Hot of the Press February 2025

Article to ponder

ICGL shows great promise as a diagnostic tool for lymphoedema due to its non-ionising nature and cost-effectiveness. However, uncertainty remains because studies lack thorough patient phenotyping and genotyping. Key imaging patterns like splash, starburst, and diffuse dermal rerouting need further validation. Future research should focus on standardised imaging protocols and genetically confirmed primary lymphoedema cases to refine its diagnostic value.

A Systematic Review of Indocyanine Green Lymphography (ICGL) Imaging for the Diagnosis of Primary Lymphoedema

G Brezgyte, M Mills, M van Zanten, K Gordon, P S Mortimer, P Ostergaard, British Journal of Radiology, 2025;, tqaf006, https://doi.org/10.1093/bjr/tqaf006

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Key Takeaway: ICGL has the potential to enhance lymphoedema diagnosis and treatment monitoring, but inconsistent protocols and reporting limit its current utility.

We have collated some great articles and material published over the last month. Click on the links below to read the  abstract or download the full paper.

Anatomy / Physiology /Pathophysiology

Primary Lymphedema: Anatomically Isolated or a Pervasive Systemic Disorder?

Wei F. Chen, Christopher Jou, Sonia K. Pandey, Shih-Lun Lo. Plast Reconstr Surg Glob Open. 2024 Dec 20. Dec

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The impact of lymphedema severity on shoulder joint function and muscle activation patterns in breast cancer survivors: a cross-sectional study.

Mohamed, M.H., Radwan, R.E., ElMeligie, M.M. et al. Support Care Cancer 33, 37 (2025).

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Unveiling global interest in lymphedema: A decade of search data through google trends global interest in lymphedema: A google trends analysis

Ömer Faruk Bucak. Phlebology. 2024 Dec 21.

INTRODUCTION: The increasing reliance on Internet search engines for health-related queries requires a thorough evaluation of the public’s engagement with medical information. This study aims to analyze global trends in interest in lymphedema over the past decade using Google Trends (GT).
METHODS: A physiatrist with expertise in lymphedema management identified and analyzed 12 key search terms according to the International Society of Lymphology (ISL) guidelines. These terms included ‘lymphedema swelling’, ‘lymphedema treatment’, ‘lymphedema stages’, ‘compression therapy for lymphedema’, ‘manual lymphatic drainage (MLD)’, ‘complete decongestive therapy (CDT)’, ‘pneumatic compression pump’, ‘lymphovenous anastomosis (LVA)’, ‘lymphedema surgery’, ‘liposuction for lymphedema’, ‘lymphedema prevention’ and ‘post-cancer lymphedema’. GT data was collected using filters set to ‘web search’, ‘all categories’, and ‘worldwide’ to provide a comprehensive overview. The analysis was conducted for two five-year intervals: 1 September 2014 to 31 August 2019 and 1 September 2019 to 31 August 2024. Relative search volume (RSV) was calculated for each term and compared to quantify changes over time.
RESULTS: Significant increases in search activity were observed for ‘lymphedema swelling’, ‘lymphedema treatment’, ‘lymphedema stages’, ‘manual lymphatic drainage’, ‘lymphedema surgery’, and ‘post-cancer lymphedema’ in the second period (p = 0.001 for each). The average GT score increased from 19 in 2014-2019 to 29 in 2019-2024 (p = 0.001), reflecting a significant increase in public awareness and interest.
CONCLUSION: The study shows a significant increase in global public interest in lymphedema and its minimally invasive treatments over the past 5 years, suggesting a growing awareness of the condition. These findings highlight the need for improved patient education and research to meet the increasing demand for lymphedema care.:10.1177/02683555241310749

Prevalence and Risk Factors

Non-contrast MRI based machine learning and radiomics signature can predict the severity of primary lower limb lymphedema

Jie Ren, Xingpeng Li, Mengke Liu, Tingting Cui, Jia Guo, Rongjie Zhou, Kun Hao, Rengui Wang, Yunlong Yue. J Vasc Surg Venous Lymphat Disord. 2024 Dec 16.

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Perceived Psychological and Physical Health as Predictors of Mortality and Quality of Life in Patients with Lymphedema: A Prospective Study Spanning Almost Two Decades.

Loibnegger-Traußnig, K., Schwerdtfeger, A.R. & Flaggl, F Int.J. Behav. Med. (2024). https://doi.org/10.1007/s12529-024-10340-z

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Assessment

Assessing Tissue Dielectric Constant Values in Tumor Bearing and Healthy Breasts

Harvey N. Mayrovitz, Mary Beth Tomaselli. Lymphat Res Biol. 2024 Dec 10. 

Background: This study aimed to investigate, characterize, and provide quantitative reference data on tissue dielectric constant (TDC) values of female breasts when measurements were made to 5 mm depths and determine the utility of these measurements to differentiate between benign and malignant breast tumors.

Methods and Results: Breast TDC was measured bilaterally in 82 women just prior to an ultrasound-guided diagnostic biopsy of one tumor in one breast. TDC was measured in triplicate over the tumor and the contralateral healthy breast. Considering all paired breasts, the average TDC (mean ± SD) for healthy breasts was less than for tumor-bearing breasts (26.7 ± 4.5 vs. 29.9 ± 8.5, p = 0.0003).

Conclusions: Breast TDC values measured to 5 mm in 82 healthy nonedematous breasts provide a two-SD threshold reference value of 35.7. This represents a TDC value above which the presence of breast edema/lymphedema may be indicated based on the two-SD threshold criterion. For unilateral cases, an interbreast TDC ratio exceeding 1.275 may be considered a breast edema/lymphedema indicator also based on the two SD criteria used. These thresholds may have utility for early detection and to track breast edema/lymphedema changes. A comparison of these TDC values obtained from benign versus malignant tumors indicates no statistically significant difference between them. However, interbreast TDC ratios were statistically higher for breasts with malignant versus benign tumors. However, the large overlap of the ratio values renders this method of discrimination between benign vs. malignant tumors inadequate based on the present findings.:10.1089.0061

Measurement Properties and Determinants of the 6-Minute Walk Test in Patients with Lower Limb Lymphedema

Ahmet Burak Cakir, Didem Karadibak, Sukriye Cansu Gultekin, Serap Acar, Pembe Keskinoglu. Lymphat Res Biol. 2024 Dec 20.

Background: The aim of this study was to investigate the validity and reliability and identify determinants of the 6-minute walk test (6MWT) in patients with lower limb lymphedema (LLL).
Methods and Results: The study included 28 patients with LLL and 28 healthy subjects. To investigate the convergent validity and determinants of the 6MWT, patients were assessed using the following measurements: circumference measurement for lymphedema severity, hand-held dynamometry for muscle strength, time up and go for functional mobility, five-time sit-to-stand test for functional lower extremity strength, Lower Extremity Functional Scale for lower extremity functionality, Lymphedema Life Impact Scale for quality of life, and International Physical Activity Questionnaire-Short Form for physical activity level. The test-retest reliability of the 6MWT was assessed using intraclass correlation coefficients (ICCs). 6MWT, a test-retest reliability analysis was carried out with 28 patients within 3-7 days. The receiver operating characteristic (ROC) curve was employed to determine the cut-off point of 6MWT. The test-retest reliability of 6MWT was detected as excellent (ICC [95%] 0.93 [0.87-0.97]). Significant correlations were found between the 6MWT health-related and disease-specific parameters, indicating sufficient convergent validity (r ≥ 0.3). The ROC curve indicated a cut-off point of 504 meters (area under the curve [AUC] 0.712 [95%CI: 0.575-0.849]). Multiple linear regression analysis demonstrated that lymphedema severity, hip abduction muscle strength, and lower limb functionality were the predictors of 6MWT.
Conclusions: The 6MWT has been shown to be a reliable and valid tool for assessing the functional capacity of patients with LLL.:10.1089.0056

The Comparative Frequency of Breast Cancer-Related Lymphedema Determined by Perometer and Circumferential Measurements: Relationship with Functional Status and Quality of Life

Gul Mete Civelek, Pınar Borman, Cansu Sahbaz Pirincci, Aysegul Yaman, Gokhan Ucar, Dogan Uncu, Seda Kahraman, Meltem Dalyan. Lymphat Res Biol. 2025 Jan 6.

Background: The aim of this study was to comparatively determine the frequency of breast cancer-related lymphedema (BCRL) by using prospective monitoring with perometer and circumferential measurements in a group of patients who underwent breast cancer surgery. We also aimed to evaluate the relationship between volume changes and functional status and quality of life (QoL) in patients with breast cancer-related subclinical lymphedema.
Materials and Methods: Patients who had unilateral breast cancer surgery for breast were assessed with circumferential and perometer, respectively, for volumes at baseline, 3rd-month, 6th-month, 9th-month, and 12th-month by the same physiotherapist. Every patient was informed about lymphedema symptoms and prevention. The demographic and clinical properties were recorded. Functional status and QoL were evaluated by Q-DASH and the Lymphedema Quality of Life Questionnaire-Arm questionnaires. Results: A total of 101 female patients with a mean age of 49.02 + 10.59 years completed the 12-month follow-up. Most of the patients were overweight, had an axillary dissection in addition to breast surgery, and received radiotherapy. The frequency of subclinical and clinical BCRL at the end of 12 months was determined by 34.7% and 23.8% with circumferential measures and perometer, respectively. QoL and functional scores did not differ between patients with and without subclinical lymphedema.
Conclusion: After the first 12 months after surgery, the frequency of BCRL assessed by circumferential measurements was higher than the frequency assessed by perometer. Periodic monitoring of women with breast cancer for the presence of BCRL, preferably by the same person together with patient education is suggested in order to allow early detection and timely intervention for BCRL.:10.1089.0008

Evaluation of Long-Term Lymphedema Rate in Patients With Subclinical Lymphedema Diagnosed in the Preoperative Period via Bioimpedance

Zeynep Erdoğan İyigün, Tolga Ozmen, Serkan İlgün, Cansu Nakipoğlu, Enver Özkurt, Filiz Çelebi, Çağlar Ünal, Alper Öztürk, Gül Alço, Çetin Ordu, Gürsel Soybir. Eur J Breast Health. 2025 Jan 1.

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Indocyanine Green Lymphography in Conservative Lymphedema Management: An Exploration of the Impact on Lymphedema Therapy Plans

Megan Trevethan, Emmah Doig, Freyr Patterson, Amanda Pigott,. Seminars in Oncology Nursing,
2024,

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Quantifying the Impact of Axillary Surgery and Nodal Irradiation on Breast Cancer-Related Lymphedema and Local Tumor Control: Long-Term Results From a Prospective Screening Trial

Naoum GE, Roberts S, Brunelle CL, Shui AM, Salama L, Daniell K, Gillespie T, Bucci L, Smith BL, Ho AY, Taghian AG. J Clin Oncol. 2020 Jul 30

PURPOSE: To independently evaluate the impact of axillary surgery type and regional lymph node radiation (RLNR) on breast cancer-related lymphedema (BCRL) rates in patients with breast cancer.

PATIENTS AND METHODS: From 2005 to 2018, 1,815 patients with invasive breast cancer were enrolled in a lymphedema screening trial. Patients were divided into the following 4 groups according to axillary surgery approach: sentinel lymph node biopsy (SLNB) alone, SLNB+RLNR, axillary lymph node dissection (ALND) alone, and ALND+RLNR. A perometer was used to objectively assess limb volume. All patients received baseline preoperative and follow-up measurements after treatment. Lymphedema was defined as a ≥ 10% relative increase in arm volume arising > 3 months postoperatively. The primary end point was the BCRL rate across the groups. Secondary end points were 5-year locoregional control and disease-free-survival.

RESULTS: The cohort included 1,340 patients with SLNB alone, 121 with SLNB+RLNR, 91 with ALND alone, and 263 with ALND+RLNR. The overall median follow-up time after diagnosis was 52.7 months for the entire cohort. The 5-year cumulative incidence rates of BCRL were 30.1%, 24.9%, 10.7%, and 8.0% for ALND+RLNR, ALND alone, SLNB+RLNR, and SLNB alone, respectively. Multivariable Cox models adjusted for age, body mass index, surgery, and reconstruction type showed that the ALND-alone group had a significantly higher BCRL risk (hazard ratio [HR], 2.66; P = .02) compared with the SLNB+RLNR group. There was no significant difference in BCRL risk between the ALND+RLNR and ALND-alone groups (HR, 1.20; P = .49) and between the SLNB-alone and SLNB+RLNR groups (HR, 1.33; P = .44). The 5-year locoregional control rates were similar for the ALND+RLNR, ALND-alone, SLNB+RLNR, and SLNB-alone groups (2.8%, 3.8%, 0%, and 2.3%, respectively).

CONCLUSION: Although RLNR adds to the risk of lymphedema, the main risk factor is the type of axillary surgery used

Measurement Properties and Determinants of the 6-Minute Walk Test in Patients with Lower Limb Lymphedema

Ahmet Burak CakirDidem KaradibakSukriye Cansu Gultekin cnsgultekin@gmail.comSerap Acar, and Pembe KeskinogluAuthors Info & Affiliations. Lymphatic Research Biology – Ahead of Print. 2025
Background: The aim of this study was to investigate the validity and reliability and identify determinants of the 6-minute walk test (6MWT) in patients with lower limb lymphedema (LLL).
Methods and Results: The study included 28 patients with LLL and 28 healthy subjects. To investigate the convergent validity and determinants of the 6MWT, patients were assessed using the following measurements: circumference measurement for lymphedema severity, hand-held dynamometry for muscle strength, time up and go for functional mobility, five-time sit-to-stand test for functional lower extremity strength, Lower Extremity Functional Scale for lower extremity functionality, Lymphedema Life Impact Scale for quality of life, and International Physical Activity Questionnaire-Short Form for physical activity level. The test–retest reliability of the 6MWT was assessed using intraclass correlation coefficients (ICCs). 6MWT, a test–retest reliability analysis was carried out with 28 patients within 3–7 days. The receiver operating characteristic (ROC) curve was employed to determine the cut-off point of 6MWT. The test–retest reliability of 6MWT was detected as excellent (ICC [95%] 0.93 [0.87–0.97]). Significant correlations were found between the 6MWT health-related and disease-specific parameters, indicating sufficient convergent validity (r ≥ 0.3). The ROC curve indicated a cut-off point of 504 meters (area under the curve [AUC] 0.712 [95%CI: 0.575–0.849]). Multiple linear regression analysis demonstrated that lymphedema severity, hip abduction muscle strength, and lower limb functionality were the predictors of 6MWT.
Conclusions: The 6MWT has been shown to be a reliable and valid tool for assessing the functional capacity of patients with LLL.

Management Strategies

Safety Evaluation of a Device for Treatment of Lymphedema of the Upper Extremity

Evgeniya Molotkova, Seth Jarvis, Leah Thomas, Selah Wangler, Tara Newberry Cota/L, Christopher Arena, Andre Muelenaer. Lymphat Res Biol. 2024 Dec 5.

Lymphedema is a chronic condition characterized by dysfunction of the lymphatic system. There is currently no available cure. The standard of care is complete decongestive physiotherapy performed by a lymphedema therapist. However, lymphedema may flare between appointments, making home care important. There are several medical devices available to treat lymphedema at home, but they can be expensive, noisy, and bulky, restricting patient mobility. Thus, there is a demand for other devices that can be utilized at home, between appointments. The overall goal of this research study is to assess the safety of a newly developed vibratory device that may be utilized to supplement lymphedema treatment. Fourteen healthy subjects were recruited and treated with the device, all while measuring pre-treatment and post-treatment upper extremity circumference/induration, vital signs, pain, side effects, and intra-treatment acceleration produced by the device. There were no significant changes in reported pain or vital signs, and side effects were largely mild and transient. We believe that this device is safe for use in healthy subjects, and further studies should assess the efficacy of this device in treating patients with lymphedema.:10.1089.0070

Interventions for Prevention and Management of Gynecological Cancer-Related Lower Limb Lymphedema: A Systematic Scoping Review

Maide Nur Tümkaya, Memnun Seven. Semin Oncol Nurs. 2024 Dec 14.

OBJECTIVES: This scoping review aims to map out evidence on interventions for reducing lower limb lymphedema incidence and symptoms after gynecological cancer surgery.
METHODS: This scoping review followed the methods and protocol outlined by the Joanna Briggs Institute Methods Manual. Five databases, including Pubmed, Scopus, Web of Science, CINAHL, and PsycINFO were searched in January 2024. RESULTS: The review included 15 interventions primarily designed to prevent and manage cancer-related lower extremity lymphedema. Most studies have examined the effect of interventions on the development of lymphedema-related symptoms and quality of life. Most studies tested complex decongestive therapy (CDT) (n = 6, 39.9%), including various techniques, such as manual lymphatic drainage, compression, exercise, and skincare. Of the interventions, 86.6% improved at least one outcome measurement, such as quality of life, lymphedema incidence, symptoms, and lower limb volume.
CONCLUSIONS: Limited evidence shows that the use of interventions appears to have the potential to reduce the risk and symptoms of lymphedema and improve the quality of life in women undergoing gynecological cancer treatment. IMPLICATIONS FOR NURSING PRACTICE: Developing and testing comprehensive lymphedema education and management strategies in nursing practice is essential to optimize patient outcomes and enhance the quality of life for women undergoing gynecological cancer treatment.:10.1016/j.soncn.2024.151781

Feasibility and efficacy of home-based lymphedema exercises for head and neck cancer patients at a safety net hospital

Kelsey Wood, Samuel Hopper, M. Caroline Murray, Josephine Alston, Oishika Paul, Gina D. Jefferson, Lana L. Jackson, Anne C. Kane. Am J Otolaryngol. 2024 Dec 10.

PURPOSE: Lymphedema therapy is an effective tool in mitigating head and neck lymphedema morbidity and long-term fibrosis. Studies have shown the efficacy of facility-based therapy; however, access can be limited by sociodemographic factors, including socioeconomic status and transportation. This study evaluates the feasibility and effectiveness of home-based lymphedema therapy in a socially vulnerable patient population.
MATERIALS AND METHODS: A retrospective chart review analyzed patients who underwent home-based lymphedema exercise regimen after training with a lymphedema-trained speech language pathologist between 2019 and 2022 at a tertiary academic medical center. Patient and cancer demographics were collected. Primary outcomes measured were quality of life surveys and diet status.
RESULTS: Of the 27 patients included, 85.1 % were in the two highest quintiles of neighborhood deprivation based on national Area Deprivation Index (ADI). Treatment breakdown included 78 % who were treated with surgery, 96 % completed radiation and 59.3 % chemotherapy. Six months after initiating lymphedema therapy, most patients (59.3 %) were compliant with exercises. Quality of life scores showed trends toward improvement, but only a decrease in condition-related anxiety at 3 months (p = 0.004) reached statistical significance. Improvement in diet was significant at 6 and 9 months after initiation of treatment (p = 0.020).
CONCLUSIONS: Patient compliance rate demonstrates feasibility of home exercises for lymphedema treatment in a tertiary care setting with a socially vulnerable patient population. Home-based head and neck lymphedema treatment showed improvements in patient diet over time.:10.1016/j.amjoto.2024.104560

Development and evaluation of a WeChat-based intervention program for prevention of breast cancer-related lymphedema

Xia Luo, Hong He, Jing Chen, Mingfang Li, Jun Yan. Support Care Cancer. 2024 Dec 11.

PURPOSE: Mobile health applications have been widely adopted among breast cancer survivors for disease management; however, their use specifically for the prevention of breast cancer-related lymphedema (BCRL) remains sparse. This study is aimed at developing a WeChat-based intervention program for the prevention of BCRL based on the common-sense model (CSM).
METHODS: This study was designed based on intervention mapping. First, a longitudinal investigation was conducted to determine the predictive effect of illness perception on BCRL prevention behaviors among breast cancer survivors. An intervention program was then constructed based on the CSM and longitudinal results. Finally, a WeChat mini-program was developed, and 15 patients were recruited to test its usability and user satisfaction through usability tests based on typical tasks and the Post- Study System Usability Questionnaire (PSSUQ), respectively. RESULTS: The longitudinal study revealed that identity, personal control, illness coherence, and behavioral and physical factors in the causes dimension could positively predict prevention behaviors, whereas treatment control and uncontrollable factors exhibited negative predictive effects. This study then developed an individualized intervention program and a WeChat mini-program (named “Nantian e-Care”) consisting of five modules: ” resources,” “questionnaires,” “homepage,” “consultation,” and “personal center.” Patients could read BCRL-related educational content, watch functional exercise videos, self-measure arm circumference, and consult questions. The five-task completion rates were 80.00 ~ 100.00%, the average completion time was 9.47 ~ 33.31 s, and the scores of PSSUQ were greater than 5 points (full score 7 points).
CONCLUSIONS: This study proposed a feasible intervention program for the prevention of BCRL and developed a customized WeChat mini-program with high usability and user satisfaction. TRIAL REGISTRATION: Chinese Clinical Trial Registry, URL: https://www.chictr.org.cn/ , ChiCTR2100048798.:10.1007

Demonstration of the effectiveness of complete decongestive treatment in secondary lymphedema developing after total knee arthroplasty

Cansın Medin Ceylan, Sedef Ersoy, Fatma Nur Kesiktas, Armagan Özokur. Eur J Orthop Surg Traumatol. 2024 Dec 23.

OBJECTIVE: The aim of the current study is to demonstrate the treatment results of patients with lymphedema that developed after total knee arthroplasty (TKA) and to compare these results with those of patients with secondary lymphedema non-TKA.
METHODS: A total of 63 patients diagnosed with secondary lymphedema and who received complete decongestive treatment (MLD + bandaging + exercise) at the lymphedema treatment unit of Istanbul Physical Medicine and Rehabilitation Training Research Hospital between June 1, 2023, and February 1, 2024, were included in our retrospective study. The circumference of both metatarsophalangeal joints was measured, and leg diameter measurements were made from the lateral malleolus to the proximal 10th, 20th, and 30th centimeters.
RESULTS: Of the 63 patients included in this study, the average age in the TKA group (n = 17) was 69.23 ± 8.27 years, and the BMI was 38.60 ± 6.52. In the non-TKA group (n = 46), the average age was 63.50 ± 14.05 years, and the BMI was 34.57 ± 9.17. There was no statistical difference between the two groups in terms of demographic data, affected sides, and initial measurements of the patients (p > 0.05). The response to continued decongestive treatment was significantly higher in both the TKA and non-TKA groups (p < 0.05). However, there was no statistically significant difference in treatment response between the two groups (p > 0.05).
CONCLUSION: Complete decongestive treatment is an effective method for treating lymphedema that develops after total knee arthroplasty. No difference in treatment response was found between patients with lymphedema following TKA and those with secondary lymphedema from other causes.:10.1007

Complex Decongestive Therapy Improves Gait Speed in Patients with Lower Limb Lymphedema

E Gökçe, N Gün, Ü Düzlü Öztürk, M Dalyan – Lymphatic Research and Biology, 2024

Background: Secondary lymphedema is acquired and caused by obstruction or injury to a normally developed lymphatic system. Loss of mobility is a common problem in patients with secondary lower limb lymphedema (LLL) following cancer treatment. In this study, we examined the effect of complex decongestive therapy (CDT) on motor function and mobility in patients with LLL.
Methods and Results: A quasi-experimental study was performed with 24 participants with stage 2 LLL (56.04 ± 14.23 years). Participants received 15 sessions of CDT. Motor function was assessed with a foot tapping test (FTT). Gait speed was measured in single-task (ST) and dual-task (DT) conditions, and DT cost was calculated. All assessments were performed before and after the intervention. The paired t-test and Wilcoxon signed-rank test were used to analyze the effect of CDT on FTT, gait speed, and DT cost. ST and DT gait speed (p = 0.002, p < 0.001) and DT cost (p = 0.001) decreased following the CDT, whereas bilateral FTT scores did not change.
Conclusion: CDT improves mobility and dual-tasking in LLL, thereby promoting independence in daily life. Future prospective controlled studies are required to corroborate our results.
The Application Effect of Manual Lymphatic Drainage Combined with Adjustable Foam Particle Arm Sleeves in Patients with Stage I Upper Limb Lymphedema
Liping Zhang*, Qinghua Luo, Huizhen Zhang, Jinlan Li, Lijuan Zhang, Qiaoling Zhong# . Journal of Cancer Therapy > Vol.15 No.12, December 2024

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