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Perspectives on treating hepatitis C infection in the liver transplantation setting. Curr Opin Organ Transplant 2016; 21:111-9. [PMID: 26927201 DOI: 10.1097/mot.0000000000000288] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW This article reviews treatment options of the approved and soon-to-be approved direct-acting antiviral (DAA)-based therapies in the transplant setting. RECENT FINDINGS DAA-based therapies have been shown to be effective and safe in achieving viral eradication in the majority of pre- and postliver transplant (LT) populations. Treatment decisions are guided by hepatitis C virus (HCV) genotype, the degree of renal dysfunction, and severity of cirrhosis. The addition of ribavirin is frequently needed to achieve highest viral eradication rates. Viral eradication pre-LT has been associated with fewer portal hypertensive complications and improved survival and effectively prevents recurrent HCV post-LT. For those with shorter time to LT, an alternative strategy is treatment with DAAs up to the time of LT to reduce the risk of post-LT recurrence. Therapies should be considered for all post-LT patients with recurrent HCV given the risk of accelerated disease progression. The sustained virological response rates among LT recipients parallel those of nontransplant patients. SUMMARY With broader application of DAA therapy in the transplant setting, improved graft and patient survival and simplified post-LT management are likely. The availability of high potency DAA therapy with excellent safety profiles has transformed the HCV-infected LT population into a group that is no longer 'difficult-to-treat.'
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Hori T, Onishi Y, Kamei H, Kurata N, Ishigami M, Ishizu Y, Ogura Y. Fibrosing cholestatic hepatitis C in post-transplant adult recipients of liver transplantation. Ann Gastroenterol 2016; 29:454-459. [PMID: 27708510 PMCID: PMC5049551 DOI: 10.20524/aog.2016.0069] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 06/06/2016] [Indexed: 02/06/2023] Open
Abstract
Hepatitis C recurrence continues to present a major challenge in liver transplantation (LT). Approximately 10% of hepatitis C virus (HCV)-positive recipients will develop fibrosing cholestatic hepatitis (FCH) after LT. FCH is clinically characterized as marked jaundice with cholestatic hepatic dysfunction and high titers of viremia. Pathologically, FCH manifests as marked hepatocyte swelling, cholestasis, periportal peritrabecular fibrosis and only mild inflammation. This progressive form usually involves acute liver failure, and rapidly results in graft loss. A real-time and precise diagnosis based on histopathological examination and viral measurement is indispensable for the adequate treatment of FCH. Typical pathological findings of FCH are shown. Currently, carefully selected combinations of direct-acting antivirals (DAAs) offer the potential for highly effective and safe regimens for hepatitis C, both in the pre- and post-transplant settings. Here, we review FCH caused by HCV in LT recipients, and current strategies for sustained virological responses after LT. Only a few cases of successfully treated FCH C after LT by DAAs have been reported. The diagnostic findings and therapeutic dilemma are discussed based on a literature review.
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Affiliation(s)
- Tomohide Hori
- Department of Transplant Surgery (Tohomide Hori, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Yasuhiro Ogura), Nagoya University Hospital, Nagoya, Japan
| | - Yasuharu Onishi
- Department of Transplant Surgery (Tohomide Hori, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Yasuhiro Ogura), Nagoya University Hospital, Nagoya, Japan
| | - Hideya Kamei
- Department of Transplant Surgery (Tohomide Hori, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Yasuhiro Ogura), Nagoya University Hospital, Nagoya, Japan
| | - Nobuhiko Kurata
- Department of Transplant Surgery (Tohomide Hori, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Yasuhiro Ogura), Nagoya University Hospital, Nagoya, Japan
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology (Masatoshi Ishigami), Nagoya University Hospital, Nagoya, Japan
| | - Yoji Ishizu
- Department of Gastroenterology and Hepatology (Masatoshi Ishigami), Nagoya University Hospital, Nagoya, Japan
| | - Yasuhiro Ogura
- Department of Transplant Surgery (Tohomide Hori, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Yasuhiro Ogura), Nagoya University Hospital, Nagoya, Japan
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Abstract
PURPOSE OF REVIEW To review the experience to date and unique challenges associated with liver transplantation in hepatitis C virus (HCV)/HIV-coinfected patients. RECENT FINDINGS The prevalence of cirrhosis and hepatocellular carcinoma is rising among HIV-infected individuals. With careful patient selection and in the absence of HCV infection, HIV-infected and HIV-uninfected liver transplant recipients have comparable posttransplant outcomes. However, in the presence of HCV infection, patient and graft survival are significantly poorer in HIV-infected recipients, who have a higher risk of aggressive HCV recurrence, acute rejection, sepsis, and multiorgan failure. Outcomes may be improved with careful recipient and donor selection and with the availability of new highly potent all-oral HCV direct acting antivirals (DAAs). Although all-oral DAAs have not been evaluated in HIV/HCV-coinfected transplant patients, HIV does not adversely impact treatment success in nontransplant populations. Therefore, there is great hope that HCV can be successful eradicated in HIV/HCV-coinfected transplant patients and will result in improved outcomes. Careful attention to drug-drug interactions with HIV antiretroviral agents, DAAs, and posttransplant immunosuppressants is required. SUMMARY Liver transplant outcomes are poorer in HIV/HCV-coinfected recipients compared with those with HCV-monoinfection. The new HCV DAAs offer tremendous potential to improve outcomes in this challenging population.
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Monaghan KG, Gonzalez HC, Levin AM, Abouljoud MS, Gordon SC. Post-transplant course of hepatitis C after living donor liver transplantation in association with polymorphisms near IFNL3. J Interferon Cytokine Res 2015; 35:313-6. [PMID: 25343304 DOI: 10.1089/jir.2014.0111] [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: 11/12/2022] Open
Abstract
Donor genotype for polymorphisms near IFNL3 influences hepatitis C virus (HCV) therapy responsiveness. This relationship has not been studied in a sample of HCV-infected living donor liver transplantation (LDLT) recipients in the United States (US). We investigated the association of donor and recipient genotypes near the IFNL3 gene at a large US liver transplant center. Recipient homozygosity for rs12979860 C was associated with increased sustained virologic response (SVR) in antiviral treatment-experienced patients pretransplant (P = 0.055). Consistently, donor homozygosity for rs12979860 C was also associated with increased SVR in patients who received post-transplant antiviral therapy (P = 0.048). Transplantation of an rs12979860 CC graft confers a favorable post-transplant antiviral response among HCV-positive recipients in an LDLT setting. Recipients with the favorable rs12979860 genotype receiving antiviral therapy before transplant are also more likely to achieve SVR. The effect of genotype status in the era of direct-acting antiviral agents will require future study.
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Jiménez-Pérez M, González-Grande R, Rando-Muñoz FJ. Management of recurrent hepatitis C virus after liver transplantation. World J Gastroenterol 2014; 20:16409-16417. [PMID: 25469009 PMCID: PMC4248184 DOI: 10.3748/wjg.v20.i44.16409] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 08/27/2014] [Accepted: 10/15/2014] [Indexed: 02/06/2023] Open
Abstract
Chronic hepatitis C virus (HCV) infection is the leading cause of death from liver disease and the leading indication for liver transplantation (LT) in the United States and Western Europe. LT represents the best therapeutic alternative for patients with advanced chronic liver disease caused by HCV or those who develop hepatocarcinoma. Reinfection by HCV of the graft is universal and occurs in 95% of transplant patients. This reinfection can compromise graft function and patient survival. In a few cases, the histological recurrence is minimal and non-progressive; however, in most patients it follows a more rapid course than in immunocompetent persons, and frequently evolves into cirrhosis with graft loss. In fact, the five-year and ten-year survival of patients transplanted because of HCV are 75% and 68%, respectively, compared with 85% and 78% in patients transplanted for other reasons. There is also a pattern of recurrence that is very severe, but rare (< 10%), called fibrosing cholestatic hepatitis, which often involves rapid graft loss. Patients who present a negative HCV viremia after antiviral treatment have better survival. Many studies published over recent years have shown that antiviral treatment of post-transplant HCV hepatitis carried out during the late phase is the best option for improving the prognosis of these patients. Until 2011, PEGylated interferon plus ribavirin was the standard of care, resulting in a sustained virological response in around 30% of recipients. The addition of protease inhibitors, such as boceprevir or telaprevir, to the standard of care, or the use of other direct-acting antiviral drugs may involve therapeutic changes in the context of HCV recurrence. This may result a better prognosis for these patients, particularly those with severe recurrence or factors predicting rapid progression of fibrosis. However, the use of these agents in LT still requires clarification in terms of safety and efficacy.
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MESH Headings
- Antiviral Agents/adverse effects
- Antiviral Agents/therapeutic use
- Carcinoma, Hepatocellular/diagnosis
- Carcinoma, Hepatocellular/mortality
- Carcinoma, Hepatocellular/surgery
- Carcinoma, Hepatocellular/virology
- Drug Therapy, Combination
- End Stage Liver Disease/diagnosis
- End Stage Liver Disease/mortality
- End Stage Liver Disease/surgery
- End Stage Liver Disease/virology
- Hepatitis C, Chronic/complications
- Hepatitis C, Chronic/diagnosis
- Hepatitis C, Chronic/drug therapy
- Hepatitis C, Chronic/immunology
- Hepatitis C, Chronic/mortality
- Humans
- Immunocompromised Host
- Immunosuppressive Agents/adverse effects
- Liver Neoplasms/diagnosis
- Liver Neoplasms/mortality
- Liver Neoplasms/surgery
- Liver Neoplasms/virology
- Liver Transplantation/adverse effects
- Liver Transplantation/mortality
- Recurrence
- Risk Factors
- Time Factors
- Treatment Outcome
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6
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Choi Y, Lee KW. The Management of HCV Recurrence after Liver Transplantation. KOREAN JOURNAL OF TRANSPLANTATION 2013. [DOI: 10.4285/jkstn.2013.27.2.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- YoungRok Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Utilizing genomic polymorphisms to personalize hepatitis C therapies. Curr Opin Organ Transplant 2013; 17:198-203. [PMID: 22414802 DOI: 10.1097/mot.0b013e328351093b] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW The need for liver transplant due to the progression of hepatitis C virus (HCV) infection necessitates the consideration of antiviral treatment. Host genomic variations affect response to HCV treatment and predict the rates of adverse effects. Recently, multiple genomic polymorphisms were found to be critical in predicting treatment response as well as the rate of neuropsychiatric adverse effects in patients infected with HCV who are receiving antiviral treatments. RECENT FINDINGS The use of antiviral treatments (pegylated IFN-alpha and ribavirin) to clear HCV infection is associated with poor response in HCV genotype 1 and with the development of depression. Polymorphisms in the promoter region of the IFN-alpha/beta receptor 1 (IFNAR1) can influence the risk of developing depression. Similar polymorphisms in the IL28B gene encoding for IFN-λ-3 are associated with a two- to three-fold improvement in response to treatment. SUMMARY In patients with HCV infection receiving antiviral treatments, genomic variations in two genes can help predict the increased risk of developing depression and the likelihood of achieving virus clearance. This can identify patients who are at an increased likelihood of virus clearance and who should be targeted to receive prophylactic approaches (antidepressants, psychotropics) to prevent the development of depression during HCV antiviral treatment.
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Ordin YS, Karayurt Ö, Wellard S. Investigation of adaptation after liver transplantation using Roy's Adaptation Model. Nurs Health Sci 2012; 15:31-8. [DOI: 10.1111/j.1442-2018.2012.00715.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 05/10/2012] [Accepted: 05/16/2012] [Indexed: 12/23/2022]
Affiliation(s)
- Yaprak S. Ordin
- Department of Surgical Nursing; Dokuz Eylul University; Izmir; Turkey
| | - Özgül Karayurt
- Department of Surgical Nursing; Dokuz Eylul University; Izmir; Turkey
| | - Sally Wellard
- School of Health Sciences; University of Ballarat; Ballarat; Victoria; Australia
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Predictive Factors of Sustained Virological Response for Recurrent Hepatitis C Virus After Liver Transplantation: The Hungarian Experience. Transplant Proc 2012; 44:2162-3. [DOI: 10.1016/j.transproceed.2012.07.099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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10
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Terrault NA, Roland ME, Schiano T, Dove L, Wong MT, Poordad F, Ragni MV, Barin B, Simon D, Olthoff KM, Johnson L, Stosor V, Jayaweera D, Fung J, Sherman KE, Subramanian A, Millis JM, Slakey D, Berg CL, Carlson L, Ferrell L, Stablein DM, Odim J, Fox L, Stock PG. Outcomes of liver transplant recipients with hepatitis C and human immunodeficiency virus coinfection. Liver Transpl 2012; 18:716-26. [PMID: 22328294 PMCID: PMC3358510 DOI: 10.1002/lt.23411] [Citation(s) in RCA: 161] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Hepatitis C virus (HCV) is a controversial indication for liver transplantation (LT) in human immunodeficiency virus (HIV)-infected patients because of reportedly poor outcomes. This prospective, multicenter US cohort study compared patient and graft survival for 89 HCV/HIV-coinfected patients and 2 control groups: 235 HCV-monoinfected LT controls and all US transplant recipients who were 65 years old or older. The 3-year patient and graft survival rates were 60% [95% confidence interval (CI) = 47%-71%] and 53% (95% CI = 40%-64%) for the HCV/HIV patients and 79% (95% CI = 72%-84%) and 74% (95% CI = 66%-79%) for the HCV-infected recipients (P < 0.001 for both), and HIV infection was the only factor significantly associated with reduced patient and graft survival. Among the HCV/HIV patients, older donor age [hazard ratio (HR) = 1.3 per decade], combined kidney-liver transplantation (HR = 3.8), an anti-HCV-positive donor (HR = 2.5), and a body mass index < 21 kg/m(2) (HR = 3.2) were independent predictors of graft loss. For the patients without the last 3 factors, the patient and graft survival rates were similar to those for US LT recipients. The 3-year incidence of treated acute rejection was 1.6-fold higher for the HCV/HIV patients versus the HCV patients (39% versus 24%, log rank P = 0.02), but the cumulative rates of severe HCV disease at 3 years were not significantly different (29% versus 23%, P = 0.21). In conclusion, patient and graft survival rates are lower for HCV/HIV-coinfected LT patients versus HCV-monoinfected LT patients. Importantly, the rates of treated acute rejection (but not the rates of HCV disease severity) are significantly higher for HCV/HIV-coinfected recipients versus HCV-infected recipients. Our results indicate that HCV per se is not a contraindication to LT in HIV patients, but recipient and donor selection and the management of acute rejection strongly influence outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Laurie Carlson
- University of California San Francisco, San Francisco, CA
| | - Linda Ferrell
- University of California San Francisco, San Francisco, CA
| | | | - Jonah Odim
- National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | - Lawrence Fox
- National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | - Peter G. Stock
- University of California San Francisco, San Francisco, CA
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11
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A score predicting survival after liver retransplantation for hepatitis C virus cirrhosis. Transplantation 2012; 93:717-22. [PMID: 22267157 DOI: 10.1097/tp.0b013e318246f8b3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Approximately one fourth of patients transplanted for hepatitis C virus (HCV)-induced liver failure progress to cirrhosis within 5 years, potentially requiring retransplantation. Although the relisting decision can be difficult in these patients, a score could help in selection of candidates with the best potential outcomes. METHODS A total of 1422 HCV-positive patients having undergone a retransplantation were included in this registry-based study. A multivariate Cox regression was performed, and an Akaike procedure was applied to design a score predicting survival after retransplantation and to allow an internal validation. Retained variables were donor age (DnAge), serum creatinine (Creat), International Normalized Ratio (INR), and serum albumin (Alb) at the second transplantation, recipient age (RecAge) at the first transplantation, and the interval between both transplantations (Int). RESULTS The score was designed as 0.23×DnAge+4.86×log Creat-2.45×log Int+2.69×INR+0.10×RecAge-3.27× Alb+40. The receiver operating characteristic area under curve was 0.643 at 3 years, and survivals were 71%, 56%, and 37% for scores <30, 30 to 40, and >40, respectively (log rank <0.0001). CONCLUSIONS Overall, the proposed score is specifically designed for HCV-positive patients, accurately predicts survival after a liver retransplantation, and is helpful in the selection of candidates with the best potential outcomes.
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12
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Sugden PB, Cameron B, Bull R, White PA, Lloyd AR. Occult infection with hepatitis C virus: friend or foe? Immunol Cell Biol 2012; 90:763-73. [PMID: 22546735 DOI: 10.1038/icb.2012.20] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hepatitis C virus (HCV) infection is a global pandemic associated with a growing disease burden due to cirrhosis and the consequent morbidity and mortality. Transmission is largely via blood-to-blood contact. Following primary infection, a minority of individuals clear the infection predominantly via cellular immune mechanisms, whereas the majority become chronically infected. Recent data suggest that a third outcome may also be possible, termed 'occult' infection in which subjects who are known, or suspected to have previously been infected with HCV, no longer have viral RNA in their serum at levels detectable by sensitive commercial assays, but do have virus detected by ultra-sensitive techniques. Occult infection has also been detected in peripheral blood mononuclear cells, which may indicate an extra-hepatic reservoir of the virus. Although the clinical significance of occult infection remains unknown, most authors have raised concerns of recrudescent infection. Here we critically review the published literature, suggest further avenues of investigation and propose that occult infection may be beneficial to the host by maintaining immunological memory to protect against reinfection.
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Affiliation(s)
- Peter B Sugden
- Inflammation and Infection Research Centre, School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
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Barritt AS, Darling JM, Hayashi PH. New and Evolving Management Paradigms for Hepatitis C after Liver Transplantation. CURRENT HEPATITIS REPORTS 2011; 10:179-185. [PMID: 22448143 PMCID: PMC3308145 DOI: 10.1007/s11901-011-0103-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Hepatitis-C induced liver failure is the leading indication for liver transplantation in the United States, and the burden of hepatitis C virus (HCV)-induced liver disease is not expected to peak for at least another decade. 2011 will usher in a new era of directly acting antiviral therapies and personalized medicine that will assist patients and clinicians in choosing the best drug regimen. Specific markers to predict sustained virologic response (SVR) in the posttransplant setting are under development, and the role of graft genetic markers like interleukin-28B and interferon-γ inducible protein-10 have yet to be fully defined. Lessons and experiences from treating the pretransplant population will be applied to patients with recurrent posttransplant HCV while studies specific to this population proceed. New paradigms for HCV treatment give promise to reducing the pretransplant burden of disease and improving SVR rates in the posttransplant population.
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Affiliation(s)
- A. Sidney Barritt
- Division of Gastroenterology and Hepatology, The University of North Carolina at Chapel Hill, 8004 Burnett Womack, CB #7568, Chapel Hill, NC 27599-7568, USA
| | - Jama M. Darling
- Division of Gastroenterology and Hepatology, The University of North Carolina at Chapel Hill, 8014 Burnett Womack, CB #7568, Chapel Hill, NC 27599-7568, USA
| | - Paul H. Hayashi
- Division of Gastroenterology and Hepatology, The University of North Carolina at Chapel Hill, 8011 Burnett Womack, CB #7568, Chapel Hill, NC 27599-7568, USA
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Nakamoto S, Kanda T, Imazeki F, Wu S, Arai M, Fujiwara K, Yokosuka O. Simple assay based on restriction fragment length polymorphism associated with IL28B in chronic hepatitis C patients. Scand J Gastroenterol 2011; 46:955-61. [PMID: 21529139 DOI: 10.3109/00365521.2011.574731] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Several studies recently revealed that single nucleotide polymorphisms (SNPs) in the interleukin28B (IL28B) region are associated with the response to pegylated interferon-alfa (PEG-IFN-alfa) and ribavirin (RBV) treatment among hepatitis C virus (HCV)-infected individuals of European, African and Asian ancestry. The purpose of the study was to establish methods for determining the SNP rs8099917 associated with IL28B, which might be useful for further research of the treatment of HCV. MATERIAL AND METHODS Blood samples obtained from 93 consecutive patients with chronic hepatitis C were examined. On the basis of the sequence data, a new simple genotyping assay based on a PCR-restriction fragment length polymorphism (RFLP) with two enzymes, BsrDI and Tsp45I, was developed. RESULTS The proportion of null virological responders in the combined TG/GG group was higher than that in the TT group (p = 0.015), suggesting that minor allele is one of the important factors playing crucial roles in IFN-resistance. Genotyping of rs8099917 by our new method showed results identical to PCR and sequence in 98.9% and 98.9% by BsrDI and Tsp45I, respectively. Using two enzymes, BsrDI and Tsp45I, it was possible to distinguish IL28B SNP rs8099917. CONCLUSION This simple method using RFLP will provide the framework for further studies of HCV.
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Affiliation(s)
- Shingo Nakamoto
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Inohana, Chuo-ku, Chiba, Japan
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