AUCTORES
Globalize your Research
Review Article | DOI: https://doi.org/10.31579/2578-8965/195
Family Physician & Public Health Consultant Bengaluru. India
*Corresponding Author: Suresh K, Family Physician & Public Health Consultant Bengaluru.
Citation: Suresh K, (2023), Diagnostic and Management Challenges of Endometrial Tumours in Developing Countries! J. Obstetrics Gynecology and Reproductive Sciences, 7(7) DOI:10.31579/2578-8965/195
Copyright: © 2023, Suresh K. This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 31 October 2023 | Accepted: 08 November 2023 | Published: 16 November 2023
Keywords: gynaecological malignancies; cross‐disease analysis; endometrial cancer; endometriosis; genome‐wide association study; genetic correlation; role of obesity; party
Gynaecological cancers are among the most common cancers in women and hence an important public health issue in very country. Ovarian, Cervical, and Endometrial cancers contribute the most of Gynaecological cancers in India and worldwide. Endometrial benign tumours like Endometrioid cystadenoma / adenofibroma with endometrioid type glands, associated with endometriosis pose challenges of diagnosis.
Endometrial cancer (EC) is the most common gynaecological malignancy in the West, but in India, the incidence rates are low. National cancer registry project (NCRP) estimated 27,922 cases of EC in 2022 in India. The possible association between cancer and endometriosis varies according to the histologic subtype of ovarian cancer and is focused mostly on endometroid and clear-cell ovarian cancer subtypes.
The only way to diagnose womb cancer for sure is to take a sample of the tissue lining the womb (biopsy) and get histopathology report. However, most of the literate and urban women with ECs present at an early stage due to menorrhagia, abdominal pain or abdominal distension and are associated with a good prognosis. But the situation in rural India is one of lack of diagnostic and management facilities in public sector even at most of the district level. Treatment for endometrial cancer usually involves a hysterectomy, and adjuvant radiotherapy and/or chemotherapy. Surgery sometimes may include the removal of uterus and the fallopian tubes and ovaries, called a Hysterectomy with salpingo-oophorectomy. Adjuvant Radio/Chemotherapy treatment is planned based on final surgical &pathological staging.
Due to the lack of cancer awareness, variable pathology, and dearth of proper screening facilities in most developing countries including India, most rural women report at advanced stages, adversely affecting the prognosis and clinical outcomes.
Materials and Methods: This article is based on a case of adenocarcinoma Stage 1, Type 2 and another case of Endometrioid Cyst clinically and radiologically suspected to be malignant, but histopathology of tissues tested branded it as Endometrioid Cyst Adenofibroma. Relevant literature review of global experiences and good practices of management of endometrial cancers are added.
About five lakh women develop Gynaecological Cancers worldwide every year and more than one lakh new patients are diagnosed in India itself. Gynaecological cancer is defined as uncontrolled growth and spread of abnormal cells that originate from the reproductive organs like uterus, fallopian tubes, and ovaries. Gynaecological cancers are among the most common cancers in women and hence an important public health issue. Due to the lack of cancer awareness, variable pathology, and dearth of proper screening facilities in most developing countries including India, most women (except for urban literate women) report at advanced stages, adversely affecting the prognosis and clinical outcomes. Ovarian, Cervical, and Endometrial cancers contribute the most of Gynaecological cancers in India and worldwide [1,2,3,4,5]. Ovarian cancer (OC) has emerged as one of the most common malignancies affecting women in worldwide and India and has shown an increase in the incidence rates over the years. Ovary cancer (OC) is one of the most common lethal and aggressive gynaecologic cancers. It still is amongst the commoner cancers in India and a leading cause of cancer-related deaths in women [12]. The traditional treatment of OC involves resecting all suspected organs followed by chemotherapy. Cervical cancer (CC) is the second most common cancers of women in India, despite being largely preventable and national Cervical cancer (CC) detection campaigns promoted by GOI. However, cervical cancer is on a declining trend, though it remains the second most common cancer in women after breast cancer [12]. Among 604,100 new cases of CC and 341,831 deaths due to this malignancy detected globally in 2020, India, accounted for 9.4% of all cancers and 18.3% (123,907) of new cases in 2020. The age-standardized incidence rate of cervical cancer decreased substantially by about 40
1.A case of Uterine endometrial Adenocarcinoma:
Roopa aged 56 years, sought a gynaecologist’s consultation for heavy Bleeding per vagina for 6 months, who referred her to a private Oncology Hospital in Mysuru, Karnataka on 18 October 2023. She has a married life of 30 years and has a daughter aged about 26 years. She attained menopause since 2012. Her general condition was fair, but BMI was 32. An USG abdomen with transvaginal Scan done on 16/10 23 showed Bulky Uterus with thickened endogenic endometrium with cystic spaces suggestive of endometrial hyperplasia. CT Scan done of the abdomen prior to coming to this hospital reported to be normal. Her basic investigations included: Hb%=12g/Dl, Urea = 30 mg/Dl, Creatinine= 4.4 mg/dl, Sodium =140 mEq /l, Potassium=4.4 mEq/dl, Chlorine=120 mEq/dl, Total WBC count 10.400/Cu mm, Neutrophils= 86%, Lymphocytes = 12%, Eosinophils=2% and Platelet count+2.41,000/cu mm. 2 D echo reported heart, functions as normal with mild Mitral Regurgitation with 60
Gynaecological cancers are among the most common cancers in women, difficult to diagnose and treat for want of diagnostic facilities in most developing countries. The drudgery of women due to this disease is more due to social stigma as most poor and illiterate women consider the symptoms as normal of aging and delay seeking care despite being almost curable in early stages. Therefore, it is of an utmost public health important issue in very country. Endometrial cancer is common in western women, and the rates are very high probably due to care seeking behaviour and diagnostic facilities. However, in India, the rates are as low as 4.3 per 100,000 adult and elderly women.
Increasing age is the first and most important risk factor as for most cancers. Other risk factors for endometrial cancer include Hormone therapy, Postmenopausal Oestrogenic therapy, Selective oestrogen receptor modifiers, Tamoxifen therapy, Obesity, Metabolic syndrome, Diabetes, Nulliparity, Early menarche or late menopause, Polycystic ovary syndrome, Family history/genetic predisposition, Mother, sister, or daughter with uterine cancer, Lynch syndrome and Endometrial hyperplasia [3].
There are hardly any community-based studies to define incidence or prevalence. A hospital-based study from Mumbai, reported that the endometrial cancer patients with localized disease at diagnosis had a good outcome in India, as the proportions of patients dying above 50 years of age, non-residents and illiterates was higher than their counterparts. Only about half (54.8%) of patients had some form of treatment before attending the hospital. The contribution of tobacco-chewers (4.2%) and family history of cancer (6.1%) was small. Whereas, among the patients a quarter (25.8%) had 3-5 pregnancies (gravida), Nulliparous to Gravidae 1 or 2 were 36.1%, and 38.1% did not even remember the pregnancy history correctly. The 5-year overall survival rate was 92%, which also indicated better prognosis for those aged less than 50 years (97%), with localized disease (93%) and those treated with surgery either alone or as a combination with hormones (95%). [5].
Endometriosis Associated Cancers and Genes Involved:
A review of the literature suggested a link between endometriosis and ovarian and Uterine cancers, but not breast and cervical cancer. Women with endometriosis appear to be more
likely to develop, non-Hodgkin’s lymphoma, and brain tumours cancers. Some case reports, indicate the complexity of the endometriosis-cancer relationship. A case of primary endometrioid carcinoma arising from deep infiltrating endometriosis 6 years after diagnosis of ovarian cancer is
reported. Somatic mutations of PIK3CA, PTEN, and ARID1A might play a role in the disease progression and malignant transformation. At present, not
a single marker is recommended for diagnosis, or treatment. The issue of how to identify which endometriosis patients develop ovarian cancer remains critical but unanswered [10,11].
The likelihood of developing endometrial polyps and uterine fibroids is higher among postmenopausal women with proliferative endometrium, according to a study published in the December 2023 issue of the journal Maturitas [20].
A cross-sectional study of all women with a tissue-proven diagnosis of endometriosis postoperatively in a tertiary care hospital over a decade between January 1, 2010, and December 31, 2019, reported that out of 800 patients, 104 (13.0%) were found to have coexistent malignancy. Among 104 total cancer cases i) ovarian cancer contributed 50, (6.2%); ii) endometrial cancers 33, (4.1%); iii) synchronous ovarian, endometrial 7, (0.9%); and breast cnacers-14, (1.8%). Postmenopausal status (Odds Ratio-OR= 6.2), duration of endometriosis over 5 years (OR 4.7), and endometriomas larger than 8 cm, increasing age over 50 years (OR 1.13), higher levels of cancer antigen 125 (CA 125 -OR 1.002), were inferred as predictive of coexistent malignancy [6].
A study of a total of 1808 postmenopausal women who underwent endometrial biopsy between January 1997 and December 2008 and followed-up for a comparable duration of 11.9 vs. 11.5 years, respectively., indicated that Endometrial polyps developed twice more often in women with proliferative endometrium (17.3%) as compared to women 9.7% in women with atrophic endometrium (9.7%). On multivariable analysis, 62.1% of women with
Figure:1 proliferative
endometrium were found to have fibroids on ultrasound compared to 50.3% of women with atrophic endometrium. The risk of endometrial polyps was 2-folds higher among women with proliferative endometrium with adjusted odds ratio (OR) of 1.9. The need for repeat endometrial biopsy was 34.9% in women with proliferative endometrium vs 16.8% in those with atrophic endometrium. Nearly a quarter (26.6%) of women in the proliferative endometrium group required hysterectomy or hysteroscopy as against 16.2% in the atrophic endometrium group. The study inferred that women with proliferative endometrium are at higher risk of malignancy, endometrial polyps, and uterine fibroids. Therefore, the authors recommend medical management to reduce estrogenic activity and associated risks in postmenopausal women with proliferative endometrium [10,11].
Pathological types: Endometrioid cystadenoma / adenofibroma are benign tumours with endometrioid type glands, associated with endometriosis, which is represented by our Pratim’s case, that needs to be differentiated with endometrial cancers only by a pathophysiologic perspective. Endometrial carcinomas have been traditionally divided into 2 types: Type 1: includes endometrioid and mucinous carcinoma and Type 2: includes serous, clear cell, undifferentiated carcinoma and carcinosarcoma. Endometrioid histotype constitutes approximately 80% of all endometrial carcinomas, most of which are low grade (FIGO grade 1 - 2), as was our Case of Roopa was one such report [13]. Surgical treatment for both conditions remains basically the same.
Type 1: These lesions are associated with long term elevated oestrogen levels, which lead to persistent proliferative stimulation of the endometrium. Risk factors leading to hypoestrogenism include obesity, exogenous hormonal therapy (e.g., tamoxifen use for breast cancer), ovarian cortical hyperplasia / hyperthecosis, polycystic ovarian syndrome and hormone producing tumours (e.g., granulosa cell tumour of the ovary). Among others PTEN, ARID1A, PIK3CA, KRAS gene alterations are common. Atypical endometrial hyperplasia / endometrioid intraepithelial neoplasia is regarded as the precursor lesion [2,3,4].
Type 2: These tumours have a lesser association with unopposed oestrogen exposure. Serous carcinoma is characterized by early alterations in TP53. Precursor lesion for clear cell carcinoma has not been identified yet but are faster growing and more likely to spread [10].
Sites involved: Most common site is the uterine corpus - endometrium, endometrial polyps or adenomyosis. Primary cervical endometrioid adenocarcinomas are extraordinarily rare and likely develop from cervical endometriosis. Drop metastasis or contiguous extension from corpus should be ruled out in these cases. Technically, any tissue involved.
All endometrial cancers must perform a complete molecular classification (POLE mut, MMRd, NSMP, p53abn) says the FIGO report of June 2023.
Figure 2: FIGO classification Illustrated:
Figure 3: Illustrated FIGO staging system for endometrial Cancer!
Treatment:
Apart from the standard treatment practices for decade listed above Immune checkpoint inhibitors, a type of immunotherapy, have shown promising outcomes in treating tumours that have defects in a specific DNA repair process, called mismatch repair [17].
On July 31, 2023, the Food and Drug Administration approved Dostarlimab-gxly (Jemperli, GlaxoSmithKline) with carboplatin and paclitaxel, followed by single-agent dostarlimab-gxly, for primary advanced or recurrent endometrial cancer (EC) that is mismatch repair deficient (dMMR), as determined by an FDA-approved test. JEMPERLI injection can be imported by patients or government hospitals only in the name of the patients.
Source: Endometrial Cancer Treatment -Health Professional Version, https://www.cancer.gov/
Treatment Options for Endometrial Cancer
Endometriosis is a chronic disease associated with severe, life-impacting pain during periods, sexual intercourse, bowel movements and/or urination, chronic pelvic pain, abdominal bloating, nausea, fatigue, and sometimes depression, anxiety, and infertility.
It affects roughly 10% (250 million) of reproductive age women and girls globally. In India endometriosis is estimated to bother about 42 million women in their lifetime.
Epidemiological, biological, and molecular data suggest links between endometriosis and endometrial cancer, with recent epidemiological studies providing evidence for an association between a previous diagnosis of endometriosis and risk of endometrial cancer.
Using the proteomics approach, anti-endometrial antibodies (AEAs - tropomyosin 3 (TPM3), stomatin-like protein2 (SLP-2), and tropomodulin 3 (TMOD3)] were detected in Indian women with endometriosis.
From a pathophysiologic perspective, endometrial carcinomas have been traditionally divided into 2 types: Type 1: includes endometrioid and mucinous carcinoma and Type 2: includes serous, clear cell, undifferentiated carcinoma and carcinosarcoma. Endometrioid histotype constitutes approximately 80% of all endometrial carcinomas, most of which are low grade.
The only way to diagnose womb cancer for sure is to take a sample of the tissue lining the womb (biopsy) and get histopathology report.
Treatment for endometrial cancer usually involves a hysterectomy, salpingo-oopherectomy and adjuvant radiotherapy and/or chemotherapy.
Immune checkpoint inhibitors, a type of immunotherapy, have shown promise in tumours that have defects in a specific DNA repair process, called mismatch repair.
Therefore, all endometriosis cases must be subjected to frozen section endometrial biopsy and the extent of surgery be based on the histopathology, report.
Main challenges for improving EC management include early diagnosis, risk stratification, control of recurrent disease, or more appropriate therapeutic strategies integrating mutational profiles.
Given the public health importance the national and provincial governments must strive to make the diagnostic and treatment facilities in rural areas of developing countries.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
