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Dev R, Amano K, Naito T, Del Fabbro E. Anamorelin for the Treatment of Cancer Anorexia-Cachexia Syndrome. Curr Oncol Rep 2024; 26:762-772. [PMID: 38771469 DOI: 10.1007/s11912-024-01549-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE OF REVIEW The following review will highlight the development of anamorelin to treat cancer anorexia-cachexia syndrome (CACS) including the potential benefits, limitations, and future directions. RECENT FINDINGS Ghrelin, a 28-amino acid peptide hormone, is secreted by the stomach mucosa and regulates appetite, promotes lipogenesis, increases body weight, improves gastric motility, reduces catabolic wasting and inflammation. Several randomized, double-blind, placebo-controlled clinical trials evaluating anamorelin, a ghrelin agonist, for the treatment of CACS have reported improvement in appetite and body composition including both lean body and fat mass; however, most studies noted no improvement in physical function as assessed by measuring non-dominant hand-grip strength. Common adverse effects of anamorelin include the development of diabetes mellitus, hyperglycemia, and less frequently, hepatic abnormalities and cardiovascular events including conduction abnormalities, hypertension, and ischemic cardiomyopathy. Anamorelin has the potential to stimulate appetite, improve gastric movement, and may have anti-inflammatory effects on patients with CACS. In patients with cancer, studies involving anamorelin combined with other multimodal treatments including nutrition counseling (branched chain amino acids, omega 3 fatty acids, and other nutrients), exercise, treatment of hormonal abnormalities including hypogonadism and hypovitaminosis D, and anti-inflammatory agents are needed. Compliance with multimodality treatment has been a barrier and future studies may need to incorporate motivational counseling to promote adherence.
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Affiliation(s)
- Rony Dev
- Department of Symptom Control & Palliative Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 1212, Houston, TX, 77030, USA.
| | - Koji Amano
- Department of Supportive and Palliative Care, Osaka International Cancer Institute, Chuo-Ku, Osaka, Japan
| | - Tateaki Naito
- Division of Thoracic Oncology and Cancer Supportive Cancer Center, Shizuoka Cancer Center, Nagaizumi-Cho, Shizuoka, Japan
| | - Egidio Del Fabbro
- Department of Medicine, Medical College of Georgia, Augusta, GA, USA
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Takayama K, Kojima A, Honda C, Nakayama M, Kanemata S, Endo T, Muro K. Real-world safety and effectiveness of anamorelin for cancer cachexia: Interim analysis of post-marketing surveillance in Japan. Cancer Med 2024; 13:e7170. [PMID: 38693813 PMCID: PMC11063721 DOI: 10.1002/cam4.7170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 03/05/2024] [Accepted: 03/27/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Anamorelin was approved in Japan in 2021 to treat cancer cachexia associated with non-small cell lung, gastric, pancreatic, or colorectal cancers. Post-marketing surveillance is being conducted to evaluate the real-world safety and effectiveness of anamorelin. METHODS This prospective, observational surveillance registered all patients who started treatment with anamorelin after April 21, 2021. Hyperglycemia, hepatic impairment, conduction disorders, and their associated adverse events related to treatment were defined as main safety specifications. Body weight (BW) and appetite were assessed as effectiveness specifications. RESULTS This analysis was based on data as of January 21, 2023. The safety and effectiveness analysis sets included 6016 and 4511 patients, respectively. Treatment-related adverse events in ≥1% of patients were hyperglycemia (3.9%) and nausea (2.6%). The incidences of hyperglycemia, hepatic impairment, conduction disorders, and their associated adverse events related to treatment were 4.8%, 1.2%, and 1.1%, respectively. The mean changes (standard error [SE]) in BW from baseline to weeks 3, 12, 24, and 52 were 0.64 (0.05) kg, 1.19 (0.12) kg, 1.40 (0.21) kg, and 1.42 (0.39) kg, respectively. The mean changes (SE) in Functional Assessment of Anorexia/Cachexia Treatment 5-item Anorexia Symptom Scale total scores from baseline to weeks 3, 12, 24, and 52 were 3.2 (0.09), 4.8 (0.18), 5.2 (0.30), and 5.3 (0.47), respectively, exceeding the clinically meaningful improvement score (2.0 points). CONCLUSION The overall safety of anamorelin raised no new safety concerns, although continued caution may be required for hyperglycemia and nausea. Improvements in BW and appetite were also observed in real-world clinical settings.
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Affiliation(s)
- Koichi Takayama
- Department of Pulmonary Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Ai Kojima
- PharmacovigilanceOno Pharmaceutical Co., Ltd.OsakaJapan
| | - Chikara Honda
- PharmacovigilanceOno Pharmaceutical Co., Ltd.OsakaJapan
| | | | | | | | - Kei Muro
- Department of Clinical OncologyAichi Cancer Center HospitalNagoyaJapan
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Fröhlich AK, Porthun J, Talha KM, Lena A, Hadzibegovic S, Wilkenshoff U, Sonntag F, Nikolski A, Ramer LV, Zeller T, Keller U, Bullinger L, Anker SD, Haverkamp W, von Haehling S, Doehner W, Rauch U, Skurk C, Cleland JGF, Butler J, Coats AJS, Landmesser U, Karakas M, Anker MS. Association of an impaired GH-IGF-I axis with cardiac wasting in patients with advanced cancer. Clin Res Cardiol 2024:10.1007/s00392-024-02400-x. [PMID: 38587563 DOI: 10.1007/s00392-024-02400-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/07/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Growth hormone (GH) resistance is characterized by high GH levels but low levels of insulin-like growth factor-I (IGF-I) and growth hormone binding protein (GHBP) and, for patients with chronic disease, is associated with the development of cachexia. OBJECTIVES We investigated whether GH resistance is associated with changes in left ventricular (LV) mass (cardiac wasting) in patients with cancer. METHODS We measured plasma IGF-I, GH, and GHBP in 159 women and 148 men with cancer (83% stage III/IV). Patients were grouped by tertile of echocardiographic LVmass/height2 (women, < 50, 50-61, > 61 g/m2; men, < 60, 60-74, > 74 g/m2) and by presence of wasting syndrome with unintentional weight loss (BMI < 24 kg/m2 and weight loss ≥ 5% in the prior 12 months). Repeat echocardiograms were obtained usually within 3-6 months for 85 patients. RESULTS Patients in the lowest LVmass/height2 tertile had higher plasma GH (median (IQR) for 1st, 2nd, and 3rd tertile women, 1.8 (0.9-4.2), 0.8 (0.2-2.2), 0.5 (0.3-1.6) ng/mL, p = 0.029; men, 2.1 (0.8-3.2), 0.6 (0.1-1.7), 0.7 (0.2-1.9) ng/mL, p = 0.003). Among women, lower LVmass was associated with higher plasma IGF-I (68 (48-116), 72 (48-95), 49 (35-76) ng/mL, p = 0.007), whereas such association did not exist for men. Patients with lower LVmass had lower log IGF-I/GH ratio (women, 1.60 ± 0.09, 2.02 ± 0.09, 1.88 ± 0.09, p = 0.004; men, 1.64 ± 0.09, 2.14 ± 0.11, 2.04 ± 0.11, p = 0.002). GHBP was not associated with LVmass. Patients with wasting syndrome with unintentional weight loss had higher plasma GH and GHBP, lower log IGF-I/GH ratio, and similar IGF-I. Overall, GHBP correlated inversely with log IGF-I/GH ratio (women, r = - 0.591, p < 0.001; men, r = - 0.575, p < 0.001). Additionally, higher baseline IGF-I was associated with a decline in LVmass during follow-up (r = - 0.318, p = 0.003). CONCLUSION In advanced cancer, reduced LVmass is associated with increased plasma GH and reduced IGF-I/GH ratio, suggesting increasing GH resistance, especially for patients with wasting syndrome with unintentional weight loss. Higher baseline IGF-I was associated with a decrease in relative LVmass during follow-up.
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Affiliation(s)
- Ann-Kathrin Fröhlich
- Charité - University Medicine Berlin corporate member of Free University Berlin and Humboldt-University Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine Campus Virchow Clinic, German Heart Center Charité, Berlin, Germany
| | - Jan Porthun
- Charité - University Medicine Berlin corporate member of Free University Berlin and Humboldt-University Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine Campus Virchow Clinic, German Heart Center Charité, Berlin, Germany
- Norwegian University of Science and Technology, Campus Gjøvik, Gjøvik, Norway
| | - Khawaja M Talha
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Alessia Lena
- Charité - University Medicine Berlin corporate member of Free University Berlin and Humboldt-University Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine Campus Benjamin Franklin, German Heart Center Charité, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Sara Hadzibegovic
- Charité - University Medicine Berlin corporate member of Free University Berlin and Humboldt-University Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine Campus Benjamin Franklin, German Heart Center Charité, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Ursula Wilkenshoff
- Charité - University Medicine Berlin corporate member of Free University Berlin and Humboldt-University Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine Campus Benjamin Franklin, German Heart Center Charité, Hindenburgdamm 30, 12200, Berlin, Germany
- Berlin Institute of Health, Charité - University Medicine Berlin, Berlin, Germany
| | - Frederike Sonntag
- Charité - University Medicine Berlin corporate member of Free University Berlin and Humboldt-University Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine Campus Virchow Clinic, German Heart Center Charité, Berlin, Germany
| | - Anja Nikolski
- Charité - University Medicine Berlin corporate member of Free University Berlin and Humboldt-University Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine Campus Virchow Clinic, German Heart Center Charité, Berlin, Germany
| | - Luisa Valentina Ramer
- Charité - University Medicine Berlin corporate member of Free University Berlin and Humboldt-University Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine Campus Virchow Clinic, German Heart Center Charité, Berlin, Germany
| | - Tanja Zeller
- University Center of Cardiovascular Science, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- Clinic for Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research, Partner Site HH/Kiel/HL, Hamburg, Germany
| | - Ulrich Keller
- Department of Hematology, Oncology and Cancer Immunology, Charité - University Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany
- German Cancer Consortium (DKTK), Partner Site Berlin, a partnership between DKFZ and Charité-Universitätsmedizin Berlin, Berlin, Germany
- Max Delbrück Center, Berlin, Germany
| | - Lars Bullinger
- German Cancer Consortium (DKTK), Partner Site Berlin, a partnership between DKFZ and Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Hematology, Oncology, and Tumor Immunology, Charité - University Medicine Berlin corporate member of Free University Berlin and Humboldt University Berlin, Berlin, Germany
| | - Stefan D Anker
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany
- Department of Cardiology Campus, Virchow Clinic of German Heart Center Charité, Charité - University Medicine Berlin, Berlin, Germany
| | - Wilhelm Haverkamp
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany
- Department of Cardiology Campus, Virchow Clinic of German Heart Center Charité, Charité - University Medicine Berlin, Berlin, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Wolfram Doehner
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine Campus Virchow Clinic, German Heart Center Charité, Berlin, Germany
- Centre for Stroke Research, Berlin, Charité-Universitätsmedizin, Berlin, Germany
| | - Ursula Rauch
- Charité - University Medicine Berlin corporate member of Free University Berlin and Humboldt-University Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine Campus Benjamin Franklin, German Heart Center Charité, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Carsten Skurk
- Charité - University Medicine Berlin corporate member of Free University Berlin and Humboldt-University Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine Campus Benjamin Franklin, German Heart Center Charité, Hindenburgdamm 30, 12200, Berlin, Germany
| | - John G F Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | | | - Ulf Landmesser
- Charité - University Medicine Berlin corporate member of Free University Berlin and Humboldt-University Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine Campus Benjamin Franklin, German Heart Center Charité, Hindenburgdamm 30, 12200, Berlin, Germany
- Berlin Institute of Health, Charité - University Medicine Berlin, Berlin, Germany
| | - Mahir Karakas
- German Centre for Cardiovascular Research, Partner Site HH/Kiel/HL, Hamburg, Germany
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus S Anker
- Charité - University Medicine Berlin corporate member of Free University Berlin and Humboldt-University Berlin, Berlin, Germany.
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany.
- Department of Cardiology, Angiology and Intensive Care Medicine Campus Benjamin Franklin, German Heart Center Charité, Hindenburgdamm 30, 12200, Berlin, Germany.
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Ishioka Y, Tanaka H, Makiguchi T, Fujishima S, Nunomura Y, Sakamoto H, Shiratori T, Taima K, Tasaka S. Predictors of efficacy of anamorelin in patients with non‑small cell lung cancer and cachexia: A retrospective study. Oncol Lett 2024; 27:22. [PMID: 38058465 PMCID: PMC10696636 DOI: 10.3892/ol.2023.14154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/23/2023] [Indexed: 12/08/2023] Open
Abstract
Anamorelin, a ghrelin receptor agonist, is approved in Japan for the treatment of cachexia in patients with lung and gastrointestinal cancer. However, there is limited research on the usefulness of anamorelin in clinical settings, therefore, the present study evaluated its efficacy using patient characteristics. A total of 40 patients with non-small cell lung cancer and cachexia who were prescribed anamorelin in the Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine (Aomori, Japan) between July 2021 and November 2022, were retrospectively assessed. Anamorelin was prescribed at a dose of 100 mg once daily to patients who had lost >5% of their body weight within 6 months. All patients were weighed before treatment and those who continued anamorelin treatment for 12 weeks were also weighed at 12 weeks. A logistic regression analysis was used to analyze the association between background characteristics and early discontinuation of treatment with anamorelin (within 4 weeks). The median age was 67 years (range, 36-88), and 65% of the patients were male. There were 24 patients (60.0%) with an Eastern Cooperative Oncology Group Performance Status (ECOG-PS) score 1, 11 patients (27.5%) with an ECOG-PS score 2 and five patients (12.5%) with an ECOG-PS score 3. The early discontinuation group included 11 patients (27.5%). An ECOG-PS score ≥2 (odds ratio, 7.85; 95% confidence interval, 1.43-43.21; P=0.018) was associated with early discontinuation. A total of 18/40 patients (45.0%) were able to continue anamorelin treatment for 12 weeks, and the mean change in body weight was +2.31 kg, which was a significant change from the weight recorded at baseline (P=0.027). The mean changes in lean body mass and soft lean mass between baseline and 12 weeks were +1.97 kg (P=0.14) and +1.26 kg (P=0.15), respectively. The results from the present study indicate that anamorelin is unlikely to be useful for patients with a poor general condition (ECOG-PS score ≥2).
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Affiliation(s)
- Yoshiko Ishioka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8562, Japan
| | - Hisashi Tanaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8562, Japan
| | - Tomonori Makiguchi
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8562, Japan
| | - Syunsuke Fujishima
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8562, Japan
| | - Yasuhito Nunomura
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8562, Japan
| | - Hiroaki Sakamoto
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8562, Japan
| | - Toshihiro Shiratori
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8562, Japan
| | - Kageaki Taima
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8562, Japan
| | - Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8562, Japan
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Takano Y, Kodera K, Tsukihara S, Takahashi S, Yasunobu K, Kanno H, Ishiyama S, Saito R, Hanyu N, Eto K. Association of a newly developed Cancer Cachexia Score with survival in Stage I-III colorectal cancer. Langenbecks Arch Surg 2023; 408:145. [PMID: 37043018 DOI: 10.1007/s00423-023-02883-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 04/03/2023] [Indexed: 04/13/2023]
Abstract
PURPOSE Cancer cachexia, a complex multifactorial syndrome associated with sarcopenia, negatively affects the quality of life and survival in patients with several cancers. We aimed to develop a new score for cachexia assessment and evaluate its effectiveness in the classification of patients undergoing radical resection for colorectal cancer. METHODS This study included 396 patients who underwent radical resection for Stage I-III colorectal cancer. To develop the Cancer Cachexia Score (CCS), we analyzed predictive factors of cachexia status related to the development of sarcopenia and incorporated significant factors into the score. We then evaluated the relationship between CCS and survival after radical resection for colorectal cancer. RESULTS As body mass index (P < 0.001), prognostic nutritional index (P = 0.005), and tumor volume (P < 0.001) were significantly associated with the development of sarcopenia, these factors were included in CCS. Using CCS, 221 (56%), 98 (25%), and 77 (19%) patients were diagnosed with mild, moderate, and severe cancer cachexia, respectively. In multivariate analysis, severe CCS (P < 0.001), N stage 1-2 (P < 0.001), and occurrence of postoperative complications (P = 0.007) were independent predictors of disease-free survival. Age ≥ 65 years (P = 0.009), severe CCS (P < 0.001), and N stage 1-2 (P < 0.001) were independent predictors of overall survival. CONCLUSIONS CCS may be a useful prognostic factor for predicting poor survival after radical resection in patients with Stage I-III colorectal cancer.
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Affiliation(s)
- Yasuhiro Takano
- Department of Surgery, Tokyo General Hospital, 3-15-2, Ekoda, Nakano, Tokyo, 165-8906, Japan.
| | - Keita Kodera
- Department of Surgery, Kasai Shoikai Hospital, Tokyo, Japan
| | - Shu Tsukihara
- Department of Surgery, Tokyo General Hospital, 3-15-2, Ekoda, Nakano, Tokyo, 165-8906, Japan
| | - Sumika Takahashi
- Department of Surgery, Tokyo General Hospital, 3-15-2, Ekoda, Nakano, Tokyo, 165-8906, Japan
| | - Kobayashi Yasunobu
- Department of Surgery, Tokyo General Hospital, 3-15-2, Ekoda, Nakano, Tokyo, 165-8906, Japan
| | - Hironori Kanno
- Department of Surgery, Tokyo General Hospital, 3-15-2, Ekoda, Nakano, Tokyo, 165-8906, Japan
| | | | - Ryota Saito
- Department of Surgery, Kasai Shoikai Hospital, Tokyo, Japan
| | - Nobuyoshi Hanyu
- Department of Surgery, Tokyo General Hospital, 3-15-2, Ekoda, Nakano, Tokyo, 165-8906, Japan
| | - Ken Eto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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