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Year : 2019  |  Volume : 15  |  Issue : 3  |  Page : 550-555

Is excision repair cross-complementation Group1 expression a biological marker in nasopharynx carcinoma?

1 Department of Medical Oncology, Medical Faculty, Firat University, Elazig, Turkey
2 Department of Medical Oncology, Medical Faculty, Inonu University, Malatya, Turkey
3 Department of Pathology, Medical Faculty, Firat University, Elazig, Turkey
4 Department of Medical Oncology, Medical Faculty, Dicle University, Diyarbakir, Turkey

Date of Web Publication29-May-2019

Correspondence Address:
Dr. Asude Aksoy
Department of Medical Oncology, Medical Faculty, Firat University, TR-23119, Elazig
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1482.206865

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 > Abstract 

Objective: To determine the prognostic value of excision repairs cross-complementation group1 (ERCC1) gene in cases with nasopharyngeal carcinoma (NPC) treated with platinum-containing chemotherapy (PCT).
Subjects and Methods: The present study was included 33 cases in local advanced stage with NPC. ERCC1 expression was evaluated by using immunohistochemical staining in biopsy specimens. We evaluated the relationship between the degree of ERCC1 expression and clinicopathological features, response to therapy, survival rates in cases with NPC, retrospectively.
Results: ERCC1 expression was not observed in 5 (15.15%) of all cases. Thirteen (39.9%) cases weakly positive (+1, +2) and 15 (45.5%) cases of all them were rather strongly positive (+3). There was no statistically significant difference between the degree of ERCC1 expression and clinicopathological features, response to treatment, survival rates (P > 0.05) in cases with NPC.
Conclusions: ERCC1 expression has no predictive value for survival in cases locally advanced stage with NPC. Evaluation of ERCC1 expression is not appropriate with a biomarker to detect cases who can benefit from PCT in NPC.

Keywords: Excision repair cross-complementation group1, nasopharyngeal carcinoma, platinum resistance, survival

How to cite this article:
Aksoy A, Elkiran ET, Harputluoglu H, Dagli AF, Isikdogan A, Urakci Z. Is excision repair cross-complementation Group1 expression a biological marker in nasopharynx carcinoma?. J Can Res Ther 2019;15:550-5

How to cite this URL:
Aksoy A, Elkiran ET, Harputluoglu H, Dagli AF, Isikdogan A, Urakci Z. Is excision repair cross-complementation Group1 expression a biological marker in nasopharynx carcinoma?. J Can Res Ther [serial online] 2019 [cited 2021 Dec 8];15:550-5. Available from: https://www.cancerjournal.net/text.asp?2019/15/3/550/206865

 > Introduction Top

Nasopharyngeal carcinoma (NPC) is different from other head and neck cancers in terms of anatomical localization, radiotherapy (RT), and chemotherapy (ChT) sensitive.

The agents containing platinum are used more often in the treatment for NPC.[1] Platinum resistance should be considered in cases with relapsed <6 months after platinum-containing treatment (PCT).[2] Excision repairs cross-complementation group1 (ERCC1) gene plays a rate-limiting role in nucleotide excision repair (NER) mechanisms that repair DNA cross-linking among chains.[2],[3] We hypothesized and investigated that ERCC1 expression could be a biomarker for cases with administered PCT, diagnosed NPC.

 > Subjects and Methods Top

In this study, 33 cases from different Medical Oncology Departments between 2007 and 2012 had been administered concurrent platinum-containing chemo-RT or alone ChT and diagnosed with NPC were investigated, retrospectively. The physical examination of cases, radiologic imaging (chest X-ray, magnetic resonance imaging (MRI), computerized tomography (CT), fludeoxyglucose positron emission tomography (FDG-PET/CT), hematologic, and biochemical values with medical records consisting of the time diagnosis in which clinical staging was performed according to American Journal Cancer Committee 7. The cases with Stage II-B, Stage III, and Stage IV-B (local advanced) NPC were included in the present study. PCT regimen was docetaxel 75 mg/m 2, cisplatin 75 mg/m 2, 5-fluorouracil (FU) 750 mg/m 2 D1-5, every 21 days or cisplatin 75 mg/m 2, D1, and 5-FU 1000 mg/m 2, D1-5, every 21 days. After induction ChT, conventional two-dimensional radiotherapy treatment was administered in some of the cases, and the remaining cases received three-dimensional conformal radiotherapy (CRT) application with three cycles of a simultaneous cisplatin weekly 35 mg/m 2. The cases were evaluated 2 months after administration RT or concurrent chemoradiotherapy (CCRT) and after every two cycles ChT. The cases which completed treatment were evaluated by flexible nasopharyngoscopic examination, complete blood count, chest X-ray and biochemical tests, nasopharynx MRI, and/or FDG-PET/CT in a control examination every 3 months for the first 2 years. The Response Evaluation Criteria in Solid Tumors criteria was used to assessment response to treatment.[4] This study was approved by the Ethics Committee at the University of Inonu.

Immunohistochemical staining

From the cases, 4–5 μm sections of paraffin blocks were taken by the appropriate technique. The slides were incubated for 10–15 min in the oven. The bars were prepared, and codes were attached. Preparations were stained with ERCC1 (D-10): Sc-17809 (Santa Cruz Biotechnology, Inc.) immune stain. The staining procedure was performed with the device Bond Polymer Refine Detection kits (Leica, DS9800). The staining was performed in the following order: Deparaffinization (Bond Dewax Solution, Leica Microsystems), rehydration (alcohol), washing (Bond Wash Solution, Leica Microsystems), mask antigenic removed (Bond Epitope Retrieval Solution, Leica Microsystems), washing (Bond Wash Solution, Leica Microsystems), inhibition of endogenous peroxidase activity (Peroxide Block, Leica Microsystems), washing (Bond Wash Solution, Leica Microsystems), primer anticore (anti-e NOS; Gene Tex Inc., Irvine, California, anti-I NOS; 1:100 Dilution, Gene Tex Inc., Irvine, California, USA), washing (Bond Wash Solution, Leica Microsystems), second anticore (Post Primary, Leica Microsystems), washing (Bond Wash Solution, Leica Microsystems), polymerization (Leica Microsystems), washing (Bond Wash Solution, Leica Microsystems), washing (with distilled water), 3,3'-diaminobenzidine tetrahydrochloride) (DAB; Mixed DAB Refine, Leica Microsystems), washing (with distilled water), contrast staining (Mayer hematoxylin), washing (with distilled water), washing (Bond Wash Solution, Leica Microsystems), and washing (with distilled water) conducted in the device.

The stained slides were covered with coverslips using a water-based gel. The slides were evaluated by an independent blind pathologist to the outcome of the cases. ERCC1 expression was examined in four categories: Negative; No staining, +1; 10% below or partial nuclear and/or cytoplasmic staining, +2; >10% on weak to moderate nuclear and/or cytoplasmic staining, and +3; >10% on strong nuclear and/or cytoplasmic staining. The specimens were exhibited as negative (no staining), weak (+1, +2), and strong (+3) ERCC1 expression.[5]

Statistical analysis

The software package International Business Machines (IBM), Statistical Package for the Social Sciences 22.0 (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis of the data. Overall survival (OS) was defined from the date of diagnosis until death time or the end date of the last visit. Progression-free survival (PFS) time was defined as the time from the first diagnosis of recurrence including locoregional metastases (in the primary site and involvement cervical lymphatic node) and distant metastases (other sites). For survival assessment, the Kaplan–Meier analysis was used; for statistical analysis, the log-rank test was used. For the relationship between ERCC1 expression and clinic pathologic features, Pearson's Chi-square test, Fisher's exact Chi-square, and likelihood ratio tests were used. Results of the 95% confidence interval and P < 0.05 were considered statistically significant.

 > Results Top

The median follow-up period of the cases was 21 months (2–66 months). The demographic characteristics of the cases are shown in [Table 1].
Table 1: The relationship between excision repair cross-complementation group1 expression and clinicopathologic features

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It was determined with different intensities ERCC1 expression in cases of NFC [Figure 1]. ERCC1 expression was not observed in 5 (15.15%) of all cases, and these cases were evaluated as ERCC1 expression negative. Of the cases, 13 (39.9%) as a weak (+1, +2) ERCC1 expression and 15 (45.5%) as strong (+3) ERCC1 expression were assessed.
Figure 1: (a) ERCC1 cytoplasmic expression negative, (b) ERCC1 (+) weak cytoplasmic expression, (c) Low ERCC1 weak cytoplasmic expression (2+), (d) Strong ERCC1 cytoplasmic expression. ERCC1: Excision repair cross-complementation group1

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There were three cases (60.0%) in Stage II–III and two cases (40.0%) in Stage IV-B of all the ERCC1 negative expression group. There were eight cases (61.5%) in Stage II–III and five cases (38.5%) in Stage IV-B of all the weak ERCC1 expression group. There were 14 cases (93.3%) in Stage II–III and only one case (6.7%) in Stage IV-B of all the strong ERCC1 expression group. There was no statistically significant difference between ERCC1 expression distribution degree and staging for NPC according to the likelihood ratio test (P > 0.05) [Table 1] and [Figure 1]. Although higher ERCC1 expression was observed in Stage II–III, lower ERCC1 expression was observed in the Stage IV-B, but there was not statistically significant (according to Pearson's Chi-square test, P > 0.05).

The median age of cases was 43 years (range: 34–80 years) in the ERCC1 negative group, 59 years (range: 47–80 years) in the weak ERCC1 expression group, and 48 years (range: 26–75 years) was in the strong ERCC1 expression group. When ERCC1 expression was evaluated according to patient age, the identifying ERCC1 expression decreased in the case of advanced age. However, this difference was not statistically significant on the Mann–Whitney U-test (P = 0.052).

There were 9 women and 27 men in the present study. ERCC1 expression degree and gender were investigated with Fisher's exact test, but the results were not statistically significant (P > 0.05).

Histopathologically, 14 cases (42.4%) had keratinized squamous carcinoma, four cases (12.1%) had nonkeratinized squamous carcinoma, and 15 (45.5%) cases had basaloid epidermoid carcinoma in all cases. Four cases (80%) were basaloid epidermoid carcinoma, and only one case (20%) was nonkeratinized squamous carcinoma in all ERCC1 negative group. Four cases (30.8%) were basaloid epidermoid carcinoma, seven cases (53.8%) were keratinized squamous carcinoma, and two cases (15.4%) were nonkeratinized squamous carcinoma in the all weak ERCC1 expression group. Seven (46.7%) cases were basaloid epidermoid carcinoma, and seven (46.7%) cases were keratinized squamous carcinoma, and only one case (6.7%) was nonkeratinized squamous carcinoma in the all strong ERCC1 expression group.[6] There was no statistically significant difference between the degree of ERCC1 expression and histopathological groups according to the likelihood ratio test (P > 0.05) [Table 1] and [Figure 1].

After treatment, 12 cases (37.5%) showed a complete response, nine cases (28.1%) had a partial response, eight cases (25%) had stable disease, and three cases (9.1%) showed progressive disease. There were no statistically significant differences between ERCC1 expression and the response to treatment (according to the likelihood ratio test; P = 0.271). At the end of the study, ten cases (30.3%) had died for reasons related to disease and 23 cases (72.72%) were still alive. The progression was observed in 11 of the cases after treatment. While ERCC1 expression did not observed on two of cases who progressed, five cases with weak ERCC1 expression, four cases with strong ERCC1 expression observed. Objective response rate (ORR) (including complete and partial response) was observed 20% in only one case within ERCC1 negative group, and 69.2% in nine cases with weak ERCC1 expression, and 73.3% in 11 cases with strong ERCC1 expression group. It was observed that there is a correlation between increased ORR and degree of ERCC1 expression but no statistical significance (P = 0.062).

In this study, a relationship between degree of ERCC1 expression and survival rate (PFS, OS) showed no significant correlation according to the Kaplan–Meier method and the log-rank test (P > 0.05) [Figure 2] and [Figure 3].
Figure 2: Overall survival graphic

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Figure 3: Progression free survival graphic

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 > Discussion Top

NPC is characterized by the anatomical location of the nasal cavity, paranasal sinuses, and oral cavity surrounded by structures such as the orbital skull base. This complex anatomical structure leads difficulties in early diagnosis, staging, and management for NPC. Today, according to guidelines, RT is applied as a gold standard and treatment can be applied in early stage cases, CCRT is also an essential treatment for other stages of NPC. Although it is still unknown whether administration of induction/adjuvant ChT appears to improve survival following CRT, the cases with advanced stage are treated only ChT.[1] The damaged DNA is repaired by DNA repair pathways, including base excision repair and NER.[2],[3] It is detected much better response to PCT when the presence of weak ERCC1 expression in studies related with ovarian, gastric, esophageal, testicular, bladder, colorectal, and nonsmall cell lung carcinomas.[7],[8] The development of resistance to platinum-containing chemotherapeutic agents is associated with strong ERCC1 expression and activity.[2] The meta-analysis examined studies in the literature of induction/adjuvant ChT compared with RT application alone; ChT has been reported a positive contribution rate of 4–6% over the 5-year survival rate.[9] Although the progression of disease can be prevented only with RT application, it is reported that the cases were subjected to chemotherapy toxicity with unnecessary chemotherapy in cases of NFC.[9] ChT-induced complications may be contribute toxic effects during RT, narrowing medical gain.[10] It should be firmly questioned the requirement of administration chT for this cases.

Today, there are no biological markers to identify cases who can benefit from platinum-containing regimens for tailor modification in the management of NPC. From three different centers in 5 years, the number of our cases were small because the number of cases in our country are very less unlike the other Eastern societies. The majority of cases were in stage II–III as in the literature.[1]

Although keratinized squamous and basaloid squamous types were identified more frequently and in almost equal proportions, nonkeratinized type was less common in our study. This diversity is not identified in the literature like Eastern societies.[11] These differences may occur from regional differences. Because, it is differentiated in regions where NPC is endemic compared to other regions in terms of incidence of human papilloma virüs (HPV), Ebstein–Barr virus (EBV), smoking, and alcohol consumption habits.

It was observed that degree of ERCC1 expression was weak in increasing age, but no statistically significant differences in the baseline characteristics between the strong ERCC1 expression group and weak ERCC1 expression group for age in our study. There may be many factors that can affect the evaluation of ERCC1 expression in advanced age.[12] These also should not be ignored. Some researchers found that the risk of regional recurrence increased with increasing ERCC1 expression in different carcinomas.[9],[11],[13] In our study, 11 cases were progressed after treatment CRT and/or ChT in the follow-up period, and we detected no statistically significant between ERCC1 weak expression and progression.

There are so many conflict results in the literature. Some of them including the more increased response to ChT in cases with weak ERCC1 expression,[7],[8],[14] other study show to prolong survival after adjuvant PCT in cases with strong ERCC1 expression in the literature.[15] In our study, the more overall response rate was detected in cases with strong ERCC1 expression group, but there was no statistical relationship similarly to some studies.[16]

According to the data in the literature, chemotherapy that contained platinum administered to cases in different stages produced conflicting results in terms of ERCC1 expression distribution and survival and response to treatment. These conflicting results may be related to the ERCC1 evaluation techniques. In the light of this work, perhaps ERCC1 activity should not be examined with immunohistochemical methods. The studies that used polymerase chain reaction (PCR) or immune histochemistry techniques have nonuniform results. A relationship between survival and ERCC1 expression was not observed using technique PCR used in a study.[17] Perhaps a genetic phenomenon was preventing the activity of ERCC1. In one study, a genetic polymorphism was observed in the activity of ERCC1 in DNA damage caused by ChT and RT.[18] Whether any polymorphisms are involved in the activity of DNA repair mechanisms is still unclear. Some researchers showed that the cases could benefit from oxaliplatin treatment the presence of single nucleotide polymorphisms in codon 118 on the ERCC1 gene in colorectal carcinoma.[19] It was showed that there was no relationship between single nucleotide polymorphism differences in codon 118 and response to therapy among groups with advanced stage NPC treated with gemcitabine/oxaliplatin or gemcitabine in phase 2 study.[19],[20] ERCC1 may not only play a main role in repair of platinum-induced DNA damage but also it probably contributes to this damage process. The activation of ERCC1 on NER pathway and DNA repair mechanisms might depend on tumor biology, patient age, and stage of tumor also researchers such as Lima found that cases with head and neck carcinoma had a more pronounced increase in ERCC1 expression according to age and stage of carcinoma.[20],[21] It is not showed that any cut-off value of ERCC1 is known immunohistochemically for activation of the NER pathway to repair resulting DNA damage in the literature.

Our study has several limitations. First, this is a multicentric study, and the specimens of the pathology were evaluated by different pathologists. This also subtyping of the NPC histopathology may not lead to an accurate reflection. I wish all of the specimens could have been assessment by only one pathologist in certain norms. Second, the number of cases are very low and we do not evaluation the smoking history, (HPV)/p16 status, EBV. Perhaps these parameters cause different alterations in the genetic structure. If we could to be analysis these parameters, we could talk more accurate, and more objective results the relationship between evaluation of ERCC1 expression and response to ChT.

 > Conclusion Top

However, weak ERCC1 expression degree was significantly associated with longer survival in the literature, no statistically significant difference was detected between ERCC1 expression degree and survival, clinicopathologic features in our study. ERCC1 expression is not as a biological marker guiding management in NPC. Evaluation of ERCC1 should be standardized and optimized by the appropriate technique. Afterward, further studies, especially should be on this standardization. The studies including genetic polymorphism would also explain to genetic alterations in cases from different countries.

Financial support and sponsorship

This study was supported by grants from the Scientific Research Coordination Unit of Inonu University (No: 2013/130).

Conflicts of interest

There are no conflicts of interest.

 > References Top

National Comprehensive Cancer Network (NCCN). Washington: Clinical Practice Guideles in Oncology. Version. 1. Head and Neck Cancers, Inc.; c2016. p. 23-5. Available from: http://www.nccn. org/. [Last updated on 2016 Jun 06].  Back to cited text no. 1
Martin LP, Hamilton TC, Schilder RJ. Platinum resistance: The role of DNA repair pathways. Clin Cancer Res 2008;14:1291-5.  Back to cited text no. 2
Rosell R, Taron M, Barnadas A, Scagliotti G, Sarries C, Roig B. Nucleotide excision repair pathways involved in Cisplatin resistance in non-small-cell lung cancer. Cancer Control 2003;10:297-305.  Back to cited text no. 3
Therasse P, Arbuck SG, Eisenhauer EA, Wanders J, Kaplan RS, Rubinstein L, et al. New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J Natl Cancer Inst 2000;92:205-16.  Back to cited text no. 4
Azuma K, Sasada T, Kawahara A, Takamori S, Hattori S, Ikeda J, et al. Expression of ERCC1 and class III beta-tubulin in non-small cell lung cancer patients treated with carboplatin and paclitaxel. Lung Cancer 2009;64:326-33.  Back to cited text no. 5
Shanmugaratnam K, Sobin LH. The World Health Organization histological classification of tumours of the upper respiratory tract and ear. A commentary on the second edition. Cancer 1993;71:2689-97.  Back to cited text no. 6
Bellmunt J, Paz-Ares L, Cuello M, Cecere FL, Albiol S, Guillem V, et al. Gene expression of ERCC1 as a novel prognostic marker in advanced bladder cancer patients receiving cisplatin-based chemotherapy. Ann Oncol 2007;18:522-8.  Back to cited text no. 7
Shirota Y, Stoehlmacher J, Brabender J, Xiong YP, Uetake H, Danenberg KD, et al. ERCC1 and thymidylate synthase mRNA levels predict survival for colorectal cancer patients receiving combination oxaliplatin and fluorouracil chemotherapy. J Clin Oncol 2001;19:4298-304.  Back to cited text no. 8
Huang PY, Li Y, Mai HQ, Luo RZ, Cai YC, Zhang L. Expression of ERCC1 predicts clinical outcome in locoregionally advanced nasopharyngeal carcinoma treated with cisplatin-based induction chemotherapy. Oral Oncol 2012;48:964-8.  Back to cited text no. 9
Lee AW, Ng WT, Hung WM, Choi CW, Tung R, Ling YH, et al. Major late toxicities after conformal radiotherapy for nasopharyngeal carcinoma-patient- and treatment-related risk factors. Int J Radiat Oncol Biol Phys 2009;73:1121-8.  Back to cited text no. 10
Cheung F, Chan O, Ng WT, Chan L, Lee A, Pang SW. The prognostic value of histological typing in nasopharyngeal carcinoma. Oral Oncol 2012;48:429-33.  Back to cited text no. 11
Lee AW, Lau WH, Tung SY, Chua DT, Chappell R, Xu L, et al. Preliminary results of a randomized study on therapeutic gain by concurrent chemotherapy for regionally-advanced nasopharyngeal carcinoma: NPC-9901 Trial by the Hong Kong Nasopharyngeal Cancer Study Group. J Clin Oncol 2005;23:6966-75.  Back to cited text no. 12
Chan SH, Cheung FM, Ng WT, Choi CW, Cheung KN, Yiu KH, et al. Can the analysis of ERCC1 expression contribute to individualized therapy in nasopharyngeal carcinoma? Int J Radiat Oncol Biol Phys 2011;79:1414-20.  Back to cited text no. 13
Handra-Luca A, Hernandez J, Mountzious G, Taranchon E, Lacau-St-Guily J, Soria JC, et al. Excision repair cross complementation group1 immuno-histochemical expression predicts objective response and cancer-specific survival in patients treadet by cisplatin-based induction chemotherapy for locally advanced head and neck squamous cell carcinoma. Clin Cancer Res 2007;13:3855-9.  Back to cited text no. 14
De Castro G Jr., Pasini FS, Siqueira SA, Ferraz AR, Villar RC, Snitcovsky IM, et al. ERCC1 protein, mRNA expression and T19007C polymorphism as prognostic markers in head and neck squamous cell carcinoma patients treated with surgery and adjuvant cisplatin-based chemoradiation. Oncol Rep 2011;25:693-9.  Back to cited text no. 15
Koh Y, Kim TM, Jeon YK, Kwon TK, Hah JH, Lee SH, et al. Class III beta-tubulin, but not ERCC1, is a strong predictive and prognostic marker in locally advanced head and neck squamous cell carcinoma. Ann Oncol 2009;20:1414-9.  Back to cited text no. 16
Cobo M, Isla D, Massuti B, Montes A, Sanchez JM, Provencio M, et al. Customizing cisplatin based on quantitative excision repair cross-complementing 1 mRNA expression: A phase III trial in non-small-cell lung cancer. J Clin Oncol 2007;25:2747-54.  Back to cited text no. 17
Vogel U, Nexø BA, Wallin H, Overvad K, Tjønneland A, Raaschou-Nielsen O. No association between base excision repair gene polymorphisms and risk of lung cancer. Biochem Genet 2004;42:453-60.  Back to cited text no. 18
Viguier J, Boige V, Miquel C, Pocard M, Giraudeau B, Sabourin JC, et al. ERCC1 codon 118 polymorphism is a predictive factor for the tumor response to oxaliplatin/5-fluorouracil combination chemotherapy in patients with advanced colorectal cancer. Clin Cancer Res 2005;11:6212-7.  Back to cited text no. 19
Ma BB, Hui EP, Wong SC, Tung SY, Yuen KK, King A, et al. Multicenter phase II study of gemcitabine and oxaliplatin in advanced nasopharyngeal carcinoma – Correlation with excision repair cross-complementing-1 polymorphisms. Ann Oncol 2009;20:1854-9.  Back to cited text no. 20
Lima LM, de Souza LR, de Silva TF, Pereira CS, Guimarães AL, Paula AM, et al. DNA repair gene excision repair cross complementing-group 1 (ERCC1) in head and neck squamous cell carcinoma: Analysis of methylation and polymorphism (G19007A), protein expression and association with epidemiological and clinicopathological factors. Histopathology 2012;60:489-6.  Back to cited text no. 21


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  [Table 1]


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