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Cao W, Xia T. Optimized strategies for precise messenger RNA delivery using site-specific lipid nanoparticle-based drug delivery systems. Nanomedicine (Lond) 2024:1-4. [PMID: 39345133 DOI: 10.1080/17435889.2024.2406218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Accepted: 09/16/2024] [Indexed: 10/01/2024] Open
Affiliation(s)
- Wei Cao
- Medical College & Henan Key Laboratory of Cancer Epigenetics, The First Affiliated Hospital, School of Clinical Medicine, Henan University of Science and Technology, Luoyang, 471023, China
| | - Tian Xia
- Department of Medicine, University of California, Los Angeles, CA 90095, USA
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2
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Liu Y, Huang Y, He G, Guo C, Dong J, Wu L. Development of mRNA Lipid Nanoparticles: Targeting and Therapeutic Aspects. Int J Mol Sci 2024; 25:10166. [PMID: 39337651 PMCID: PMC11432440 DOI: 10.3390/ijms251810166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Revised: 07/07/2024] [Accepted: 07/12/2024] [Indexed: 09/30/2024] Open
Abstract
Lipid nanoparticles (LNPs) have emerged as leading non-viral carriers for messenger RNA (mRNA) delivery in clinical applications. Overcoming challenges in safe and effective mRNA delivery to target tissues and cells, along with controlling release from the delivery vehicle, remains pivotal in mRNA-based therapies. This review elucidates the structure of LNPs, the mechanism for mRNA delivery, and the targeted delivery of LNPs to various cells and tissues, including leukocytes, T-cells, dendritic cells, Kupffer cells, hepatic endothelial cells, and hepatic and extrahepatic tissues. Here, we discuss the applications of mRNA-LNP vaccines for the prevention of infectious diseases and for the treatment of cancer and various genetic diseases. Although challenges remain in terms of delivery efficiency, specific tissue targeting, toxicity, and storage stability, mRNA-LNP technology holds extensive potential for the treatment of diseases.
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Affiliation(s)
- Yaping Liu
- College of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Shenyang 110016, China
- Center for Chemical Biology and Drug Discovery, Guangzhou Institute of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou 510530, China
| | - Yingying Huang
- College of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Shenyang 110016, China
- Center for Chemical Biology and Drug Discovery, Guangzhou Institute of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou 510530, China
| | - Guantao He
- Center for Chemical Biology and Drug Discovery, Guangzhou Institute of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou 510530, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Chun Guo
- College of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Jinhua Dong
- College of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Linping Wu
- Center for Chemical Biology and Drug Discovery, Guangzhou Institute of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou 510530, China
- Key Laboratory of Immune Response and Immunotherapy, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou 510530, China
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3
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Wei PS, Thota N, John G, Chang E, Lee S, Wang Y, Ma Z, Tsai YH, Mei KC. Enhancing RNA-lipid nanoparticle delivery: Organ- and cell-specificity and barcoding strategies. J Control Release 2024; 375:366-388. [PMID: 39179112 DOI: 10.1016/j.jconrel.2024.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 07/25/2024] [Accepted: 08/19/2024] [Indexed: 08/26/2024]
Abstract
Recent advancements in RNA therapeutics highlight the critical need for precision gene delivery systems that target specific organs and cells. Lipid nanoparticles (LNPs) have emerged as key vectors in delivering mRNA and siRNA, offering protection against enzymatic degradation, enabling targeted delivery and cellular uptake, and facilitating RNA cargo release into the cytosol. This review discusses the development and optimization of organ- and cell-specific LNPs, focusing on their design, mechanisms of action, and therapeutic applications. We explore innovations such as DNA/RNA barcoding, which facilitates high-throughput screening and precise adjustments in formulations. We address major challenges, including improving endosomal escape, minimizing off-target effects, and enhancing delivery efficiencies. Notable clinical trials and recent FDA approvals illustrate the practical applications and future potential of LNP-based RNA therapies. Our findings suggest that while considerable progress has been made, continued research is essential to resolve existing limitations and bridge the gap between preclinical and clinical evaluation of the safety and efficacy of RNA therapeutics. This review highlights the dynamic progress in LNP research. It outlines a roadmap for future advancements in RNA-based precision medicine.
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Affiliation(s)
- Pu-Sheng Wei
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Binghamton, Johnson City, New York, NY 13790, USA
| | - Nagasri Thota
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Binghamton, Johnson City, New York, NY 13790, USA
| | - Greshma John
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Binghamton, Johnson City, New York, NY 13790, USA
| | - Evelyn Chang
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Binghamton, Johnson City, New York, NY 13790, USA
| | - Sunjae Lee
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Binghamton, Johnson City, New York, NY 13790, USA
| | - Yuanjun Wang
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Binghamton, Johnson City, New York, NY 13790, USA
| | - Zitao Ma
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Binghamton, Johnson City, New York, NY 13790, USA
| | - Yu-Hsuan Tsai
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Binghamton, Johnson City, New York, NY 13790, USA
| | - Kuo-Ching Mei
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Binghamton, Johnson City, New York, NY 13790, USA.
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4
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Eftekhari Z, Zohrabi H, Oghalaie A, Ebrahimi T, Shariati FS, Behdani M, Kazemi-Lomedasht F. Advancements and challenges in mRNA and ribonucleoprotein-based therapies: From delivery systems to clinical applications. MOLECULAR THERAPY. NUCLEIC ACIDS 2024; 35:102313. [PMID: 39281702 PMCID: PMC11402252 DOI: 10.1016/j.omtn.2024.102313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 09/18/2024]
Abstract
The use of mRNA and ribonucleoproteins (RNPs) as therapeutic agents is a promising strategy for treating diseases such as cancer and infectious diseases. This review provides recent advancements and challenges in mRNA- and RNP-based therapies, focusing on delivery systems such as lipid nanoparticles (LNPs), which ensure efficient delivery to target cells. Strategies such as microfluidic devices are employed to prepare LNPs loaded with mRNA and RNPs, demonstrating effective genome editing and protein expression in vitro and in vivo. These applications extend to cancer treatment and infectious disease management, with promising results in genome editing for cancer therapy using LNPs encapsulating Cas9 mRNA and single-guide RNA. In addition, tissue-specific targeting strategies offer potential for improved therapeutic outcomes and reduced off-target effects. Despite progress, challenges such as optimizing delivery efficiency and targeting remain. Future research should enhance delivery efficiency, explore tissue-specific targeting, investigate combination therapies, and advance clinical translation. In conclusion, mRNA- and RNP-based therapies offer a promising avenue for treating various diseases and have the potential to revolutionize medicine, providing new hope for patients worldwide.
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Affiliation(s)
- Zohre Eftekhari
- Venom and Biotherapeutics Molecules Laboratory, Biotechnology Department, Biotechnology Research Center, Pasteur Institute of Iran, Tehran 1316943551, Iran
| | - Horieh Zohrabi
- Venom and Biotherapeutics Molecules Laboratory, Biotechnology Department, Biotechnology Research Center, Pasteur Institute of Iran, Tehran 1316943551, Iran
| | - Akbar Oghalaie
- Venom and Biotherapeutics Molecules Laboratory, Biotechnology Department, Biotechnology Research Center, Pasteur Institute of Iran, Tehran 1316943551, Iran
| | - Tahereh Ebrahimi
- Department of Nanobiotechnology, New Technologies Research Group, Pasteur Institute of Iran, Tehran 1316943551, Iran
| | - Fatemeh Sadat Shariati
- Department of Influenza and other Respiratory Viruses, Pasteur Institute of Iran, Tehran 1316943551, Iran
| | - Mahdi Behdani
- Venom and Biotherapeutics Molecules Laboratory, Biotechnology Department, Biotechnology Research Center, Pasteur Institute of Iran, Tehran 1316943551, Iran
| | - Fatemeh Kazemi-Lomedasht
- Venom and Biotherapeutics Molecules Laboratory, Biotechnology Department, Biotechnology Research Center, Pasteur Institute of Iran, Tehran 1316943551, Iran
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Sam Lee J, Kim M, Jin H, Kwak M, Cho E, Kim KS, Kim DE. DNA aptamer-conjugated lipid nanoparticle for targeted PTEN mRNA delivery to prostate cancer cells. Int J Pharm 2024; 662:124519. [PMID: 39067551 DOI: 10.1016/j.ijpharm.2024.124519] [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: 04/19/2024] [Revised: 07/17/2024] [Accepted: 07/24/2024] [Indexed: 07/30/2024]
Abstract
The use of messenger RNA (mRNA) as a cancer vaccine and gene therapy requires targeted vehicle delivery to the site of disease. Here, we designed a mRNA-encapsulating lipid nanoparticle (LNP) conjugated with anti-programmed death-ligand 1 (PD-L1) DNA aptamer that delivers mRNA encoding a tumor suppressor gene, namely phosphatase and tensin homolog (PTEN), to castration-resistant prostate cancer (CRPC) cells expressing PD-L1 on the cell surface. The DNA aptamer-conjugated LNP-based mRNA delivery system (Apt-LNP[PTEN mRNA]) mediated efficient mRNA delivery and transfection in CRPC cells than LNPs without targeting ligands. Cancer-targeted PTEN mRNA delivery using Apt-LNPs achieved significantly higher PTEN expression via aptamer-mediated endocytosis in target cancer cells compared with non-targeted LNP delivery, resulting in significant downregulation of AKT phosphorylation. This enhanced PI3K/AKT pathway regulation, and in turn reduced cell migration after two days along with a 70 % decrease in cell viability, leading to effective apoptotic cell death. In a CRPC xenograft model, Apt-LNP[PTEN mRNA] led to an approximate 60 % reduction in tumor growth, which was attributable to the effective PTEN restoration and PI3K/AKT signaling pathway regulation. PTEN expression was significantly enhanced in CRPC tumor tissues, which abolished cancer cell tumorigenicity. These findings demonstrated the potential of Apt-LNPs for targeted mRNA delivery to cancer cells, thus providing a promising tool for targeted mRNA delivery to a range of cancers and tissues using a conventional LNP systems.
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Affiliation(s)
- Jong Sam Lee
- Department of Bioscience and Biotechnology, Konkuk University, Seoul 05029, Republic of Korea
| | - Minhee Kim
- Department of Bioscience and Biotechnology, Konkuk University, Seoul 05029, Republic of Korea
| | - Hyesoo Jin
- Department of Bioscience and Biotechnology, Konkuk University, Seoul 05029, Republic of Korea
| | - Minseo Kwak
- Department of Bioscience and Biotechnology, Konkuk University, Seoul 05029, Republic of Korea
| | - Eunbin Cho
- Department of Bioscience and Biotechnology, Konkuk University, Seoul 05029, Republic of Korea
| | - Keun-Sik Kim
- Department of Biomedical Laboratory Science, Konyang University, Daejeon 35365, Republic of Korea
| | - Dong-Eun Kim
- Department of Bioscience and Biotechnology, Konkuk University, Seoul 05029, Republic of Korea.
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Nelson AL, Mancino C, Gao X, Choe JA, Chubb L, Williams K, Czachor M, Marcucio R, Taraballi F, Cooke JP, Huard J, Bahney C, Ehrhart N. β-catenin mRNA encapsulated in SM-102 lipid nanoparticles enhances bone formation in a murine tibia fracture repair model. Bioact Mater 2024; 39:273-286. [PMID: 38832305 PMCID: PMC11145078 DOI: 10.1016/j.bioactmat.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 05/08/2024] [Accepted: 05/08/2024] [Indexed: 06/05/2024] Open
Abstract
Fractures continue to be a global economic burden as there are currently no osteoanabolic drugs approved to accelerate fracture healing. In this study, we aimed to develop an osteoanabolic therapy which activates the Wnt/β-catenin pathway, a molecular driver of endochondral ossification. We hypothesize that using an mRNA-based therapeutic encoding β-catenin could promote cartilage to bone transformation formation by activating the canonical Wnt signaling pathway in chondrocytes. To optimize a delivery platform built on recent advancements in liposomal technologies, two FDA-approved ionizable phospholipids, DLin-MC3-DMA (MC3) and SM-102, were used to fabricate unique ionizable lipid nanoparticle (LNP) formulations and then tested for transfection efficacy both in vitro and in a murine tibia fracture model. Using firefly luciferase mRNA as a reporter gene to track and quantify transfection, SM-102 LNPs showed enhanced transfection efficacy in vitro and prolonged transfection, minimal fracture interference and no localized inflammatory response in vivo over MC3 LNPs. The generated β-cateninGOF mRNA encapsulated in SM-102 LNPs (SM-102-β-cateninGOF mRNA) showed bioactivity in vitro through upregulation of downstream canonical Wnt genes, axin2 and runx2. When testing SM-102-β-cateninGOF mRNA therapeutic in a murine tibia fracture model, histomorphometric analysis showed increased bone and decreased cartilage composition with the 45 μg concentration at 2 weeks post-fracture. μCT testing confirmed that SM-102-β-cateninGOF mRNA promoted bone formation in vivo, revealing significantly more bone volume over total volume in the 45 μg group. Thus, we generated a novel mRNA-based therapeutic encoding a β-catenin mRNA and optimized an SM-102-based LNP to maximize transfection efficacy with a localized delivery.
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Affiliation(s)
- Anna Laura Nelson
- Steadman Philippon Research Institute (SPRI), Center for Regenerative and Personalized Medicine, Vail, CO, USA
- Colorado State University, School of Biomedical Engineering, Fort Collins CO, USA
| | - Chiara Mancino
- Houston Methodist Research Institute, Center for Musculoskeletal Regeneration, Houston TX, USA
| | - Xueqin Gao
- Steadman Philippon Research Institute (SPRI), Center for Regenerative and Personalized Medicine, Vail, CO, USA
| | - Joshua A. Choe
- University of Wisconsin-Madison, Department of Orthopedics and Rehabilitation, Department of Biomedical Engineering, Medical Scientist Training Program, Madison, WI, USA
| | - Laura Chubb
- Colorado State University, Department of Clinical Sciences, Fort Collins CO, USA
| | - Katherine Williams
- Colorado State University, Department of Microbiology, Immunology, and Pathology, Fort Collins, CO, USA
| | - Molly Czachor
- Steadman Philippon Research Institute (SPRI), Center for Regenerative and Personalized Medicine, Vail, CO, USA
| | - Ralph Marcucio
- University of California, San Francisco (UCSF), Orthopaedic Trauma Institute, San Francisco, CA, USA
| | - Francesca Taraballi
- Houston Methodist Research Institute, Center for Musculoskeletal Regeneration, Houston TX, USA
| | - John P. Cooke
- Houston Methodist Research Institute, Center for RNA Therapeutics, Department of Cardiovascular Sciences, Houston, TX, USA
| | - Johnny Huard
- Steadman Philippon Research Institute (SPRI), Center for Regenerative and Personalized Medicine, Vail, CO, USA
- Colorado State University, Department of Clinical Sciences, Fort Collins CO, USA
| | - Chelsea Bahney
- Steadman Philippon Research Institute (SPRI), Center for Regenerative and Personalized Medicine, Vail, CO, USA
- Colorado State University, Department of Clinical Sciences, Fort Collins CO, USA
- University of California, San Francisco (UCSF), Orthopaedic Trauma Institute, San Francisco, CA, USA
| | - Nicole Ehrhart
- Colorado State University, School of Biomedical Engineering, Fort Collins CO, USA
- Colorado State University, Department of Clinical Sciences, Fort Collins CO, USA
- Colorado State University, Department of Microbiology, Immunology, and Pathology, Fort Collins, CO, USA
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Parvin N, Joo SW, Mandal TK. Enhancing Vaccine Efficacy and Stability: A Review of the Utilization of Nanoparticles in mRNA Vaccines. Biomolecules 2024; 14:1036. [PMID: 39199422 PMCID: PMC11353004 DOI: 10.3390/biom14081036] [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: 07/21/2024] [Revised: 08/12/2024] [Accepted: 08/18/2024] [Indexed: 09/01/2024] Open
Abstract
The development of vaccines has entered a new era with the advent of nanotechnology, particularly through the utilization of nanoparticles. This review focuses on the role of nanoparticles in enhancing the efficacy and stability of mRNA vaccines. Nanoparticles, owing to their unique properties such as high surface area, tunable size, and their ability to be functionalized, have emerged as powerful tools in vaccine development. Specifically, lipid nanoparticles (LNPs) have revolutionized the delivery of mRNA vaccines by protecting the fragile mRNA molecules and facilitating their efficient uptake by cells. This review discusses the various types of nanoparticles employed in mRNA vaccine formulations, including lipid-based, polymer-based, and inorganic nanoparticles, highlighting their advantages and limitations. Moreover, it explores the mechanisms by which nanoparticles improve immune responses, such as enhanced antigen presentation and the prolonged release of mRNA. This review also addresses the challenges and future directions in nanoparticle-based vaccine development, emphasizing the need for further research to optimize formulations for broader applications. By providing an in-depth analysis of the current advancements in and potential of nanoparticles in mRNA vaccines, this review aims to shed light on their critical role in combating infectious diseases and improving public health outcomes.
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Affiliation(s)
| | - Sang Woo Joo
- School of Mechanical Engineering, Yeungnam University, Gyeongsan 38541, Republic of Korea;
| | - Tapas Kumar Mandal
- School of Mechanical Engineering, Yeungnam University, Gyeongsan 38541, Republic of Korea;
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Arjunan P, Kathirvelu D, Mahalingam G, Goel AK, Zacharaiah UG, Srivastava A, Marepally S. Lipid-nanoparticle-enabled nucleic acid therapeutics for liver disorders. Acta Pharm Sin B 2024; 14:2885-2900. [PMID: 39027251 PMCID: PMC11252464 DOI: 10.1016/j.apsb.2024.04.015] [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: 01/01/2024] [Revised: 02/08/2024] [Accepted: 03/19/2024] [Indexed: 07/20/2024] Open
Abstract
Inherited genetic disorders of the liver pose a significant public health burden. Liver transplantation is often limited by the availability of donor livers and the exorbitant costs of immunosuppressive therapy. To overcome these limitations, nucleic acid therapy provides a hopeful alternative that enables gene repair, gene supplementation, and gene silencing with suitable vectors. Though viral vectors are the most efficient and preferred for gene therapy, pre-existing immunity debilitating immune responses limit their use. As a potential alternative, lipid nanoparticle-mediated vectors are being explored to deliver multiple nucleic acid forms, including pDNA, mRNA, siRNA, and proteins. Herein, we discuss the broader applications of lipid nanoparticles, from protein replacement therapy to restoring the disease mechanism through nucleic acid delivery and gene editing, as well as multiple preclinical and clinical studies as a potential alternative to liver transplantation.
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Affiliation(s)
- Porkizhi Arjunan
- Center for Stem Cell Research (A Unit of inStem, Bengaluru), Christian Medical College Campus, Bagayam, Vellore 632002, Tamil Nadu, India
- Manipal academy for higher education, Mangalore 576104, Karnataka, India
| | - Durga Kathirvelu
- Center for Stem Cell Research (A Unit of inStem, Bengaluru), Christian Medical College Campus, Bagayam, Vellore 632002, Tamil Nadu, India
| | - Gokulnath Mahalingam
- Center for Stem Cell Research (A Unit of inStem, Bengaluru), Christian Medical College Campus, Bagayam, Vellore 632002, Tamil Nadu, India
| | - Ashish Kumar Goel
- Department of Hepatology, Christian Medical College & Hospital, Vellore 632004, Tamil Nadu, India
| | - Uday George Zacharaiah
- Department of Hepatology, Christian Medical College & Hospital, Vellore 632004, Tamil Nadu, India
| | - Alok Srivastava
- Center for Stem Cell Research (A Unit of inStem, Bengaluru), Christian Medical College Campus, Bagayam, Vellore 632002, Tamil Nadu, India
- Department of Hematology, Christian Medical College & Hospital, Vellore 632004, Tamil Nadu, India
| | - Srujan Marepally
- Center for Stem Cell Research (A Unit of inStem, Bengaluru), Christian Medical College Campus, Bagayam, Vellore 632002, Tamil Nadu, India
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Lin HH, Chang CW, Liao YT, Yeh SD, Lin HP, Ho HM, Cheung CHY, Juan HF, Chen YR, Su YW, Chen LM, Tan TH, Lin WJ. DUSP22 inhibits lung tumorigenesis by suppression of EGFR/c-Met signaling. Cell Death Discov 2024; 10:285. [PMID: 38877005 PMCID: PMC11178881 DOI: 10.1038/s41420-024-02038-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/15/2024] [Accepted: 05/21/2024] [Indexed: 06/16/2024] Open
Abstract
DUSP22, an atypical dual-specificity phosphatase enzyme, plays a significant role in regulating multiple kinase signaling pathways by dephosphorylation. Our study demonstrated that decreased DUSP22 expression is associated with shorter disease-free survival, advanced TNM (tumor, lymph nodes, and metastasis), cancer stage, and higher tumor grade in lung adenocarcinoma (LUAD) patients. Exogenous DUSP22 expression reduces the colony-forming capacity of lung cancer cells and inhibits xenograft tumor growth primarily by targeting EGFR and suppressing its activity through dephosphorylation. Knockdown of DUSP22 using shRNA enhances EGFR dependency in HCC827 lung cancer cells and increases sensitivity to gefitinib, an EGFR inhibitor. Consistently, genetic deletion of DUSP22 enhances EGFRdel (exon 19 deletion)-driven lung tumorigenesis and elevates EGFR activity. Pharmacological inhibition of DUSP22 activates EGFR, ERK1/2, and upregulates downstream PD-L1 expression. Additionally, lentiviral deletion of DUSP22 by shRNA enhances lung cancer cell migration through EGFR/c-Met and PD-L1-dependent pathways. Gefitinib, an EGFR inhibitor, mechanistically suppresses migration induced by DUSP22 deletion and inhibits c-Met activity. Furthermore, cabozantinib, a c-Met inhibitor, reduces migration and attenuates EGFR activation caused by DUSP22 deletion. Collectively, our findings support the hypothesis that loss of DUSP22 function in lung cancer cells confers a survival advantage by augmenting EGFR signaling, leading to increased activation of downstream c-Met, ERK1/2, and PD-L1 axis, ultimately contributing to the progression of advanced lung cancer.
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Affiliation(s)
- Hsiao-Han Lin
- Immunology Research Center, National Health Research Institutes, Miaoli County, 35053, Taiwan
| | - Cheng-Wei Chang
- Immunology Research Center, National Health Research Institutes, Miaoli County, 35053, Taiwan
| | - Yu-Ting Liao
- Immunology Research Center, National Health Research Institutes, Miaoli County, 35053, Taiwan
| | - Shauh-Der Yeh
- Department of Urology, Graduate Institute of Clinical Medicine, Taipei Medical University, Taipei, 110301, Taiwan
| | - Hsiu-Ping Lin
- Immunology Research Center, National Health Research Institutes, Miaoli County, 35053, Taiwan
| | - Hui-Min Ho
- Immunology Research Center, National Health Research Institutes, Miaoli County, 35053, Taiwan
| | | | - Hsueh-Fen Juan
- Department of Life Science, National Taiwan University, Taipei, 10617, Taiwan
| | - Yi-Rong Chen
- Institute of Molecular and Genomic Medicine, National Health Research Institutes, Miaoli County, 35053, Taiwan
| | - Yu-Wen Su
- Immunology Research Center, National Health Research Institutes, Miaoli County, 35053, Taiwan
| | - Li-Mei Chen
- Immunology Research Center, National Health Research Institutes, Miaoli County, 35053, Taiwan
| | - Tse-Hua Tan
- Immunology Research Center, National Health Research Institutes, Miaoli County, 35053, Taiwan
| | - Wen-Jye Lin
- Immunology Research Center, National Health Research Institutes, Miaoli County, 35053, Taiwan.
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10
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Yang R, Liu Y, Yang N, Zhang T, Hou J, He Z, Wang Y, Sun X, Shen J, Jiang H, Xie Y, Lang T. Combination of miR159 Mimics and Irinotecan Utilizing Lipid Nanoparticles for Enhanced Treatment of Colorectal Cancer. Pharmaceutics 2024; 16:570. [PMID: 38675231 PMCID: PMC11054162 DOI: 10.3390/pharmaceutics16040570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/27/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Colorectal cancer (CRC) ranks as the third most prevalent global malignancy, marked by significant metastasis and post-surgical recurrence, posing formidable challenges to treatment efficacy. The integration of oligonucleotides with chemotherapeutic drugs emerges as a promising strategy for synergistic CRC therapy. The nanoformulation, lipid nanoparticle (LNP), presents the capability to achieve co-delivery of oligonucleotides and chemotherapeutic drugs for cancer therapy. In this study, we constructed lipid nanoparticles, termed as LNP-I-V by microfluidics to co-deliver oligonucleotides miR159 mimics (VDX05001SI) and irinotecan (IRT), demonstrating effective treatment of CRC both in vitro and in vivo. The LNP-I-V exhibited a particle size of 118.67 ± 1.27 nm, ensuring excellent stability and targeting delivery to tumor tissues, where it was internalized and escaped from the endosome with a pH-sensitive profile. Ultimately, LNP-I-V significantly inhibited CRC growth, extended the survival of tumor-bearing mice, and displayed favorable safety profiles. Thus, LNP-I-V held promise as an innovative platform to combine gene therapy and chemotherapy for improving CRC treatment.
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Affiliation(s)
- Rulei Yang
- School of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing 210023, China; (R.Y.); (J.S.); (H.J.)
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China;
- Vigonvita Life Sciences Co., Ltd., Suzhou 215125, China
| | - Yiran Liu
- Lingang Laboratory, Shanghai 200031, China; (Y.L.); (N.Y.); (T.Z.); (J.H.); (Z.H.); (Y.W.)
| | - Ning Yang
- Lingang Laboratory, Shanghai 200031, China; (Y.L.); (N.Y.); (T.Z.); (J.H.); (Z.H.); (Y.W.)
| | - Tian Zhang
- Lingang Laboratory, Shanghai 200031, China; (Y.L.); (N.Y.); (T.Z.); (J.H.); (Z.H.); (Y.W.)
| | - Jiazhen Hou
- Lingang Laboratory, Shanghai 200031, China; (Y.L.); (N.Y.); (T.Z.); (J.H.); (Z.H.); (Y.W.)
| | - Zongyan He
- Lingang Laboratory, Shanghai 200031, China; (Y.L.); (N.Y.); (T.Z.); (J.H.); (Z.H.); (Y.W.)
| | - Yutong Wang
- Lingang Laboratory, Shanghai 200031, China; (Y.L.); (N.Y.); (T.Z.); (J.H.); (Z.H.); (Y.W.)
| | - Xujie Sun
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China;
- Lingang Laboratory, Shanghai 200031, China; (Y.L.); (N.Y.); (T.Z.); (J.H.); (Z.H.); (Y.W.)
| | - Jingshan Shen
- School of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing 210023, China; (R.Y.); (J.S.); (H.J.)
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China;
| | - Hualiang Jiang
- School of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing 210023, China; (R.Y.); (J.S.); (H.J.)
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China;
- Lingang Laboratory, Shanghai 200031, China; (Y.L.); (N.Y.); (T.Z.); (J.H.); (Z.H.); (Y.W.)
| | - Yuanchao Xie
- Lingang Laboratory, Shanghai 200031, China; (Y.L.); (N.Y.); (T.Z.); (J.H.); (Z.H.); (Y.W.)
| | - Tianqun Lang
- Lingang Laboratory, Shanghai 200031, China; (Y.L.); (N.Y.); (T.Z.); (J.H.); (Z.H.); (Y.W.)
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11
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Di J, Huang P, Chen X. Targeting Strategies for Site-Specific mRNA Delivery. Bioconjug Chem 2024; 35:453-456. [PMID: 38491941 DOI: 10.1021/acs.bioconjchem.4c00038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2024]
Abstract
mRNA therapeutics hold great promise for disease treatment, yet a key challenge lies in achieving site-specific mRNA delivery to maximize therapeutic efficacy while minimizing off-target side effects. This viewpoint delves into multiple complementary targeting strategies to achieve precise site-specific mRNA delivery, covering topics of administration routes, passive targeting, and active targeting. It highlights the critical importance of rationally designed nanocarriers for obtaining desired therapeutic effects and accelerating the clinical translation of mRNA therapeutics.
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Affiliation(s)
- Jiaxing Di
- School of Pharmacy, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Pei Huang
- Departments of Diagnostic Radiology, Surgery, Chemical and Biomolecular Engineering, and Biomedical Engineering, Yong Loo Lin School of Medicine and College of Design and Engineering, National University of Singapore, Singapore 119074, Singapore
- Nanomedicine Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Xiaoyuan Chen
- Departments of Diagnostic Radiology, Surgery, Chemical and Biomolecular Engineering, and Biomedical Engineering, Yong Loo Lin School of Medicine and College of Design and Engineering, National University of Singapore, Singapore 119074, Singapore
- Nanomedicine Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Clinical Imaging Research Centre, Centre for Translational Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117599, Singapore
- Institute of Molecular and Cell Biology, Agency for Science, Technology, and Research (A*STAR), 61 Biopolis Drive, Proteos, Singapore 138673, Singapore
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12
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Dang BTN, Kwon TK, Lee S, Jeong JH, Yook S. Nanoparticle-based immunoengineering strategies for enhancing cancer immunotherapy. J Control Release 2024; 365:773-800. [PMID: 38081328 DOI: 10.1016/j.jconrel.2023.12.007] [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: 09/07/2023] [Revised: 11/27/2023] [Accepted: 12/03/2023] [Indexed: 12/17/2023]
Abstract
Cancer immunotherapy is a groundbreaking strategy that has revolutionized the field of oncology compared to other therapeutic strategies, such as surgery, chemotherapy, or radiotherapy. However, cancer complexity, tumor heterogeneity, and immune escape have become the main hurdles to the clinical application of immunotherapy. Moreover, conventional immunotherapies cause many harmful side effects owing to hyperreactivity in patients, long treatment durations and expensive cost. Nanotechnology is considered a transformative approach that enhances the potency of immunotherapy by capitalizing on the superior physicochemical properties of nanocarriers, creating highly targeted tissue delivery systems. These advantageous features include a substantial specific surface area, which enhances the interaction with the immune system. In addition, the capability to finely modify surface chemistry enables the achievement of controlled and sustained release properties. These advances have significantly increased the potential of immunotherapy, making it more powerful than ever before. In this review, we introduce recent nanocarriers for application in cancer immunotherapy based on strategies that target different main immune cells, including T cells, dendritic cells, natural killer cells, and tumor-associated macrophages. We also provide an overview of the role and significance of nanotechnology in cancer immunotherapy.
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Affiliation(s)
| | - Taeg Kyu Kwon
- Department of Immunology, School of Medicine, Keimyung University, Daegu 42601, Republic of Korea
| | - Sooyeun Lee
- College of Pharmacy, Keimyung University, Daegu 42601, Republic of Korea
| | - Jee-Heon Jeong
- Department of Precision Medicine, School of Medicine, Sungkyunkwan University, Suwon 16419, Republic of Korea.
| | - Simmyung Yook
- Department of Biopharmaceutical Convergence, Sungkyunkwan University, Suwon 16419, Republic of Korea; School of Pharmacy, Sungkyunkwan University, Suwon 16419, Republic of Korea.
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13
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Kusumoputro S, Au C, Lam KH, Park N, Hyun A, Kusumoputro E, Wang X, Xia T. Liver-Targeting Nanoplatforms for the Induction of Immune Tolerance. NANOMATERIALS (BASEL, SWITZERLAND) 2023; 14:67. [PMID: 38202522 PMCID: PMC10780512 DOI: 10.3390/nano14010067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/14/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024]
Abstract
Liver-targeting nanoparticles have emerged as a promising platform for the induction of immune tolerance by taking advantage of the liver's unique tolerogenic properties and nanoparticles' physicochemical flexibility. Such an approach provides a versatile solution to the treatment of a diversity of immunologic diseases. In this review, we begin by assessing the design parameters integral to cell-specific targeting and the tolerogenic induction of nanoplatforms engineered to target the four critical immunogenic hepatic cells, including liver sinusoidal epithelial cells (LSECs), Kupffer cells (KCs), hepatic stellate cells (HSCs), and hepatocytes. We also include an overview of multiple therapeutic strategies in which nanoparticles are being studied to treat many allergies and autoimmune disorders. Finally, we explore the challenges of using nanoparticles in this field while highlighting future avenues to expand the therapeutic utility of liver-targeting nanoparticles in autoimmune processes.
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Affiliation(s)
- Sydney Kusumoputro
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA 19129, USA; (S.K.); (N.P.)
- Department of Ecology and Evolutionary Biology, University of California, Los Angeles, CA 90095, USA
| | - Christian Au
- Department of Bioengineering, University of California, Los Angeles, CA 90095, USA;
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90007, USA;
| | - Katie H. Lam
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90007, USA;
- Department of Microbiology, Immunology, and Molecular Genetics, University of California, Los Angeles, CA 90095, USA
| | - Nathaniel Park
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA 19129, USA; (S.K.); (N.P.)
| | - Austin Hyun
- Department of Medicine, Lake Erie College of Osteopathic Medicine, Bradenton, FL 34211, USA;
- Department of Integrative Biology and Physiology, University of California, Los Angeles, CA 90095, USA
| | - Emily Kusumoputro
- Department of Evolution, Ecology, and Organismal Biology, University of California, Riverside, CA 92521, USA;
| | - Xiang Wang
- Division of NanoMedicine, Department of Medicine, University of California, Los Angeles, CA 90095, USA
- California NanoSystems Institute, University of California, Los Angeles, CA 90095, USA
| | - Tian Xia
- Division of NanoMedicine, Department of Medicine, University of California, Los Angeles, CA 90095, USA
- California NanoSystems Institute, University of California, Los Angeles, CA 90095, USA
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14
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Inagaki M. Cell Reprogramming and Differentiation Utilizing Messenger RNA for Regenerative Medicine. J Dev Biol 2023; 12:1. [PMID: 38535481 PMCID: PMC10971469 DOI: 10.3390/jdb12010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/06/2023] [Accepted: 12/19/2023] [Indexed: 06/16/2024] Open
Abstract
The COVID-19 pandemic generated interest in the medicinal applications of messenger RNA (mRNA). It is expected that mRNA will be applied, not only to vaccines, but also to regenerative medicine. The purity of mRNA is important for its medicinal applications. However, the current mRNA synthesis techniques exhibit problems, including the contamination of undesired 5'-uncapped mRNA and double-stranded RNA. Recently, our group developed a completely capped mRNA synthesis technology that contributes to the progress of mRNA research. The introduction of chemically modified nucleosides, such as N1-methylpseudouridine and 5-methylcytidine, has been reported by Karikó and Weissman, opening a path for the practical application of mRNA for vaccines and regenerative medicine. Yamanaka reported the production of induced pluripotent stem cells (iPSCs) by introducing four types of genes using a retrovirus vector. iPSCs are widely used for research on regenerative medicine and the preparation of disease models to screen new drug candidates. Among the Yamanaka factors, Klf4 and c-Myc are oncogenes, and there is a risk of tumor development if these are integrated into genomic DNA. Therefore, regenerative medicine using mRNA, which poses no risk of genome insertion, has attracted attention. In this review, the author summarizes techniques for synthesizing mRNA and its application in regenerative medicine.
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Affiliation(s)
- Masahito Inagaki
- Graduate School of Science, Nagoya University, Nagoya 464-8602, Japan
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15
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Huang P, Deng H, Wang C, Zhou Y, Chen X. Cellular Trafficking of Nanotechnology-Mediated mRNA Delivery. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2023:e2307822. [PMID: 37929780 DOI: 10.1002/adma.202307822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/30/2023] [Indexed: 11/07/2023]
Abstract
Messenger RNA (mRNA)-based therapy has emerged as a powerful, safe, and rapidly scalable therapeutic approach that involves technologies for both mRNA itself and the delivery vehicle. Although there are some unique challenges for different applications of mRNA therapy, a common challenge for all mRNA therapeutics is the transport of mRNA into the target cell cytoplasm for sufficient protein expression. This review is focused on the behaviors at the cellular level of nanotechnology-mediated mRNA delivery systems, which have not been comprehensively reviewed yet. First, the four main therapeutic applications of mRNA are introduced, including immunotherapy, protein replacement therapy, genome editing, and cellular reprogramming. Second, common types of mRNA cargos and mRNA delivery systems are summarized. Third, strategies to enhance mRNA delivery efficiency during the cellular trafficking process are highlighted, including accumulation to the cell, internalization into the cell, endosomal escape, release of mRNA from the nanocarrier, and translation of mRNA into protein. Finally, the challenges and opportunities for the development of nanotechnology-mediated mRNA delivery systems are presented. This review can provide new insights into the future fabrication of mRNA nanocarriers with desirable cellular trafficking performance.
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Affiliation(s)
- Pei Huang
- Departments of Diagnostic Radiology, Surgery, Chemical and Biomolecular Engineering, and Biomedical Engineering, Yong Loo Lin School of Medicine and College of Design and Engineering, National University of Singapore, Singapore, 119074, Singapore
- Nanomedicine Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117597, Singapore
- School of Chemistry and Chemical Engineering, Frontiers Science Center for Transformative Molecules, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Hongzhang Deng
- School of Life Science and Technology and Engineering Research Center of Molecular and Neuro Imaging, Ministry of Education, Xidian University, Xi'an, Shaanxi, 710126, China
| | - Changrong Wang
- School of Life Science and Technology and Engineering Research Center of Molecular and Neuro Imaging, Ministry of Education, Xidian University, Xi'an, Shaanxi, 710126, China
| | - Yongfeng Zhou
- School of Chemistry and Chemical Engineering, Frontiers Science Center for Transformative Molecules, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Xiaoyuan Chen
- Departments of Diagnostic Radiology, Surgery, Chemical and Biomolecular Engineering, and Biomedical Engineering, Yong Loo Lin School of Medicine and College of Design and Engineering, National University of Singapore, Singapore, 119074, Singapore
- Nanomedicine Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117597, Singapore
- Clinical Imaging Research Centre, Centre for Translational Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117599, Singapore
- Institute of Molecular and Cell Biology, Agency for Science, Technology, and Research (A*STAR), 61 Biopolis Drive Proteos, Singapore, 138673, Singapore
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16
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Zhang A, Ji Q, Sheng X, Wu H. mRNA vaccine in gastrointestinal tumors: Immunomodulatory effects and immunotherapy. Biomed Pharmacother 2023; 166:115361. [PMID: 37660645 DOI: 10.1016/j.biopha.2023.115361] [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: 07/03/2023] [Revised: 08/04/2023] [Accepted: 08/22/2023] [Indexed: 09/05/2023] Open
Abstract
Gastrointestinal tumors remain a significant healthcare burden worldwide, necessitating the development of innovative therapeutic strategies. mRNA vaccines have emerged as a promising approach in cancer immunotherapy, harnessing the immune system's potential to recognize and eliminate tumor cells. mRNA vaccines offer several advantages, including their ability to elicit both innate and adaptive immune responses, ease of production, and adaptability to different tumor types. In the context of gastrointestinal tumors, mRNA vaccines hold great potential as a therapeutic strategy. In this review, we will delve into the immunomodulatory mechanisms and immunotherapy strategies of mRNA vaccines in gastrointestinal tumors. Additionally, we will discuss the challenges and ongoing research efforts in optimizing mRNA vaccine development, delivery, and stability. By understanding the potential of mRNA vaccines in addressing the unmet medical need of gastrointestinal tumors, we aim to pave the way for improved treatment strategies and better patient outcomes.
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Affiliation(s)
- Ao Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun 130012, China
| | - Qingming Ji
- Department of Intensive Care Medicine, The First Hospital of Jilin University, Changchun 130012, China
| | - Xia Sheng
- Department of Cadre Ward, The First Hospital of Jilin University, Changchun 130012, China
| | - Hui Wu
- Department of Ophthalmology, The First Hospital of Jilin University, Changchun 130012, China.
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17
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Dubey AK, Mostafavi E. Biomaterials-mediated CRISPR/Cas9 delivery: recent challenges and opportunities in gene therapy. Front Chem 2023; 11:1259435. [PMID: 37841202 PMCID: PMC10568484 DOI: 10.3389/fchem.2023.1259435] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 09/15/2023] [Indexed: 10/17/2023] Open
Abstract
The use of biomaterials in delivering CRISPR/Cas9 for gene therapy in infectious diseases holds tremendous potential. This innovative approach combines the advantages of CRISPR/Cas9 with the protective properties of biomaterials, enabling accurate and efficient gene editing while enhancing safety. Biomaterials play a vital role in shielding CRISPR/Cas9 components, such as lipid nanoparticles or viral vectors, from immunological processes and degradation, extending their effectiveness. By utilizing the flexibility of biomaterials, tailored systems can be designed to address specific genetic diseases, paving the way for personalized therapeutics. Furthermore, this delivery method offers promising avenues in combating viral illnesses by precisely modifying pathogen genomes, and reducing their pathogenicity. Biomaterials facilitate site-specific gene modifications, ensuring effective delivery to infected cells while minimizing off-target effects. However, challenges remain, including optimizing delivery efficiency, reducing off-target effects, ensuring long-term safety, and establishing scalable production techniques. Thorough research, pre-clinical investigations, and rigorous safety evaluations are imperative for successful translation from the laboratory to clinical applications. In this review, we discussed how CRISPR/Cas9 delivery using biomaterials revolutionizes gene therapy and infectious disease treatment, offering precise and safe editing capabilities with the potential to significantly improve human health and quality of life.
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Affiliation(s)
- Ankit Kumar Dubey
- Global Research and Publishing Foundation, New Delhi, India
- Institute of Scholars, Bengaluru, Karnataka, India
| | - Ebrahim Mostafavi
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
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