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Donner DB, Nakakura EK, Venook AP, Lenz HJ, Zhang W, Hwang J, Bergsland EK, Lin MH, Toriguchi K, Antonia RJ, Warren RS. High thymidylate synthase gene expression predicts poor outcome after resection of hepatocellular carcinoma. PLoS One 2019; 14:e0219469. [PMID: 31291332 PMCID: PMC6620013 DOI: 10.1371/journal.pone.0219469] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 06/24/2019] [Indexed: 12/16/2022] Open
Abstract
Introduction Prognosis after resection of hepatocellular carcinoma (HCC) is highly variable. Compared to clinicopathologic factors, the use of molecular markers to predict outcome has not been well studied. We investigated the prognostic importance of thymidylate synthase (TS) gene expression and polymorphisms in patients after resection of HCC. Methods Patients who underwent complete resection of HCC for whom tissue was available were identified. TS gene expression level and polymorphisms were determined in HCC specimens. Prognostic factors were evaluated using Kaplan-Meier curves and Cox proportional hazard models. Results The study included 67 patients. In univariate analysis, variables that negatively influenced survival included TNM stage, microvascular invasion, and high TS expression. For the high TS expression group, median survival was 54 months and 5-year actuarial survival was 47%. For the low TS expression group, median survival was not reached and the 5-year actuarial survival was 91%. In multivariate analysis, only high TS expression remained an independent predictor of poor survival (HR = 10.77, 95% CI 1.36–84.91; P = 0.02). TS gene polymorphisms were not associated with TS expression or overall survival. Conclusions High TS expression predicts poor outcome after resection of HCC. Molecular markers might be robust predictors of patient outcome after resection of HCC.
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Affiliation(s)
- David B. Donner
- Department of Surgery, The University of California San Francisco, San Francisco, California, United States of America
- The Helen Diller Family Comprehensive Cancer Center, The University of California San Francisco, San Francisco, California, United States of America
- * E-mail: (DD); (EN)
| | - Eric K. Nakakura
- Department of Surgery, The University of California San Francisco, San Francisco, California, United States of America
- The Helen Diller Family Comprehensive Cancer Center, The University of California San Francisco, San Francisco, California, United States of America
- * E-mail: (DD); (EN)
| | - Alan P. Venook
- The Helen Diller Family Comprehensive Cancer Center, The University of California San Francisco, San Francisco, California, United States of America
- Department of Medicine, The University of California San Francisco, San Francisco, California, United States of America
| | - Heinz-Josef Lenz
- Department of Preventive Medicine, University of Southern California/Norris Comprehensive Cancer Center, Los Angeles, California, United States of America
| | - Wu Zhang
- Department of Preventive Medicine, University of Southern California/Norris Comprehensive Cancer Center, Los Angeles, California, United States of America
| | - Jimee Hwang
- The Helen Diller Family Comprehensive Cancer Center, The University of California San Francisco, San Francisco, California, United States of America
- Biostatistics Core Facility, The University of California San Francisco, San Francisco, California, United States of America
| | - Emily K. Bergsland
- The Helen Diller Family Comprehensive Cancer Center, The University of California San Francisco, San Francisco, California, United States of America
- Department of Medicine, The University of California San Francisco, San Francisco, California, United States of America
| | - Meng Hsun Lin
- Department of Surgery, The University of California San Francisco, San Francisco, California, United States of America
- The Helen Diller Family Comprehensive Cancer Center, The University of California San Francisco, San Francisco, California, United States of America
| | - Kan Toriguchi
- Department of Surgery, The University of California San Francisco, San Francisco, California, United States of America
- The Helen Diller Family Comprehensive Cancer Center, The University of California San Francisco, San Francisco, California, United States of America
| | - Ricardo J. Antonia
- Department of Surgery, The University of California San Francisco, San Francisco, California, United States of America
- The Helen Diller Family Comprehensive Cancer Center, The University of California San Francisco, San Francisco, California, United States of America
| | - Robert S. Warren
- Department of Surgery, The University of California San Francisco, San Francisco, California, United States of America
- The Helen Diller Family Comprehensive Cancer Center, The University of California San Francisco, San Francisco, California, United States of America
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Okano Y, Kuramochi H, Nakajima G, Katagiri S, Yamamoto M. Elevated levels of mRNAs encoding dihydropyrimidine dehydrogenase and thymidylate synthase are associated with improved survival of patients with hepatocellular carcinoma treated with S-1. Oncol Lett 2017; 14:930-936. [PMID: 28693254 DOI: 10.3892/ol.2017.6241] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 03/09/2017] [Indexed: 12/20/2022] Open
Abstract
Thymidylate synthase (TYMS) and dihydropyrimidine dehydrogenase (DPYD) are associated with the response of tumors to fluoropyrimidines. The aim of the present study was to investigate the association between the levels of TYMS and DPYD mRNAs and the efficacy of S-1 for treating patients with HCC. A total of 35 patients with HCC who received S-1 upon recurrence (S-1 group) and 20 patients who never received a fluoropyrimidine (control group) were studied. The levels of TYMS and DPYD mRNA in surgically resected specimens were determined using reverse transcription-polymerase chain reaction assays. Overall survival (OS) time of S-1 group patients with high levels of DPYD mRNA was significantly longer compared with that of patients with low levels (median 501 days vs. 225 days; P=0.016). Similarly, the OS time of those patients with high levels of TYMS mRNA was significantly longer compared with those with low levels (median 503 days vs. 239 days; P=0.0076). By contrast, there was no difference in OS time of the control group between patients with high and low levels of DPYD and TYMS mRNAs. The levels of TYMS and DPYD mRNAs may serve as predictive markers for patients with HCC who receive S-1 chemotherapy.
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Affiliation(s)
- Yusuke Okano
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Shunjukuku, Tokyo 162-8666, Japan
| | - Hidekazu Kuramochi
- Department of Chemotherapy and Palliative Care, Tokyo Women's Medical University, Shunjukuku, Tokyo 162-8666, Japan.,Department of Surgery, Tokyo Women's Medical University, Yachiyo Medical Center, Yachiyo, Chiba 276-8524, Japan
| | - Go Nakajima
- Department of Chemotherapy and Palliative Care, Tokyo Women's Medical University, Shunjukuku, Tokyo 162-8666, Japan
| | - Satoshi Katagiri
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Shunjukuku, Tokyo 162-8666, Japan.,Department of Surgery, Tokyo Women's Medical University, Yachiyo Medical Center, Yachiyo, Chiba 276-8524, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Shunjukuku, Tokyo 162-8666, Japan
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Shigeta K, Ishii Y, Hasegawa H, Okabayashi K, Kitagawa Y. Evaluation of 5-fluorouracil metabolic enzymes as predictors of response to adjuvant chemotherapy outcomes in patients with stage II/III colorectal cancer: a decision-curve analysis. World J Surg 2015; 38:3248-56. [PMID: 25167895 DOI: 10.1007/s00268-014-2738-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The effectiveness of 5-fluorouracil (5-FU)-based adjuvant chemotherapy is reported in patients with colorectal cancer (CRC), but the usefulness of 5-FU metabolic enzymes as predictive biomarkers of the efficacy of this chemotherapy remains unclear. OBJECTIVE This study aims to verify whether 5-FU metabolic enzymes are predictive biomarkers in the clinical setting of adjuvant chemotherapy for stage II/III CRC. METHODS In total, 179 patients with stage II/III CRC who were treated at our institute between 2000 and 2010 were enrolled. Messenger RNA (mRNA) expression of major 5-FU metabolic enzymes, namely thymidylate synthase, dihydropyrimidine dehydrogenase, thymidine phosphorylase (TP), orotate phosphoribosyl transferase, and β-actin (control) was evaluated using the Danenberg Tumor Profile method. mRNA expression and other clinicopathological data were investigated with regard to CRC relapse. RESULTS A total of 78 patients underwent surgery alone, while 101 underwent adjuvant chemotherapy (5-FU plus leucovorin [LV] or tegafur plus uracil /LV) following surgery. Relapse-free survival was longer and risk of recurrence was lower in association with high TP mRNA expression than in association with low TP mRNA expression in the adjuvant chemotherapy group (hazard ratio 0.66; 95 % confidence interval 0.47-0.92; p = 0.016), but not in the surgery alone group. mRNA expression of no other enzymes was associated with relapse in both groups. In decision-curve analyses, the predictive efficiency of TP mRNA expression plus clinicopathological factors was slightly better than that of clinicopathological factors only. CONCLUSIONS TP mRNA expression in tumors predicted the effects of adjuvant chemotherapy for stage II/III CRC, although the beneficial effects were marginal.
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Affiliation(s)
- Kohei Shigeta
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan,
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Bard-Chapeau EA, Nguyen AT, Rust AG, Sayadi A, Lee P, Chua BQ, New LS, de Jong J, Ward JM, Chin CK, Chew V, Toh HC, Abastado JP, Benoukraf T, Soong R, Bard FA, Dupuy AJ, Johnson RL, Radda GK, Chan EC, Wessels LF, Adams DJ, Jenkins NA, Copeland NG. Transposon mutagenesis identifies genes driving hepatocellular carcinoma in a chronic hepatitis B mouse model. Nat Genet 2014; 46:24-32. [PMID: 24316982 PMCID: PMC4131144 DOI: 10.1038/ng.2847] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 11/08/2013] [Indexed: 12/15/2022]
Abstract
The most common risk factor for developing hepatocellular carcinoma (HCC) is chronic infection with hepatitis B virus (HBV). To better understand the evolutionary forces driving HCC, we performed a near-saturating transposon mutagenesis screen in a mouse HBV model of HCC. This screen identified 21 candidate early stage drivers and a very large number (2,860) of candidate later stage drivers that were enriched for genes that are mutated, deregulated or functioning in signaling pathways important for human HCC, with a striking 1,199 genes being linked to cellular metabolic processes. Our study provides a comprehensive overview of the genetic landscape of HCC.
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Affiliation(s)
- Emilie A Bard-Chapeau
- Institute Molecular and Cell Biology, Agency for Science, Technology and Research (ASTAR), Biopolis, Singapore
| | - Anh-Tuan Nguyen
- Institute Molecular and Cell Biology, Agency for Science, Technology and Research (ASTAR), Biopolis, Singapore
| | - Alistair G Rust
- Experimental Cancer Genetics, Wellcome Trust Sanger Institute, Hinxton, Cambridge, CB10 1HH, UK
| | - Ahmed Sayadi
- Institute Molecular and Cell Biology, Agency for Science, Technology and Research (ASTAR), Biopolis, Singapore
| | - Philip Lee
- Clinical Imaging Research Centre, National University of Singapore, Centre for Translation Medicine, 14 Medical Drive, #B1-01, 117599, Singapore
| | - Belinda Q Chua
- Institute Molecular and Cell Biology, Agency for Science, Technology and Research (ASTAR), Biopolis, Singapore
| | - Lee-Sun New
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, 117543, Singapore
| | - Johann de Jong
- Department of Molecular Carcinogenesis, The Netherlands Cancer Institute, Plesmanlaan 121, 1066CX Amsterdam
| | - Jerrold M Ward
- Institute Molecular and Cell Biology, Agency for Science, Technology and Research (ASTAR), Biopolis, Singapore
| | - Christopher Ky Chin
- Institute Molecular and Cell Biology, Agency for Science, Technology and Research (ASTAR), Biopolis, Singapore
| | - Valerie Chew
- Singapore Immunology Network (SIgN), Agency for Science, Technology and Research (ASTAR), Biopolis, Singapore
| | | | - Jean-Pierre Abastado
- Singapore Immunology Network (SIgN), Agency for Science, Technology and Research (ASTAR), Biopolis, Singapore
| | - Touati Benoukraf
- Cancer Science Institute of Singapore, National University of Singapore, Department of Pathology, National University Health System, Singapore
| | - Richie Soong
- Cancer Science Institute of Singapore, National University of Singapore, Department of Pathology, National University Health System, Singapore
| | - Frederic A Bard
- Institute Molecular and Cell Biology, Agency for Science, Technology and Research (ASTAR), Biopolis, Singapore
| | - Adam J Dupuy
- Department of Anatomy and Cell Biology, Carver College of Medicine, University of Iowa, Iowa City, IA, 52242
| | - Randy L Johnson
- Department of Biochemistry and Molecular Biology, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
| | - George K Radda
- Clinical Imaging Research Centre, National University of Singapore, Centre for Translation Medicine, 14 Medical Drive, #B1-01, 117599, Singapore
| | - Eric Cy Chan
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, 117543, Singapore
| | - Lodewyk Fa Wessels
- Department of Molecular Carcinogenesis, The Netherlands Cancer Institute, Plesmanlaan 121, 1066CX Amsterdam
| | - David J Adams
- Experimental Cancer Genetics, Wellcome Trust Sanger Institute, Hinxton, Cambridge, CB10 1HH, UK
| | - Nancy A Jenkins
- Institute Molecular and Cell Biology, Agency for Science, Technology and Research (ASTAR), Biopolis, Singapore
| | - Neal G Copeland
- Institute Molecular and Cell Biology, Agency for Science, Technology and Research (ASTAR), Biopolis, Singapore
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Zhao H, Zhao Y, Guo Y, Huang Y, Lin S, Xue C, Xu F, Zhang Y, Zhao L, Hu Z, Zhang L. Clinical significance of the thymidylate synthase, dihydropyrimidine dehydrogenase, and thymidine phosphorylase mRNA expressions in hepatocellular carcinoma patients receiving 5-fluorouracil-based transarterial chemoembolization treatment. Onco Targets Ther 2013; 6:811-8. [PMID: 23861589 PMCID: PMC3704606 DOI: 10.2147/ott.s46498] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Purpose To determine whether 5-fluorouracil (5-FU) sensitivity is associated with the mRNA expressions of thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), and thymidine phosphorylase (TP) in patients with hepatocellular carcinoma (HCC) treated with 5-FU-based transarterial chemoembolization (TACE). Methods Formalin-fixed, paraffin-embedded tumor specimens from 40 patients treated with 5-FU-based TACE were selected for the examination of TS, DPD, and TP expression level by a quantitative real-time reverse transcription- polymerase chain reaction (PCR) technique. Patients were categorized into high and low expression groups according to the median expression level of each enzyme. Associations between the mRNA expression levels of TS, DPD, and TP and clinical parameters including treatment efficacies, clinicopathological factors, and prognosis were assessed. Results High DPD expression was associated with worse treatment outcome, including intrahepatic disease progression rate (hazard ratio [HR] for high DPD versus low DPD, 2.212; 95% confidence interval [CI], 1.030–4.753; P = 0.042), extrahepatic disease progression rate (HR for high versus low DPD, 3.171; 95% CI, 1.003–10.023; P = 0.049), and progression-free survival (HR for high versus low DPD, 2.308; 95% CI, 1.102–4.836; P = 0.027). No correlation was found between the mRNA expression of TS/TP and treatment outcome. Conclusion DPD mRNA expression level was negatively correlated with the clinical outcomes of HCC patients treated with 5-FU-based TACE. These results provide indirect evidence that high DPD mRNA expression is a predictive marker of treatment resistance for 5-FU.
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Affiliation(s)
- Hongyun Zhao
- State Key Laboratory of Oncology in South China and National Anti-Cancer Drug Clinical Research Centre
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Iwahashi S, Shimada M, Utsunomiya T, Morine Y, Imura S, Ikemoto T, Mori H, Hanaoka J. Role of thymidylate synthase and dihydropyrimidine dehydrogenase mRNA expressions in gallbladder carcinoma. Surg Today 2012; 42:565-9. [PMID: 22270332 DOI: 10.1007/s00595-012-0118-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Accepted: 05/06/2011] [Indexed: 12/16/2022]
Abstract
PURPOSE Thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD) are important enzymes in the metabolism of 5-fluorouracil, which have been examined as possible predictive markers. We conducted this study to clarify the role of TS and DPD expressions in gallbladder carcinoma (GBC). METHODS The subjects were 28 patients who underwent surgical resection of GBC. We examined intratumoral TS and DPD mRNA expressions, using the Danenberg tumor profile method. The expression levels were classified into two groups, based on median values. Clinicopathological variables, including prognosis, were then compared between the high and low expression groups. RESULTS There was a significant difference in the incidence of lymph node metastasis between the high and low TS expression groups. The incidence of advanced clinical stage was higher in the low TS expression group than in the high TS expression group. However, no clear correlation was observed between the DPD mRNA expression and any clinicopathological variable. There was no significant difference in the postoperative survival rates between the groups, in accordance with the expression of TS or DPD genes. CONCLUSION Low TS mRNA was correlated with a high incidence of lymph node metastasis and advanced clinical stage. Therefore, TS gene expression may help identify patients at increased risk of the progression of GBC.
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Affiliation(s)
- Shuichi Iwahashi
- Department of Surgery, Institute of Health Biosciences, The University of Tokushima Graduate School, 3-18-15 Kuramoto-cho, Tokushima, Japan
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Morine Y, Shimada M, Utsunomiya T, Imura S, Ikemoto T, Hanaka J, Kanamoto M, Kurita N, Miyake H. Role of thymidylate synthase and dihydropyrimidine dehydrogenase mRNA in intrahepatic cholangiocarcinoma. Surg Today 2011; 42:135-40. [PMID: 22143355 DOI: 10.1007/s00595-011-0054-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 02/06/2011] [Indexed: 12/17/2022]
Abstract
PURPOSE Thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD) are important enzymes in the metabolism of 5-fluorouracil and possible predictive markers. We conducted this study to clarify if TS and DPD gene expressions are a prognostic indicator for intrahepatic cholangiocarcinoma (IHCC). METHODS The subjects of this study were 21 patients with IHCC who had undergone surgical resection. Intratumoral TS and DPD mRNA expressions were examined using the Danenberg tumor profile method and classified into two groups according to the median value of each. We then compared the clinicopathological variables, including prognosis, between the high and low expression groups. RESULTS Low DPD expression was correlated with macroscopic type, namely, mass-forming + infiltrative (P = 0.08). Postoperative survival rates in the low DPD expression group were significantly lower than those in the high DPD expression group. Multivariate analysis revealed macroscopic type to be an independent prognostic factor, whereas TS mRNA expression did not correlate with any clinicopathological variables, including prognosis. CONCLUSIONS Low DPD mRNA expression was related to macroscopic type and associated with poor prognosis. DPD mRNA expression in tumor cells is suggested to be an important regulator of malignant behavior in IHCC.
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Affiliation(s)
- Yuji Morine
- Department of Surgery, Institute of Health Biosciences, University of Tokushima Graduate School, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan.
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Scartozzi M, Maccaroni E, Giampieri R, Pistelli M, Bittoni A, Del Prete M, Berardi R, Cascinu S. 5-Fluorouracil pharmacogenomics: still rocking after all these years? Pharmacogenomics 2011; 12:251-65. [PMID: 21332317 DOI: 10.2217/pgs.10.167] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The 5-fluorouracil (5-FU) metabolic pathway is mainly dependent on the activity of several intracellular enzymes. Among them, four in particular; thymidylate synthase, methylenetetrahydrofolate reductase, dihydropyrimidine dehydrogenase and thymidine phosphorylase are considered the key points in determining sensitivity or resistance to this drug. These enzymes are needed to metabolize the drug in its active form (thymidylate phosphorylase) or to drop the concentration of the active drug in the cell (dihydropyrimidine dehydrogenase) or both (thymidylate synthase and methylenetetrahydrofolate reductase). Several different studies have tried to investigate the relationship between the presence of mutations in these enzymes and a reduced/improved activity of treatment based on 5-FU or its derivatives. In this article, we will focus on the often contradictory results of these studies.
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Affiliation(s)
- Mario Scartozzi
- Clinica di Oncologia Medica, AO Ospedali Riuniti-Ancona, Università Politecnica delle Marche, Ancona, Italy.
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Nishi M, Shimada M, Utsunomiya T, Morine Y, Imura S, Ikemoto T, Mori H, Hanaoka J, Bando Y. Role of dihydropyrimidine dehydrogenase and thymidylate synthase expression in immunohistochemistry of intrahepatic cholangiocarcinoma. Hepatol Res 2011; 41:64-70. [PMID: 20880064 DOI: 10.1111/j.1872-034x.2010.00722.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIMS Dihydropyrimidine dehydrogenase (DPD) and thymidylate synthase (TS) are key enzymes in the metabolism of 5-fluorouracil and have been implicated as possible prognostic markers for cancer patients. However, the clinical roles of DPD and TS in intrahepatic cholangiocarcinoma (IHCC) have not been investigated. The aim of this study was to clarify the clinicopathological role of DPD and TS expressions in IHCC. METHODS Twenty-nine patients who had undergone hepatic resection for IHCC were enrolled in this study. Expressions of DPD and TS in the resected IHCC specimens were examined using anti-DPD or anti-TS antibody. The patients were divided into positive and negative groups according to DPD/TS expressions: DPD-positive group (n = 18) and DPD-negative group (n = 11)/TS-positive group (n = 14) and TS-negative group (n = 15). Clinicopathological factors were compared between the two groups. RESULTS The overall survival rate was significantly lower in the DPD-negative group than in the DPD-positive group (1-year 36.4% vs. 77.4%, 3-year 18.2% vs. 43.0%; P < 0.05). The disease-free survival rate in the DPD-negative group tended to be lower than that in the DPD-positive group. The overall survival rate or disease-free survival rate did not appear to be associated with the TS-expression status. The Ki-67 labeling index in the DPD-negative group was significantly higher than that in the DPD-positive group (16.9 ± 3.2% vs.13.2 ± 3.3%; P < 0.05). CONCLUSIONS The negative DPD expression was significantly associated with the enhanced tumor cell proliferation and poorer prognosis in patients with IHCC. DPD expression is a potential prognostic indicator for IHCC.
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Affiliation(s)
- Masaaki Nishi
- Department of Surgery Department of Molecular and Environmental Pathology, Institute of Health Bioscience, The University of Tokushima, Kuramoto-cho, Tokushima, Japan
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