Cdk3-promoted epithelial-mesenchymal transition through activating AP-1 is involved in colorectal cancer metastasis.

Cyclin dependent kinase-3 (Cdk3) is a positive regulator of the G1 mammalian cell cycle phase. Cdk3 is involved in cancer progression, but very little is known about its mechanism in cancer development and progression. Herein, we found that Cdk3 increased colorectal cancer metastasis through promoting epithelial-mesenchymal transition (EMT) shift. Cdk3 was found to highly express in metastatic cancer and induce cell motility and invasion. Cdk3 was shown to phosphorylate c-Jun at Ser 63 and Ser 73 in vitro and ex vivo. Cdk3-phosphorylated c-Jun at Ser 63 and Ser 73 resulted in an increased AP-1 activity. Ectopic expression of Cdk3 promoted colorectal cancer from epithelial to mesenchymal transition conjugating AP-1 activation, while AP-1 inhibition dramatically decreased Cdk3-increased EMT shift. These results showed that the Cdk3/c-Jun signaling axis mediating epithelial-mesenchymal transition plays an important role in colorectal cancer metastasis.

[Multidrug-resistant Acinetobacter Baumannii infection in Intensive Care Unit: A retrospective analysis].

OBJECTIVE: To analyze the clinical characteristics of patients with bloodstream Acinetobacter baumannii infection in Intensive Care Unit (ICU).
 METHODS: Eighty-three ICU patients with bloodstream Acinetobacter baumannii infection from January 2012 to March 2015 were retrospectively analyzed, including infection-related risk factors, drug-resistant bacteria, treatments and prognosis.
 RESULTS: Among 83 patients, 60 patients (72.29%) were male, 23 (27.71%) were female. The youngest patient was 40 days old, the oldest was 92 years old, the age was (46.23±19.22) years old. In total, there were 20 patients (24.10%) with plural bacterial infection in blood, 60 (72.29%) with more than 3 kinds of disorders, 52 patients suffered homologous bacterial infection in blood and other organs. Among these cases, lower respiratory tract had the highest percentage of homologous bacteria (29 cases), followed by catheter (11 cases), wound secretion (8 cases), cerebrospinal fluid (3 cases) and ascites (1 case). The risk factors of bloodstream infection by Acinetobacter baumannii included catheterization, serious primary disease and basic disease, usage of corticosteroids, surgery and invasive operation and so on. Acinetobacter baumannii were highly resistant. Most of them were multi-drug resistance, and some were pan-drug resistance. It showed more than 80% drug resistant rate to antibiotics except sulbactam, cefopcrazone and amikacin. Among 83 patients, 55 cases (66.26%) were dead, 25 cases (30.12%) were improved and 3 cases (3.62%) were cured.
 CONCLUSION: Acinetobacter baumannii are highly and multidrug-resistant to commonly used antibiotics. Patients in ICU suffering serious basic diseases should be shorten hospitalization time, restricted the use of breathing machine and immunosuppressant. It must carry out disinfection for invasive operation to reduce the risk of bloodstream infections, and the abuse of antibiotics must be avoided to slow bacteria resistance.

Dinitrosopiperazine-mediated phosphorylated-proteins are involved in nasopharyngeal carcinoma metastasis.

N,N'-dinitrosopiperazine (DNP) with organ specificity for nasopharyngeal epithelium, is involved in nasopharyngeal carcinoma (NPC) metastasis, though its mechanism is unclear. To reveal the pathogenesis of DNP-induced metastasis, immunoprecipitation was used to identify DNP-mediated phosphoproteins. DNP-mediated NPC cell line (6-10B) motility and invasion was confirmed. Twenty-six phosphoproteins were increased at least 1.5-fold following DNP exposure. Changes in the expression levels of selected phosphoproteins were verified by Western-blotting analysis. DNP treatment altered the phosphorylation of ezrin (threonine 567), vimentin (serine 55), stathmin (serine 25) and STAT3 (serine 727). Furthermore, it was shown that DNP-dependent metastasis is mediated in part through ezrin at threonine 567, as DNP-mediated metastasis was decreased when threonine 567 of ezrin was mutated. Strikingly, NPC metastatic tumors exhibited a higher expression of phosphorylated-ezrin at threonine 567 than the primary tumors. These findings provide novel insight into DNP-induced NPC metastasis and may contribute to a better understanding of the metastatic mechanisms of NPC tumors.

Identification of novel signaling components in N,N'-dinitrosopiperazine-mediated metastasis of nasopharyngeal carcinoma by quantitative phosphoproteomics.

BACKGROUND: Nasopharyngeal carcinoma (NPC) is a highly invasive and metastatic cancer. N,N'-dinitrosopiperazine (DNP), a carcinogen with specificity for nasopharyngeal epithelium, facilitates NPC metastasis. However, the underlying mechanism is not known. METHODS: Quantitative phosphoproteomics, using stable isotope labeling of amino acids in cell cultures, was employed to identify phosphoproteins associated with NPC metastasis mediated by DNP. NPC cell line 6-10B, which is relatively less metastatic, was used to investigate DNP-mediated metastasis. Boyden chamber invasion assay was used to measure DNP-induced motility and invasion, and nude mice were used to verify DNP-mediated metastasis in vivo. Several different phosphoproteins detected by proteomics analysis were verified by immunoblotting. DNP-mediated metastasis facilitated by lysine-rich CEACAM1 co-isolated protein (LYRIC) phosphorylation at serine 568 was confirmed using mutations targeting the phosphorylation site of LYRIC. DNP-mediated metastasis through LYRIC phosphorylation was confirmed in the NPC cell line CNE1. DNP-mediated LYRIC phosphorylation at serine 568 was also verified in metastatic tumors of BABL/c nude mice. RESULTS: Boyden chamber invasion assay indicated that DNP mediated cell motility and invasion of NPC cell 6-10B in vitro, and experiments with nude mice indicated that DNP increased 6-10B metastasis in vivo. In the phosphoproteomics analysis, we detected 216 phosphorylation sites on 130 proteins; among these, 48 phosphorylation sites on 30 unique phosphopeptides were modulated by DNP by at least 1.5-fold. DNP mediated the expression of phosphorylated GTPase, ferritin, LYRIC, and RNA polymerase, and it decreased the expression of phosphorylated torsin-1A protein 1. Furthermore, DNP induced LYRIC phosphorylation at serine 568 to facilitate cell motility and invasion, whereas DNP-mediated motility and invasion was decreased when serine 568 in LYRIC was mutated. In another NPC cell line, CNE1, DNP also mediated cell motility and invasion followed by enhanced phosphorylation of LYRIC at serine 568. Finally, phosphorylated-LYRIC expression at serine 568 was significantly increased in metastatic tumors induced by DNP. CONCLUSION: DNP regulates multiple signaling pathways through protein phosphorylation, including the phosphorylation of LYRIC at serine 568, and mediates NPC metastasis. These findings provide insights on the complexity and dynamics of DNP-facilitated metastasis, and may help to gain a better understanding of the mechanisms by clarifying NPC-induced metastasis.

N,N'-dinitrosopiperazine-mediated AGR2 is involved in metastasis of nasopharyngeal carcinoma.

Nasopharyngeal carcinoma (NPC) has a high metastatic character in the clinic, but its mechanism is not clear. As a carcinogen with organ specificity for the nasopharyngeal epithelium, N,N'-Dinitrosopiperazine (DNP) is involved in NPC metastasis. Herein, our data revealed that anterior gradient 2 (AGR2) was overexpressed in human NPC tissues, particularly in cervical lymph node metastatic NPC (LMNPC). High AGR2 expression was associated with NPC metastasis. Importantly, DNP induced AGR2 expression, and increased cell motility and invasion in the NPC cell line 6-10B. However, DNP-mediated cell motility and invasion was dramatically decreased when transfected with siRNA-AGR2. Further, AGR2 directly regulated cathepsin (CTS) B and D by binding them in vitro. These results indicate that DNP induces AGR2 expression, regulates CTSB and CTSD, increases cell motility and invasion, and promotes NPC tumor metastasis. Therefore, DNP-mediated AGR2 expression may be an important factor in prolific NPC metastasis.

N,N'-dinitrosopiperazine--mediated heat-shock protein 70-2 expression is involved in metastasis of nasopharyngeal carcinoma.

N,N'-Dinitrosopiperazine (DNP) is invovled in nasopharyngeal carcinoma (NPC) development and metastasis, and it shows organ specificity to the nasopharyngeal epithelium. Herein, we demonstrate that DNP induces heat-shock protein (HSP) 70-2 expression in NPC cells (6-10B) at a non-cytotoxic concentration. DNP induced HSP70-2 expression in a dose- and time- dependent manner, but showed no effect on other HSP70 family members. Furthermore, DNP also increased HSP70-2 RNA transcription through directly binding to the hypoxia-responsive elements (HRE) and heat shock elements (HSE) located in the HSP70-2 promoter. DNP-mediated HSP70-2 expression might act through enhancing the transcription of HSP70-2 RNA. Importantly, DNP induced motility and invasion of 6-10B cells dose- and time-dependently, and DNP-mediated NPC metastasis was confirmed in nude mice, which showed high HSP70-2 expression in the metastatic tumor tissue. However, the motility and invasion of NPC cells that were stably transfected using short interfering RNA against HSP70-2 could not effectively induce DNP. These results indicate that DNP induces HSP70-2 expression through increasing HSP70-2 transcription, increases the motility and invasion of cells, and promotes NPC tumor metastasis. Therefore, DNP mediated HSP70-2 expression may be an important factor of NPC-high metastasis.

Proteomic analysis on N, N'-dinitrosopiperazine-mediated metastasis of nasopharyngeal carcinoma 6-10B cells.

BACKGROUND: Nasopharyngeal carcinoma (NPC) has a high metastatic feature. N,N'-Dinitrosopiperazine (DNP) is involved in NPC metastasis, but its mechanism is not clear. The aim of this study is to reveal the pathogenesis of DNP-involved metastasis. 6-10B cells with low metastasis are from NPC cell line SUNE-1, were used to investigate the mechanism of DNP-mediated NPC metastasis. RESULTS: 6-10B cells were grown in DMEM containing 2H4-L-lysine and 13C 6 15 N4-L-arginine or conventional L-lysine and L-arginine, and identified the incorporation of amino acid by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Labeled 6-10B cells were treated with DNP at 0 -18 µM to establish the non-cytotoxic concentration (NCC) range. NCC was 0 -10 µM. Following treatment with DNP at this range, the motility and invasion of cells were detected in vitro, and DNP-mediated metastasis was confirmed in the nude mice. DNP increased 6-10B cell metastasis in vitro and vivo. DNP-induced protein expression was investigated using a quantitative proteomic. The SILAC-based approach quantified 2698 proteins, 371 of which showed significant change after DNP treatment (172 up-regulated and 199 down-regulated proteins). DNP induced the change in abundance of mitochondrial proteins, mediated the status of oxidative stress and the imbalance of redox state, increased cytoskeletal protein, cathepsin, anterior gradient-2, and clusterin expression. DNP also increased the expression of secretory AKR1B10, cathepsin B and clusterin 6-10B cells. Gene Ontology and Ingenuity Pathway analysis showed that DNP may regulate protein synthesis, cellular movement, lipid metabolism, molecular transport, cellular growth and proliferation signaling pathways. CONCLUSION: DNP may regulate cytoskeletal protein, cathepsin, anterior gradient-2, and clusterin expression, increase NPC cells motility and invasion, is involved NPC metastasis.

Identification of aberrantly expressed miRNAs in rectal cancer.

Disturbance of miRNA expression may play a key role in the initiation and progression of colorectal cancer (CRC). CRC should be viewed as a heterogeneous disease, but previous studies have only screened dysregulated miRNAs in CRC from a panel of 96, 145, 287 and 455 miRNAs, respectively. It is necessary to identify new aberrantly expressed miRNAs in rectal cancer. In this study tissue samples were derived from patients undergoing a surgical procedure to remove a portion of cancers. The expression profile of 904 miRNAs was analyzed using a miRCURY™ LNA Array from 6-paired rectal cancers and normal tissues. The expression levels of 4 miRNAs were compared by real-time PCR between colon and rectal cancer, and also the expression levels of metastatic miRNAs in different stages of rectal cancer were analyzed. We found that 67 miRNA precursors are upregulated in rectal cancer (p<0.05) and 21 of those have never been reported in colorectal cancer (CRC); 39 miRNA precursors are downregulated (p<0.05) and 24 novel dysregulated miRNAs were identified in rectal cancer. miR-31, miR-126 and miR-143 are differentially expressed between colon cancer and rectal cancer. Here, we report an miRNA profile of rectal cancer, and we identified differential expression patterns of miRNAs between rectal and colon cancers. This novel information may suggest the potential roles of these miRNAs in the diagnosis of rectal cancer.

Baicalein mediates inhibition of migration and invasiveness of skin carcinoma through Ezrin in A431 cells.

BACKGROUND: Ezrin is highly expressed in skin cancer and promotes tumor metastasis. Ezrin serves as a promising target for anti-metastasis therapy. The aim of this study is to determine if the flavonoid bacailein inhibits the metastasis of skin cancer cells through Ezrin. METHODS: Cells from a cutaneous squamous carcinoma cell line, A431, were treated with baicalein at 0-60 µM to establish the non-cytotoxic concentration (NCC) range for baicalein. Following treatment with baicalein within this range, total Ezrin protein (both phosphorylated and unphosphorylated forms) and phosphorylated-Ezrin (phos-Ezrin) were detected by western blotting, and Ezrin RNA was detected in A431 cells using reverse transcription-polymerase chain reaction (RT-PCR). Thereafter, the motility and invasiveness of A431 cells following baicalein treatment were determined using wound-healing and Boyden chamber invasion assays. Short-interfering RNA (si-RNA) specifically targeting Ezrin was transfected into A431 cells, and a si-RNA Ezrin-A431 cell line was established by G418 selection. This stable cell line was transiently transfected with Ezrin and mutant Ezrin plasmids, and its motility and invasiveness was subsequently determined to clarify whether bacailein inhibits these processes through Ezrin. RESULTS: We determined the range of NCCs for baicalein to be 2.5-40 µM in A431 cells. Baicalein displayed a dose- and time-dependent inhibition of expressions of total Ezrin and phos-Ezrin within this range NCCs. In addition, it exerted this inhibitory effect through the reduction of Ezrin RNA transcript. Baicalein also inhibited the motility and invasiveness of A431 skin carcinoma cells within the range of NCCs, in a dose- and time-dependent manner. A431 cell motility and invasiveness were inhibited by 73% and 80% respectively when cells were treated with 20 µM baicalein. However, the motility and invasiveness of A431 cells containing the Ezrin mutant were not effectively inhibited by baicalein. CONCLUSIONS: Baicalein reduces the migration and invasiveness of A431 cells through the inhibition of Ezrin expression, which leads to the suppression of tumor metastasis.

N,N'-dinitrosopiperazine-mediated ezrin protein phosphorylation via activation of Rho kinase and protein kinase C is involved in metastasis of nasopharyngeal carcinoma 6-10B cells.

N,N'-Dinitrosopiperazine (DNP) is a carcinogen for nasopharyngeal carcinoma (NPC), which shows organ specificity to nasopharyngeal epithelium. Herein, we demonstrate that DNP induces fiber formation of NPC cells (6-10B) and also increases invasion and motility of 6-10B cells. DNP-mediated NPC metastasis also was confirmed in nude mice. Importantly, DNP induced the expression of phosphorylated ezrin (phos-ezrin) at threonine 567 (Thr-567) dose- and time-dependently but had no effect on the total ezrin expression at these concentrations. Furthermore, DNP-induced phos-ezrin expression was dependent on increased Rho kinase and protein kinase C (PKC) activity. DNP may activate Rho kinase through binding to its pleckstrin homology and may activate PKC through promoting its translocation to the plasma membrane in vivo. DNP-induced phos-ezrin was associated with induction of fiber growth in 6-10B cells. However, DNP could not induce motility and invasion of NPC cells containing ezrin mutated at Thr-567. Similarly, DNP could not induce motility and invasion of the cells containing siRNAs against Rho or PKC. These results indicate that DNP induces ezrin phosphorylation at Thr-567, increases motility and invasion of cells, and promotes tumor metastasis. DNP may be involved in NPC metastasis through regulation of ezrin phosphorylation at Thr-567.

Berberine inhibits the invasion and metastasis of nasopharyngeal carcinoma cells through Ezrin phosphorylation.

OBJECTIVE: To determine the molecular mechanism of berberine (BBR) inhibiting the metastasis and invasion of nasopharyngeal carcinoma 5-8F cells, and identify whether berberine suppresses the tumor-invasive action through inhibiting Ezrin or phosphate-Ezrin. METHODS: The non-cytotoxic concentration of berberine was detected by MTT assay. Filopodia formation of 5-8F cells was observed by electron microscope. The invasion and motility of 5-8F cells with berberine treatment were measured with Trans-well assay. Western blot was used to investigate the Ezrin and phos-Ezrin expression in 5-8F cells treated by berberine. pcDNA3.1-Ezrin and pcDNA3.1-Ezrin M were transfected into 6-10B cells. The inhibitory effect of berberine on the motility and invasion of 6-10B-pcDNA3.1-Ezrin and 6-10B-pcDNA3.1-Ezrin M was detected, respectively. RESULTS: Berberine non-cytotoxic concentration was 0-40 µmol/L. After being treated by berberine, filopodia of 5-8F cells obviously reduced, and the permeating artificial basement membrane cells largely decreased in both time- and concentration-dependent manner. There was significant difference compared with the control group (P<0.05). Berberine suppressed the phos-Ezrin expression of 5-8F cells in both time- and concentration-dependent manner (P<0.05), but the effect of berberine was weaker on 6-10B-pcDNA3.1-Ezrin M than on 6-10B-pcDNA3.1-Ezrin. CONCLUSION: Berberine inhibits nasopharyngeal carcinoma cell invasion through inhibiting phos-Ezrin expression and filopodia formation.

Novel potential markers of nasopharyngeal carcinoma for diagnosis and therapy.

OBJECTIVE: To search for markers of nasopharyngeal carcinoma (NPC) for diagnosis. DESIGN AND METHODS: Using gas chromatography and mass spectrometry, we evaluated 51 serum metabolites in 49 NPC, 37 throat cancer patients and 40 healthy controls. High metabolites were selected and confirmed in NPC tissues. Sensitivity and specificity were appraised for 53 NPC diagnoses. RESULTS: Metabolic profiling revealed that kynurenine, N-acetylglucosaminylamine, N-acetylglucosamine and hydroxyphenylpyruvate increased in NPC patient sera. Their sensitivity and specificity were respectively 79% and 71%, 78% and 69%, 83% and 68%, 84% and 73% for NPC diagnosis. These increases were confirmed in NPC cells. Four metabolites gradually increased from stage I to stage III. After radiotherapy, four metabolites decreased gradually, and tended to a normal level, and were associated with rate of tumor reduction. CONCLUSION: The results reveal that kynurenine, N-acetylglucosaminylamine, N-acetylglucosamine and hydroxyphenylpyruvate are potentially markers of NPC for diagnosis and therapy.

[Association of CK20 expression with the progression, metastasis and prognosis of breast cancer].

AIM: To analyze the expression of CK20 in human breast cancer, and to evaluate the association between its expression and tumor's progression and prognosis. METHODS: 86 cases with breast cancer, 20 cases of benign tumor tissues were examined for the expression of CK20 by immunohistochemical staining. RESULTS: The positive rate of CK20 expression in breast cancer was 80.23% (69/86), which was significantly higher than that in benign tumor tissues of breast [20.00% (4/20), P<0.01]. CK20 expression was associated with the histologic grades (P<0.05) and the pathological types (P<0.01). The expression of CK20 was observed to correlate positively with TNM stages (r=0.86, P<0.05), lymph node status (r=0.73, P<0.05) and HER-2 status (r=0.69, P<0.05), and correlate negatively with ER status (r=-0.58, P<0.05). Moreover, Kaplan Meier curves of overall survival analysis showed a significant difference between CK20 positive groups and negative group (P<0.01). CONCLUSION: The results suggest that the expression of CK20 may be associated with the progression and prognosis of breast cancer.

Berberine inhibits metastasis of nasopharyngeal carcinoma 5-8F cells by targeting Rho kinase-mediated Ezrin phosphorylation at threonine 567.

Ezrin is highly expressed in metastatic tumors and is involved in filopodia formation as well as promotion of tumor metastasis. Thus, Ezrin may serve as a potential target for anti-metastatic therapy. This study demonstrates that berberine reduces filopodia formation of a nasopharyngeal carcinoma (NPC) cell line, 5-8F, at non-cytotoxic concentrations. Furthermore, invasion and motility of 5-8F cells are decreased in a dose- and time-dependent manner, resulting in 73.0% invasion and 67.0% motility inhibition at 20 mum. The inhibitory effects of berberine on 5-8F cell metastasis were further confirmed in a mouse model of metastasis. Berberine treatment in vivo resulted in a 51.1% inhibition of tumor metastasis to the lymph nodes and decreased Ezrin phosphorylation at threonine 567 in metastatic samples. Berberine suppressed the presence of phosphorylated Ezrin (phospho-Ezrin) in a dose- and time-dependent manner but had no effect on total Ezrin protein expression at non-cytotoxic concentrations. Furthermore, the inhibitory effects of berberine on phospho-Ezrin were dependent on the suppression of Rho kinase activity. Reduction of Ezrin phosphorylation at Thr(567) by berberine was associated with its inhibitory effect on filopodia formation in 5-8F cells. However, berberine did not effectively inhibit the motility and invasion of NPC cells containing Ezrin Thr(567) mutants. These results confirm that berberine inhibits Ezrin phosphorylation at Thr(567). Nonetheless, berberine reduces motility and invasion of cells and inhibits tumor metastasis. The reduction of Rho kinase-mediated Ezrin phosphorylation mediated by berberine may be a novel anti-metastatic pathway in NPC 5-8F cells.

HSP70 and mucin 5B: novel protein targets of N,N'-dinitrosopiperazine-induced nasopharyngeal tumorigenesis.

N,N'-Dinitrosopiperazine (DNP) induces nasopharyngeal carcinoma (NPC) and shows organ specificity to the nasopharyngeal epithelium. To investigate its mechanism, the rat NPC model was induced using DNP. Rat NPC and normal nasopharyngeal cells were obtained from the NPC model using laser capture. The total proteins from these cell samples were separated with two-dimension polyacrylamide gel electrophoresis techniques, and highly expressed proteins (> five-fold) were analyzed using matrix-assisted laser desorption/ionization time of flight and bioinformatics. The results showed that HSP70 and mucin 5B expression increased not only in rat NPC but also in atypical hyperplasia nasopharyngeal tissues, a precancer stage of NPC. High-expression of heat shock protein 70 (HSP70) and mucin 5B was further supported by western blot analysis. The immunofluorescence and western-blotting studies further showed that DNP induced the expression of HSP70 and mucin 5B in a dosage-dependent manner in normal nasopharyngeal epithelia cells. Our data indicate that DNP triggers over-expression of HSP70 and mucin 5B, and is involved in nasopharyngeal tumorigenesis. HSP70 and mucin 5B may be important targets in nasopharyngeal tumorigenesis induced by DNP.

Prediction of prognosis in gallbladder carcinoma by CD147 and MMP-2 immunohistochemistry.

AIM: To investigate whether the presence of CD147 and MMP-2 in cancerous gallbladder tissues might help us to predict the patients' prognosis. METHODS: Tissue samples from 168 patients with gallbladder carcinomas and 37 patients with chronic cholecystitis were stained with anti-CD147 and anti-MMP-2 antibodies for immunohistochemical analysis. Then, the association of their expression with clinicopathologic characteristics and 108 patients' prognosis was analyzed. RESULTS: CD147 and MMP-2 were detected mainly in cancerous tissues, but also expressed in some chronic cholecystitis patients. Out of 168 patients with gallbladder carcinoma 121 (72.02%) and 136 (80.95%) patients showed CD147 and MMP-2 positive expression, whereas the 37 patients with chronic cholecystitis only 5 (13.51%) and 3 (8.11%) patients expressed them, respectively. Pathologic findings demonstrated that the intensity of CD147 and MMP-2 staining in cancerous tissues was associated significantly with histological types (P = 0.03), distant metastasis (P < 0.01), and Nevin stages (P = 0.02) of gallbladder carcinomas. Using a proportional hazard model, the survival rate of the patients with CD147+/MMP-2+ expression was the lowest (P < 0.01), and including information on CD147 and MMP-2 staining patterns within cancerous tissues along with clinical cancer staging may improve the accuracy of predicting patients' prognosis. CONCLUSION: The results suggest that the expression of CD147 and MMP-2 may be an important feature of gallbladder carcinomas. The detection of these two markers combined with cancerous staging may increase the ability of investigators to predict the prognosis of patients with gallbladder carcinomas.