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Országhová Z, Kalavska K, Mego M, Chovanec M. Overcoming Chemotherapy Resistance in Germ Cell Tumors. Biomedicines 2022; 10:biomedicines10050972. [PMID: 35625709 PMCID: PMC9139090 DOI: 10.3390/biomedicines10050972] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/20/2022] [Accepted: 04/20/2022] [Indexed: 12/03/2022] Open
Abstract
Testicular germ cell tumors (GCTs) are highly curable malignancies. Excellent survival rates in patients with metastatic disease can be attributed to the exceptional sensitivity of GCTs to cisplatin-based chemotherapy. This hypersensitivity is probably related to alterations in the DNA repair of cisplatin-induced DNA damage, and an excessive apoptotic response. However, chemotherapy fails due to the development of cisplatin resistance in a proportion of patients. The molecular basis of this resistance appears to be multifactorial. Tracking the mechanisms of cisplatin resistance in GCTs, multiple molecules have been identified as potential therapeutic targets. A variety of therapeutic agents have been evaluated in preclinical and clinical studies. These include different chemotherapeutics, targeted therapies, such as tyrosine kinase inhibitors, mTOR inhibitors, PARP inhibitors, CDK inhibitors, and anti-CD30 therapy, as well as immune-checkpoint inhibitors, epigenetic therapy, and others. These therapeutics have been used as single agents or in combination with cisplatin. Some of them have shown promising in vitro activity in overcoming cisplatin resistance, but have not been effective in clinical trials in refractory GCT patients. This review provides a summary of current knowledge about the molecular mechanisms of cisplatin sensitivity and resistance in GCTs and outlines possible therapeutic approaches that seek to overcome this chemoresistance.
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Affiliation(s)
- Zuzana Országhová
- 2nd Department of Oncology, Faculty of Medicine, Comenius University and National Cancer Institute, 833 10 Bratislava, Slovakia; (Z.O.); (M.M.)
| | - Katarina Kalavska
- Translational Research Unit, Faculty of Medicine, Comenius University and National Cancer Institute, 833 10 Bratislava, Slovakia;
- Department of Molecular Oncology, Cancer Research Institute, Biomedical Research Center, Slovak Academy Sciences, 845 05 Bratislava, Slovakia
| | - Michal Mego
- 2nd Department of Oncology, Faculty of Medicine, Comenius University and National Cancer Institute, 833 10 Bratislava, Slovakia; (Z.O.); (M.M.)
- Translational Research Unit, Faculty of Medicine, Comenius University and National Cancer Institute, 833 10 Bratislava, Slovakia;
| | - Michal Chovanec
- 2nd Department of Oncology, Faculty of Medicine, Comenius University and National Cancer Institute, 833 10 Bratislava, Slovakia; (Z.O.); (M.M.)
- Correspondence:
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Shiraishi T, Nakamura T, Takamura T, Oishi M, Yamada T, Yamada Y, Ueda T, Fujihara A, Hongo F, Okihara K, Ukimura O. Less nephrotoxicity of paclitaxel and ifosfamide plus nedaplatin for refractory or relapsed germ cell tumors in patients with impaired renal function. Int J Urol 2019; 27:134-139. [PMID: 31701563 DOI: 10.1111/iju.14147] [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: 05/19/2019] [Accepted: 10/06/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the safety and efficacy of the combined regimen of paclitaxel and ifosfamide plus nedaplatin for patients with refractory or relapsed germ cell tumors and impaired renal function. METHODS Of a total of 68 patients who received paclitaxel, ifosfamide and nedaplatin chemotherapy for germ cell tumors, those with an estimated glomerular filtration rate <60 mL/min/1.73 m2 before paclitaxel, ifosfamide and nedaplatin treatment were defined as having renal dysfunction. The combination chemotherapy regimen included paclitaxel (210 mg/m2 on day 1) and ifosfamide (1.2 g/m2 on days 2-6) with nedaplatin (100 mg/m2 on day 2) on a 3-week cycle. RESULTS A total of 10 patients had renal dysfunction with a median estimated glomerular filtration rate of 49.97 mg/mL/1.73 m2 (range 31.7-57.5 mg/mL/1.73 m2 ). Paclitaxel, ifosfamide and nedaplatin chemotherapy was given as second-line therapy in four patients, third-line in four and fourth-line or later in two. Patients with impaired renal function received pretreatment of a median of 5.5 cycles of platinum-based chemotherapy (range 3-11 cycles) with a median cisplatin dose of 550 mg/m2 . The patients were given two to six cycles of paclitaxel, ifosfamide and nedaplatin chemotherapy with no dose reduction, with an overall response rate of 60%. Chemotherapy-induced kidney dysfunction was not observed in any patient with decreased renal function. Furthermore, there was no difference in the frequency of adverse events between patients with renal dysfunction (estimated glomerular filtration rate <60 mL/min/1.73 m2 ) and those with normal renal function (estimated glomerular filtration rate ≥60 mL/min/1.73 m2 ). CONCLUSIONS Paclitaxel, ifosfamide and nedaplatin chemotherapy can be considered a safe and effective regimen that results in less nephrotoxicity in germ cell tumor patients with renal dysfunction.
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Affiliation(s)
- Takumi Shiraishi
- Department of Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Terukazu Nakamura
- Department of Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Urology, Saiseikai Imperial Gift Foundation, Saiseikai Suita Hospital, Osaka, Japan
| | - Toshiya Takamura
- Department of Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masakatsu Oishi
- Department of Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takeshi Yamada
- Department of Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasuhiro Yamada
- Department of Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takashi Ueda
- Department of Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Atsuko Fujihara
- Department of Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fumiya Hongo
- Department of Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Koji Okihara
- Department of Urology, North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Osamu Ukimura
- Department of Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Metastatic testicular cancer presenting with liver and kidney dysfunction treated with modified BEP chemotherapy combined with continuous hemodiafiltration and rasburicase. Anticancer Drugs 2016; 27:364-8. [PMID: 26736135 PMCID: PMC4777219 DOI: 10.1097/cad.0000000000000334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A 25-year-old man was admitted to our hospital complaining of right scrotal pain and upper abdominal pain. A computed tomographic scan indicated a right scrotal mass, a huge liver mass, and multiple lung masses, although there was no enlarged retroperitoneal lymph node swelling. Laboratory tests showed severe liver and kidney dysfunction and high levels of serum α-fetoprotein (11 997 ng/ml). Although needle biopsies of the testicular and liver masses were performed, the tissues were insufficient for a pathological diagnosis. As liver and kidney function worsened, we started chemotherapy with bleomycin, etoposide, and cisplatin (BEP chemotherapy), which was modified because of the liver and renal dysfunction. We also used continuous hemodiafiltration and rasburicase to prevent tumor lysis syndrome. After induction of chemotherapy, the liver and kidney dysfunction improved immediately and the high orchiectomy was performed on day 8 after chemotherapy. The pathological diagnosis was a yolk sac tumor. He underwent four courses of the BEP regimen and five courses of the TIN regimen (paclitaxel, ifosphamide, and nedaplatin), followed by the resection of liver metastases. There was no evidence of viable cells in the resected liver and no recurrence was evident at 1 year postoperatively.
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Nakamura T, Ueda T, Oishi M, Nakanishi H, Shiraishi T, Fujihara A, Naito Y, Kamoi K, Naya Y, Hongo F, Okihara K, Miki T. Importance of continuous sequential chemotherapy and multimodal treatment for advanced testicular cancer: a high-volume Japanese center experience. Medicine (Baltimore) 2015; 94:e653. [PMID: 25789960 PMCID: PMC4602480 DOI: 10.1097/md.0000000000000653] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients with "difficult-to-treat" advanced testicular cancer can require multiple therapies. We retrospectively assessed our patients with advanced germ cell tumors (GCTs) and characterized the clinical efficacy, outcomes, and factors affecting overall survival (OS).Two hundred fifty-three patients with advanced GCTs were treated at Kyoto Prefectural University of Medicine, Kyoto, Japan, from June 1998 to September 2013. Of 253 patients, 142 patients had salvage chemotherapy.As first-line therapy, bleomycin, etoposide, and cisplatin, and etoposide and cisplatin therapies were performed in 234 cases (92.5%). As second-line therapy, etoposide, ifosfamide, and cisplatin/vinblastine, ifosfamide, and cisplatin, and paclitaxel, ifosfamide, and cisplatin/paclitaxel, ifosfamide, and nedaplatin therapies were carried out in 44 and 59 cases, respectively. Furthermore, 111, 72, 44, and 28 cases had third, fourth, fifth, and sixth-or-later-line chemotherapy, respectively. Five-year OS rate stratified by chemotherapy line was 95.5% in the first line, 89.4% in the second line, 82.1% in the third line, 45.1% in the fourth line, and 58.9% in the fifth or after line. A statistical significant difference was found when comparing fourth-or-after-line versus first to third-line therapy. Additional procedures were performed, including retroperitoneal lymph node dissection (RPLND) (n = 168), extra-RPLN resection (n= 114), and external beam radiotherapy/stereotactic radiotherapy (n = 78).Multivariate analysis showed that factors predicting better outcomes were in serum tumor marker (STM) normalization, RPLND, and extra-RPLN resection.Good outcomes were obtained in patients who completed chemotherapy up to third line. After fourth-line chemotherapy, approximately 50% of "difficult-to-treat" patients could be cured with normalization of STM levels and residual mass resection. Continuous or sequential chemotherapy with multimodality therapy is important for patients with "difficult-to-treat" advanced GCTs. Effective chemotherapy after third line should be developed.
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Affiliation(s)
- Terukazu Nakamura
- From the Department of Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Nakamura T, Ueda T, Oishi M, Nakanishi H, Fujihara A, Naya Y, Hongo F, Kamoi K, Okihara K, Miki T. Salvage combined chemotherapy with paclitaxel, ifosfamide and nedaplatin for patients with advanced germ cell tumors. Int J Urol 2014; 22:288-93. [PMID: 25393104 DOI: 10.1111/iju.12665] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 10/01/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate the efficacy of combined regimen with paclitaxel, ifosfamide and nedaplatin as salvage chemotherapy in patients with cisplatin-refractory or multiple relapsed germ cell tumors. METHODS A total of 65 patients refractory to cisplatin-based chemotherapy or with relapse after induction or salvage chemotherapy received paclitaxel 210 mg/m(2) on day 1, ifosfamide 1.2 g/m(2) on days 2-6 and nedaplatin 100 mg/m(2) on day 2 of a 3-week cycle. The primary and secondary end-points were the response rate and overall survival, respectively. RESULTS Paclitaxel, ifosfamide and nedaplatin therapy was carried out as second-line therapy in 17 patients, third-line in 31 and fourth-line or later in 17. Patients were pretreated with a median of six cycles of platinum-based chemotherapy (range 3-15 cycles). The overall response rate was 62.9%, including one patient with complete response and 38 with partial response. Serum tumor marker levels normalized in 35 (56.5%) patients. Overall survival at a median follow up of 34 months was 59.3%, and median time to progression was 12 months. Multivariate analysis showed that serum tumor marker normalization was the only independent predictor of better progression-free survival and overall survival. Grade 3/4 of neutropenia, anemia and thrombocytopenia was observed in 96.9%, in 81.5%, and in 90.8% of patients, respectively. CONCLUSION Paclitaxel, ifosfamide and nedaplatin chemotherapy appears to be effective when used as first or second salvage treatment in advanced relapsed germ cell tumors. Even after fourth-line therapy, patients with serum tumor marker normalization might have a chance for a cure.
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Affiliation(s)
- Terukazu Nakamura
- Department of Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Current chemotherapeutic approaches for recurrent or refractory germ cell tumors. Urol Oncol 2014; 33:343-54. [PMID: 25308563 DOI: 10.1016/j.urolonc.2014.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 08/18/2014] [Accepted: 09/07/2014] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Up to 25% of patients with metastatic testicular germ cell tumour (GCT) are not cured by first line therapy and require treatment for refractory or relapsed disease. METHODS A literature search was conducted through PubMed, Medline, Cochrane and EMBASE from January 1950 to April 2014 for articles relating to trials of chemotherapy for patients with relapsed or refractory germ cell tumours. Relevant review papers and conference proceedings were hand searched for additional references. RESULTS A range of conventional dose chemotherapy (CDCT) regimens can provide durable remissions in 20-30% of patients at first or subsequent salvage. CONCLUSIONS This article reviews the evidence underlying commonly used salvage CDCT based on ifosfamide and cisplatin such as TIP, VIP and VeIP; other active combinations; and single agent salvage regimens. The treatment of growing teratoma syndrome and malignant transformation of teratoma will also be discussed. Companion articles will explore the role of high dose chemotherapy (HDCT) and novel targeted agents.
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Murakami Y, Tabata KI, Sugita A, Mochizuki K, Maeyama R, Okazaki M, Nishi M, Matsumoto K, Fujita T, Satoh T, Jiang SX, Saegusa M, Iwamura M. Multidisciplinary treatment including systemic chemotherapy for a malignant phyllodes tumour of the prostate. Can Urol Assoc J 2014; 8:E263-5. [PMID: 24839496 DOI: 10.5489/cuaj.1648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A 22-year-old man was referred to our hospital with macroscopic hematuria and consistent anal pain. Magnetic resonance imaging revealed an enlarged prostate tumour invading the bladder and rectum. A biopsy revealed an unclassified spindle cell sarcoma. Subsequently, radical cystoprostatectomy and resection of the rectum were performed. A histopathological examination revealed a prostatic malignant phyllodes tumour with a negative surgical margin. However, a local recurrence was identified 2 months after surgery. Induction therapy included 4 cycles of systemic chemotherapy comprising etoposide with ifosfamide and cisplatin. Although a partial response was observed at the local site, lung metastasis developed. Second-line chemotherapy with ifosfamide and doxorubicin with radiotherapy to the pelvis was administered and led to complete regression; however, its efficacy was transient. Although additional chemotherapy was administered, the patient eventually died due to the rapidly growing, recurrent tumour.
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Affiliation(s)
- Yasukiyo Murakami
- Department of Urology, Kitasato University School of Medicine, Japan
| | - Ken-Ichi Tabata
- Department of Urology, Kitasato University School of Medicine, Japan
| | - Atsushi Sugita
- Department of Urology, Kitasato University School of Medicine, Japan
| | - Kohei Mochizuki
- Department of Urology, Kitasato University School of Medicine, Japan
| | - Ryota Maeyama
- Department of Urology, Kitasato University School of Medicine, Japan
| | - Miyoko Okazaki
- Department of Pharmacology, Kitasato University School of Medicine, Japan
| | - Morihiro Nishi
- Department of Urology, Kitasato University School of Medicine, Japan
| | | | - Tetsuo Fujita
- Department of Urology, Kitasato University School of Medicine, Japan
| | - Takefumi Satoh
- Department of Urology, Kitasato University School of Medicine, Japan
| | - Shi-Xu Jiang
- Department of Pathology, Kitasato University School of Medicine, Japan
| | - Makoto Saegusa
- Department of Pathology, Kitasato University School of Medicine, Japan
| | - Masatsugu Iwamura
- Department of Urology, Kitasato University School of Medicine, Japan
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Salvage Chemotherapy with Docetaxel, Ifosfamide and Nedaplatin (DIN) for Patients with Advanced Germ Cell Tumors: A Preliminary Report. Jpn J Clin Oncol 2013; 43:734-9. [DOI: 10.1093/jjco/hyt060] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kawai K, Akaza H. Current status of chemotherapy in risk-adapted management for metastatic testicular germ cell cancer. Cancer Sci 2010; 101:22-8. [PMID: 19922501 PMCID: PMC11159163 DOI: 10.1111/j.1349-7006.2009.01373.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Today, approximately 80% of men with metastatic testicular cancer can be cured with chemotherapy combined with the appropriate surgery. The improved treatment outcome has led to the stratification of patients with metastatic disease by the consensus prognostic index; the International Germ Cell Cancer Consensus Group classification. Currently, the first-line chemotherapy with bleomycin, etoposide, and cisplatin (BEP) remains the standard management of metastatic testicular cancer. Three cycles of BEP for good-prognosis patients and four cycles of BEP for intermediate- and poor-prognosis patients are the standard first-line chemotherapy. To achieve the optimal outcome, BEP should be given with appropriate supportive care and risk assessment for toxicity. Although no universal prognostic criteria have been defined for the recurrent or refractory disease, the risk-adapted approach may clarify the role of ifosfamide- and paclitaxel-containing conventional-dose chemotherapy or high-dose chemotherapy in the second-line setting. Several investigators reported recent improvement of treatment outcome of testicular cancer patients, especially those with poor prognosis. Along with the progress in chemotherapy, the risk-adapted management at experienced hospitals seems to be responsible for the recent progress in treatment outcome.
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Affiliation(s)
- Koji Kawai
- Department of Urology, Institute of Clinical Medicine, University of Tsukuba Graduate School of Comprehensive Human Sciences, Tsukuba, Ibaraki, Japan.
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Shiraishi T, Nakamura T, Mikami K, Takaha N, Kawauchi A, Miki T. Salvage chemotherapy with paclitaxel and gemcitabine plus nedaplatin (TGN) as part of multidisciplinary therapy in patients with heavily pretreated cisplatin-refractory germ cell tumors. Int J Clin Oncol 2009; 14:436-41. [DOI: 10.1007/s10147-009-0899-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Accepted: 03/31/2009] [Indexed: 02/07/2023]
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Tanaka T, Kitamura H, Takahashi A, Masumori N, Tsukamoto T. Long-term outcome of chemotherapy for advanced testicular and extragonadal germ cell tumors: a single-center 27-year experience. Jpn J Clin Oncol 2009; 40:73-8. [PMID: 19773268 DOI: 10.1093/jjco/hyp121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE We retrospectively assessed long-term outcomes of chemotherapy for advanced germ cell tumors (GCTs) at our institution. METHODS Ninety-five consecutive males with advanced GCTs of the testis or extragonadal origin who received chemotherapy between 1980 and 2006 were enrolled. All patients underwent induction chemotherapy including cisplatin. RESULTS The median follow-up period was 36.1 months (0 - 288.5) for all patients and 52.6 months (2.2 - 288.5) for the 73 current survivors. Totally, 75 patients (78.9%) achieved complete remission (CR). CR was achieved in 61.1%, 37.9% and 75.0% of the patients after induction therapy, second-line therapy and third-line or more, respectively. As salvage therapy, high-dose chemotherapy was performed in 11 patients (11.7%) and regimens with novel anticancer agents such as paclitaxel and irinotecan were employed for 8 patients (8.5%) from 2003 and later. The era of the treatment, extrapulmonary metastasis and serum alpha-fetoprotein were independent prognostic factors for patients. The 5-year overall survival of patients after 1992 was 83.0%, which was significantly higher than that of those before 1992 (56.3%). CR was never achieved in 20 patients and most of them met the criteria of the poor-prognosis group. Disease recurrence after CR was found in nine patients who were initially classified into the good- or intermediate-prognosis group. CONCLUSIONS Improvement of medical management during chemotherapy and the development of several regimens for salvage chemotherapy seemed to contribute to improving outcomes of patients with advanced testicular cancer. Newly established chemotherapy regimens are needed for improvement of survival of patients in the poor-prognosis group.
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Affiliation(s)
- Toshiaki Tanaka
- Department of Urology, Sapporo Medical University, S-1, W-16, Chuo-ku, Sapporo, Hokkaido 060-8543, Japan.
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Kinebuchi Y, Ishikawa M, Ishizuka O, Nishizawa O, Hongo K. Leptomeningeal metastases in a patient with an extragonadal germ cell tumor. Clin Med Oncol 2008; 2:371-4. [PMID: 21892301 PMCID: PMC3161680 DOI: 10.4137/cmo.s687] [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] [Indexed: 12/02/2022] Open
Abstract
We present a case of leptomeningeal metastases in a 30-year-old man with an extragonadal germ cell tumor. The patient was referred to our hospital for treatment of an occipital brain metastasis. This lesion was resected, followed by whole brain radiotherapy and further chemotherapy, and a temporary complete remission was achieved. However, leptomeningeal recurrence developed, and despite salvage chemotherapy, the patient died of disease. Although multidisciplinary treatment is given to treat brain metastases of germ cell tumors, the patients’ prognosis has been unsatisfactory. The identification of a standard/effective treatment is required.
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Affiliation(s)
- Yoshiaki Kinebuchi
- Department of Urology, Shinshu University School of Medicine, Matsumoto, Japan
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