AUCTORES
Globalize your Research
Case Report
*Corresponding Author: Lena Marinova, Complex Oncology Center; Department of Radiotherapy -Ruse, Bulgaria.
Citation: L Marinova, B Yordanova, N Evgeniev. (2021). Uterine carcinosarcoma аfter prolonged antiestrogenic therapy - pathohistological characteristics, immunohistichemical analysis, prognosis and complex treatment. Clinical Oncology Research and Reports. 2(2) Doi: 10.31579/2693-4787/027
Copyright: © 2021 Lena Marinova. 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: 11 August 2021 | Accepted: 23 August 2021 | Published: 02 September 2021
Keywords: uterine carcinosarcoma; pathohistological analysis; immunohistochemical analysis; surgery; simultaneous chemo-radiotherapy; complex treatment
Uterine carcinosarcoma (UCS) is a rare aggressive neoplasm.We present a clinical case with UCS, developed during along-term five years adjuvant tamoxifen treatment and ovarian suppression with LHRH agonist on the occasion of invasive ductal breast carcinoma. Crucial for obtaining diagnosis of this rare aggressive neoplasm is the strict pathohistological and immunohistochemical analysis, carried out by an experienced pathologist. Every patient with a history of breast carcinoma is a subject for periodic monitoring. Genital bleeding is required to perform a separated endometrial abrasion with a precise histological study. For UCS / III C2 FIGO stage without distant metastases is necessary to conduct a maximal surgical tumor reduction, involving ever total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, peritoneal cytology, and omentectomy, followed by a combined simultaneous chemo-radiotherapy of tumor bed and pelvic lymph nodes, definitive radiotherapy of para-aortical lymph nodes, as well as adjuvant chemotherapy.
Malignant uterine neoplasms containing both carcinomatous and sarcomatous elements are designated in the World Health Organisation (WHO) classification of uterine neoplasms as carcinosarcomas [1]. Uterine carcinosarcomas (UCS) are characterized with a rare occurrence, accounting for only 2–5% of all uterine malignancies [2-5]. They are aggressive undifferentiated carcinomas which include both carcinomatous and sarcomatous elements, arising from a single malignant epithelial clone [6-9]. Carcinosarcomas are classified into two histological subtypes based on their sarcomatous component, namely homologous or heterologous [10,11]. Extremely important for the diagnostics of this rare aggressive neoplasm is the strict pathohistological and immunohistochemical analysis, carried out by an experienced pathologist. Due to rare diagnosis, there are no established standards for complex oncology treatment. We will present a rare UCS, developed on the basis of long-term antiestrogenic hormone treatment for invasive ductal breast carcinoma.
Clinical case - A 50-year-old woman diagnosed with breast cancer invasive ductal carcinoma of the right breast / pT2 N1 M0; G2; ER and PR-positive; HER2 –negative) seven years ago. A quadrectomy with axillary dissection has been performed in 2013 and followed with 6 courses adjuvant chemotherapy (Ch) with docetaxel and postoperative radiotherapy (RT) of the right breast and the regional lymph nodes up to total dose (TD) 50 Gy, an ovarian suppression with LHRH agonist and anti-estrogenic hormone therapy with tamoxifen have been added. Separated endometrial abrasion have been performed in July 2020 for genital bleeding. From pathohistological and immunohistochemical analysis an uterine carcinosarcoma (UCS) with cervical tumor infiltration was confirmed. Patohistological morphology and immunohistichemical analysis of the material from separated endometrial abrasion - Histological examination revealed classical malignant biphasic growth pattern with undifferentiated epithelial component, composed of clear cells with light, relatively wide cytoplasm and small- round nuclei, atypical cells with hyperchromatic nuclei. Cells form wide fields and adenoid structures. Tumor infiltration in smooth muscle and subepitelial endocervical area is reported. The epithelial component is surrounded by undifferentiated mesenchymal tissue, consisting of pleomorphic and bizarre tumor cells visualized variable cellularity with varied size, as well as giant cells usually bizarre with multilobulated nuclei, irregular mitosis, histiocyte-like cells with vacuolated nuclei with abundant clear cytoplasm (mesenchymal component) (Fig.1,Fig.2B). In the carcinoma component, a positive IHC reaction to Cytokerin is reported and the sarcomoid component shows negative expression. And the two cellular components are positive to Vimentin. Focal positive IHC expression to S-100 protein in single tumor cells with with atypical cell mitosis. Negative IHC expression to Myogenin, Desmin and SMA in tumor cells, but positive expression in the smooth muscular walls of the blood vessels. (Fig.2A-Fig.5). Based on the morphological and immunohistochemical (IHC) study, a malignant mixed Mullerian tumor of the uterus was found. The carcinoma component consists of clear cell carcinoma with hight grade endometroid adenocarcinoma. The sarcomatoid cells consist undifferentiated sarcoma with scars of lipogenic phenotype in pathogenesis, given the focal immunohistochemical expression of S-100 protein in single tumor cells. In August 2020 has been carried out Robot-assisted total hysterectomy with two-sided adnexectomy without lymph nodes pelvic dissection. Pathohistological analysis reports endometrium with carcinosarcoma infiltration, meometrium with an invasion of up to 50% of the uterine wall with abundant lymphovascular invasion; uterine cervix and endocervix with tumor emboli and neoplastic invasion; Fallopian tubes and ovaries with tumor emboli and metastases. Immunohistochemical analysis reports positive expression of tumor cells to CKAE 1/3 and negative to GATA 3, Mammaglobin and GCDFP.
PET/CT have been performed 3 months after surgery in Oct 2020. Metabolically active pelvic and para-aortic lymph nodes at L2-L3 level, have been suspected for metastatic (Fig.6). Thus, it was confirmed locally advanced uterine carcinosarcoma (pT3bcN2M0), but postoperative pelvic and para-aortic lymph nodes dissection was not carried out. After surgery, the patient conducted combined with Ch (cisplatin) intensity modulated radiation therapy (IMRT) in the tumor bed and bilaterally pelvic lymph nodes up to total dose (TD) 50 Gy (Fig.7), followed by definitive RT of the para-aortic lymph nodes up to 52 Gy with daily dose (DD) 1.8 Gy ( Fig.8). Control CT and PET/CT from May 2021 reports disease progression with metabolic active bone marrow engagement zones in the vertebra C1 and L3, a pathological fracture of L1 and a metabolic active area on the right para-aortic lymph nodes at level L2-L3 (Fig.9). After a biopsy of a pathologically increased inguinal lymphatic node done on 10 Jun 2021, immunohistochemical analysis proved metastasis of uterine carcinosarcoma (Fig.10-Fig.14). Due to pain syndrome, we conducted palliative re-irradiation in the area of metastatic vertebrae and metastatic para-aortic lymph nodes at L2-L3 level in June 2021 (Fig.15)
In humans, UCSs are very aggressive tumors and comprise ~5% of uterine malignancies [12, 13]. Carcinosarcoma /malignant mixed Mullerian tumor (MMMT) of the endometrium accounts for only 1%−2% of all gynecological malignancies [14]. Carcinosarcomas are biphasic malignant tumors composed of 2 distinct neoplastic cell populations: epithelial (or carcinomatous) cells, and mesenchymal (or sarcomatous) cells [15].
The risk factors to develop the UCS include obesity, nulliparity, exogenous estrogen, tamoxifen, and exposure to pelvic radiation, while progestin-containing contraceptives are thought to have protective effects [7, 16]. We present a rare clinical case with UCS, developed on the basis of long-term antiestrogenic hormone treatment with tamoxifen and ovarian suppression with LHRH agonist on the occasion of invasive ductal breast carcinoma.
A neoplastic population may undergo mutations that lead to transformation from an epithelial to a mesenchymal phenotype (epithelial–mesenchymal transition) [12]. The tumor relapse can be explained by the mesenchymal transdifferentiated subpopulations of cancer cell nests that are induced by the fibroblastic stroma and are readily radio-resistant and chemo-resistant [17]. Epithelial to mesenchymal transition (EMT) is involved in tumor progression with metastatic expansion, and the generation of tumor cells with stem cell properties that play a major role in resistance to anticancer treatment [18-20]. EMT is a crucial step in metastasis that enables polarized immotile epithelial cells to gain fibroblast-like mesenchymal abilities such as enhanced motility [21]. In Fig. 3, we present the positive IHC expression in both cell populations carcinomatous and sarcomatous with infiltration in myometrium. Vimentin staining confirms mesenchymal origin of some tumors, but it is normally positivated in endometrial stromal cells, endometrial glandular structures and in lymphocytes, neutrophils, macrophages and platelets [22]. Normal proliferative-phase and secretory-phase endometrial stromal cells showed the following immunopositivity: vimentin 10 of 10, muscle-specific actin (MSA) 10 of 10, alpha-smooth muscle actin (alpha SMA) 10 of 10, desmin nine of 10, cytokeratin (AE1/AE3 and CAM 5.2) zero of 10, epithelial membrane antigen (EMA) zero of 10, and S-100 protein zero of 10 [23]. In recent years, Vimentin has been recognized as a marker for epithelial-mesenchymal transition [24].
MRI and fluorodeoxyglucose (FDG) PET-CT can help detect lymph node involvement prior to surgery [25]. In the presented clinical case, PET-CT is carried out after the operation without lymphatic dissection of pelvic lymph nodes. The imaging study shows a local advanced tumor with pelvic and paraaortic lymph nodes infiltration, which is typical of carcinosarcomas (Fig.6). Despite the combined chemo-radiotherapy of pelvic and paraaortic lymph nodes (Fig.7, Fig.8), a progression of UCS is detected with an inguinal lymph node and bone marrow desimination / distant metastasis M1 after six months (Fig.9). This progression of the disease impedes the re-irradiation of the metastatic lymph nodes and palliative exposure of metastatic vertebrae in strict observance of tolerant doses in neighboring critical organs / thin bowels, kidneys, spinal cord (Fig.15).
The overall prognosis of UCS is poor, even with the best of care, due to its aggressive behavior [7, 16]. It is likely that a sarcomatous component within an endometrial cancer is a histological marker of increased aggressiveness [26]. The risk of recurrence is higher with larger tumors, higher cancer stage at initial presentation, the existence of lymphovascular involvement, and deeper myometrial invasion [27]. UCS with the epithelial elements, high grade carcinoma and serous and clear cell components were associated with a higher frequency of metastases, deep myometrial invasion, lymphatic or vascular space invasion, and cervical involvement, all parameters indicative of an aggressive behaviour [11, 28]. In our clinical case, we take into account all the above-mentioned adverse prognostic factors as a mixed carcinoma cell component composed of clear cell carcinoma and high-grade endometrial carcinoma, advanced UCS (pT3bcN2M0), lymphovascular tumor invasion, pleorphic sarcomatous component with phenotype of lipublastoma and metastases in the paraaortic lymph nodes.All these factors show an extremely malignant tumor requiring aggressive complex treatment.
The basic definition of UCS is the following: 1/ Biphasic, malignant tumor with high grade epithelial and sarcomatous components.; 2/ Sarcomatous component is derived from the carcinomatous component as a result of metaplasia / transdifferentiation epithelial to mesenchymal transition [29]. Malignant mixed mesodermal tumors, also called carcinosarcomas, are diagnosed mainly in postmenopausal women and are composed of mixed malignant epithelial and mesenchymal components, usually high grade [30]. This proves that the basic meaning for diagnosis is a precise pathohistological feature of combination of the two tumor components-carcinoma, (more frequently high grade carcinoma- high grade endometrial adenocarcinoma, clear cell or serous carcinoma) and a homologous or heterologous sarcomatoid component (Fig.1,Fig.2A,Fig13). Histological examination in our clinical case revealed classical malignant biphasic growth pattern with carcinoma cells in glandular structures undifferentiated epithelial component, mixed by undifferentiated mesenchymal tissue (sarcomatoid component), consisting of monstruous and multinucleated tumor cells with hyperchromatic nuclei and scant cytoplasm, myxoid areas, tumor necrosis and haemorrhage with type of pleomorphic sarcoma (Fig.1, Fig.2B, Fig 10 A/B). Cells are visualized variable cellularity with varied size, as well as giant cells usually bizarre, irregular mitosis, histiocyte-like cells with vacuolated nuclei, atypical cells with hyperchromatic nuclei, irregular fascicles, cells with abundant clear cytoplasm, psammoma bodies and hyalinized stroma, associated with solid pattern (Fig.11, Fig.12). The carcinoma cells component consists of clear cell carcinoma with high grade endometrioid endometrial carcinoma. Endometrial clear cell carcinomas (CCC) constitute fewer than 5% of all carcinomas of the endometrium [31]. Cells have clear cytoplasm, hyalinized stroma associated with solid pattern, numerous grade 3 nuclei and thin fibrous septae [32].These pathologist characteristics are well visible in Fig.1B/C, Fig.2A. Solid architecture and polygonal cells with moderate to abundant clear or eosinophilic cytoplasm are characterized in clear cell carcinoma [33]. The definition of undifferentiated/unclassified sarcoma is pleomorphic sarcoma composed of fibroblasts, myofibroblasts and histiocyte-like cells [34]. In the presented clinical case, the sarcomatoid component is made up of рleomorphic and bizarre tumor cells with foamy cytoplasm and marked atypia, in background of collagenous and mixoid stroma, which is typical of the undifferentiated sarcoma cells (Fig.10 A/B, Fig.11, Fig.12). Fig.11 and Fig.12presents pronounced cellular polymorphism, lipoblasts and zones of hemorrhage.
Histopathology and immunohistochemistry revealed a mixed, anti-cytokeratin AE1/AE3-positive epithelial, and vimentin-positive mesenchymal neoplasm consistent with a homologous carcinosarcoma, also called malignant mixed Müllerian tumor, with areas of double-labeling [35]. Immunohistochemically, UCSs typically express epithelial (cytokeratins and epithelial membrane antigen) and stromal lineage markers (vimentin, CD10, CD34) in relation to their histologic appearances [36]. Areas of double-labeling with cytokeratins and vimentin, and immunohistochemical staining for p16, p53, and PAX8, may be helpful in establishing a diagnosis of UCS [37].For precision diagnosis of the carcinoma and sarcoma component, IHC is required. We received positive diffuse IHC reaction to Cytokeratin AE1/AE3 in the carcinoma component in which clear cell adenocarcinoma stands out and negative reaction to Cytokeratin AE1/AE3 in the sarcomatoid component, which is mixed by the adenocarcinoma cells component (Fig.2/A,Fig.13/A).Immunohistochemically clear cell carcinoma has negative expression to estrogen and progesterone receptors [31], we take into account a positive reaction to these receptors due to high-grade cells of endometroid endometrial carcinoma (Fig.10C/D). Undifferentiated/unclassified sarcoma is high grade sarcoma with no distinctive microscopic, immunohistochemical or molecular features fitting any specific line of differentiation [34, 38]. Large round, spindle or bizarre cells with marked nuclear anaplasia and large prominent nucleoli are Cytokeratin AE1/AE3 negative, which proves the presence of high-grade sarcoma cells (Fig.2A/B, Fig.13/A). In the heterologous subtype USC, the mesenchymal element includes foci of striated muscle, cartilage, bone (sometimes covered by plump osteoblasts), and/or adipose tissue (i.e., tissue types not normally present in the uterus). These foci also often display malignant features [39]. In the presented clinical case, the sarcomatoid component displays positive expression not only to Vimentin, but also focal expression to S-100 protein in single tumor cells, which shows lipoblastic sarcoma histogenesis (Fig.3A/B, Fig.4). The definition of pleomorphic liposarcoma is widespread high grade, pleomorphic tumor cells with some lipoblasts but no evidence of well differentiated liposarcoma. Pleomorphic lypoblastoma cells show positive expression to Vimentin and S-100 Protein [40], which is visible in Fig.3A/B and Fig.4. In the pleomorphic areas the expression of smooth muscle markers (desmin 10 of 28, muscle-specific actin 13 of 28, and α-smooth muscle actin 14 of 28) was significantly reduced [36]. In Figure 5, we report negative IHC expression to Myogenin and Desmin, as well as negative expression to SMA in tumor cells, but positive expression in the smooth muscular walls of the blood vessels.The liposarcom cells are negative to Desmine [41]. In the clinical case, due to a history of breast carcinoma 7 years ago, for differential diagnosis between lymph metastasis of uterine carcinosarcoma or breast carcinoma, we conducted immunohistichemic analysis with the specific breast carcinoma immune histochemical markers HER2, Mamaglobin and GCDFP (Fig.14 A/B,D). A negative expression is reported, indicating that it is a metastase of a uterine carcinosarcoma. A negative IHC reaction to Melan A excludes the diagnosis malignant melanoma (Fig.14 C).
Uterine carcinosarcomas should be regarded as metaplastic carcinomas and adjuvant treatment should probably be similar to that directed against aggressive high grade endometrial carcinomas, rather than being sarcoma based [26]. The principal treatment in early and locally-advanced UCS is surgery; because of its aggressiveness [42]. Total hysterectomy and bilateral salpingo-oophorectomy along with surgical staging are the first line in patients without distant metastasis [43]. Staging surgery consisted of total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, peritoneal cytology, and omentectomy [44]. Lymphadenectomy as part of the surgical procedure has shown to prolong survival even for early-stage disease. A combined chemo-radiotherapeutic approach has shown a survival benefit [45]. Surgery and adjuvant RT seem beneficial for excellent LRC rate [46].
There is enough evidence that the most UCSs are monoclonal and that the carcinomatous element is the driving force. Probably the adjuvant chemotherapy should be more similar to that given for a high stage, high grade endometrioid adenocarcinoma or an aggressive histological subtype of endometrial adenocarcinoma, such as serous or clear cell adenocarcinoma [26].
Previous GOG phase III trials have shown a better response to single agent treatment using cisplatin rather than doxorubicin [47,48]. Chemotherapy alone or associated with RT seems to improve disease free survival (DFS) and overall survival (OS) in stage III and IV UCS [42].In the future, the emergence of combination of chemotherapeutic agents with molecular-targeted agents may show promising results [45]. The transcription profile induced by EMT acquires radio-resistance in tumor cells that share the properties of stem cells [49]. Furthermore, research directed toward elucidating the role of vimentin in various signaling pathways would reveal new approaches for the development of therapeutic agents [24].
The endometrial carcinosarcomas are rare aggressive neoplasms. The strict pathohistological and immunohistochemical study is crucial for obtaining diagnosis and determine the need for aggressively complex treatment. Patients with a history of breast carcinoma were subject to periodic monitoring. In case of genital bleeding a separated abrasion with a precise histological study is required. In patients without distant metastases is necessary to conduct a maximal surgical tumor reduction, combined simultaneous chemo-radiotherapy of tumor bed and pelvic lymph nodes. Definitive radiotherapy of para-aortic lymph nodes, as well as chemotherapy are also recommended OS to be improved.
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.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
