Development and Application of Tumor Organoids: An Emerging Platform for Gynecological Cancers

FAM64A is a mitotic regulator which promotes cell metaphase-anaphase transition and is highly expressed in a cell-cycle-dependent manner. In this study, we examined the clinicopathological and prognostic significance of FAM64A mRNA expression in gynecological cancers. We conducted a bioinformatics analysis of FAM64A mRNA expression using Gene Expression Omnibus (GEO), The Cancer Genome Atlas (TCGA), xiantao, The University of ALabama at Birmingham CANcer data analysis Portal (UALCAN), and Kaplan-Meier (KM) plotter databases. FAM64A expression was elevated in breast, cervical, endometrial, and ovarian cancers when compared with normal tissue. Expression was positively correlated with white race, low T stages, infiltrating ductal carcinoma, or favourable PAM50 classification in breast cancer patients, and with clinical stage, histological grade and TP53 mutation, and endometrial cancer serous subtype. FAM64A expression was negatively associated with overall and/or recurrence-free survival rates in breast and endometrial cancer patients, while the opposite was observed in cervical and ovarian cancer patients. FAM64A functioned as an independent predictor of overall and disease-specific survival in breast cancer patients. FAM64A-correlated genes were involved in ligand-receptor interactions, and chromosomal, cell cycle, and DNA replication processes in breast, cervical, endometrial and ovarian cancers. Top hub genes primarily included cell cycle-related proteins in breast cancer, mucins and acetylgalactosaminyl transferases in cervical cancer, kinesin family members in endometrial cancer, and synovial sarcoma X and the cancer/testis antigen in ovarian cancer. FAM64A mRNA expression was positively related to Th2 cell infiltration, but negatively associated with neutrophil and Th17 cell infiltration in breast, cervical, endometrial, and ovarian cancers. FAM64A expression may be considered a potential biomarker reflecting carcinogenesis, histogenesis, aggressive behaviour, and prognosis in gynecological cancers. Impact statement What is already known on this subject? FAM64A is located in cell nucleolar and nucleoplasmic regions, and during mitosis it putatively controls metaphase-to-anaphase transition. FAM64A appears to regulate different physiological processes, including apoptosis, tumorigenesis, neural differentiation, stress responses, and the cell cycle. What the results of this study add? FAM64A expression was up-regulated in breast, cervical, endometrial, and ovarian cancers, and positively correlated with white race, low T stages, infiltrating ductal carcinoma, or favourable PAM50 classification in breast cancer patients, and with clinical stage, histological grade, and TP53 mutation, and a serous subtype in endometrial cancer. FAM64A expression was negatively associated with overall and/or recurrence-free survival rates in breast and endometrial cancer patients, while the opposite was observed in cervical and ovarian cancer patients. FAM64A functioned as an independent predictor of overall and disease-specific survival in breast cancer. FAM64A-correlated genes were involved in ligand-receptor interactions, chromosomal, cell cycle, and DNA replication processes, while FAM64A mRNA expression was positively related to Th2 cell infiltration but negatively correlated with neutrophil and Th17 cell infiltration in four gynecological cancers. What the implications of these findings for clinical practice and/or further research? In the future, abnormal FAM64A mRNA expression may serve as a biomarker of carcinogenesis, histogenesis, aggressiveness, and prognosis in gynecological malignancies.

To clarify the clinicopathological importance of REG4 mRNA expression, we used GEO, TCGA, xiantao, UALCAN, and Kaplan-Meier plotter for a bioinformatics analysis in breast, cervical, endometrial and ovarian cancers. Compared to normal tissues, REG4 expression was found to be upregulated in breast, cervical, endometrial, and ovarian cancers (p < 0.05). Breast cancer had a higher level of REG4 methylation than normal tissues (p < 0.05), which was negatively correlated with its mRNA expression. REG4 expression was positively correlated with oestrogen and progesterone receptor expression, and aggressiveness of PAM50 classification of breast cancer patients (p < 0.05). Breast infiltrating lobular carcinomas expressed more REG4 than ductal carcinomas (p < 0.05). The REG4-related signal pathways mainly included peptidase, keratinisation, brush border and digestion and so forth in gynecological cancers. Our results indicated that REG4 overexpression was associated with gynecological carcinogenesis and their histogenesis, and may be used as a marker for aggressive behaviour and prognosis of breast or cervical cancer. IMPACT STATEMENT What is already known on this subject? REG4 encodes a secretory c-type lectin and plays an essential role in inflammation, carcinogenesis, apoptotic and radiochemotherapeutic resistance. What do the results of this study add? As a standalone predictor, REG4 expression was positively correlated with progression-free survival. Expression of REG4 mRNA was positively associated with the T stage and adenosquamous cell carcinoma of cervical cancer. The top signal pathways related to REG4 included smell and chemical stimulus, peptidase, intermediate filament, and keratinisation in breast cancer; ligand-receptor interaction, metabolism of hormone, xenobiotic and retinol, peptidase, brush border and digestion in cervical and ovarian cancers; bile secretion, intermediate filament, chemical carcinogenesis, brush border and keratinisation in endometrial cancer. REG4 mRNA expression was positively correlated with DC cell infiltration in breast cancer, positively with Th17 cells, TFH, cytotoxic cells and T cells in cervical and endometrial cancers, and negatively with DC cell infiltration, cytotoxic cells and T cells in ovarian cancer. The top hub genes mainly included small proline rich protein 2B in breast cancer; fibrinogens and apoproteins in cervical, endometrial and ovarian cancers. What are the implications of these finding for clinical practice and/or further research? Our study has showed that REG4 mRNA expression is a potential biomarker or therapeutic target for gynaecologic cancers.

During the past decade, considerable strides have been made in the understanding and treatment of gynecologic cancers. The advent of PARP inhibitors, antiangiogenic therapies, immunotherapy combinations, and targeted agents have altered the standard of care in ovarian, endometrial, and cervical cancers. However, continued advancement in the treatment of gynecologic cancers is critical. Fortunately, exciting work defining new therapeutic targets and novel treatment strategies is on the horizon. Here, we discuss emerging treatments for gynecologic cancers, including endometrial, cervical, ovarian, and rare gynecologic cancers. We highlight research that has deepened our understanding of the unique biology and molecular underpinnings of these cancers and is being translated into powerful new treatment approaches. We particularly highlight the advent of immunotherapy in endometrial cancer; radiosensitizers in cervical, vaginal, and vulvar cancers; targeted therapies in ovarian cancer; and molecularly driven approaches to treat rare gynecologic cancers. Continued basic, translational, and clinical research holds the promise to change the landscape of gynecologic cancer and improve the lives of all women impacted by these diseases.

Introduction Cancer is a global public health issue and one of the worldwide pathologies with severe morbidity and mortality. Gynaecological cancers are defined as cancer of the breast and organs of the genital tract. Breast cancer is the first gynaecological cancer worldwide, with more than 15 million cases and 600,000 deaths per annum. It is followed by cervical cancer, with about 528,000 new cases and 266,000 deaths per year. Endometrial cancer comes 3rd and is closely followed by ovarian cancer. Cancer of the vagina is sporadic, representing about 1% of all gyneacological cancers. The objective of this study is to establish the prevalence of various gynaecological cancers. Methodology A retrospective study was carried out in the histopathology laboratory of the regional hospital Buea. Data were extracted from the registry of this department. The period for this study was from the 4th of March 2016 to the 25th of May 2019. The various cancers were aggregated according to age through basic descriptive statistics. Results Breast cancer is the 1st gynaecological cancer with a percentage of 69.82%. Cancer of the cervix, the uterus, the ovary, the vulvae, the fallopian tube, and the vagina, followed respectively with the following percentages; 24.01 %, 3.75 %, 1.5 %,0.44%,0.22%, and 0.22%. Discussion Our study agreed with the findings of many authors, which classified breast cancer as the 1st gynaecological cancer in women. Cervix Cancer spikes in the 41-50 age group and maintain the same trend in the 5th decade, now alongside Breast cancer. Our findings are slightly different from those of many authors who think that the peak of cervical cancer appears earlier before giving way to the one of breast cancer.&nbsp; These two cancers were found in this work to develop concomitantly in the 5th decade. The findings of the other types of cancers were in agreement with those of many authors. Conclusion Gyneacological cancers are a public health concern the world over. Their epidemiology varies according to geographical location and socioeconomic standard. Breast cancer comes first, followed by endometrial, ovarian, vulvar, fallopian, and vaginal cancers. Breast and cervical cancers, regardless of age, seem to develop concomitantly, in this population.

Identification of common candidate genes and pathways for progression of ovarian, cervical and endometrial cancers

BackgroundGlobally, common gynecological disorders such as Polycystic Ovary Syndrome (PCOS), endometriosis, uterine fibroids (non-malignant gynecological diseases), as well as cervical cancer, uterine cancer, and ovarian cancer (gynecological cancers), profoundly impact women’s physical and mental health. The burden of these diseases exhibits significant geographical disparities across different countries and regions, making a comprehensive and precise assessment of the global burden of gynecological diseases particularly crucial. Such an assessment will facilitate the development of region-specific prevention and treatment strategies, contributing to a more effective response to these health challenges.MethodsIncidence, prevalence, mortality rates, and Disability-Adjusted Life Years (DALYs) data for the aforementioned gynecological conditions were obtained from the 2021 Global Burden of Disease (GBD) study and analyzed by age, location, and year. The burden associated with gynecological diseases was analyzed based on the Socio-demographic Index (SDI) and attributable risk factors. The Estimated Annual Percentage Change (EAPC) and its 95% Confidence Interval (CI) were used to assess temporal trends in burden.ResultsIn 2021, uterine fibroids were the leading non-malignant gynecological condition contributing to the highest Age-Standardized Incidence Rate (ASIR) and Age-Standardized Prevalence Rate (ASPR), with rates of 250.93 and 2841.07 per 100,000, respectively. Cervical cancer was the main contributor to the Age-Standardized Mortality Rate (ASMR) and Age-Standardized Disability Rate (ASDR) among the eight selected gynecological diseases, with rates of 6.62 and 226.28 per 100,000, respectively. From 1990 to 2021, the ASIR and ASPR for non-malignant gynecological conditions, such as PCOS and uterine fibroids, increased, while the ASDR for PCOS also rose. Among gynecological cancers, the ASIR for uterine cancer increased, while the ASPR for cervical cancer rose. However, the ASIR for cervical and ovarian cancers decreased, along with reductions in the ASMR and ASDR for these cancers and uterine cancer. There were notable regional disparities based on the SDI. In 2021, lower SDI regions had higher incidence, prevalence, mortality rates, and DALYs for endometriosis and cervical cancer, whereas higher SDI regions saw higher rates for PCOS, uterine fibroids, ovarian cancer, and uterine cancer, with more significant mortality and DALYs for ovarian and uterine cancers. The age distribution of these conditions varied. Non-malignant gynecological conditions, such as PCOS and uterine fibroids, primarily affect women aged 30–34 and 40–69. Endometriosis is most common in women aged 20–34, particularly between 25 and 29. Gynecological cancers, including cervical, uterine, and ovarian cancers, predominantly affect women over 35, especially between 40 and 69, with cervical cancer peaking at ages 50–54. Regarding attributable risk factors globally, 1% of cervical cancer deaths were linked to unsafe sexual behaviors, while a high Body Mass Index(BMI) contributed to 0.09% of ovarian cancer deaths and 0.34% of uterine cancer deaths.ConclusionThe global burden of these six gynecological conditions poses a significant public health challenge. There is an urgent need for international collaboration to advance the development of age and regionally differentiated management strategies for gynecological diseases, including the development of effective diagnostic screening tools and the implementation of high-quality, targeted prevention and treatment strategies.

Introduction: In 2008 The International Agency for Research on Cancer concluded that combined oral contraceptives (OCs) are a cause of cancer of the breast and cervix but decrease the risk of ovarian and endometrial cancer. They also concluded that estrogen-only hormone replacement therapy (HRT) increases the risk of both endometrial and ovarian cancer, while use of estrogen plus progestogen (combined) HRT increases the risks of breast cancer. The level of risk associated with each cancer type varies by duration and recency of use of hormones. Our aim was to calculate the proportion of breast and gynecological cancers arising in Australian women (population attributable fractions - PAF) that could be attributed to these commonly used hormonal medications. Methods: We calculated PAFs using the standard formula, which requires an estimate of the relative risk for each exposure-cancer association and the prevalence of the causal factor in the population. Relative risks were obtained from published pooled or meta-analyses of the associations and prevalence estimates were derived from Australian National Health Survey estimates or other large national studies. For factors inversely associated with cancer we calculated the “prevented fraction” and estimated the number of cancers that were prevented due to exposure to the factor. Results: The estimated PAFs suggested that fewer than 5% of breast and gynecological cancers in Australia in 2010 could be attributed to oral contraceptive use and estimates were similar for HRT use. However, the calculated preventive fractions for oral contraceptives suggested that the numbers of endometrial and ovarian cancers may have been 46% and 24% higher respectively if no Australian women had used OCs. Given combined HRT increases breast cancer risk and breast cancer is much more common than endometrial or ovarian cancer we also assessed the likely effect if all women taking combined HRT instead took estrogen-only HRT. Under this scenario, we estimate the absolute numbers of ovarian and endometrial cancers would increase slightly but the number of breast cancers attributable to HRT use would decrease substantially. Conclusions: Our analyses suggest that the use of combined OCs confers more benefit than harm with respect to cancer incidence, with a small increase in breast/cervical cancer diagnoses weighed against a much larger decrease in numbers of endometrial and ovarian cancers. In contrast, our results indicate that there would be fewer cancers overall if women did not use HRT. When HRT is required, most guidelines recommend that women with a uterus take combined HRT to prevent endometrial cancer. However, our findings suggest that, in terms of total cancer burden, it might be safer for women to avoid progestogens and use estrogen-only HRT for symptom relief. Future studies should examine this possibility. Citation Format: Susan J. Jordan, Louise Wilson, David Whiteman, Penelope Webb, PAF Project Group. The proportion of breast and gynecological cancers in Australian women that can be attributed to the use of oral contraceptives and hormone replacement therapy. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 866. doi:10.1158/1538-7445.AM2015-866

e17500 Background: Targeted therapy for human epidermal growth factor receptor 2 (HER2) has become a standard of care in several HER2-expressing solid tumors. Nonetheless, there remains an unmet need for effective treatment, for instance, anti-HER2 antibody-drug conjugates (ADCs), in advanced stage gynecological cancer. In this context, we presented a retrospective study on the incidence of HER2 expression in primary gynecological cancer based on a single-center data from southwestern China. Methods: Paraffin-embedded tumor tissue blocks, clinicopathological, and survival data of gynecological cancer patients were collected from Chongqing University Cancer Hospital. HER2 IHC scoring was carried out according to the updated ASCO/CAP guidelines for breast and gastroesophageal adenocarcinoma by two pathologists independently. Data analysis was performed using SPSS v.24. Results: A total of 104 cases of cervical cancer, 102 cases of endometrial cancer and 103 cases of ovarian cancer were included between 2019 and 2023. HER2 expression was detected in 31.7% samples, with scores of 1+, 2+, and 3+ in 23.9% (74/309: 36/104, 16/102, 22/103), 5.8% (18/309: 7/104, 7/102, 4/103), and 1.9% (6/309: 2/104, 1/102, 3/103) of patients, respectively. Notably, ultra-low HER2 expression with incomplete and faint staining in ≤10% of tumor cells was observed in 41.1% (127/309: 37/104, 53/102, 37/103) of patients. Metastasis and lymphovascular invasion were associated with elevated HER2 expression in endometrial cancer (p=0.037, 0.040, respectively), while a larger tumor size was associated with elevated HER2 expression in cervical cancer (p=0.004). However, no positive association between HER2 status and overall survival (OS) was found in cervical, endometrial or ovarian cancer. In our cohort, metastasis was the only risk factor related to reduced OS of gynecological cancer patients by COX regression analysis (HR=14.00, 95%CI=1.32-148.21, p=0.028). Conclusions: Our data revealed a considerable number of patients with HER2-low and ultra-low gynecological cancer. It might represent a significant portion in real-world scenarios and warrant more consideration in selecting candidates for HER2-targeted ADCs, especially for those with relapsed or refractory conditions. Given the inherent challenge in interpretation, the study highlights the necessity for a consensus on evaluating HER2 immuno-staining results in gynecological cancer. Clinical trial information: MR-50-23-019676 . [Table: see text]

Chemotherapy is the principal treatment for advanced cancer patients. However, chemotherapeutic resistance, an important hallmark of cancer, is considered as a key impediment to effective therapy in cancer patients. Multiple signaling pathways and factors have been underscored to participate in governing drug resistance. Posttranslational modifications, including ubiquitination, glycosylation, acetylation and phosphorylation, have emerged as key players in modulating drug resistance in gynecological tumors, such as ovarian cancer, cervical cancer and endometrial cancer. In this review article, we summarize the role of ubiquitination in governing drug sensitivity in gynecological cancers. Moreover, we describe the numerous compounds that target ubiquitination in gynecological cancers to reverse chemotherapeutic resistance. In addition, we provide the future perspectives to fully elucidate the mechanisms by which ubiquitination controls drug resistance in gynecological tumors, contributing to restoring drug sensitivity. This review highlights the complex interplay between ubiquitination and drug resistance in gynecological tumors, providing novel insights into potential therapeutic targets and personalized treatment strategies to overcome the bottleneck of drug resistance.

Exploring delays in primary gynecologic and breast cancer diagnosis after emergency department presentation.

Objective:The purpose of this study is to explore risk factors and prognosis of deep vein thrombosis (DVT)/pulmonary thromboembolism (PTE) in gynecologic (GY) cancer patients.Methods: This is a single-center retrospective cohort study of patients with cervix, uterine, and ovarian cancer from 2006 to 2022.Patient characteristics such as age, body mass index, medical and smoking history, cancer type, stage, histology, grade, and type of cancer treatment were included and each association with DVT/PTE and cancer prognosis were analyzed.Multivariate logistic regression analysis was performed to identify risk factors associated with DVT/PTE.Kaplan-Meier survival curves were calculated using the log-rank test, and the Cox proportional hazards model was used to estimate the independent factors for survival.Results: Total 706 GY cancer patients were included; 32 patients (4.5%) were diagnosed with DVT/PTE.On multivariate analysis, endometrial cancer (p=0.035),poorly differentiated grade (p=0.011),smoking history (p=0.022),treatment of chemotherapy (p=0.028), and treatment of surgery (p=0.033) were independent risk factors of DVT/PTE.Cox multivariate regression analysis showed DVT/PTE was negative prognostic factor for both progression-free survival (hazard ratio [HR]=2.78;95% confidence interval [CI]=1.p=0.008) and overall survival (HR=2.90;p=0.002). Conclusion:In this study, poor survival outcomes were observed in patients with DVT/PTE.Cancer and grade type, smoking history, treatment of chemotherapy and surgery were associated with DVT/PTE.Thus, thorough surveillance of GY cancer patients with these risk factors is crucial to improve the oncologic outcome.

Background: Patient survival has been improved in gynecological cancer due to recent advances in diagnosis and treatment modalities. However longer survival time makes quality of life an even more challenging aspect of care. The aim of study was cross sectional evaluation of the quality of life in Gynecological cancer survivors completing at least 5 years of follow-up after treatment. Materials and Methods: In this prospective, single-center study, 162 women were interviewed at least 3 months after completion of treatment and no longer than 5 years. Data was collected on validated questionnaire i.e. EORTC QLQ-C30 from all participants &amp; specific questionnaires specific to cancers i.e. OV28, CX24 &amp; EN24. Results: The study population comprised of 25 (15.4%), 82 (50.6%) and 55 (34%) women with Cervical, endometrial, and Ovarian cancer, respectively. Average Quality of life was found to be 77.93±16.65. Mean Quality of life was reported as 74.67 in cervical cancer, 77.34 in endometrial cancer &amp; 80.30 in ovarian cancer respectively. Similarly, five functional scales like physical (PF), role (RF), emotional (EF), cognitive (CF) and social (SF) were estimated within the mean range of 80 to 90. Fatigue &amp; insomnia were the most common symptoms reported. Sexual functioning was the main concern among patients included in the study. Other than that, musculoskeletal pain and lymphedema were the main issues reported by patients of endometrial cancer. Conclusion: Study Participants showed overall a good quality of life. However, certain concerns related to sexual quality of life, and chronic lymphedema need special attention to improve quality of care.

This review paper investigated existing literature on the relationship between physical activity, exercise, and gynecological cancers, focusing on ovarian, endometrial, and cervical cancers. Epidemiological studies consistently demonstrate an inverse association between physical activity levels and the risk of developing gynecological cancers, as well as improved survival outcomes among cancer survivors engaging in regular exercise. Mechanistic insights suggest that physical activity and exercise may modulate key pathways involved in carcinogenesis, tumor progression, and treatment response, offering promising avenues for preventive and adjunctive therapeutic interventions. However, despite a growing body of research in exercise oncology, there is a lack of disease-specific synthesis addressing how exercise can be tailored to the distinct pathophysiological, treatment-related, and psychosocial challenges of gynecological cancers. Current guidelines often generalize exercise recommendations across all cancer types, overlooking the unique symptom burdens, such as pelvic floor dysfunction, sarcopenia, and menopausal symptoms, specific to gynecologic malignancies. This review addresses this gap by examining the evidence base for exercise in ovarian, endometrial, and cervical cancers, with an emphasis on mechanistic, clinical, and rehabilitative dimensions. By integrating epidemiological findings with preclinical and intervention data, this work aims to establish a gynecologic-specific framework for exercise prescription. This review underscores the importance of multidisciplinary research efforts to optimize lifestyle interventions, inform evidence-based guidelines, and improve outcomes for individuals affected by gynecological cancers.

The sociodemographic and histological patterns of gynaecological malignancies is important in their management. Facilities are now available for prevention, detection, treatment and palliative care for the wide spectrum of female genital tract malignancies. The study aim to determine the socio demographic and histological patterns of Gynaecological malignancies identified at the University of Abuja Teaching Hospital (UATH). This was a retrospective study carried out in the Obstetrics and Gynaecology department of the University of Abuja Teaching Hospital (UATH), Abuja, Nigeria between 1st January, 2012 and 31st December, 2016. The case notes of patients admitted for Gynaecological malignancy were retrieved from the medical records and studied for relative frequency, age distribution, parity and histological types of the Gynaecological malignancies. Out of 3786 women admitted during the study period, 113 had Gynaecological malignancies, giving an incidence of 3.0%. Majority of the women had cervical cancer (65.5%) followed by ovarian cancer (22.1%). Endometrial cancer, Choriocarcinoma, and vulva cancer accounted for 7.1, 4.4 and 0.9%, respectively. Squamous cell carcinoma accounted for 93.2% of cervical cancers. Epithelial tumours accounted for 84% of ovarian tumours, while adenocarcinoma accounted for 61.5% of cancers of the corpus uteri. The mean age for the various female genital cancers were: cervical cancer (52.6 ± 0.88 years), ovarian cancer (40.9± 1.68 years), vulva cancer (34.5 ± 0 years), choriocarcinoma (30.5 ± 1.44 years), and endometrial cancer (54.5 ± 1.77 years). Cervical cancer remains the most common female genital tract malignancy seen. The challenges with cervical cancer screening need to be addressed to reduce its incidence. Key words: Gynaecological cancers, pattern, frequency, histology.

We have previously reported elevated serum levels of cervical human papilloma viral proteins E6 and E7 and serum insulin-like growth factor II (IGF-II) in women with cervical cancer and advanced cervical intraepithelial neoplasia. As most women with cervical cancer have elevated levels of serum IGF-II, we sought to determine whether the cervical cancer and lymph node biopsies from these women demonstrated increased production of IGF-II and whether this elevation was also present in ovarian and endometrial cancers. We used the semi-quantitative immunofluorescent antibody assay established in our laboratory to identify the levels of IGF-II in 21 cervical cancers (seven with matching lymph nodes), 18 benign cervical biopsies, 13 endometrial cancers, 15 benign endometrial biopsies, 5 ovarian cancers, and 15 benign ovarian biopsies. The immunofluorescent IGF-II levels (relative intensity per pixel) were the highest in cervical cancers; they were significantly higher than in matched controls. IGF-II levels were not higher in ovarian cancers and only slightly elevated in endometrial cancers. The presence of IGF-II in pelvic lymph nodes of women with cervical cancer paralleled with those in the cervical cancers. Interestingly, we could identify small nests of metastases of malignant cells in the nodes (pauci-cellular metastasis) by using IGF-II as the marker. We propose that measurement and identification of IGF-II in the cervical biopsy may be a sensitive method of detecting cervical cancer and metastatic spread in the lymph nodes.