Change in pitching biomechanics in the late-inning in Taiwanese high school baseball pitchers.

Repetitive overhead throwing may result in overuse injuries and a change in the pitching mechanics of a baseball pitcher. Accordingly, the purpose of this study is to quantify the changes in the muscle strength and pitching motion kinematics in the late-innings stage of a baseball game. Sixteen healthy baseball pitchers (16.77 ± 0.73 years) recruited from a high school, which won the National High School Baseball Championship in Taiwan in 2011; each performed 100 pitches in a bullpen throwing session. Isometric muscle strength measurements and joint kinematic data were obtained before and after the throwing session. The mean Borg's Rating of Perceived Exertion index was found to have a value of 14.14, indicating a medium-to-large degree of perceived tiredness. The results showed that the ball velocity and horizontal abduction angle decreased significantly as the pitchers became tired. Moreover, the upper torso forward tilt and knee flexion angle both increased significantly at the moment of ball release. Finally, the muscle strength of the upper extremity remained decreased 2 days after the bullpen throwing session. Overall, the results suggest that an adequate amount of rest and specific strengthening programs for the shoulder external rotator, shoulder internal rotator, shoulder flexor, shoulder extensor, shoulder adductor, and shoulder abductor muscles are recommended to the coaches and for adolescent baseball pitchers. In addition, the changes in pitching mechanics noted in this study should be carefully monitored during the course of a baseball game to minimize the risk for overuse injuries.

Elbow joint fatigue and bench-press training.

CONTEXT: Bench-press exercises are among the most common form of training exercise for the upper extremity because they yield a notable improvement in both muscle strength and muscle endurance. The literature contains various investigations into the effects of different bench-press positions on the degree of muscle activation. However, the effects of fatigue on the muscular performance and kinetics of the elbow joint are not understood fully. OBJECTIVE: To investigate the effects of fatigue on the kinetics and myodynamic performance of the elbow joint in bench-press training. DESIGN: Controlled laboratory study. SETTING: Motion research laboratory. PATIENTS OR OTHER PARTICIPANTS: A total of 18 physically healthy male students (age = 19.6 ± 0.8 years, height = 168.7 ± 5.5 cm, mass = 69.6 ± 8.6 kg) participated in the investigation. All participants were right-hand dominant, and none had a history of upper extremity injuries or disorders. INTERVENTION(S): Participants performed bench-press training until fatigued. MAIN OUTCOME MEASURE(S): Maximal possible number of repetitions, cycle time, myodynamic decline rate, elbow-joint force, and elbow-joint moment. RESULTS: We observed a difference in cycle time in the initial (2.1 ± 0.42 seconds) and fatigue (2.58 ± 0.46 seconds) stages of the bench-press exercise (P = .04). As the participants fatigued, we observed an increase in the medial-lateral force (P = .03) and internal-external moment (P ≤ .04) acting on the elbow joint. Moreover, a reduction in the elbow muscle strength was observed in the elbow extension-flexion (P ≤ .003) and forearm supination-pronation (P ≤ .001) conditions. CONCLUSIONS: The results suggest that performing bench-press exercises to the point of fatigue increases elbow-joint loading and may further increase the risk of injury. Therefore, when clinicians design bench-press exercise regimens for general athletic training, muscle strengthening, or physical rehabilitation, they should control carefully the maximal number of repetitions.

Effect of forearm axially rotated posture on shoulder load and shoulder abduction / flexion angles in one-armed arrest of forward falls.

BACKGROUND: Falling onto the outstretched hand is the most common cause of upper extremity injury. This study develops an experimental model for evaluating the shoulder load during a simulated forward fall onto one hand with three different forearm axially rotated postures, and examines the shoulder abduction angle and shoulder flexion angle in each case. METHODS: Fifteen healthy young male subjects with an average age of 23.7 years performed a series of one-armed arrests from a height of 5 cm onto a force plate. The kinematics and kinetics of the upper extremity were analyzed for three different forearm postures, namely 45° externally rotated, non-rotated, and 45° internally rotated. FINDINGS: The shoulder joint load and shoulder abduction/flexion angles were significantly dependent on the rotational posture of the forearm. The shoulder medio-lateral shear forces in the externally rotated group were found to be 1.61 and 2.94 times higher than those in the non-rotated and internally rotated groups, respectively. The shoulder flexion angles in the externally rotated, non-rotated and internally rotated groups were 0.6°, 8.0° and 19.2°, respectively, while the corresponding shoulder abduction angles were 6.1°, 34.1° and 46.3°, respectively. INTERPRETATION: In falls onto the outstretched hand, an externally rotated forearm posture should be avoided in order to reduce the medio-lateral shear force acting on the shoulder joint. In falls of this type, a 45° internally rotated forearm posture represents the most effective fall strategy in terms of minimizing the risk of upper extremity injuries.

Molecular analysis of secondary kinase mutations in imatinib-resistant gastrointestinal stromal tumors.

Most gastrointestinal stromal tumors (GISTs) are associated with activating kinase mutation in KIT or platelet-derived growth factor receptor alpha (PDGFRA) gene, and imatinib has revolutionized the care of advanced GISTs. However, most patients gradually developed resistance to imatinib. We intend to identify the secondary kinase mutations in imatinib-resistant GISTs and to study the relationship between secondary kinase mutations and the clinical response to imatinib. Twelve advanced GIST patients, who have developed resistance to imatinib were included in this study. Paraffin-embedded pretreatment GIST specimens and progression lesions of the tumors after resistance to imatinib were analyzed for kinase mutations in exons 9, 11, 13, and 17 of KIT gene and exons of 10, 12, 14, and 18 of PDGFRA gene. Primary KIT mutations have been found in all but one of the primary tumors including one case harboring de novo double KIT exon 11 mutations. Secondary kinase mutations in KIT and PDGFRA were found in seven and 1 of 12 patients, respectively. Two patients harbored more than one secondary KIT mutations in different progression sites, and there are four types of clonal or polyclonal evolution being observed. The secondary PDGFRA exon 14 mutation H687Y is a novel mutation that has never been reported before. Acquired secondary kinase mutations are the most important cause of secondary imatinib resistance in advanced GISTs. The identification of secondary kinase mutations is important in the development of new therapeutic strategies.

Lack of prognostic value of EGFR mutations in primary resected non-small cell lung cancer.

PURPOSE: To investigate the prognostic value of epidermal growth factor receptor (EGFR) mutations in a series of Taiwanese patients with primary resected lung adenocarcinomas never treated with epidermal growth factor receptor tyrosine kinase (TK) inhibitor. PATIENTS AND METHODS: A total of 27 of 35 patients whose EGFR mutational status in exons 18, 19, and 21 of the TK domain had been previously determined using nested polymerase chain reaction (PCR) were included in this retrospective study. All 27 patients underwent potentially curative pulmonary resection. Clinicopathological information was obtained from patient records and pathology reports. Disease-free survival (DFS) and overall survival (OS) of patients were estimated with the Kaplan-Meier method, and Cox regression model was used for multivariate analysis. RESULTS: Heterozygous EGFR mutations were detected in 15 of 27 patients (55.5%). There was no significant difference in DFS between patients with wild-type EGFR (median, 16.87 months) and mutant EGFR (median, 18.13 months; P = 0.83). No significant difference in OS was also noted between the wild-type and mutant groups (P = 0.45, median follow-up 22.6 months). Cox regression model and multivariate analysis of survival difference by age, stage, histology, and adjuvant treatment did not reach statistical significance. CONCLUSION: EGFR mutations do not have significant prognostic value in primary resected non-small cell lung cancer (NSCLC), and further well-designed large prospective studies are warranted to determine the prognostic value of EGFR mutations in NSCLC.

Downregulation of c-Myc is critical for valproic acid-induced growth arrest and myeloid differentiation of acute myeloid leukemia.

Valproic acid (VPA), an agent used for neurological disorders, has been shown to be a novel class of histone deacetylase inhibitor (HDACI), able to induce apoptosis and myeloid differentiation of acute myeloid leukemia (AML). In this study, we examined the underlying mechanisms in VPA-mediated activities in AML cells. VPA not only inhibited the growth of HL-60, U937 and NB4 cells by causing cell-cycle arrest at G(0)/G(1) phase and apoptosis, but also induced morphologic and phenotypic changes. VPA markedly increased p21WAF1, and downregulated c-Myc expression at transcriptional levels. Ectopic expression of wildtype c-Myc and T58A mutant significantly inhibited VPA-mediated growth inhibition. As with results from cell line studies, VPA also downregulated c-Myc levels, and induced apoptosis and myeloid differentiation of primary AML cells, leading to decreased colony-forming ability. Given the role of c-Myc in leukemogenesis, our study suggests that VPA might be a potential therapeutic agent for AML.

A small-molecule c-Myc inhibitor, 10058-F4, induces cell-cycle arrest, apoptosis, and myeloid differentiation of human acute myeloid leukemia.

OBJECTIVE: The protooncogene c-Myc plays an important role in the control of cell proliferation, apoptosis, and differentiation, and its aberrant expression is frequently seen in multiple human cancers, including acute myeloid leukemia (AML). As c-Myc heterodimerizes with Max to transactivate downstream target genes in leukemogenesis. Inhibition of the c-Myc/Max heterodimerization by the recently identified small-molecule compound, 10058-F4, might be a novel antileukemic strategy. MATERIALS AND METHODS: HL-60, U937, and NB4 cells and primary AML cells were used to examine the effects of 10058-F4 on apoptosis and myeloid differentiation. RESULTS: We showed that 10058-F4 arrested AML cells at G0/G1 phase, downregulated c-Myc expression and upregulated CDK inhibitors, p21 and p27. Meanwhile, 10058-F4 induced apoptosis through activation of mitochondrial pathway shown by downregulation of Bcl-2, upregulation of Bax, release of cytoplasmic cytochrome C, and cleavage of caspase 3, 7, and 9. Furthermore, 10058-F4 also induced myeloid differentiation, possibly through activation of multiple transcription factors. Similarly, 10058-F4-induced apoptosis and differentiation could also be observed in primary AML cells. CONCLUSION: Our study has shown that inhibition of c-Myc/Max dimerization with small-molecule inhibitors affects multiple cellular activities in AML cells and represents a potential antileukemic approach.

Clinical implications of C-kit gene mutation in patients with large gastrointestinal stromal tumors.

BACKGROUND AND AIM: To evaluate the clinical implications of C-kit gene mutation in patients with gastrointestinal stromal tumors (GIST) greater than 10 cm in size. METHODS: All cases of pathologically diagnosed GIST with positive CD117 immunostaining from one hospital were retrospectively reviewed. Tissue from the 25 patients with tumors greater than 10 cm in diameter were collected and DNA was extracted. Exons 9, 11, and 13 of the C-kit gene were analyzed and the mutations compared with the clinical and pathological characteristics of the corresponding tumors. RESULTS: Of the 25 tumors studied, 16 had C-kit gene mutations and nine did not. Of the 16 with mutations, there were four with exon 9 mutations, 12 with exon 11 mutations, and none with exon 13 mutations. Gene mutations were more frequent in male than female patients (12/13, 92% vs 4/12, 33%). There were no significant differences in age, resectability, recurrence rate, tumor characteristics (ulceration, necrosis, hemorrhage and mitotic counts), or survival in patients with or without gene mutations. CONCLUSIONS: C-kit gene mutations were frequently found in patients with large GIST, more commonly in men than in women. However, the presence of a mutation was not predictive of prognosis in patients with large GIST.

Clinical outcome of primary gastric lymphoma treated with chemotherapy alone or surgery followed by chemotherapy.

BACKGROUND: The role of surgical resection in the treatment of primary gastric lymphoma (PGL) remains unclear. This retrospective study evaluated the clinical outcome of PGL treated with chemotherapy alone or surgery followed by chemotherapy. METHODS: During 1986-2003, 59 patients with PGL (other than mucosa-associated lymphoid tissue type lymphoma) were identified from hospital files. The medical records, pathologic sections, radiographic images and treatment modalities of these patients were reviewed. Patients were categorized into localized (stage IE and IIE-1) and advanced (stage IIE-2 or beyond) stage groups. Survival was estimated by the Kaplan-Meier method. RESULTS: The study included 55 patients who received treatment at the same institute. Among them, 32 had localized PGL (15 stage IE, 17 stage IIE-1) and 23 had advanced disease. The median survival of the localized stage group was not reached during a mean follow-up of 168.1 +/- 16.7 months (95% confidence interval [CI], 135.4-200.8 months), while that of the advanced stage group was 33.0 +/- 6.8 months (95% CI, 19.7-46.5; p < 0.001, log-rank test). Among patients with localized PGL, the 5-year overall survival rate of those receiving chemotherapy alone (n = 19) or combination therapy (surgery followed by chemotherapy, n = 13) was 73.4% and 87.5%, respectively (p = 0.229). The 5-year disease-free survival was 68.4% and 84.6%, respectively (p = 0.540). However, post-chemotherapy life-threatening hemorrhage occurred in five of the 32 patients (15.6%) in the localized stage group: four in the chemotherapy-alone group, and one in the combination therapy group, all of whom had failed to achieve complete response. CONCLUSION: The clinical outcome of localized PGL treated by chemotherapy alone is similar to that treated by surgery followed by chemotherapy in terms of tumor response, disease-free survival and overall survival, suggesting that surgery be reserved for those with residual tumors after chemotherapy.

Female sex and bronchioloalveolar pathologic subtype predict EGFR mutations in non-small cell lung cancer.

STUDY OBJECTIVES: The prevalence of epidermal growth factor receptor (EGFR) mutations in gefitinib-naive lung cancer patients is higher in adenocarcinomas, in women, and in Japanese. To further investigate the prevalence of EGFR mutations in relation to ethnic and geographic factors, we evaluated EGFR mutations in a series of Taiwanese patients with primary lung adenocarcinomas who had never been treated with gefitinib. DESIGN AND METHODS: We retrospectively studied 35 primary lung adenocarcinoma samples for mutations in the tyrosine kinase domain of EGFR; exons 18, 19, and 21 were analyzed by nested polymerase chain reaction and automated sequencing. Clinicopathologic information was obtained from patient records and pathology reports. Correlation between EGFR mutations and patient characteristics, including sex, smoking history, and pathologic subtypes, were evaluated by using the chi(2) test and logistic regression analysis. RESULTS: Heterozygous EGFR mutations were detected in 17 of 35 patients (48%). Missense mutations in exon 21 (13 of 17 patients, 76%) were the most frequent mutations detected. EGFR mutations were more frequent in women (13 of 18 patients [72%]) than in men (4 of 17 patients [23%]; p = 0.004), more frequent in nonsmokers (14 of 21 patients [66%]) than in current smokers (3 of 14 patients [21%]; p = 0.009), and when any degree of bronchioloalveolar carcinoma (BAC) was present (14 of 21 patients [66%]) compared with pure adenocarcinoma (3 of 14 patients [21%]; p = 0.009). Logistic regression analysis demonstrated that female gender (odds ratio [OR], 10.913; 95% confidence interval [CI], 1.778 to 66.97; p = 0.01) and BAC, including adenocarcinomas with any bronchioloalveolar features (OR, 9.708; 95% CI, 1.464 to 64.393; p = 0.019), were significantly associated with EGFR mutations. CONCLUSIONS: In our series, female sex and bronchioloalveolar pathologic subtype predicted the presence of EGFR mutations in lung adenocarcinomas, and the high frequency of EGFR mutations supports the hypothesis that genetic backgrounds and/or environmental factors may affect the pathogenesis of certain lung cancers.

Change of plasma transforming growth factor-beta1 levels in nasopharyngeal carcinoma patients treated with concurrent chemo-radiotherapy.

OBJECTIVE: Our aim was to study the correlation between plasma transforming growth factor (TGF)-beta1 level and radiation-induced mucositis and dermatitis in nasopharyngeal carcinoma (NPC) patients. METHODS: Blood samples obtained from patients treated with concurrent chemo-radiotherapy (CCRT) were divided into two groups according to the pre-treatment plasma TGF-beta1 level (> or =7.5 ng/ml as group 1 and < 7.5 ng/ml as group 2). Enzyme-linked immunosorbent assay (ELISA) was used for the measurement of the TGF-beta1 level. Radiation toxicity was evaluated according to Radiation Treatment Oncology Group criteria. Data were analyzed by the generalized estimation equation method. RESULTS: TGF-beta1 levels of group 1 patients were decreased significantly (P = 0.002) at the end of the treatment. The rate of decrease was 0.12 ng/ml per fraction (P = 0.02). The average TGF-beta1 level in patients who suffered acute radiation morbidity (grade > or =2) was significantly higher (P = 0.0057) than that of those who suffered less (grade < 2). CONCLUSION: A lower pre-treatment plasma TGF-beta1 level and the grade of radiation toxicity both appeared to contribute to the elevated plasma TGF-beta1 after CCRT.

Ultrasonography of splenic abnormalities.

AIM: This report gives a comprehensive overview of ultrasonography of splenic abnormalities. Certain ultrasonic features are also discussed with pathologic correlation. METHODS: We review the typical ultrasonic characteristics of a wide range of splenic lesions, illustrating them with images obtained in our institution from 2000 to 2003. One hundred and three patients (47 men, 56 women), with a mean age of 54 years (range 9-92 years), were found to have an abnormal ultrasonic pattern of spleen. RESULTS: We describe the ultrasonic features of various splenic lesions such as accessory spleen, splenomegaly, cysts, cavernous hemangiomas, lymphomas, abscesses, metastatic tumors, splenic infarctions, hematomas, and rupture, based on traditional gray-scale and color Doppler sonography. CONCLUSION: Ultrasound is a widely available, noninvasive, and useful means of diagnosing splenic abnormalities. A combination of ultrasonic characteristics and clinical data may provide an accurate diagnosis. If the US appearance alone is not enough, US may also be used to guide biopsy of suspicious lesions.

EGFR mutations in malignant pleural effusion of non-small cell lung cancer: a case report.

EGFR mutations have been shown to correlate with the clinical responsiveness to epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI). The detection of EGFR mutations in non-small cell lung cancer (NSCLC) is important from the perspective of targeted anticancer therapy. We report the first case showing that the status of EGFR mutations can be successfully determined in malignant pleural effusion of NSCLC using polymerase chain reaction (PCR) technique, and correlated to the clinical responsiveness to gefitinib, an EGFR-TKI. This case demonstrated the importance of molecular cytology in the era of targeted therapy.

Primary carcinoid tumor of prostate presenting with bone marrow metastases.

Primary carcinoid tumor of the prostate is a rare tumor derived from the amine precursor uptake and decarboxylation cells of the prostate. We report a case of a 71-year-old man who presented with progressive anemia due to bone marrow metastases from primary carcinoid tumor of the prostate. No other metastasis was found clinically. This pattern of metastasis is very unusual and illustrates that carcinoid tumor of the prostate may metastasize distantly without locoregional lymph node involvement. This unique case highlights the need for a multidisciplinary approach to the evaluation of a metastatic carcinoid tumor of an unknown primary and that it should include the prostate.

Neurofibromatosis with gastrointestinal stromal tumors: insights into the association.

The frequent association of stromal tumors with neurofobromatosis raises high suspicion of a possible correlation between the two entities. The aim of this study was to analyze clinicopathologic features of patients with concomitant neurofibromatosis and gastrointestinal stromal tumors and to discuss the molecular basis for their possible pathogenesis. Detailed information about clinical presentation, histology, immunostains, polymerase chain reaction amplification, and sequencing in three of our own cases was obtained. Stromal tumors presented with abdominal pain in one case and hemorrhage in another. One patient underwent surgery for malignant transformation of neurofibroma and stromal tumors were found incidentally. Stromal tumors were consistently positive for CD117, while the malignant peripheral sheath tumor was not. Mutation in the KIT juxtamembrane domain was found in one case. In this respect, some stromal tumors lack demonstrable KIT mutations but KIT remains activated. We reasoned that other mechanisms, like the Ras pathway involved in neurofibromatosis type 1, might play a role in KIT activation.

Hypersensitivity reactions to oxaliplatin: a case report and the success of a continuous infusional desensitization schedule.

Oxaliplatin is a third-generation platinum analog that is used mainly to treat advanced colorectal cancer. The reported incidence of hypersensitivity reactions to oxaliplatin, especially after multiple cycles of therapy, is less than 1%. We report a patient with metastatic colon cancer who developed a hypersensitivity reaction to oxaliplatin during the sixth cycle of combination chemotherapy with oxaliplatin, high-dose 5-fluorouracil and leucovorin. The same reaction occurred again after re-exposure to oxaliplatin 2 weeks later even with prophylactic administration of steroids and H1 antihistamines. After failing third-line treatment with oral tegafur-uracil, we desensitized the patient by using a fixed-rate 24-h continuous infusion of dilute oxaliplatin (0.15 mg/ml), in addition to steroids and H1 antihistamines. He had no hypersensitivity reaction during or after that infusion or when the same concentration was infused in the same way 2 weeks later. Because his condition subsequently deteriorated and the cancer progressed, no further oxaliplatin was given. Our experience does demonstrate, however, that a fixed-rate 24-h continuous infusion of oxaliplatin in a low concentration may prevent a hypersensitivity reaction in a previously sensitized patient.

Clinical manifestations and prognostic factors in patients with gastrointestinal stromal tumors.

AIM: To investigate the incidence of CD117-positive immunohistochemical staining in previously diagnosed gastrointestinal (GI) tract stromal tumors (GIST) and to analyze the tumors' clinical manifestations and prognostic factors. METHODS: We retrospectively reviewed 91 cases with a previous diagnosis of GI stromal tumor, leiomyoma, or leiomyosarcoma. Tissue samples were assessed with CD117, CD34, SMA and S100 immunohistochemical staining. Clinical and pathological characteristics were analyzed for prognostic factors. RESULTS: CD117 was positive in 81 (89%) of 91 tissue samples. There were 59 cases (72.8%) positive for CD34, 13 (16%) positive for SMA, and 12 (14.8%) positive for S100. There was no gender difference in patients with CD117-positive GIST. Their mean age was 65 years. There were 44 (54%) tumors located in the stomach and 29 (36%) in the small intestine. The most frequent presenting symptoms were abdominal pain and GI bleeding. The mean tumor size was 7.5 +/- 5.7 cm. There were 35 cases (43.2%) with tumors >5 cm. The tumor size correlated significantly with tumor mitotic count and resectability. Tumor size, mitotic count, and resectability correlated significantly with tumor recurrence and survival. There was recurrent disease in 39% of our patients, and their mean survival after recurrence was 16.6 months. Most recurrences were at the primary site or metastatic to the liver. Twenty-six percent of our patients died of their disease. CONCLUSION: Traditional histologic criteria are not specific enough to diagnose GIST. This diagnosis must be confirmed with CD117 immunohistochemical staining. Prognosis is dependent on tumor size, mitotic count, and resectability.

Combined effect of topical arsenic trioxide and radiation therapy on skin-infiltrating lesions of breast cancer-a pilot study.

It has been reported that arsenic trioxide (As2O3) is an apoptosis inducer and radiation sensitizer for various cancer cell lines. In this study of breast cancer patients, we examined the combined effect of topical As2O3 and radiation therapy on fungating and/or skin-infiltrating lesions of breast cancer. The dermatological, gastrointestinal, hematological, renal and hepatic toxicities of the treatment were also monitored. As2O3 gel (0.05%) was applied to tumor lesions 1 h prior to delivery of each fraction, with the gel removed about 5 min before the irradiation. Superficial radiation was delivered using an electron beam from a linear accelerator. Every week, the tumor lesions were photographed to evaluate effectiveness, and blood was sampled to monitor changes in hemogram and biochemical profile. Seven breast cancer patients with cutaneous metastasis were enrolled in this study. In terms of tumor, the rates for complete, partial response and stable disease were 42.9 (three of seven), 42.9 (three of seven) and 14.3% (one of seven), respectively. The skin pain, assessed by a visual analog scale, and secretion from all of the seven superficial and fungating wounds decreased markedly after treatment. Significant bone marrow suppression or granulocytosis was not noted. Further, changes in renal and hepatic function were also not significant. It seems reasonable to conclude that As2O3 may be an effective and safe radiosensitizer for palliative radiotherapy for skin-infiltrating lesions of breast cancer.

The correlation between CpG methylation and protein expression of P16 in oral squamous cell carcinomas.

We examined the P16 expression by immunohistochemical stain and detected the methylation by methylation specific polymerase chain reaction (MSP) in 48 primary oral squamous cell carcinoma (SCC) tissues. The results showed that 20/48 (41.7%) of cancerous tissues had CpG methylation around the promoter region, but 8/48 (17%) of the nearby non-cancerous tissues also had CpG methylation, around the promoter region. The results from immunohistochemical studies showed that reduced and heterogeneous expression of P16 were found in the tissues, which had CpG methylation around the promoter region. In conclusion, the methylation of P16 in oral SCC occurs in pre-cancerous and cancerous stage, which results in decreasing or abolishing the P16 expression, which is heterogeneous in the cancer cells.