2 mRNA Covid-19 vaccine: incidence assessed by [, Correlation between BNT162b2 mRNA Covid-19 vaccine-associated hypermetabolic lymphadenopathy and humoral immunity in patients with hematologic malignancy, COVID-19 mRNA vaccination: age and immune status and its association with axillary lymph node PET/CT uptake, Coordination and optimization of FDG PET/CT and COVID-19 vaccination; lessons learned in the early stages of mass vaccination, COVID-19 vaccination may cause FDG uptake beyond axillary area, COVID-19 vaccination-associated lymphadenopathy on FDG PET/CT: distinctive features in adenovirus-vectored vaccine, COVID-19 vaccine as a cause for unilateral lymphadenopathy detected by, PET findings after COVID-19 vaccination: keep calm and carry on., Prevalence and significance of hypermetabolic lymph nodes detected by 2-[, The challenge of staging breast cancer with PET/CT in the era of COVID vaccination, FDG PET/CT: EANM procedure guidelines for tumour imagingversion 2.0, A stepwise AIC method for variable selection in linear regression, Humoral immune response to COVID-19 mRNA vaccine in patients with multiple sclerosis treated with high-efficacy disease-modifying therapies, BNT162b2 COVID-19 vaccine is significantly less effective in patients with hematologic malignancies, Absolute lymphocyte count predicts the response to new influenza virus H1N1 vaccination in pediatric cancer patients, The role of the lymphocyte in antibody formation, Rituximab blocks protective serologic response to influenza A (H1N1) 2009 vaccination in lymphoma patients during or within 6 months after treatment, Effect of cancer chemotherapy on the immune response to influenza virus vaccine: review of published studies, mRNA vaccine-induced neoantigen-specific T cell immunity in patients with gastrointestinal cancer, Survival Outcomes in Metastatic Gastroenteropancreatic Neuroendocrine Tumor Patients Receiving Concomitant, C-X-C Motif Chemokine Receptor 4Targeted Radioligand Therapy in Patients with Advanced T-Cell Lymphoma, Improved Tumor Responses with Sequential Targeted -Particles Followed by Interleukin 2 Immunocytokine Therapies in Treatment of CEA-Positive Breast and Colon Tumors in CEA Transgenic Mice, https://creativecommons.org/licenses/by/4.0/, http://jnm.snmjournals.org/site/misc/permission.xhtml, Absolute Lymphocyte Count After COVID-19 Vaccination Is Associated with Vaccine-Induced Hypermetabolic Lymph Nodes on 18F-FDG PET/CT: A Focus in Breast Cancer Care. 2021;384:403416. -, Haakonsen HB, Nystedt A. The site is secure. A few case studies have reported people admitted to the hospital with leukemia shortly after developing COVID-19. However, its not clear if COVID-19 played a role or how much of a role it played. Herein, we report a patient who underwent transient lymphedema after vaccination with BNT16b2. 2021;397:99111. Hippisley-Cox J, Patone M, Mei XW, Saatci D, Dixon S, Khunti K, Zaccardi F, Watkinson P, Shankar-Hari M, Doidge J, Harrison DA, Griffin SJ, Sheikh A, Coupland CAC. Among them, median ALC was 1.5109/L (range, 0.45.0 109/L), and 41 (39%) displayed lymphopenia. KEYWORDS 18F -FDG PET/CT; COVID 19 vaccination; absolute lymphocyte count; hypermetabolic lymph nodes; immune response. COVID-19 vaccine BNT162b1 elicits human antibody and TH1 T cell responses. Ah-Thiane L, Ferrer L, Maucherat B, Fleury V, Le Thiec M, Rusu D, Rousseau C. Clin Nucl Med. Dynamic changes of blood cell count in patients with COVID-19. 2022 Dec 6;9:1067082. doi: 10.3389/fmed.2022.1067082. Epub 2020 Aug 24. Epub 2022 Oct 27. However, its not clear if COVID-19 played a role or how much of a role it played. WebIn breast cancer patients, the absence of lymphopenia was the only independent factor significantly associated with v-HLNs (OR, 2.9; 95% CI, 1.2-7.4). In any case, our work confirms the potential of 18F-FDG PET/CT as a potent tool to assess immune response after COVID-19 vaccination, as can be explained by the fact that immune response increases glucose metabolism in lymphoid organs (e.g., regional lymph nodes), which are critical modulators of immunity (33). Immunogenicity, safety, and reactogenicity of heterologous COVID-19 primary vaccination incorporating mRNA, viral-vector, and protein-adjuvant vaccines in the UK (Com-COV2): a single-blind, randomised, phase 2, non-inferiority trial. HHS Vulnerability Disclosure, Help The .gov means its official. Viruses. J Educ Health Promot. WebA reduced peripheral blood absolute lymphocyte count with an elevated neutrophil count has been a consistent observation in hospitalized coronavirus disease 2019 (COVID-19) patients. This essential result might be the missing link between the presence of v-HLNs and vaccine effectiveness in inducing a strong immune response and, therefore, robust immunity. 2021 Aug 24;13(9):1675. doi: 10.3390/v13091675. N Engl J Med. A single immunization with nucleoside-modified mRNA vaccines elicits strong cellular and humoral immune responses against SARS-CoV-2 in mice. eCollection 2021. eCollection 2022. Readers were masked and did not know the patients characteristics. Conclusion: Patients with a normal ALC after COVID-19 vaccination were more likely to have v-HLNs on 18 F-FDG PET/CT, both of which might be associated with a stronger immune response to Steroids such as Prednisolone have a very short-lived effect of increasing the neutrophils. Lymphocytes screening on admission is essential for predicting in-hospital clinical outcome in COVID-19 patients: A retrospective cohort study. 2022 Aug 10;14(8):e27862. All reported P values are 2-sided, and P values of less than 0.05 were considered to be significant. 2021 Feb 16;12:581469. doi: 10.3389/fimmu.2021.581469. Tabbakh TA, Alhashemi HH, Alharbi K, Qanash S, Alzahrani MS, Saati A, Alsulami S, Alsulami A, Neyazi A, Alzahrani A, Taher ZA, Aljedaani G, Alhejaili A. Cureus. sharing sensitive information, make sure youre on a federal . Bookshelf Characterization and clinical course of 1000 patients with coronavirus disease 2019 in New York: retrospective case series. Conclusion: Patients with a normal ALC after COVID-19 vaccination were more likely to have v-HLNs on 18F-FDG PET/CT, both of which might be associated with a stronger immune response to vaccination. The results showed that there were differences in levels of leukocytes, neutrophils and lymphocytes at almost every time point in the severe cases and 60 critical cases (29 recovered cases, 31 deaths). Zhang P, Du W, Yang T, Zhao L, Xiong R, Li Y, Geng Y, Lu W, Zhou J. Int J Immunopathol Pharmacol. Further analysis showed that 70.2% of the COVID-19 cases had low circulating lymphocyte count, of which 64.1% were severe cases and 85.0% were critical cases (75.9% recovered cases and 93.5% died). Copyright 2021 the Author(s). PMC We aimed to predict the presence of vaccine-induced hypermetabolic lymph nodes (v-HLNs) on 18F-FDG PET/CT after coronavirus disease 2019 (COVID-19) vaccination and determine their association with lymphocyte counts. Adverse Events after COVID-19 Vaccination Are Rare Adverse events , including severe allergic reactions, after COVID-19 vaccination are rare but can happen. Now proven to be more than 90% effective against SARS-CoV-2, the mRNA technology will probably modify the therapeutic armamentarium in patients with solid malignant tumors (34). Careers. 1 University of Manchester immunologists are the first to make an interesting observation about the white blood cells of patients with COVID-19. Herein, we report a patient who underwent transient lymphedema after vaccination with BNT16b2. WebA reduced peripheral blood absolute lymphocyte count with an elevated neutrophil count has been a consistent observation in hospitalized coronavirus disease 2019 (COVID-19) patients. Family doctors, hematologists, breast surgeons, and radiologists must be aware of the fact that axillary, lower neck, supraclavicular, and infraclavicular lymphadenopathy may be related to the COVID-19 vaccine rather than representing actual more sinister pathologic processes. 2022 Jan 1;399(10319):36-49. doi: 10.1016/S0140-6736(21)02718-5. Accessibility FOIA License: https://creativecommons.org/licenses/by/4.0/. we divided the length of, Dynamic changes of blood cell count in patients with COVID-19. It is not related to whether the EBV is still present in your body. 2022 Sep 1;6(1):17. doi: 10.1186/s41824-022-00138-1. Patients were then screened, and we focused on 145 severe cases and 60 critical cases (29 recovered cases, 31 deaths). 2022 Jun 16;13:867907. doi: 10.3389/fphar.2022.867907. We identified 7 BC patients who had axillary HLNs ipsilateral to the recently vaccinated arm but also ipsilateral to the known tumor. Covid vaccines eight times less effective against this variant of concern A claim suggesting that the Covid-19 booster shot causes lymphoma has gone viral on social media. PMC A recent Johns Hopkins Medicine study suggests that T lymphocytes immune system cells that target the spike protein and direct antibodies against the COVID-19 virus persist six months after vaccination Please enable it to take advantage of the complete set of features! We sought to explore the sensitivity of absolute lymphocyte count in patients presenting to the emergency department requiring subsequent hospitalization who were found to have COVID-19. demonstrating a strong inverse association between v-HLNs and immunosuppressive therapies (OR, 0.37; 95% CI, 0.200.64; P < 0.01) in a large cohort of 377 patients after mRNA-based COVID-19 vaccination (14). Terms of Use. The .gov means its official. 2021 Jan-Dec;35:20587384211048567. doi: 10.1177/20587384211048567. The absence of lymphopenia was the only independent factor significantly associated with v-HLNs (OR, 2.9; 95% CI, 1.27.4). However, its not clear if COVID-19 played a role or how much of a role it played. Furthermore, the survival analysis revealed differences in the probability of survival within 30 days between COVID-19 patients with lymphopenia and those without (HR: 5.5722 (3.2509-9.5510), 95% CI; p<0.0001). The body keeps a few T-lymphocytes, called memory cells, that go into action quickly if the body encounters the same virus again. However, it remains unclear whether similar results would be obtained after the administration of another type of vaccine (e.g., viral vectors). (B) Lymphoscintigraphy showed a decreased lymphatic transport in both lower extremities, especially on the left side. PMC Ipsilateral Upper-Limb Lymphedema After COVID-19 Vaccine Booster. Epub 2022 Nov 28. Methods: In this retrospective single-center study, we included consecutive patients who underwent 18F-FDG PET/CT imaging after messenger RNA- or viral vector-based COVID-19 vaccination between early March and late April 2021. Axillary lymph node characteristics in breast cancer patients versus post-COVID-19 vaccination: Overview of current evidence per imaging modality. Their demographic characteristics, vaccination information, 18F-FDG PET/CT parameters, ALC, and histologic data are reported in Table 4. The HLN SUVmax was defined as the highest SUVmax among all HLNs detected in the drainage territory (axillary or supraclavicular for vaccination in the deltoid, inguinal for vaccination in the thigh or buttock). government site. Unauthorized use of these marks is strictly prohibited. 2021. This site needs JavaScript to work properly. Methods: This is a prognostic study that is conducted from March 1 to August 31, 2020. 2021 Aug 26;374:n1931. COVID -19 vaccines are also associated with cytopenias of varying degrees. . It typically takes a few weeks after vaccination for the body to produce T-lymphocytes and B-lymphocytes. The findings of this study indicated a significant difference in outcome between lymphopenia and non-lymphopenia patients. Published by Wolters Kluwer Health, Inc. WebAdditionally, lower mean absolute lymphocyte counts were identified in males, patients who required intubation, and patients who died. On the one hand, Thomassen etal. Eifer M, Pinian H, Klang E, Alhoubani Y, Kanana N, Tau N, Davidson T, Konen E, Catalano OA, Eshet Y, Domachevsky L. Eur Radiol. The outbreak of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been rapidly spreading on a global scale and poses a great threat to human health. Zhang J, Wang Z, Wang X, Hu Z, Yang C, Lei P. Front Immunol. Evaluation of coronavirus diseases (COVID-19) in terms of epidemiological and clinical features, comorbidities, diagnostic methods, treatment, and mortality. Interestingly, for patients displaying lymphopenia after vaccination, we evaluated the dynamic of ALC and found that a low ALC existed before vaccination in most patients (67%, n = 36) suggesting that lymphopenia was not related to vaccination. Where there was any uncertainty about HLN etiology (disease-related or vaccine-induced), we categorized the patients into an indeterminate-HLN group. All parameters remained independent predictors of the v-HLN status on multivariate analysis. CR = complete response; DLBCL = diffuse large B-cell lymphoma. In breast cancer patients, the absence of lymphopenia was the only independent factor significantly associated with v-HLNs (OR, 2.9; 95% CI, 1.2-7.4). Please enable it to take advantage of the complete set of features! and transmitted securely. Conclusion: This site needs JavaScript to work properly. Both of these interrelated elements (age and ALC) might modulate the quality of the immune response after COVID-19 vaccination. N Engl J Med. Additionally, lower mean absolute lymphocyte counts were identified in males, patients who required intubation, and patients who died. Clinical data consisted of the patients age, sex, disease (cancer type if applicable), and current specific treatment (chemotherapy, endocrine therapy, immunotherapy with immune checkpoint inhibitors, or targeted therapy). The immunosuppression, the type of vaccine, and the number of doses were not associated Further analysis showed that 70.2% of the COVID-19 cases had low circulating lymphocyte count, of which 64.1% were severe cases and 85.0% were critical cases (75.9% recovered cases and 93.5% died). Epub 2021 Dec 6. WebAdditionally, lower mean absolute lymphocyte counts were identified in males, patients who required intubation, and patients who died. The length of hospitalization was divided into five time points, namely admission, 25%, 50%, 75% and discharge or death, according to the principle of interquartile distance. Interestingly, for patients displaying lymphopenia after vaccination, we evaluated the dynamic of ALC and found that a low ALC existed before vaccination in most patients (67%, n = 36) suggesting that lymphopenia was not related to vaccination. One patient (14%) was not investigated and began neoadjuvant endocrine therapy; the planned partial mastectomy with sentinel lymph node biopsy will help determine the cause of HLNs afterward. Covid vaccines eight times less effective against this variant of concern A claim suggesting that the Covid-19 booster shot causes lymphoma has gone viral on social media. -, Xu Z, Shi L, Wang Y, et al. and transmitted securely. We aimed to predict the presence of vaccine-induced hypermetabolic lymph nodes (v-HLNs) on 18F-FDG PET/CT after coronavirus disease 2019 (COVID-19) vaccination and determine their association with lymphocyte counts. Interestingly, for patients displaying lymphopenia after vaccination, we evaluated the dynamic of ALC and found that a low ALC existed before vaccination in most patients (67%, n = 36) suggesting that lymphopenia was not related to vaccination. Images were converted to SUV units by normalization using the patients body weight. Methods: This is a prognostic study that is conducted from March 1 to August 31, 2020. eCollection 2022 Sep. See this image and copyright information in PMC, Abstracts of Presentations at the Association of Clinical Scientists 143. Privacy Policy We also divided critical patients into group A (<1.1 109/L) and group B (>1.1 109/L) according to number of lymphocytes. We considered a subgroup of patients who theoretically had a weakened immune system, whom we called immunosuppressed, caused by any of the following treatments: chemotherapy within the last 3 mo, rituximab-containing regimens or bone marrow transplantation within the last 6 mo, or current steroid therapy with more than 10 mg/d of prednisone-equivalent. MeSH In particular, there are no case reports of lymphedema in a healthy patient following vaccination. Such important results have been previously demonstrated after vaccination, especially against SARS-CoV-2 (27,28) but also against other viruses (29). Epub 2022 Aug 16. Unable to load your collection due to an error, Unable to load your delegates due to an error. Methods: Table 1 summarizes the detailed demographic and clinicobiologic characteristics and PET imaging parameters of the 145 BC patients. Intervention: Blood samples were analyzed when performed after vaccination and in the previous 28 d before 18F-FDG PET/CT. Further analyses are needed to explore the specific relationship between v-HLNs, immune status, and the immune response to the COVID-19 vaccine. The Lancet 2020;395:50713. Int J Infect Dis. . 2022 Sep 18;12(9):2255. doi: 10.3390/diagnostics12092255. The authors have no potential conflicts of interest relevant to this article to report. MeSH A retrospective chart review was performed on 312 patients with laboratory-confirmed COVID-19 who were admitted to the hospital from the emergency department. Furthermore, the patient was trained to apply a multilayer compressive bandage to the lower extremities. 2020 Sep;30(9):928-932. doi: 10.29271/jcpsp.2020.09.928. The median time between the last vaccination dose and 18F-FDG PET/CT scanning was 14d (range, 151d) for patients who received only 1 dose and 23 d (range, 167 d) for patients who received a second dose. PMC Front Med (Lausanne). Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lymphopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: a systemic review and meta-analysis. Unauthorized use of these marks is strictly prohibited. sharing sensitive information, make sure youre on a federal -, Voysey M, Clemens SAC, Madhi SA, et al. Please enable it to take advantage of the complete set of features! Other effects of body weakening can also be associated with vaccines. The absolute lymphocyte count for these patients was used to calculate sensitivities at various cut-off values. Sign In to Email Alerts with your Email Address. Patient was treated with brentuximab and nivolumab and experienced complete metabolic response 2 mo after initiation of therapy (January 2021). 8600 Rockville Pike 2022 Jun 23;13:875637. doi: 10.3389/fimmu.2022.875637. Accessibility Epub 2020 Jul 10. Epub 2022 Apr 6. Patients fasted for at least 6 h before scanning to ensure a blood glucose level of less than 10mmol/L. [Correlation between the early dynamic changes of lymphocyte and severity of disease in coronavirus disease 2019 patients]. Indeed, BC patients with a normal value of ALC were more likely to have v-HLNs on 18F-FDG PET/CT. Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine. Please enable it to take advantage of the complete set of features! As a result, the 3 parameters (age, timing of last injection dose, and ALC) that we identified in the current study may help to guide nuclear medicine physicians in interpreting 18F-FDG PET/CT images and oncologists in choosing whether to perform a biopsy. National Library of Medicine In BC patients, normal values of ALC after vaccination and before 18F-FDG PET/CT were the best indicator of the v-HLN status. HHS Vulnerability Disclosure, Help Careers. Unfortunately, because blood sample analysis was not available for all these patients, we could not determine whether patients with benign reactive changes had significantly higher ALCs than patients with signs of malignancy. Tidsskr Nor Laegeforen 2021;141.doi: 10.4045/tidsskr.21.0274. 1 University of Manchester immunologists are the first to make an interesting observation about the white blood cells of patients with COVID-19. Our results are consistent with previously published data, suggesting that v-HLNs are significantly less common in elderly patients and conversely more frequent in patients who received their last vaccine injection a few days before 18F-FDG PET/CT (14). Axillary Lymph Nodes Hypermetabolism After BNT162b2 mRNA COVID-19 Vaccination in Cancer Patients Undergoing 18F-FDG PET/CT: A Cohort Study. Stuart ASV, Shaw RH, Liu X, Greenland M, Aley PK, Andrews NJ, Cameron JC, Charlton S, Clutterbuck EA, Collins AM, Darton T, Dinesh T, Duncan CJA, England A, Faust SN, Ferreira DM, Finn A, Goodman AL, Green CA, Hallis B, Heath PT, Hill H, Horsington BM, Lambe T, Lazarus R, Libri V, Lillie PJ, Mujadidi YF, Payne R, Plested EL, Provstgaard-Morys S, Ramasamy MN, Ramsay M, Read RC, Robinson H, Screaton GR, Singh N, Turner DPJ, Turner PJ, Vichos I, White R, Nguyen-Van-Tam JS, Snape MD; Com-COV2 Study Group. Enter multiple addresses on separate lines or separate them with commas. Clinical, radiological, and laboratory characteristics and risk factors for severity and mortality of 289 hospitalized COVID-19 patients. PERTINENT FINDINGS: Patient ALC (>lower limit of normal), patient age (50 y), and timing of last injection dose (<30 d before PET) significantly correlated with v-HLNs. Conclusion: Patients with a normal ALC after COVID-19 vaccination were more likely to have v-HLNs on 18 F-FDG PET/CT, both of which might be associated with a stronger immune response to Converted to SUV units by normalization using the patients body weight immunologists are the first to make an observation. Count in patients with COVID-19 B-cell lymphoma JE, Kweon YO, Tak,. Status, and histologic data are reported in Table 4, make sure youre on federal! Risk factors for severity and mortality of 289 hospitalized COVID-19 patients: a cohort...: this site needs JavaScript to work properly, the patient was treated with brentuximab and nivolumab and complete. Viruses ( 29 ) it played an indeterminate-HLN group 2022 Jun 23 ; 13:875637. doi: 10.3390/diagnostics12092255 set of!! Hypermetabolic lymph nodes ; immune response to the hospital from the emergency.... 31, 2020 Events after COVID-19 vaccination are Rare adverse Events after COVID-19 vaccination with your Email.. 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January 2021 ) antibody and TH1 T cell responses:1675. doi: 10.1186/s41824-022-00138-1 information make...: a cohort study PET imaging parameters of the 145 BC patients with a normal value of were... Disease in coronavirus disease 2019 in New York: retrospective case series = complete response ; DLBCL = large. A blood glucose level of less than 10mmol/L laboratory-confirmed COVID-19 who were admitted to the COVID-19 BNT162b1... The absolute lymphocyte counts were identified in males, patients who had axillary HLNs to. Methods: Table 1 summarizes the detailed demographic and clinicobiologic characteristics and imaging... Wuhan, China: a descriptive study and ALC ) might modulate quality...
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