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Background & objectives: Studies have shown that immunohistochemical (IHC) staining using epidermal growth factor receptor (EGFR) mutation specific antibodies, is an easy and cost-effective, screening method compared with molecular techniques. The purpose of present study was to assess the percentage positivity of IHC using EGFR mutation specific antibodies in lung biopsy samples from patients with primary lung adenocarcinoma (ADC). Methods: Two hundred and six biopsies of primary lung ADC were subjected to EGFR mutation specific antibodies against del E746-A750 and L858R. Detection of EGFR mutation done by high resolution melting analysis (HRM) was used as gold standard. A concordance was established between molecular and IHC results. Frequency of IHC positivity was assessed. Results: Of the 206 patients, 129 were male and 77 were female patients, with a mean age of 54.1 yr. Fifty five (26.6%) patients (36 men; 19 women) showed positivity for IHC of del E746-A750 (33) and L858R (22). HRM results were available in 14 patients which showed EGFR mutations in correspondence with del E746-750 or L858R in 64.2 per cent cases. Positive cases on HRM were further confirmed by DNA sequencing and fragment analysis. Three patients showed exon[20] variation. Two cases were negative for mutation. The genotype of del E746-750 mutation was more common than L858R. A concordance was established between molecular mutation and IHC in 85.7 per cent cases. Interpretation & conclusions: In this preliminary study from India mutation specific IHC was used for assessment of mutation status of EGFR. Although the number tested was small, a good concordance was observed between molecular EGFR mutation and IHC expression. IHC methodology is a potentially useful tool to guide clinicians for personalized treatment in lung ADC, especially where facilities for molecular analysis are not readily available and for use in small biopsies where material is scant for molecular tests.

Background Intravenous high-dose melphalan has a short half-life, and application of this single drug in MM transplant favors the use of stem cells without cryopreservation, for wider use in general and in resource-limited settings in particular. Patients and Methods Ninety-two patients with MM were given high-dose melphalan and rescued with granulocyte colony stimulating factor (G-CSF) mobilized noncryopreserved autologous PBSC, in our hospital during the past 18 years. Stem cells were mobilized with 4 days of G-CSF, harvested (median CD34 dose, 2.9 × 10 6 /kg) and then stored at 4°C in a refrigerator for a median of 2 days (range, 1-5 days) before reinfusion. Results Median time to neutrophil (> 500/mm 3 ) and platelet (> 20,000/mm 3 ) engraftment were 10 and 14 days respectively. There was no graft failure. Mucositis grade 3/4 was seen in 66 patients (72%). Transplant-related mortality at 100 days was 3.2%. The overall response to transplant was 88% and improvement compared with pretransplant status was seen in 48%. The median overall survival (OS) and progression-free survival (PFS) were 61.7 months and 35.4 months respectively; independent predictors of survival were Eastern Cooperative Oncology Group Performance Status and hemoglobin for OS and chemosensitive disease and remission status after transplant for PFS. Conclusion We conclude that high-dose chemotherapy and autologous transplant with noncryopreserved PBSC is a simple, effective, and safe method for MM with equivalent results, and that cryopreservation is not necessary. It reduces the cost of transplant and avoids dimethyl sulfoxide toxicity.

Background Significance of mutations in FLT3 and c-KIT genes in AML has been well established, but role of their coexpression has not been evaluated. The aim of this study was to evaluate clinical significance of FLT3 (CD135) and c-KIT (CD117) coexpression on myeloblasts in AML. Methods Using flow-cytometry, we prospectively observed in 115 AML patients that CD135, CD117, and CD135+CD117 coexpression was expressed in 95 (82%), 104 (90%), and 81 (70%) patients respectively. Median expression of CD135, CD117, and their co expression was used as cut off for high and low expression. Results FLT3 ITD (internal tandem duplication) was present in 20 (17%) patients. High coexpression did not correlate with FLT3 ITD (P = 0.432) and cytogenetics (P = 0.244). Out of 115 patients, 86 (74.7%) achieved remission. At median followup of 15.5 months, EFS and OS was 29% and 35%, respectively for the entire cohort. Patients with high coexpression of CD135 and CD117 in comparison to those with low coexpression had significantly inferior EFS (20% vs 38% P < 0.001) and OS (27% vs 44% P = 0.001). In step wise Cox regression multivariable analysis, hazard ratio for high hemoglobin, WBC count, and coexpression of CD135 and CD117 was 0.63, 1.73, and 2.46 respectively for EFS, and for OS only CD135+CD117 coexpression emerged as an independent predictor (hazard ratio 2.25). Conclusions This is the first study to show that high coexpression of CD135+CD117 is an independent predictor of poor outcome in AML and is easily measurable by routine diagnostic flow-cytometry. © 2013 International Clinical Cytometry Society

Invasive fungal infections (IFI) lead to morbidity and mortality in neutropenic patients and in allogenic stem cell transplantation. Serum-based fungal detection assays have limitation of specificity or sensitivity. Studies on fungal DNA detection using real-time PCR in childhood leukaemia are lacking. The aim of this study was to develop sensitive and specific diagnostic tools for IFI in paediatric acute leukaemia patients using real-time PCR. Of 100 randomised paediatric acute leukaemia patients receiving antifungal prophylaxis with voriconazole/amphotericin B, single peripheral whole blood sample in EDTA was used for Pan-AC real-time PCR assay (detects nine Candida and six Aspergillus species) in patients who failed prophylaxis due to proven, probable, possible or suspected fungal infections. PCR results were retrospectively correlated with clinical profile. Real-time PCR test was positive in 18/29 (62%) patients who failed prophylaxis. The only patient with proven IFI (mucormycosis), real-time PCR assay was negative. Real-time PCR was positive in 2/4 (50%) patients with possible and 16/24 (66.6%) suspected IFI and 5/10 (50%) patients with pneumonia. By applying method A/B, sensitivity and positive predictive value could not be commented due to unproven Aspergillus or Candida infections; specificity and negative predictive values (NPV) were 41% and 100% respectively; by method C (included episodes of possible IFI as true positive), sensitivity, specificity, PPV and NPV were 50%, 36%, 11% and 81% respectively. In those with suspected IFI, 8/24 (33.3%) were PCR negative and unnecessarily received empirical antifungal therapy (EAFT). Real-time PCR is a practical, rapid, non-invasive screening test for excluding IFI in paediatric leukaemia. The high NPV makes real-time PCR a promising tool to use this prior to initiating EAFT in antibiotic-resistant febrile neutropenic patients; this would avoid toxicity, cost and hospitalisation for EAFT (ClinicalTrials.gov identifier:NCT00624143).

Background: Invasive aspergillosis (IA) is a leading cause of mortality in acute leukemia and hematopoietic stem cell transplantation (HSCT). Aims: To determine the yield of galactomannan (GM) assay for the diagnosis of probable IA, its temporal relationship with the computed tomography (CT) scans and correlation with mortality in AL and HSCT. Patients and Methods: Consecutive neutropenic episodes (n=150) among inpatients aged ≥15 years with AL or recipients of HSCT were prospectively evaluated over 1΍ years. All patients underwent weekly serum GM assay and optical density index >0.5 for ≥2 samples was defined as positive. IA was diagnosed according to EORTC 2008 guidelines. Results: Of the 150 episodes enrolled, 43 (28.7%) were diagnosed with IA: possible 25 (16.7%), probable 17 (11.3%) and proven 1 (0.7%). The yield of GM assay in diagnosing probable IA was 17/42 (40.5%). In 88.2% of probable IA episodes, GM was positive before high-resolution CT at a median of 10 days (range 1-16). In the episodes with ≥2 samples tested, fatality was higher in those ≥2 values positive for GM, compared to the rest (31% vs. 13.2%, odd ratio 2.96, 95% CI 1.09-8.00; P=0.04). Conclusions: In AL and HSCT, GM assay could identify patients with probable IA earlier than CT chest and also predicted a higher risk of death.

BEAM (BCNU, etoposide, cytarabine, melphalan) is the most widely used high dose chemotherapy regimen for autologous transplant in lymphoid malignancies. We report our early experience with an alternative regimen LEAM where BCNU was replaced with the oral analogue CCNU (lomustine) to tide over the non-availability of BCNU. Fifty one patients of relapsed or refractory lymphoma who received BEAM (n= 34) and LEAM (n= 17) from September 2001 to February 2012 were analyzed. From October 2009 onwards LEAM was used as the conditioning regimen instead of conventional BEAM. Patients in the LEAM group had more chemorefractory disease (35% vs 9%, p = 0.045) and high risk comorbidity score (24% vs 0%, p = 0.019). Grade 3 and 4 oral mucositis (67.6% vs. 64.7%, p = 0.834) and diarrhea (47% vs. 41.1%, p = 0.691) were similar. No difference was noted between the two groups in terms of engraftment, documented infections, antibiotic use, cumulative toxicity risk, length of hospital stay and 100 day transplant related mortality. The estimated 2 year overall survival (61.7% vs. 62.7%, p = 0.928) and event free survival (44.6% vs. 41.1%, p = 0.510) of the regimens BEAM and LEAM respectively were comparable. Thus LEAM appeared equivalent to BEAM in terms of toxicity and efficacy and can be used as an alternative to BEAM.

INTRODUCTION AND AIM: Wnt signaling pathway plays a critical role in stem cell self-renewal and proliferation of leukemic stem cells and its association with the pathogenesis of acute myeloid leukemia (AML) has also been described. Beta-Catenin, a key regulator of Wnt signaling is highly expressed in cancers. Its role has been recently documented in AML however its prognostic significance in AML is not clear. The present study was carried to determine the potential prognostic implications of B-catenin expression and mutations in de novo AML patients. METHODS: We performed the gene expression of B-Catenin and its mutations analysis in exon 3. We investigated the expression of B-Catenin gene in bone marrow and/or blood samples by quantitative PCR using SYBR-Green chemistry and analysis was done by ΔΔCT Method. 18S RNA and B2M genes were used as reference genes. B-Catenin mutations analysis was by done direct DNA Sanger sequencing. RESULTS: Total 117 de novo non M3 AML patients and 40 healthy controls were included for the gene expression and analyzed for their clinicopathologic and prognostic significance. Median age for entire cohort (n = 117) was 17.0 years (Range 1-60 years) with male:female ratio of (1.8:1). FLT3-ITD mutation was positive in 11 (9.5%) patients. Only 4% of AML patients showed genetic alterations in exon 3 of B-catenin and no significant correlation with base line characteristics. B-catenin showed a significantly increased mRNA expression with a 5 fold rise as compared to healthy controls (p CONCLUSION: These results provide the evidence for WNT signaling activation existence in AML patients and suggest that B-Catenin could be the key component in the pathogenesis and can be prognostically important marker in AML. However B-catenin expression in larger cohort of samples and with longer follow-up is required to confirm our findings. Citation Format: Mohsin Maqbool, Sobuhi Iqbal, Atul Sharma, Sameer Bakhshi, Sreenivas Vishnubhatla, Ashish Datt Upadhyay, Lalit Kumar. B-Catenin gene expression and its mutations: promising and key component in the pathogenesis of acute myeloid leukemia (AML). [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3120.

BACKGROUND: Manifestation of chemotherapy (Cisplatin) resistance is an important cause of treatment failure in patients of locally advanced (FIGO stage, IIB to IVA) cervix cancer. We hypothesised that Cisplatin (CDDP) resistance might be associated with PARP-1 hyper-activation and inhibition of PARP-1 enzyme through PJ34 could sensitise cells to cisplatin mediated cytotoxicity. METHODS: We studied combined effect of “PJ34 (PARP-1 inhibitor) and CDDP” in vitro in SiHa and HeLa cell line. Cytotoxicity and cell cycle progression was determined with MTT assay and FACS analysis, respectively. Poly(ADP-ribosyl)ation was assessed by western blotting to determine PARP-1 enzymatic activity inhibition by PJ34. Statistical analysis was done by two-tailed Student t tests using GraphPad software and P-values were considered significant at RESULTS: In both cell lines, poly(ADP-ribosyl)ation was inhibited by PJ34 when used at very low concentration (≤ 3μM) and negligible band was observed at concentrations selected for further experiments. In SiHa cells, PJ34 significantly potentiated CDDP mediated cytotoxicity as assessed by MTT assay (p CONCLUSION: Suppression of PARP-1 enzymatic activity makes cervix cancer cells more sensitive toward CDDP induced toxicity. It seems to be a plausible mechanism for CDDP-resistant cancer cells to develop a dependency to PARP-1. Thus, PARP-1 enzyme inhibition could be explored as a potential therapy for treating CDDP resistance in cancer cervix. Citation Format: Minakshi Mann, S. S. Chauhan, Sunesh Kumar, Neerja Bhatla, Sameer Bakhshi, Ritu Gupta, Sobuhi Iqbal, Lalit Kumar. PJ34-mediated PARP-1 enzymatic activity inhibition in cervical cancer modulates the cellular response to cisplatin. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2152.

8050Background: In multiple myeloma (MM), a variety of genetic events have been described to be associated with disease progression. Besides, the activation of the NF-κB (nuclear factor-kappa B) pa...

7023Background: The canonical Wnt signaling plays an essential role in leukemic stem cells and regulates self-renewal and cell differention. Dysregulation of Wnt signaling activation is thought to ...

Significance of mutations in FLT3 and c-KIT genes in AML has been well established, but role of their coexpression has not been evaluated. The aim of this study was to evaluate clinical significance of FLT3 (CD135) and c-KIT (CD117) coexpression on myeloblasts in AML.Using flow-cytometry, we prospectively observed in 115 AML patients that CD135, CD117, and CD135+CD117 coexpression was expressed in 95 (82%), 104 (90%), and 81 (70%) patients respectively. Median expression of CD135, CD117, and their co expression was used as cut off for high and low expression.FLT3 ITD (internal tandem duplication) was present in 20 (17%) patients. High coexpression did not correlate with FLT3 ITD (P = 0.432) and cytogenetics (P = 0.244). Out of 115 patients, 86 (74.7%) achieved remission. At median followup of 15.5 months, EFS and OS was 29% and 35%, respectively for the entire cohort. Patients with high coexpression of CD135 and CD117 in comparison to those with low coexpression had significantly inferior EFS (20% vs 38% P0.001) and OS (27% vs 44% P = 0.001). In step wise Cox regression multivariable analysis, hazard ratio for high hemoglobin, WBC count, and coexpression of CD135 and CD117 was 0.63, 1.73, and 2.46 respectively for EFS, and for OS only CD135+CD117 coexpression emerged as an independent predictor (hazard ratio 2.25).This is the first study to show that high coexpression of CD135+CD117 is an independent predictor of poor outcome in AML and is easily measurable by routine diagnostic flow-cytometry.

Invasive fungal infections (IFI) lead to morbidity and mortality in neutropenic patients and in allogenic stem cell transplantation. Serum-based fungal detection assays have limitation of specificity or sensitivity. Studies on fungal DNA detection using real-time PCR in childhood leukaemia are lacking. The aim of this study was to develop sensitive and specific diagnostic tools for IFI in paediatric acute leukaemia patients using real-time PCR. Of 100 randomised paediatric acute leukaemia patients receiving antifungal prophylaxis with voriconazole/amphotericin B, single peripheral whole blood sample in EDTA was used for Pan-AC real-time PCR assay (detects nine Candida and six Aspergillus species) in patients who failed prophylaxis due to proven, probable, possible or suspected fungal infections. PCR results were retrospectively correlated with clinical profile. Real-time PCR test was positive in 18/29 (62%) patients who failed prophylaxis. The only patient with proven IFI (mucormycosis), real-time PCR assay was negative. Real-time PCR was positive in 2/4 (50%) patients with possible and 16/24 (66.6%) suspected IFI and 5/10 (50%) patients with pneumonia. By applying method A/B, sensitivity and positive predictive value could not be commented due to unproven Aspergillus or Candida infections; specificity and negative predictive values (NPV) were 41% and 100% respectively; by method C (included episodes of possible IFI as true positive), sensitivity, specificity, PPV and NPV were 50%, 36%, 11% and 81% respectively. In those with suspected IFI, 8/24 (33.3%) were PCR negative and unnecessarily received empirical antifungal therapy (EAFT). Real-time PCR is a practical, rapid, non-invasive screening test for excluding IFI in paediatric leukaemia. The high NPV makes real-time PCR a promising tool to use this prior to initiating EAFT in antibiotic-resistant febrile neutropenic patients; this would avoid toxicity, cost and hospitalisation for EAFT (ClinicalTrials.gov identifier:NCT00624143).

7082 Background: Data on B cell Acute Lymphoblastic leukemia (ALL) in the poor prognostic age group of > 9 years from India is minimal. Methods: This is an analysis of patients of above 9 years that were diagnosed and treated from January 2000 to December 2010 at a single institute . All patients who completed at least 4 weeks of induction therapy were analysed for various outcomes. Results: Of the 241 newly registered patients, the median age was 19 years (Range 10-78 years) with an M:F ratio of 1.9:1. Out of this 47%, 25% & 28% patients belonged to 10-18, 19-30 & > 31 years age group respectively. Twenty seven (11.6%) and 5(2%) had CSF and testicular involvement respectively. Thirty nine per cent had a total leucocyte count (TLC) of above 30x109/L. Philadelphia chromosome (Ph) positivity was seen in 27% and was equally distributed among the different age groups. Patients available for outcome analysis were 213(88.4%). Complete remission rate (CRR) was 66.6% and induction mortality was 26.3%.At a median follow up of 65.8 months 5 year leukemia free survival was 30.5%. Seventy eight (55%) patients relapsed (median relapse time of 13.5 months, range 1.7 to 53.4 months) , 55% during maintenance phase. The 5 year overall survival (OS) was 30.3% with a median OS of 15.8 months. The OS was similar in 10-18 and 19-30 age groups (5 year OS 35% vs. 27.5%, p=0.641) but it was significantly lower in >31 years (5year OS 21%, p=0.008). Apart from this, extramedullary disease, not attaining a CR in 1st induction, albumin at presentation below 3.5gm% and TLC of >100x109/L were significant poor prognostic markers for survival. Conclusions: This is a large study of B-ALL outcomes in patients above 9 years from a single center in India. Patients above 30 years had a worse prognosis while the prognosis of 10-18 and 19-30 years age group were similar. Induction mortality was higher mainly because of advanced disease and poor performance status at presentation.

Background We report the outcome of autologous stem cell transplant (ASCT) in multiple myeloma (MM) after high dose melphalan with peripheral blood stem cell (PBSC) rescue without cryopreservation in terms of feasibility, safety and 100 day morbidity and mortality. Methods Between Sept 1994 and Feb 2012 a total of 81 patients (56 males, 25 females) were treated with non cryopreserved ASCT, with conditioning regimen of high dose melphalan 140-200 mg/m2 given on day-1. PBSC was collected after G-CSF mobilization with a mean number of leukapheresis of 1.5 (range 1-3) and was stored at 40C for 1-3 days (median = 2) before reinfusion on day 0. The median MNC was 3.0 x 108/kg (range 0.99 – 8.07) and CD34 dose was 2.34 x 106/kg (range 0.18 – 7.67). Results Median age was 50 years (range 22-65). The median time from diagnosis to transplant was 12.1 months (range 4.3 - 99.9). Prior to transplant, 67 patients (83%) had chemosensitive disease (CR, VGPR, PR) and 13(16%) had chemoresistant (stable, refractory or progressive) disease. Forty five (55%) patients had an ECOG PS of 0-1. The median score for hematopoietic cell transplant comorbidity index (HCT-CI) was 0 (range 0-6). The median time to neutrophil engraftment was 10 days (range 8-27) and platelet engraftment was 14 days (range 9-38). Febrile neutropenia occurred in 98.7% patients with a clinically defined focus observed in 14.8%, microbiologically documented infection in 27.1% and fever of unknown origin in 56.7% cases. Antibiotics were used for a median of 10 days (range 5-42). Total toxicity score (sum of toxicity grades for all organs as per Seattle criteria) ranged from 0-13 (median =2) and the median length of hospital stay (LOS) was 18 days (range 12-62). Day 100 mortality was 2.4% (n = 2). Disease status post transplant was CR in 14.8%, VGPR in 60.4% and PR in 11.1% with stable or refractory disease in 8.6%. LOS significantly correlated with age ≥ 50 yrs and HCT-CI of > 0 (p = 0.028 and 0.007 respectively) but not with ECOG PS (p = 0.28). Cumulative toxicity score had no significant correlation with either age, HCT-CI or PS. Conclusion ASCT in MM using non cryopreserved PBSC graft is safe and effective. It may be a prudent alternative with potential for wider applicability. Disclosure All authors have declared no conflicts of interest.

Background The significance of the mutations in FLT3 and c-kit genes in AML has been well established but the role of their expression is not studied together. The aim of this study was to evaluate clinical significance of FLT3 (CD135) and c-kit (CD117) co-expression on myeloblasts in AML. Methods Five ml peripheral blood/bone marrow from consecutive AML patients at diagnosis from April 2008 to May 2010 was evaluated by flow-cytometry. CD135 and CD117 expression was evaluated on dim CD45 positive myeloblasts. Positive expression was considered as >20% surface antigen expression. Results During the study period, there were 115 AML patients with median age 16 years and male:female ratio 2.02:1. M2 was the most common subtype 57% (66/115) followed by M4 14% (16/115). Cytogenetically (n = 85) these patients were classified as good risk in 20 (23%), intermediate risk in 50 (59%) and poor risk in 15 (18%) patients. Flt3 internal tandem duplication was present in 20 (17%) patients. CD135 was positive in 95 (82%) patients; CD117 was positive in 104 (90%) patients; co-expression of CD135 and CD117 was observed in 74 (64%) patients. In those patients who co-expressed CD135 and CD117, the median expression was 34.1% of the gated myeloblasts and patients were classified as high co-expression (>/= 34.1% expression) and low ( Conclusion High co-expression of proliferative markers CD135 and CD117 is an independent prognostic factor for poor outcome in AML. Disclosure All authors have declared no conflicts of interest.

6538 Background: IA is a major cause of mortality in AL and HSCT. The objectives of this study were to determine the yield of GM assay for the diagnosis of probable IA, its temporal relationship with high-resolution computed tomographic scan (HRCT) scans and correlation with mortality in patients of AL and recipients of HSCT. Methods: Consecutive neutropenic episodes among inpatients aged ≥ 15 years with a diagnosis of AL and recipients of HSCT were prospectively evaluated over 1½ years. All patients received oral itraconazole or thrice weekly IV amphotericin B (AmB) as prophylaxis. Weekly serum GM assay was performed for all subjects. Optical density index (ODI) > 0.5 for two or more samples was defined as positive. Patients with persistent fever for ≥ 96 hours on intravenous antibiotics were evaluated with HRCT chest and received empiric AmB. IA was diagnosed according to EORTC 2008 guidelines and treated with therapeutic doses of voriconazole or AmB. Results: Of the 150 episodes enrolled, AL induction ...

9579 Background: Sensitive and specific diagnostic tools for invasive fungal infections (IFI) in acute leukemia (AL) patients are lacking. Blood cultures are often negative and performing invasive ...

The aim of our study was to look for alternative predictive biomarkers for breast cancer management in limited resource setup. A comprehensive analysis of circulating cell-free DNA (CCFD) in serum at baseline was performed to assess its prognostic potential. Quantitative polymerase chain reaction (qPCR) of ALU sequences using ALU115 and ALU247 primers was carried out in patients (N: baseline 148, postoperative 47) and 51 healthy controls. Mean serum DNA integrity, levels of ALU 247 and levels of ALU 115 were significantly higher in patients than in healthy females. No significant differences were observed in the levels ALU 247 and ALU 115 between stage IV and earlier stages of the disease. The DNA integrity was significantly higher in stage IV than earlier stages. A significant decrease in DNA integrity was observed after surgery (pre: 0.55 ± 0.23 vs post: 0.43 ± 0.30; P = 0.002) while no such change could be observed for ALU 247 and ALU 115. Baseline DNA integrity was significantly higher in relapsed patients than in patients who were free of disease (P = 0.005). Higher baseline DNA integrity was also indicated, though statistically not significant, in patients who died (P = 0.14). In contrast, ALU 247 and ALU 115 levels were decreased in died patients as compared to survivors (24.8 ± 34.80 vs 73.5 ± 170.83, P = 0.02 for ALU 247 and 41.0 ± 47.99 vs 159.5 ± 299.54, P = 0.005 for ALU 115). Baseline levels of ALU 115 and ALU 247 were lower in relapsed patients, though statistically not significant. In univariate analysis, the only clinic-pathological parameter associated with disease prognosis was tumor size. The hazards of 5-year overall mortality was 3.60 (95 % CI: 1.03 12.53, P = 0.03) among patients with lower baseline serum levels of CCFD (ALU 247