|Year : 2019 | Volume
| Issue : 3 | Page : 149-154
Association of absolute lymphocyte count and circulating CD4+ and CD8+ t-cells with positive clinical outcome in survivors of cancer: An observational study
Suresh Rao1, Venkatesh Ponemone2, Krishna Prasad3, Sanath K Hegde1, Prajna D'silva2, Manjeshwar Shrinath Baliga2
1 Department of Radiation Oncology, Mangalore Institute of Oncology, Mangalore, Karnataka, India
2 Department of Research Unit, Mangalore Institute of Oncology, Mangalore, Karnataka, India
3 Department of Medical Oncology, Mangalore Institute of Oncology, Mangalore, Karnataka, India
|Date of Submission||12-Mar-2019|
|Date of Decision||13-May-2019|
|Date of Acceptance||22-Jun-2019|
|Date of Web Publication||25-Jul-2019|
Dr. Suresh Rao
Department of Radiation Oncology, Mangalore Institute of Oncology, Pumpwell, Mangalore - 575 002, Karnataka
Source of Support: None, Conflict of Interest: None
Background: The objective of this observational study is to determine the changes in the circulating immune cells as a predictor of outcomes in patients who have survived cancer. Materials and Methods: A peripheral blood immune-profile evaluation was performed in all the survivors of cancer (n = 66) during their visit to the hospital for regular follow-up and thereafter followed up for two consecutive years for any morbidity or mortality. The changes in hematological and biochemical parameters were evaluated in all the patients. The frequency of circulating lymphocyte cell population i.e., CD3+, CD4+, and CD8+ lymphocytes were analyzed using flow cytometry in the peripheral blood of the patients. The variability in the circulating lymphocytes was correlated with tumor relapse and overall survival (OS). Results: In the study, 47 of the 66 patients with cancer survived at the end of 2 years observation time period, while 19 patients died due to infection related complications and not due to tumor relapse. A significant reduction in the neutrophil (P < 0.0001) and lymphocyte (P < 0.0001) counts were observed in patients who succumbed to the illness within 2 years when compared to the cohorts that were surviving. A statistically significant reduction in the absolute lymphocyte counts (P < 0.004), absolute CD3 (P < 0.0001), CD4 (P < 0.002), and CD8 (P < 0.04) were observed in the deceased group compared to the surviving group. CD4/CD8 ratios between both live and deceased groups did not show any significant difference. Conclusion: This preliminary observational study indicates a correlation of circulatory lymphocytes to OS in survivors of cancer and that it could be a predictive marker.
Keywords: Cancer survivors, CD4/CD8 ratio, CD4+ T-cells, CD8+ T-cells, lymphocyte subset, overall survival
|How to cite this article:|
Rao S, Ponemone V, Prasad K, Hegde SK, D'silva P, Baliga MS. Association of absolute lymphocyte count and circulating CD4+ and CD8+ t-cells with positive clinical outcome in survivors of cancer: An observational study. Indian J Med Spec 2019;10:149-54
|How to cite this URL:|
Rao S, Ponemone V, Prasad K, Hegde SK, D'silva P, Baliga MS. Association of absolute lymphocyte count and circulating CD4+ and CD8+ t-cells with positive clinical outcome in survivors of cancer: An observational study. Indian J Med Spec [serial online] 2019 [cited 2019 Sep 16];10:149-54. Available from: http://www.ijms.in/text.asp?2019/10/3/149/264527
| Introduction|| |
In the treatment of cancer, radiotherapy and chemotherapy are two important modalities that play a vital role in control and cure. However, the use of both these agents is associated with deleterious side effects.,, In case of radiotherapy, the effects are usually localized and restricted to the area where the therapy has been delivered. However, chemotherapy is a systemic therapy and depending on the dose, regimen and general health of the individual, it can cause a range of side effects on nontarget tissues and this consequentially leads to development of long-term side effects.,
The recent advances in diagnosis and treatment has increased the overall survival (OS) rates for many cancers, and for some, it is also being considered as a chronic disease. This has now resulted in a large population of survivors of cancer who are free of the disease but are enduring the long-term side effects of the therapy.,, A late effect is a side effect that occurs months or years after treatment. Accordingly, increasing attention is being given to mitigate the long-term effects of cancer treatment.,,
One of the most important side effects is increased risk of infection due to severe immunosuppression in these patients following radio or chemo treatment., These survivors have low immunity and this condition enhances the risk of infections, which when severe can result in morbidity and even death., The immune cells particularly T- and B-lymphocytes play an important role in immunological surveillance and can help in the elimination of tumor cells.,
Lymphocytes play a crucial role in immunity and are essential for anti-tumor immunity. The percentage of circulating lymphocyte subsets may serve as predictive factors of positive outcome of OS in cancer patients. The biomarkers measured following treatment or changes when compared with later values to the baseline findings can potentially predict side effects or positive outcomes. In this study, we aimed to evaluate the correlation between circulatory lymphocyte subset distribution and OS of cancer patients in order to design a convenient and effective predictive model for positive outcome.
| Materials and Methods|| |
This was a prospective observational study that was carried out at Mangalore Institute of Oncology, Mangalore, Karnataka, India from January 2016 to February 2016. The study was approved by the Institutional Ethics Committee (MIOIEC/2015/02/07) and was conducted only with willing volunteers. The participants of the study were adult survivors of cancer (above 18 years) who have completed their proposed treatment at least a year back, had a complete treatment response, and were on regular follow-up (after the completion of their treatment). The exclusion criteria were those patients who were terminally ill, on active treatment, who had metastasis/regrowth, and patients who were on any maintenance drugs (such as geftinab, latronet, and antiestrogens).
During the follow-up visit, one of the authors explained the nature and purpose of the study to eligible patients satisfying the inclusion criteria, in either English or their mother tongue (Kannada, Konkani, Tulu, or Malayalam). The individuals were informed that they had the right to withdraw from the study at any time during the study and that their nonwillingness to be a part of the study will not deprive them of the follow-up investigations and medical care. The willing patients were then included in the study, and a written informed consent was obtained.
Collection of blood and analysis
Five ml of peripheral blood was collected in vacutainers by a trained phlebotomist from willing volunteers using standard peripheral blood collection technique. The blood collected was analyzed for the hematological parameters such as red blood cells, hemoglobin, white blood cells, neutrophils, lymphocytes, eosinophil, monocytes, platelets (PLT), aspartate transaminase, alanine transaminase, alkaline phosphatase, bilirubin, conjugated bilirubin, unconjugated bilirubin, total protein, albumin, globulin, albumin to globulin ratio, creatinine, urea using standard procedures of blood chemistry analysis. The neutrophil lymphocyte ratio (NLR), monocyte lymphocyte ratio (MLR), and platelet lymphocyte ratio (PLR) were calculated in accordance to the standard laboratory procedures. The heparinized peripheral blood samples were analyzed for CD3+, CD4+, and CD8+ T-cell counts using flow cytometry as per standard procedures (Lal path laboratories, Bangalore, India). The results on survival and death at the volunteers in whom the immunological assays were performed were ascertained from the medical records 2 years after the estimation in March 2018.
The accrued data were entered in to Microsoft excel and categorized as demographic details, clinical, and investigative data. The data were then transferred to SPSS (IBM version 22, Chicago Inc, USA) and calculated. The demographic and clinical details were subjected to the χ2 analysis, while the biochemical values analyzed in the individual samples were subjected to unpaired t-test between the patients who were surviving and succumbed to illness. In addition, the Pearson correlation analysis was also used to see for an association between the hematological, immunological, liver function tests, and renal function test parameters collected. A statistical value of P < 0.05 was considered to be significant.
| Results|| |
The results of the study are represented in [Table 1], [Table 2], [Table 3], [Table 4]. The data indicate that the age of the alive group was 50.40 ± 13.14 years while that of deceased was 55.05 ± 13.12 years [Table 1]. Majority of the patients in both groups were men [Table 1]. With regard to habits and comorbidities (diabetes mellitus and hypertension), it was observed that when compared to the cohorts with disease free status, the percentage of habitual and comorbidities was more in the cohorts that succumbed to cancer [Table 1]. With respect to the stage of cancer at the point of initial diagnosis, it was observed that 62% of the patients had come with stage 3 and 4 cancer in cohorts who later succumbed and was significant (P < 0.03) [Table 1]. Most of the patients had undergone multimodality treatment [Table 1].
|Table 1: Tumor site, tumor-node-metastasis grading, age, gender, habits, stage, and previous treatment details|
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|Table 3: Standard hematological and biochemical parameters in the cancer patients evaluated for CD3, CD4 and CD8|
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|Table 4: Liver function tests and renal function test parameters in the cancer patients evaluated for CD3, CD4 and CD8|
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With regard to the immunological parameters evaluated with flow cytometry, it was observed that the absolute lymphocyte counts (ALCs), CD3, CD4, and CD8 were significantly lower in patients who later succumbed to the illness [Table 2]. In addition, it was also observed that there was a statistically significant difference between surviving and deceased patients with respect to the levels in total count, neutrophils, lymphocytes, monocytes, and platelets [Table 3]. A statistically significant difference was seen in the NLR and MLR but not in the PLR [Table 3]. However, there was no significant change in the hepatic or renal parameters evaluated [Table 4].
| Discussion|| |
The immune system is a major regulatory mechanism in the defense of the body, and several scientific findings have indicated that chemoradiation therapy alters the immune function significantly and that the damage may persist for several years after completion of treatment., Furthermore, poor or altered immune recovery may increase the risk of individual susceptibility to adverse health outcomes.
Among the components of the peripheral immune system, the circulating lymphocytes play an important role in protecting the body against infection and in suppressing tumor growth. Several studies have shown that the presence of T infiltration lymphocytes correlates to a significant prognosis in several types of cancer.,, From a functional overview, in the thymus, T-cells multiply and differentiate into helper, regulatory, or cytotoxic T-cells or become memory T-cells. These T-cells are then seeded to peripheral tissues or circulate in the blood or lymphatic system. Peripheral blood contains approximately 2% of all lymphocytes at any point of time and the rest are found in the lymphatic organs such as the spleen, thymus, and lymph nodes. However, accumulating evidence indicates that chemotherapy causes deletion of all subtypes of circulating lymphocytes.,,,,, Chemotherapy causes lymphopenia with a significant reduction of T- and B-cells which takes more than a year to recover thereby compromising the body's immune functioning.,,
In the present study, it was observed that the ALC, CD3, CD4, and CD8 were lower in patients who later succumbed to the illness [Table 2] indicating that their quantitative levels could be of significance in ascertaining the immunological status of the individual. From an immunological perspective, the cell-mediated immunity plays a critical role in antitumor immune responses. The activation of both CD4 helper and CD8 cytotoxic T lymphocytes (CTLs) are needed for an effective immune response. CD4 helper T-cells get activated when they are presented with peptide antigens by major histocompatibility complex (MHC) Class II molecules that are expressed on the surface of antigen-presenting cells. Once activated, they divide rapidly and secrete small proteins called cytokines that regulate or suppress immune response. The CD4 T helper cells are involved in the maturation of B-cells into plasma cells and memory B-cells, and activation of cytotoxic T-cells and macrophages.
The CD8 cytotoxic T-cells ("suppressor" or "killer" cells) destroy tumor cells and virus infected cells, and express the CD8 glycoprotein at their surfaces. CD8+ CTLs recognize their targets by binding to antigen associated with MHC Class I molecules present on the surface of all nucleated cells. The CD4 helper T-cells play a critical role in controlling viral infections by promoting CD8 T-cell responses as well as humoral immunity. Further CD8 cytotoxic T-cells are crucial components towards tumor specific adaptive immunity that fights against the tumor cells., CD4 helper T-cells play a central role in initiation and maintenance of anti-cancer immune responses, which significantly affects the function of CD8cytotoxic T-cells. It is evident that tumors are infiltrated by a heterogeneous population of immune cells including T-cells, B-cells, natural killer cells, and macrophages.
In this study, there was no significant difference in CD3%, CD4%, and CD8% observed between both surviving and deceased group. However, the absolute CD3 T-cells, CD4 T-cells, and CD8 T-cells in the deceased group were significantly lower compared to the surviving group, which coincides with the fact that T-cell immune suppression was associated with worsened recurrent infections. These results indicate the importance of cell-mediated immunity during the reactivation of several viruses, probably due to the spread of infections within the body. The main parameters of cell mediated immunity are T lymphocyte subsets in the peripheral blood.
The balance of T lymphocyte subset population is the key factor for regulating normal immune function and any abnormal changes trigger a disordered immune system that results in a series of pathological changes and makes the individual succumb to an increase in the risk of potential infections. There is well-established scientific evidence to demonstrate a strong relationship between the presence of tumor-infiltrating CTLs to that of better survival in patients with ovarian, endometrial, pancreatic, and colorectal cancers.,,, The leukocytes especially neutrophils and lymphocytes play a unique and important role in providing immunity against infectious diseases. Any alterations to these cell numbers could significantly influence the body's ability to fight infections. Polymorphonuclear neutrophils are the first among the leukocytes to be recruited at the site of injury and are considered the hallmark of acute inflammation. It is noted in this study that neutrophil counts were higher in the deceased group as compared to the surviving group, while in contrast, lymphocytes were lowered in the deceased group as when compared to surviving group. Any serious infection can result in a temporary reduction of lymphocyte count, but most of these are acute and at times require hospitalization of patients. The rationale for the utility of peripheral blood tests to predict prognosis of patient with cancer and the therapeutic effectiveness has progressively increased over the years. Furthermore, notably in various types of cancers, the relative number of neutrophils, platelets, and monocytes to lymphocytes appear to be superior predictive measures as compared to assessing each component independently.,,,
The NLR is a measure of the relative number of neutrophils to lymphocytes in the peripheral blood and can be simply derived from blood tests by dividing the absolute number of circulating neutrophils by the circulating lymphocyte population per volume. Several clinical studies investigating NLR as a predictor of patient surving cancer have been previously reported to have an association with prognosis and survival.,,, The current study shows an increased NLR in deceased group compared to the surviving group [Table 2]. An increased NLR (NLR >4) is associated with increased mortality and our study observations are in concurrence with previous published reports.,, In contrast, there are reports that found no association between NLR and cancer survival. In addition, platelet-to-lymphocyte has been shown to be a useful metric for determining the prognosis of a variety of cancers in patients [Table 2]. The observations of the study show a significant increase in PLR in the deceased group when compared to the surviving group. An increased PLR level indicated a poor prognosis with respect to OS in patients with gastric, colorectal, ovarian, hepatocellular, and lung cancers.,, Our study observations concur with previously published literature where increased PLR correlates to decrease and OS.
| Conclusion|| |
The results of the study indicate that estimation of the CD3, CD4, and CD8 lymphocytes could be a very useful prognostic marker in indicating the risk of death in survivors of cancer who are free of any illness. Detailed studies are planned to ascertain the significance of CD3, CD4, and CD8 lymphocytes in the recently diagnosed people and in survivors of cancer and on ways to improve the immune functioning.
The authors are grateful to Mangalore Institute of Oncology board of studies for providing financial assistance to carry out the study. The investigators are also thankful to the volunteers for their support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Demirci U, Benekli M, Buyukberber S, Coskun U. Late side effects of cancer therapy. Int J Hematol Oncol 2010;4:250-61.
Coura CF, Modesto PC. Impact of late radiation effects on cancer survivor children: An integrative review. Einstein (Sao Paulo) 2016;14:71-6.
Kenyon M, Mayer DK, Owens AK. Late and long-term effects of breast cancer treatment and surveillance management for the general practitioner. J Obstet Gynecol Neonatal Nurs 2014;43:382-98.
Hu FJ, Ge MH, Li P, Wang CC, Ling YT, Mao WM, et al.
Unfavorable clinical implications of circulating CD44+ lymphocytes in patients with nasopharyngeal carcinoma undergoing radiochemotherapy. Clin Chim Acta 2012;413:213-8.
Schmidt MA, Förtsch C, Schmidt M, Rau TT, Fietkau R, Distel LV. Circulating regulatory T cells of cancer patients receiving radiochemotherapy may be useful to individualize cancer treatment. Radiother Oncol 2012;104:131-8.
Ascierto ML, De Giorgi V, Liu Q, Bedognetti D, Spivey TL, Murtas D, et al.
An immunologic portrait of cancer. J Transl Med 2011;9:146.
Verma R, Foster RE, Horgan K, Mounsey K, Nixon H, Smalle N, et al.
Lymphocyte depletion and repopulation after chemotherapy for primary breast cancer. Breast Cancer Res 2016;18:10.
Leffers N, Gooden MJ, de Jong RA, Hoogeboom BN, ten Hoor KA, Hollema H, et al.
Prognostic significance of tumor-infiltrating T-lymphocytes in primary and metastatic lesions of advanced stage ovarian cancer. Cancer Immunol Immunother 2009;58:449-59.
Ruffini E, Asioli S, Filosso PL, Lyberis P, Bruna MC, Macrì L, et al.
Clinical significance of tumor-infiltrating lymphocytes in lung neoplasms. Ann Thorac Surg 2009;87:365-71.
Dunn GP, Dunn IF, Curry WT. Focus on TILs: Prognostic significance of tumor infiltrating lymphocytes in human glioma. Cancer Immun 2007;7:12.
Westermann J, Pabst R. Lymphocyte subsets in the blood: A diagnostic window on the lymphoid system? Immunol Today 1990;11:406-10.
Strender LE, Petrini B, Blomgren H, Wasserman J, Wallgren A, Baral E. Influence of adjuvant chemotherapy on the blood lymphocyte population in operable breast carcinoma. Comparison between two types of treatments. Acta Radiol Oncol 1982;21:217-24.
Sabbioni ME, Bernhard J, Siegrist HP, Schmitz SF, Gertsch MC, Thürlimann B, et al.
Does subjective burden of early breast cancer and its treatment affect immune measures during adjuvant therapy? Breast Cancer Res Treat 2004;87:75-86.
Mozaffari F, Lindemalm C, Choudhury A, Granstam-Björneklett H, Helander I, Lekander M, et al.
NK-cell and T-cell functions in patients with breast cancer: Effects of surgery and adjuvant chemo- and radiotherapy. Br J Cancer 2007;97:105-11.
Wijayahadi N, Haron MR, Stanslas J, Yusuf Z. Changes in cellular immunity during chemotherapy for primary breast cancer with anthracycline regimens. J Chemother 2007;19:716-23.
Murta EF, de Andrade JM, Falcão RP, Bighetti S. Lymphocyte subpopulations in patients with advanced breast cancer submitted to neoadjuvant chemotherapy. Tumori 2000;86:403-7.
Kotsakis A, Sarra E, Peraki M, Koukourakis M, Apostolaki S, Souglakos J, et al.
Docetaxel-induced lymphopenia in patients with solid tumors: A prospective phenotypic analysis. Cancer 2000;89:1380-6.
Mackay IR, Goodyear MD, Riglar C, Penschow J, Whittingham S, Russell IS, et al.
Effect on immunologic and other indices of adjuvant cytotoxic chemotherapy including melphalan in breast cancer. Cancer 1984;53:2619-27.
Doyle C, Strominger JL. Interaction between CD4 and class II MHC molecules mediates cell adhesion. Nature 1987;330:256-9.
Norment AM, Salter RD, Parham P, Engelhard VH, Littman DR. Cell-cell adhesion mediated by CD8 and MHC class I molecules. Nature 1988;336:79-81.
Zhang N, Bevan MJ. CD8(+) T cells: Foot soldiers of the immune system. Immunity 2011;35:161-8.
Halle S, Halle O, Förster R. Mechanisms and dynamics of T cell-mediated cytotoxicity in vivo
. Trends Immunol 2017;38:432-43.
van der Woude LL, Gorris MA, Halilovic A, Figdor CG, de Vries IJ. Migrating into the tumor: A roadmap for T cells. Trends Cancer 2017;3:797-808.
Aaltomaa S, Lipponen P, Eskelinen M, Kosma VM, Marin S, Alhava E, et al.
Lymphocyte infiltrates as a prognostic variable in female breast cancer. Eur J Cancer 1992;28A: 859-64.
Ouwendijk WJ, Laing KJ, Verjans GM, Koelle DM. T-cell immunity to human alphaherpesviruses. Curr Opin Virol 2013;3:452-60.
Precopio ML, Sullivan JL, Willard C, Somasundaran M, Luzuriaga K. Differential kinetics and specificity of EBV-specific CD4+ and CD8+ T cells during primary infection. J Immunol 2003;170:2590-8.
Mandl JN, Monteiro JP, Vrisekoop N, Germain RN. T cell-positive selection uses self-ligand binding strength to optimize repertoire recognition of foreign antigens. Immunity 2013;38:263-74.
Prall F, Dührkop T, Weirich V, Ostwald C, Lenz P, Nizze H, et al.
Prognostic role of CD8+ tumor-infiltrating lymphocytes in stage III colorectal cancer with and without microsatellite instability. Hum Pathol 2004;35:808-16.
Pardoll DM, Topalian SL. The role of CD4+ T cell responses in antitumor immunity. Curr Opin Immunol 1998;10:588-94.
Sato E, Olson SH, Ahn J, Bundy B, Nishikawa H, Qian F, et al.
Intraepithelial CD8+ tumor-infiltrating lymphocytes and a high CD8+ /regulatory T cell ratio are associated with favorable prognosis in ovarian cancer. Proc Natl Acad Sci U S A 2005;102:18538-43.
Fukunaga A, Miyamoto M, Cho Y, Murakami S, Kawarada Y, Oshikiri T. CD8+tumor-infiltrating lymphocytes together with CD4+ tumor-infiltrating lymphocytes and dendritic cells improve the prognosis of patients with pancreatic adenocarcinoma. Pancreas 2004;28:e26-31.
Absenger G, Szkandera J, Pichler M, Stotz M, Arminger F, Weissmueller M, et al.
Aderived neutrophil to lymphocyte ratio predicts clinical outcome in stage II and III colon cancer patients. Br J Cancer 2013;109:395-400.
Szkandera J, Pichler M, Absenger G, Stotz M, Arminger F, Weissmueller M, et al.
The elevated preoperative platelet to lymphocyte ratio predicts decreased time to recurrence in colon cancer patients. Am J Surg 2014;208:210-4.
Guthrie GJ, Charles KA, Roxburgh CS, Horgan PG, McMillan DC, Clarke SJ. The systemic inflammation-based neutrophil-lymphocyte ratio: Experience in patients with cancer. Crit Rev Oncol Hematol 2013;88:218-30.
Huang SH, Waldron JN, Milosevic M, Shen X, Ringash J, Su J, et al.
Prognostic value of pretreatment circulating neutrophils, monocytes, and lymphocytes in oropharyngeal cancer stratified by human papillomavirus status. Cancer 2015;121:545-55.
Proctor MJ, McMillan DC, Morrison DS, Fletcher CD, Horgan PG, Clarke SJ. A derived neutrophil to lymphocyte ratio predicts survival in patients with cancer. Br J Cancer 2012;107:695-9.
Cho H, Hur HW, Kim SW, Kim SH, Kim JH, Kim YT, et al.
Pre-treatment neutrophil to lymphocyte ratio is elevated in epithelial ovarian cancer and predicts survival after treatment. Cancer Immunol Immunother 2009;58:15-23.
Azab B, Bhatt VR, Phookan J, Murukutla S, Kohn N, Terjanian T, et al.
Usefulness of the neutrophil-to-lymphocyte ratio in predicting short- and long-term mortality in breast cancer patients. Ann Surg Oncol 2012;19:217-24.
Nakamura K, Nagasaka T, Nishida T, Haruma T, Ogawa C, Kusumoto T, et al.
Neutrophil to lymphocyte ratio in the pre-treatment phase of final-line chemotherapy predicts the outcome of patients with recurrent ovarian cancer. Oncol Lett 2016;11:3975-81.
Stevens L, Pathak S, Nunes QM, Pandanaboyana S, Macutkiewicz C, Smart N, et al.
Prognostic significance of pre-operative C-reactive protein and the neutrophil-lymphocyte ratio in resectable pancreatic cancer: A systematic review. HPB (Oxford) 2015;17:285-91.
Yu D, Liu B, Zhang L, DU K. Platelet count predicts prognosis in operable non-small cell lung cancer. Exp Ther Med 2013;5:1351-4.
Krenn-Pilko S, Langsenlehner U, Thurner EM, Stojakovic T, Pichler M, Gerger A, et al.
The elevated preoperative platelet-to-lymphocyte ratio predicts poor prognosis in breast cancer patients. Br J Cancer 2014;110:2524-30.
Raungkaewmanee S, Tangjitgamol S, Manusirivithaya S, Srijaipracharoen S, Thavaramara T. Platelet to lymphocyte ratio as a prognostic factor for epithelial ovarian cancer. J Gynecol Oncol 2012;23:265-73.
[Table 1], [Table 2], [Table 3], [Table 4]