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World Journal of Urology

, Volume 25, Issue 6, pp 595–605 | Cite as

Reproducibility and reliability of tumor grading in urological neoplasms

  • Rainer Engers
Review

Abstract

Histopathologic tumor grading reflects the degree of differentiation of a given tumor and for most urological tumors grading is an important factor in predicting their biological aggressiveness. Consequently, the clinical management of tumor patients is often strongly influenced by the tumor grade, provided by pathologists. This implicates that an ideal grading system should not only be of high prognostic relevance, but also of high reproducibility among different pathologists. To this end individual histological grading systems have been developed for different tumor entities and even for a given tumor type several grading systems have been proposed. All of these grading systems possess an inherent degree of subjectivity and consequently, both intra- and interobserver variability exist. In this review, grading systems for the most frequent urological tumors (i.e. prostate cancer, renal cell carcinoma, and urothelial tumors) are mentioned and data on the reproducibility and reliability of the most commonly used grading systems are summarized.

Keywords

Grading Reproducibility Reliability Urological tumors Prostate cancer Renal cell carcinoma Urothelial neoplasms 

References

  1. 1.
    Hammond ME, Fitzgibbons PL, Compton CC, Grignon DJ, Page DL, Fielding LP, Bostwick D, Pajak TF (2000) College of American pathologists conference XXXV: solid tumor prognostic factors-which, how and so what? Summary document and recommendations for implementation. Cancer committee and conference participants. Arch Pathol Lab Med 124:958–965PubMedGoogle Scholar
  2. 2.
    Cohen JA (1960) A coefficient of agreement for nominal scales. Educ Psychol Meas 20:37–46CrossRefGoogle Scholar
  3. 3.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174PubMedCrossRefGoogle Scholar
  4. 4.
    Brennan P, Silman A (1992) Statistical methods for assessing observer variability in clinical measures. BMJ 304:1491–1494PubMedGoogle Scholar
  5. 5.
    Gleason DF (1966) Classification of prostatic carcinomas. Cancer Chemother Rep 50:125–128PubMedGoogle Scholar
  6. 6.
    Brawn PN, Ayala AG, Von Eschenbach AC, Hussey DH, Johnson DE (1982) Histologic grading study of prostate adenocarcinoma: the development of a new system and comparison with other methods—a preliminary study. Cancer 49:525–532PubMedCrossRefGoogle Scholar
  7. 7.
    Bocking A, Kiehn J, Heinzel-Wach M (1982) Combined histologic grading of prostatic carcinoma. Cancer 50:288–294PubMedCrossRefGoogle Scholar
  8. 8.
    Helpap B, Bocking A, Dhom G, Faul P, Kastendieck H, Leistenschneider W, Muller HA (1985) Classification, histological and cytological grading and assessment of regression grading in prostatic carcinomas. A recommendation of the pathologic-urological task force on prostatic carcinoma. Pathologe 6:3–7PubMedGoogle Scholar
  9. 9.
    Mostofi FK (1975) Grading of prostatic carcinoma. Cancer Chemother Rep 59:111–117PubMedGoogle Scholar
  10. 10.
    Mostofi FK, Sesterhenn IA, Sobin LH (1980) Histological typing of prostate tumours. In: International histological classification of tumours, No. 22. World Health Organization, GenevaGoogle Scholar
  11. 11.
    Epstein JI, Algaba F, Allsbrook WC Jr, Bastacky S, Boccon-Gibod L, De Marzo AM, Egevad L, Furosato M, Hamper UM, Helpap B, Humphrey PA, Iczkowski KA, Lopez-Beltran A, Montironi R, Rubin MA, Sakr WA, Samaratunga H, Parkin DM (2004) Acinar adenocarcinoma. In: Eble JN, Sauter G, Epstein JI, Sesterhenn IA (eds) World Health Organizaion classification of tumours. pathology and genetics: tumours of the urinary system and male genital organs. IARC, Lyon, France, pp 179–184Google Scholar
  12. 12.
    Mellinger GT, Gleason D, Bailar J III (1967) The histology and prognosis of prostatic cancer. J Urol 97:331–337PubMedGoogle Scholar
  13. 13.
    Gleason DF, Mellinger GT (1974) Prediction of prognosis for prostatic adenocarcinoma by combined histological grading and clinical staging. J Urol 111:58–64PubMedGoogle Scholar
  14. 14.
    Mellinger GT (1977) Prognosis of prostatic carcinoma. Recent Results Cancer Res 61–72Google Scholar
  15. 15.
    Epstein JI, Allsbrook WC Jr, Amin MB, Egevad LL (2005) The 2005 international society of urological pathology (ISUP) consensus conference on gleason grading of prostatic carcinoma. Am J Surg Pathol 29:1228–1242PubMedCrossRefGoogle Scholar
  16. 16.
    Helpap B, Egevad L (2006) The significance of modified Gleason grading of prostatic carcinoma in biopsy and radical prostatectomy specimens. Virchows Arch 449:622–627PubMedCrossRefGoogle Scholar
  17. 17.
    Carlson GD, Calvanese CB, Kahane H, Epstein JI (1998) Accuracy of biopsy Gleason scores from a large uropathology laboratory: use of a diagnostic protocol to minimize observer variability. Urology 51:525–529PubMedCrossRefGoogle Scholar
  18. 18.
    Cookson MS, Fleshner NE, Soloway SM, Fair WR (1997) Correlation between Gleason score of needle biopsy and radical prostatectomy specimen: accuracy and clinical implications. J Urol 157:559–562PubMedCrossRefGoogle Scholar
  19. 19.
    Spires SE, Cibull ML, Wood DP Jr, Miller S, Spires SM, Banks ER (1994) Gleason histologic grading in prostatic carcinoma. Correlation of 18-gauge core biopsy with prostatectomy. Arch Pathol Lab Med 118:705–708PubMedGoogle Scholar
  20. 20.
    Steinberg DM, Sauvageot J, Piantadosi S, Epstein JI (1997) Correlation of prostate needle biopsy and radical prostatectomy Gleason grade in academic and community settings. Am J Surg Pathol 21:566–576PubMedCrossRefGoogle Scholar
  21. 21.
    Lopez-Beltran A, Mikuz G, Luque RJ, Mazzucchelli R, Montironi R (2006) Current practice of Gleason grading of prostate carcinoma. Virchows Arch 448:111–118PubMedCrossRefGoogle Scholar
  22. 22.
    Montironi R, Mazzuccheli R, Scarpelli M, Lopez-Beltran A, Fellegara G, Algaba F (2005) Gleason grading of prostate cancer in needle biopsies or radical prostatectomy specimens: contemporary approach, current clinical significance and sources of pathology discrepancies. BJU Int 95:1146–1152PubMedCrossRefGoogle Scholar
  23. 23.
    Egevad L, Allsbrook WC Jr, Epstein JI (2005) Current practice of Gleason grading among genitourinary pathologists. Hum Pathol 36:5–9PubMedCrossRefGoogle Scholar
  24. 24.
    Egevad L, Norlen BJ, Norberg M (2001) The value of multiple core biopsies for predicting the Gleason score of prostate cancer. BJU Int 88:716–721PubMedCrossRefGoogle Scholar
  25. 25.
    Mian BM, Lehr DJ, Moore CK, Fisher HA, Kaufman RP Jr, Ross JS, Jennings TA, Nazeer T (2006) Role of prostate biopsy schemes in accurate prediction of Gleason scores. Urology 67:379–383PubMedCrossRefGoogle Scholar
  26. 26.
    Cintra ML, Billis A (1991) Histologic grading of prostatic adenocarcinoma: intraobserver reproducibility of the Mostofi, Gleason and Bocking grading systems. Int Urol Nephrol 23:449–454PubMedCrossRefGoogle Scholar
  27. 27.
    Ozdamar SO, Sarikaya S, Yildiz L, Atilla MK, Kandemir B, Yildiz S (1996) Intraobserver and interobserver reproducibility of WHO and Gleason histologic grading systems in prostatic adenocarcinomas. Int Urol Nephrol 28:73–77PubMedCrossRefGoogle Scholar
  28. 28.
    Melia J, Moseley R, Ball RY, Griffiths DF, Grigor K, Harnden P, Jarmulowicz M, McWilliam LJ, Montironi R, Waller M, Moss S, Parkinson MC (2006) A UK-based investigation of inter- and intra-observer reproducibility of Gleason grading of prostatic biopsies. Histopathology 48:644–654PubMedCrossRefGoogle Scholar
  29. 29.
    Gleason DF (1992) Histologic grading of prostate cancer: a perspective. Hum Pathol 23:273–279PubMedCrossRefGoogle Scholar
  30. 30.
    Allsbrook WC Jr, Mangold KA, Johnson MH, Lane RB, Lane CG, Amin MB, Bostwick DG, Humphrey PA, Jones EC, Reuter VE, Sakr W, Sesterhenn IA, Troncoso P, Wheeler TM, Epstein JI (2001) Interobserver reproducibility of Gleason grading of prostatic carcinoma: urologic pathologists. Hum Pathol 32:74–80PubMedCrossRefGoogle Scholar
  31. 31.
    Allsbrook WC Jr, Mangold KA, Johnson MH, Lane RB, Lane CG, Epstein JI (2001) Interobserver reproducibility of Gleason grading of prostatic carcinoma: general pathologist. Hum Pathol 32:81–88PubMedCrossRefGoogle Scholar
  32. 32.
    Oyama T, Allsbrook WC Jr, Kurokawa K, Matsuda H, Segawa A, Sano T, Suzuki K, Epstein JI (2005) A comparison of interobserver reproducibility of Gleason grading of prostatic carcinoma in Japan and the United States. Arch Pathol Lab Med 129:1004–1010PubMedGoogle Scholar
  33. 33.
    Kronz JD, Silberman MA, Allsbrook WC, Epstein JI (2000) A web-based tutorial improves practicing pathologists’ Gleason grading of images of prostate carcinoma specimens obtained by needle biopsy: validation of a new medical education paradigm. Cancer 89:1818–1823PubMedCrossRefGoogle Scholar
  34. 34.
    Egevad L (2001) Reproducibility of Gleason grading of prostate cancer can be improved by the use of reference images. Urology 57:291–295PubMedCrossRefGoogle Scholar
  35. 35.
    Mikami Y, Manabe T, Epstein JI, Shiraishi T, Furusato M, Tsuzuki T, Matsuno Y, Sasano H (2003) Accuracy of gleason grading by practicing pathologists and the impact of education on improving agreement. Hum Pathol 34:658–665PubMedCrossRefGoogle Scholar
  36. 36.
    Glaessgen A, Hamberg H, Pihl CG, Sundelin B, Nilsson B, Egevad L (2004) Interobserver reproducibility of modified Gleason score in radical prostatectomy specimens. Virchows Arch 445:17–21PubMedGoogle Scholar
  37. 37.
    Hand JR, Broders A (1932) Carcinoma of the kidney: the degree of malignancy in relation to factors bearing on prognosis. J Urol 28:199–216Google Scholar
  38. 38.
    Goldstein NS (1997) The current state of renal cell carcinoma grading. Union Internationale Contre le Cancer (UICC) and the American joint committee on cancer (AJCC). Cancer 80:977–980PubMedCrossRefGoogle Scholar
  39. 39.
    Skinner DG, Colvin RB, Vermillion CD, Pfister RC, Leadbetter WF (1971) Diagnosis and management of renal cell carcinoma. A clinical and pathologic study of 309 cases. Cancer 28:1165–1177PubMedCrossRefGoogle Scholar
  40. 40.
    Fuhrman SA, Lasky LC, Limas C (1982) Prognostic significance of morphologic parameters in renal cell carcinoma. Am J Surg Pathol 6:655–663PubMedCrossRefGoogle Scholar
  41. 41.
    Thoenes W, Storkel S, Rumpelt HJ (1986) Histopathology and classification of renal cell tumors (adenomas, oncocytomas and carcinomas). The basic cytological and histopathological elements and their use for diagnostics. Pathol Res Pract 181:125–143PubMedGoogle Scholar
  42. 42.
    Medeiros LJ, Jones EC, Aizawa S, Aldape HC, Cheville JC, Goldstein NS, Lubensky IA, Ro J, Shanks J, Pacelli A, Jung SH (1997) Grading of renal cell carcinoma: workgroup No. 2. Union Internationale Contre le Cancer and the American Joint Committee on Cancer (AJCC). Cancer 80:990–991PubMedCrossRefGoogle Scholar
  43. 43.
    Storkel S, Thoenes W, Jacobi GH, Lippold R (1989) Prognostic parameters in renal cell carcinoma—a new approach. Eur Urol 16:416–422PubMedGoogle Scholar
  44. 44.
    Lanigan D, Conroy R, Barry-Walsh C, Loftus B, Royston D, Leader M (1994) A comparative analysis of grading systems in renal adenocarcinoma. Histopathology 24:473–476PubMedCrossRefGoogle Scholar
  45. 45.
    Lohse CM, Blute ML, Zincke H, Weaver AL, Cheville JC (2002) Comparison of standardized and nonstandardized nuclear grade of renal cell carcinoma to predict outcome among 2,042 patients. Am J Clin Pathol 118:877–886PubMedCrossRefGoogle Scholar
  46. 46.
    Delahunt B, Sika-Paotonu D, Bethwaite PB, McCredie MR, Martignoni G, Eble JN, Jordan TW (2007) Fuhrman grading is not appropriate for chromophobe renal cell carcinoma. Am J Surg Pathol 31:957–960PubMedCrossRefGoogle Scholar
  47. 47.
    Ficarra V, Martignoni G, Maffei N, Brunelli M, Novara G, Zanolla L, Pea M, Artibani W (2005) Original and reviewed nuclear grading according to the Fuhrman system: a multivariate analysis of 388 patients with conventional renal cell carcinoma. Cancer 103:68–75PubMedCrossRefGoogle Scholar
  48. 48.
    Lang H, Lindner V, de Fromont M, Molinie V, Letourneux H, Meyer N, Martin M, Jacqmin D (2005) Multicenter determination of optimal interobserver agreement using the Fuhrman grading system for renal cell carcinoma: assessment of 241 patients with >15-year follow-up. Cancer 103:625–629PubMedCrossRefGoogle Scholar
  49. 49.
    Al Aynati M, Chen V, Salama S, Shuhaibar H, Treleaven D, Vincic L (2003) Interobserver and intraobserver variability using the Fuhrman grading system for renal cell carcinoma. Arch Pathol Lab Med 127:593–596PubMedGoogle Scholar
  50. 50.
    Mostofi FK, Sobin LH, Torloni H (1973) Histological typing of urinary bladder tumors, vol 10. World Health Organization, GenevaGoogle Scholar
  51. 51.
    Bergkvist A, Ljungqvist A, Moberger G (1965) Classification of bladder tumours based on the cellular pattern. Preliminary report of a clinical-pathological study of 300 cases with a minimum follow-up of eight years. Acta Chir Scand 130:371–378PubMedGoogle Scholar
  52. 52.
    Murphy WM (1989) Diseases of the urinary bladder, urethra, ureters, and renal pelves. In: Murphy WM (ed) Urological pathology. WB Saunders, Philadelphia, pp 64–96Google Scholar
  53. 53.
    Pauwels RP, Schapers RF, Smeets AW, Debruyne FM, Geraedts JP (1988) Grading in superficial bladder cancer. (1). Morphological criteria. Br J Urol 61:129–134PubMedGoogle Scholar
  54. 54.
    Epstein JI, Amin MB, Reuter VR, Mostofi FK (1998) The World Health Organization/international society of urological pathology consensus classification of urothelial (transitional cell) neoplasms of the urinary bladder. Bladder consensus conference committee. Am J Surg Pathol 22:1435–1448PubMedCrossRefGoogle Scholar
  55. 55.
    MacLennan GT, Kirkali Z, Cheng L (2007) Histologic grading of noninvasive papillary urothelial neoplasms. Eur Urol 51:889–897PubMedCrossRefGoogle Scholar
  56. 56.
    Gönül II, Poyraz A, Ünsal C, Acar C, Alkibay T (2007) Comparison of 1998 WHO/ISUP and 1973 WHO classifications for interobserver variability in grading of papillary urothelial neoplasms of the bladder. Pathological evaluation of 258 Cases. Urol Int 78:338–344PubMedCrossRefGoogle Scholar
  57. 57.
    Jordan AM, Weingarten J, Murphy WM (1987) Transitional cell neoplasms of the urinary bladder. Can biologic potential be predicted from histologic grading? Cancer 60:2766–2774PubMedCrossRefGoogle Scholar
  58. 58.
    Lipponen PK (1992) Histological and quantitative prognostic factors in transitional cell bladder cancer treated by cystectomy. Anticancer Res 12:1527–1532PubMedGoogle Scholar
  59. 59.
    Ooms EC, Anderson WA, Alons CL, Boon ME, Veldhuizen RW (1983) Analysis of the performance of pathologists in the grading of bladder tumors. Hum Pathol 14:140–143PubMedCrossRefGoogle Scholar
  60. 60.
    Tosoni I, Wagner U, Sauter G, Egloff M, Knonagel H, Alund G, Bannwart F, Mihatsch MJ, Gasser TC, Maurer R (2000) Clinical significance of interobserver differences in the staging and grading of superficial bladder cancer. BJU Int 85:48–53PubMedCrossRefGoogle Scholar
  61. 61.
    Robertson AJ, Beck JS, Burnett RA, Howatson SR, Lee FD, Lessells AM, Mclaren KM, Moss SM, Simpson JG, Smith GD (1990) Observer variability in histopathological reporting of transitional cell carcinoma and epithelial dysplasia in bladders. J Clin Pathol 43:17–21PubMedCrossRefGoogle Scholar
  62. 62.
    Samaratunga H, Makarov DV, Epstein JI (2002) Comparison of WHO/ISUP and WHO classification of noninvasive papillary urothelial neoplasms for risk of progression. Urology 60:315–319PubMedCrossRefGoogle Scholar
  63. 63.
    Whisnant RE, Bastacky SI, Ohori NP (2003) Cytologic diagnosis of low-grade papillary urothelial neoplasms (low malignant potential and low-grade carcinoma) in the context of the 1998 WHO/ISUP classification. Diagn Cytopathol 28:186–190PubMedCrossRefGoogle Scholar
  64. 64.
    Bircan S, Candir O, Serel TA (2004) Comparison of WHO 1973, WHO/ISUP 1998, WHO 1999 grade and combined scoring systems in evaluation of bladder carcinoma. Urol Int 73:201–208PubMedCrossRefGoogle Scholar
  65. 65.
    Yin H, Leong AS (2004) Histologic grading of noninvasive papillary urothelial tumors: validation of the 1998 WHO/ISUP system by immunophenotyping and follow-up. Am J Clin Pathol 121:679–687PubMedCrossRefGoogle Scholar
  66. 66.
    Curry JL, Wojcik EM (2002) The effects of the current World Health Organization/International Society of Urologic Pathologists bladder neoplasm classification system on urine cytology results. Cancer 96:140–145PubMedCrossRefGoogle Scholar
  67. 67.
    Murphy WM, Takezawa K, Maruniak NA (2002) Interobserver discrepancy using the 1998 World Health Organization/International Society of Urologic Pathology classification of urothelial neoplasms: practical choices for patient care. J Urol 168:968–972PubMedCrossRefGoogle Scholar
  68. 68.
    Campbell PA, Conrad RJ, Campbell CM, Nicol DL, MacTaggart P (2004) Papillary urothelial neoplasm of low malignant potential: reliability of diagnosis and outcome. BJU Int 93:1228–1231PubMedCrossRefGoogle Scholar
  69. 69.
    Yorukoglu K, Tuna B, Dikicioglu E, Duzcan E, Isisag A, Sen S, Mungan U, Kirkali Z (2003) Reproducibility of the 1998 World Health Organization/International Society of Urologic Pathology classification of papillary urothelial neoplasms of the urinary bladder. Virchows Arch 443:734–740PubMedCrossRefGoogle Scholar
  70. 70.
    Cheng L, Neumann RM, Bostwick DG (1999) Papillary urothelial neoplasms of low malignant potential. Clinical and biologic implications. Cancer 86:2102–2108PubMedCrossRefGoogle Scholar
  71. 71.
    Holmang S, Andius P, Hedelin H, Wester K, Busch C, Johansson SL (2001) Stage progression in Ta papillary urothelial tumors: relationship to grade, immunohistochemical expression of tumor markers, mitotic frequency and DNA ploidy. J Urol 165:1124–1128PubMedCrossRefGoogle Scholar
  72. 72.
    Holmang S, Hedelin H, Anderstrom C, Holmberg E, Busch C, Johansson SL (1999) Recurrence and progression in low grade papillary urothelial tumors. J Urol 162:702–707PubMedCrossRefGoogle Scholar
  73. 73.
    Pich A, Chiusa L, Formiconi A, Galliano D, Bortolin P, Comino A, Navone R (2002) Proliferative activity is the most significant predictor of recurrence in noninvasive papillary urothelial neoplasms of low malignant potential and grade 1 papillary carcinomas of the bladder. Cancer 95:784–790PubMedCrossRefGoogle Scholar
  74. 74.
    Fujii Y, Kawakami S, Koga F, Nemoto T, Kihara K (2003) Long-term outcome of bladder papillary urothelial neoplasms of low malignant potential. BJU Int 92:559–562PubMedCrossRefGoogle Scholar
  75. 75.
    Bain GO, Koch M, Hanson J (1982) Feasibility of grading carcinomas. Arch Pathol Lab Med 106:265–267Google Scholar
  76. 76.
    Svanholm H, Mygind H (1985) Prostatic carcinoma reproducibility of histologic grading. Acta Pathol Microbiol Immunol Scand [A] 93:67–71Google Scholar
  77. 77.
    ten Kate FJW, Gallee MPW, Schmitz PIM, Joebis AC, van der Heul RO, Prins MEF, Blom JHM (1986) Problems in grading of prostatic carcinoma: interobserver reproducibility of five different grading systems. World J Urol 4:147–152CrossRefGoogle Scholar
  78. 78.
    Rousselet MC, Saint-Andre JP, Six P, Soret JY (1986) Reproducibility and prognostic value of Gleason's and Gaeta's histological grades in prostatic carcinoma. Ann Urol (Paris) 20:317–322Google Scholar
  79. 79.
    de las Morenas A, Siroky MB, Merriam J, Stilmant MM (1988) Prostatic adenocarcinoma: reproducibility and correlation with clinical stages of four grading systems. Hum Pathol 19:595–597PubMedCrossRefGoogle Scholar
  80. 80.
    di Loreto C, Fitzpatrick B, Underhill S, Kim DH, Dytch HE, Galera-Davidson H, Bibbo M (1991) Correlation between visual clues, objective architectural features, and interobserver agreement in prostate cancer. Am J Clin Pathol 96:70–75PubMedGoogle Scholar
  81. 81.
    McLean M, Srigley J, Banerjee D, Warde P, Hao Y (1997) Interobserver variation in prostate cancer Gleason scoring: are there implications for the design of clinical trials and treatment strategies? Clin Oncol (R Coll Radiol) 9:222–225Google Scholar
  82. 82.
    Lessells AM, Burnett RA, Howatson SR, Lang S, Lee FD, McLaren KM, Nairn ER, Ogston SA, Robertson AJ, Simpson JG, Smith GD, Tavadia HB, Walker F (1997) Observer variability in the histopathological reporting of needle biopsy specimens of the prostate. Hum Pathol 28:646–649PubMedCrossRefGoogle Scholar
  83. 83.
    Bova GS, Parmigiani G, Epstein JI, Wheeler T, Mucci NR, Rubin MA (2001) Web-based tissue microarray image data analysis: initial validation testing through prostate cancer Gleason grading. Hum Pathol 32:417–427PubMedCrossRefGoogle Scholar
  84. 84.
    De La TA, Viellefond A, Berger N, Boucher E, De Fromont M, Fondimare A, Molinie V, Piron D, Sibony M, Staroz F, Triller M, Peltier E, Thiounn N, Rubin MA (2003) Evaluation of the interobserver reproducibility of Gleason grading of prostatic adenocarcinoma using tissue microarrays. Hum Pathol 34:444–449CrossRefGoogle Scholar
  85. 85.
    Bretheau D, Lechevallier E, de Fromont M, Sault MC, Rampal M, Coulange C (1995) Prognostic value of nuclear grade of renal cell carcinoma. Cancer 76:2543–2549PubMedCrossRefGoogle Scholar
  86. 86.
    Abel PD, Henderson D, Bennett MK, Hall RR, Williams G (1988) Differing interpretations by pathologists of the pT category and grade of transitional cell cancer of the bladder. Br J Urol 62:339–342PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  1. 1.Institute of PathologyUniversity Hospital DuesseldorfDuesseldorfGermany

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