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Sepahi S, Kiaei L, Kiaei M, Ghorani-Azam A. A systematic review of emerging technologies to enhance the treatment of ovarian cancer. Pharm Dev Technol 2023; 28:660-677. [PMID: 37417773 DOI: 10.1080/10837450.2023.2233588] [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: 03/29/2023] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 07/08/2023]
Abstract
The efficacy and safety of chemotherapy are two major challenges when it comes to treating ovarian cancer. The associated undesirable side effects of chemotherapy agents jeopardize the clinical intent and the efficiency of the therapy. Multiple studies have been published describing new developments and novel strategies utilizing the latest therapeutic and drug delivery technologies to address the efficacy and safety of chemotherapeutics in ovarian cancers. We have identified five novel technologies that are available and, if used, have the potential to mitigate the above-mentioned challenges. Nanocarriers in different forms (Nano-gel, Aptamer, peptide medicated formulations, Antibody-drug conjugation, surface charge, and nanovesicle technologies) are developed and available to be employed to target the cancerous tissue. These strategies are promising to improve clinical efficacy and reduce side effects. We have systematically searched and analyzed published data, as well as the authors intent for the described technology on each publication. We narrowed to 81 key articles and extracted their data to be discussed in this review. In summary, the selected articles investigated the pharmacokinetic properties of drugs combined with nanocarriers and found significant improvement in efficacy and safety by reducing the IC50 values and drug doses. These key papers described promising novel technologies in anti-cancer therapeutic approaches to enable sustained drug release and achieve prolonged drug performance near the tumor site or target tissue.
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Affiliation(s)
- Samaneh Sepahi
- Food and Beverages Safety Research Center, Urmia University of Medical Sciences, Urmia, Iran
| | - Lily Kiaei
- RockGen Therapeutics, LLC, Little Rock, AR, USA
- University of California Los Angeles, Los Angeles, CA, USA
| | - Mahmoud Kiaei
- RockGen Therapeutics, LLC, Little Rock, AR, USA
- Department of Pharmacology and Toxicology, Department of Neurology, Department of Geriatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Adel Ghorani-Azam
- Department of Forensic Medicine and Toxicology, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
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2
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Guo D, Zhang S, Gao Y, Shi J, Wang X, Zhang Z, Zhang Y, Wang Y, Zhao K, Li M, Wang A, Wang P, Gou Y, Zhang M, Liu M, Zhang Y, Chen R, Sun J, Wang S, Wu X, Liang Z, Chen J, Lang J. Exploring the cellular and molecular differences between ovarian clear cell carcinoma and high-grade serous carcinoma using single-cell RNA sequencing and GEO gene expression signatures. Cell Biosci 2023; 13:139. [PMID: 37525249 PMCID: PMC10391916 DOI: 10.1186/s13578-023-01087-3] [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: 04/26/2023] [Accepted: 07/13/2023] [Indexed: 08/02/2023] Open
Abstract
The two most prevalent subtypes of epithelial ovarian carcinoma (EOC) are ovarian clear cell carcinoma (OCCC) and high-grade serous ovarian carcinoma (HGSC). Patients with OCCC have a poor prognosis than those with HGSC due to chemoresistance, implying the need for novel treatment target. In this study, we applied single-cell RNA sequencing (scRNA-seq) together with bulk RNA-seq data from the GEO (Gene Expression Omnibus) database (the GSE189553 dataset) to characterize and compare tumor heterogeneity and cell-level evolution between OCCC and HGSC samples. To begin, we found that the smaller proportion of an epithelial OCCC cell subset in the G2/M phase might explain OCCC chemoresistance. Second, we identified a possible pathogenic OCCC epithelial cell subcluster that overexpresses LEFTY1. Third, novel biomarkers separating OCCC from HGSC were discovered and subsequently validated on a wide scale using immunohistochemistry. Amine oxidase copper containing 1 (AOC1) was preferentially expressed in OCCC over HGSC, while S100 calcium-binding protein A2 (S100A2) was detected less frequently in OCCC than in HGSC. In addition, we discovered that metabolic pathways were enriched in the epithelial compartment of the OCCC samples. In vitro experiments verified that inhibition of oxidative phosphorylation or glycolysis pathways exerted direct antitumor effects on both OCCC and HGSC cells, while targeting glutamine metabolism or ferroptosis greatly attenuated chemosensitivity only in OCCC cells. Finally, to determine whether there were any variations in immune cell subsets between OCCC and HGSC, data from scRNA-seq and mass cytometry were pooled for analysis. In summary, our work provides the first holistic insights into the cellular and molecular distinctions between OCCC and HGSC and is a valuable source for discovering new targets to leverage in clinical treatments to improve the poor prognosis of patients with OCCC.
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Affiliation(s)
- Dan Guo
- Clinical Biobank, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Sumei Zhang
- Clinical Biobank, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yike Gao
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Jinghua Shi
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Xiaoxi Wang
- Clinical Biobank, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zixin Zhang
- Clinical Biobank, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yaran Zhang
- Clinical Biobank, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuming Wang
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Kun Zhao
- Clinical Biobank, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Mei Li
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Anqi Wang
- Clinical Biobank, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Pan Wang
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
- Department of Pathology, Affiliated Hospital of Hebei University, Baoding, China
| | - Yanqin Gou
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
- Department of Pathology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, China
| | - Miao Zhang
- Clinical Biobank, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Meiyu Liu
- Clinical Biobank, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuhan Zhang
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Rui Chen
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Jian Sun
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.
| | - Shu Wang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China.
| | - Xunyao Wu
- Clinical Biobank, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
- Department of Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - Zhiyong Liang
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Jie Chen
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Jinghe Lang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
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3
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Uno K, Iyoshi S, Yoshihara M, Kitami K, Mogi K, Fujimoto H, Sugiyama M, Koya Y, Yamakita Y, Nawa A, Kanayama T, Tomita H, Enomoto A, Kajiyama H. Metastatic Voyage of Ovarian Cancer Cells in Ascites with the Assistance of Various Cellular Components. Int J Mol Sci 2022; 23:4383. [PMID: 35457198 PMCID: PMC9031612 DOI: 10.3390/ijms23084383] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/10/2022] [Accepted: 04/12/2022] [Indexed: 12/16/2022] Open
Abstract
Epithelial ovarian cancer (EOC) is the most lethal gynecologic malignancy and has a unique metastatic route using ascites, known as the transcoelomic root. However, studies on ascites and contained cellular components have not yet been sufficiently clarified. In this review, we focus on the significance of accumulating ascites, contained EOC cells in the form of spheroids, and interaction with non-malignant host cells. To become resistant against anoikis, EOC cells form spheroids in ascites, where epithelial-to-mesenchymal transition stimulated by transforming growth factor-β can be a key pathway. As spheroids form, EOC cells are also gaining the ability to attach and invade the peritoneum to induce intraperitoneal metastasis, as well as resistance to conventional chemotherapy. Recently, accumulating evidence suggests that EOC spheroids in ascites are composed of not only cancer cells, but also non-malignant cells existing with higher abundance than EOC cells in ascites, including macrophages, mesothelial cells, and lymphocytes. Moreover, hetero-cellular spheroids are demonstrated to form more aggregated spheroids and have higher adhesion ability for the mesothelial layer. To improve the poor prognosis, we need to elucidate the mechanisms of spheroid formation and interactions with non-malignant cells in ascites that are a unique tumor microenvironment for EOC.
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Affiliation(s)
- Kaname Uno
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (K.U.); (S.I.); (K.K.); (K.M.); (H.F.); (Y.Y.); (H.K.)
- Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, 223-62 Lund, Sweden
| | - Shohei Iyoshi
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (K.U.); (S.I.); (K.K.); (K.M.); (H.F.); (Y.Y.); (H.K.)
- Spemann Graduate School of Biology and Medicine, University of Freiburg, 79104 Freiburg, Germany
| | - Masato Yoshihara
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (K.U.); (S.I.); (K.K.); (K.M.); (H.F.); (Y.Y.); (H.K.)
| | - Kazuhisa Kitami
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (K.U.); (S.I.); (K.K.); (K.M.); (H.F.); (Y.Y.); (H.K.)
| | - Kazumasa Mogi
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (K.U.); (S.I.); (K.K.); (K.M.); (H.F.); (Y.Y.); (H.K.)
| | - Hiroki Fujimoto
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (K.U.); (S.I.); (K.K.); (K.M.); (H.F.); (Y.Y.); (H.K.)
- Discipline of Obstetrics and Gynecology, Adelaide Medical School, Robinson Research Institute, University of Adelaide, Adelaide 5005, Australia
| | - Mai Sugiyama
- Bell Research Center, Department of Obstetrics and Gynecology Collaborative Research, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (M.S.); (Y.K.); (A.N.)
| | - Yoshihiro Koya
- Bell Research Center, Department of Obstetrics and Gynecology Collaborative Research, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (M.S.); (Y.K.); (A.N.)
| | - Yoshihiko Yamakita
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (K.U.); (S.I.); (K.K.); (K.M.); (H.F.); (Y.Y.); (H.K.)
- Bell Research Center, Department of Obstetrics and Gynecology Collaborative Research, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (M.S.); (Y.K.); (A.N.)
| | - Akihiro Nawa
- Bell Research Center, Department of Obstetrics and Gynecology Collaborative Research, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (M.S.); (Y.K.); (A.N.)
| | - Tomohiro Kanayama
- Department of Tumor Pathology, Graduate School of Medicine, Gifu University, Gifu 501-1194, Japan; (T.K.); (H.T.)
| | - Hiroyuki Tomita
- Department of Tumor Pathology, Graduate School of Medicine, Gifu University, Gifu 501-1194, Japan; (T.K.); (H.T.)
| | - Atsushi Enomoto
- Department of Pathology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan;
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (K.U.); (S.I.); (K.K.); (K.M.); (H.F.); (Y.Y.); (H.K.)
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Guo T, Dong X, Xie S, Zhang L, Zeng P, Zhang L. Cellular Mechanism of Gene Mutations and Potential Therapeutic Targets in Ovarian Cancer. Cancer Manag Res 2021; 13:3081-3100. [PMID: 33854378 PMCID: PMC8041604 DOI: 10.2147/cmar.s292992] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/19/2021] [Indexed: 02/05/2023] Open
Abstract
Ovarian cancer is a common and complex malignancy with poor prognostic outcome. Most women with ovarian cancer are diagnosed with advanced stage disease due to a lack of effective detection strategies in the early stage. Traditional treatment with cytoreductive surgery and platinum-based combination chemotherapy has not significantly improved prognosis and 5-year survival rates are still extremely poor. Therefore, novel treatment strategies are needed to improve the treatment of ovarian cancer patients. Recent advances of next generation sequencing technologies have both confirmed previous known mutated genes and discovered novel candidate genes in ovarian cancer. In this review, we illustrate recent advances in identifying ovarian cancer gene mutations, including those of TP53, BRCA1/2, PIK3CA, and KRAS genes. In addition, we discuss advances in targeting therapies for ovarian cancer based on these mutated genes in ovarian cancer. Further, we associate between detection of mutation genes by liquid biopsy and the potential early diagnostic value in ovarian cancer.
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Affiliation(s)
- Tao Guo
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Xue Dong
- Department of Gynecology, Cheng Du Shang Jin Nan Fu Hospital, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Shanli Xie
- First People's Hospital of Guangyuan, Guangyuan, Sichuan, 628000, People's Republic of China
| | - Ling Zhang
- Department of Gynecology and Obstetrics, Guangyuan Central Hospital, Guangyuan, Sichuan, 628000, People's Republic of China
| | - Peibin Zeng
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Lin Zhang
- Department of Forensic Biology, West China School of Preclinical and Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
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Samartzis EP, Labidi-Galy SI, Moschetta M, Uccello M, Kalaitzopoulos DR, Perez-Fidalgo JA, Boussios S. Endometriosis-associated ovarian carcinomas: insights into pathogenesis, diagnostics, and therapeutic targets-a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1712. [PMID: 33490224 PMCID: PMC7812165 DOI: 10.21037/atm-20-3022a] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Endometriosis is a benign gynecologic condition affecting up to one woman out of ten of reproductive age. It is defined by the presence of endometrial-like tissue in localizations outside of the uterine cavity. It often causes symptoms such as chronic pain, most frequently associated with the menstrual cycle, and infertility, but may also be oligo- or asymptomatic. There is evidence that some ovarian carcinoma (OC) histotypes, mainly the ovarian clear cell (OCCC) and endometrioid (EnOC) carcinoma, may arise from endometriosis. The most frequent genomic alterations in these carcinomas are mutations in the AT-rich interacting domain containing protein 1A (ARID1A) gene, a subunit of the SWI/SNF chromatin remodeling complex, and alterations in the phosphatidylinositol 3-kinase (PI3K)/AKT/mTOR pathway, which frequently co-occur. In ARID1A deficient cancers preclinical experimental data suggest different targetable mechanisms including epigenetic regulation, cell cycle, genomic instability, the PI3K/AKT/mTOR pathway, inflammatory pathways, immune modulation, or metabolic alterations as potential precision oncology approaches. Most of these strategies are relying on the concept of synthetic lethality in which tumors deficient in ARID1A are more sensitive to the different compounds. Some of these approaches are currently being or have recently been investigated in early clinical trials. The remarkably frequent occurrence of these mutations in endometriosis-associated ovarian cancer, the occurrence in a relatively young population, and the high proportion of platinum-resistant disease certainly warrants further investigation of precision oncology opportunities in this population. Furthermore, advanced knowledge about oncogenic mutations involved in endometriosis-associated ovarian carcinomas may be potentially useful for early cancer detection. However, this approach may be complicated by the frequent occurrence of somatic mutations in benign endometriotic tissue as recent studies suggest. In this narrative review of the current literature, we will discuss the data available on endometriosis-associated ovarian carcinoma, with special emphasis on epidemiology, diagnosis and molecular changes that could have therapeutic implications and clinical applicability in the future.
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Affiliation(s)
- Eleftherios P Samartzis
- Department of Gynecology and Gynecological Cancer Center, University Hospital Zurich, Zurich, Switzerland
| | - S Intidhar Labidi-Galy
- Department of Oncology, Hôpitaux Universitaires de Genève, Geneva, Switzerland.,Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | | - Mario Uccello
- Northampton General Hospital NHS Trust, Cliftonville, Northampton, UK
| | - Dimitrios R Kalaitzopoulos
- Department of Gynecology and Gynecological Cancer Center, University Hospital Zurich, Zurich, Switzerland.,Department of Gynecology and Obstetrics, Kantonsspital Schaffhausen, Schaffhausen, Switzerland
| | - J Alejandro Perez-Fidalgo
- Department of Medical Oncology, Hospital Clinico Universitario de Valencia, INCLIVA, CIBERONC, Valencia, Spain
| | - Stergios Boussios
- Department of Medical Oncology, Medway NHS Foundation Trust, Gillingham, Kent, UK.,AELIA Organization, 9th Km Thessaloniki - Thermi, Thessaloniki, Greece
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Gingival Biopsy to Detect Mosaicism in Overgrowth Syndromes: Report of Two Cases of Megalencephaly-Capillary Malformation Syndrome with Periodontal Anomalies. Case Rep Dent 2020; 2020:8826945. [PMID: 33005459 PMCID: PMC7509567 DOI: 10.1155/2020/8826945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/12/2020] [Accepted: 09/02/2020] [Indexed: 11/25/2022] Open
Abstract
Background Megalencephaly-capillary malformation (MCAP) is a rare overgrowth syndrome caused by postzygotic activating mutations in the PIK3CA gene. Aim To illustrate the benefits of gingival biopsy in the genetic diagnosis of overgrowth syndromes. Design Gingival biopsy was performed on a 13-year-old patient and a 16-year-old patient with MCAP and who suffered from periodontal disease. PIK3CA sequencing was performed on DNA extracted from gingival biopsies, blood, and saliva. Results Pathogenic p.Glu365Lys and p.Glu545Asp PIK3CA mutations were found in the gingival biopsies with an allelic frequency of 22% and 35%, respectively, while they were undetectable in blood or saliva. The genetic diagnosis of MCAP through detection of PIK3CA somatic mosaicism in a periodontal biopsy is unprecedented. Conclusions Considering the tissue distribution and level of somatic mosaicism for PIK3CA mutation, the composite embryologic origin of periodontium and its high fibroblast cell content make it an ideal target for molecular analysis in overgrowth syndromes, and multidisciplinary approach including paediatric dentists should be encouraged. In addition, our clinical findings suggest that periodontal disease is part of the MCAP phenotypic spectrum and should be systematically investigated.
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7
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Makii C, Ikeda Y, Oda K, Uehara Y, Nishijima A, Koso T, Kawata Y, Kashiyama T, Miyasaka A, Sone K, Tanikawa M, Tsuruga T, Mori-Uchino M, Nagasaka K, Matsumoto Y, Wada-Hiraike O, Kawana K, Hasegawa K, Fujiwara K, Aburatani H, Osuga Y, Fujii T. Anti-tumor activity of dual inhibition of phosphatidylinositol 3-kinase and MDM2 against clear cell ovarian carcinoma. Gynecol Oncol 2019; 155:331-339. [PMID: 31493899 DOI: 10.1016/j.ygyno.2019.08.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/15/2019] [Accepted: 08/23/2019] [Indexed: 12/19/2022]
Abstract
INTRODUCTION PI3K pathway signaling has received attention as a molecular target in clear cell ovarian carcinoma (CCOC). MDM2 is one of the AKT effectors in the PI3K pathway, which binds to and degrades p53. In this study, we aimed to clarify the prognostic significance of PIK3CA and MDM2 expression, and potential therapeutic effect of a dual inhibition of the PI3K pathway and MDM2. MATERIALS AND METHODS cDNA expression was evaluated by using microarray data using 75 samples of CCOC. DS-7423 (dual inhibitor of pan-PI3K and mTOR) and RG7112 (MDM2 inhibitor) were used on CCOC cell lines to evaluate cell proliferation, expression level of MDM2 related proteins, and apoptosis by MTT assay, western blotting, and flow cytometry. DS-7423 (3 mg/kg) and/or RG7112 (50 mg/kg) were orally administrated every day for three weeks, and the anti-tumor effect was evaluated using tumor xenografts, along with immunohistochemistry. RESULTS Tumors with high expression of both PIK3CA and MDM2 showed significantly worse prognosis in expression array of 71 CCOCs (P = 0.013). Dual inhibition of the PI3K pathway by DS-7423 and MDM2 by RG7112 showed synergistic anti-proliferative effect in 4 CCOC cell lines without TP53 mutations. The combination therapy more robustly induced pro-apoptotic proteins (PUMA and cleaved PARP) with increase of sub G1 population and apoptotic cells, compared with either single agent alone. The combination therapy significantly reduced tumor volume in mice (P < 0.001 in OVISE, and P = 0.038 in RMG-I) without severe body weight loss. Immunohistochemistry from the xenograft tumors showed that the combination treatment significantly reduced vascularity and cell proliferation, with an increase of apoptotic cell death. CONCLUSION A combination therapy targeting the PI3K pathway and MDM2 might be a promising therapeutic strategy in CCOC.
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Affiliation(s)
- Chinami Makii
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan
| | - Yuji Ikeda
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan; Current address; Department of Obstetrics and Gynecology, Nihon University, Tokyo, Japan
| | - Katsutoshi Oda
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan.
| | - Yuriko Uehara
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan; Division of Genome Science, Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Akira Nishijima
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan; Division of Genome Science, Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Takahiro Koso
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan; Division of Genome Science, Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Yoshiko Kawata
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan
| | - Tomoko Kashiyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan
| | - Aki Miyasaka
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan
| | - Kenbun Sone
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan
| | - Michihiro Tanikawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan
| | - Tetsushi Tsuruga
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan
| | - Mayuyo Mori-Uchino
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan
| | - Kazunori Nagasaka
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan
| | - Yoko Matsumoto
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan
| | - Osamu Wada-Hiraike
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan
| | - Kei Kawana
- Department of Obstetrics and Gynecology, Nihon University, Tokyo, Japan
| | - Kosei Hasegawa
- Department of Gynecologic Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Keiichi Fujiwara
- Department of Gynecologic Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Hiroyuki Aburatani
- Division of Genome Science, Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan
| | - Tomoyuki Fujii
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Japan
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Oda K, Hamanishi J, Matsuo K, Hasegawa K. Genomics to immunotherapy of ovarian clear cell carcinoma: Unique opportunities for management. Gynecol Oncol 2018; 151:381-389. [PMID: 30217369 PMCID: PMC7526052 DOI: 10.1016/j.ygyno.2018.09.001] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/28/2018] [Accepted: 09/01/2018] [Indexed: 12/12/2022]
Abstract
Ovarian clear cell carcinoma (OCCC) is distinctive from other histological types of epithelial ovarian cancer, with genetic/epigenetic alterations, a specific immune-related molecular profile, and epidemiologic associations with ethnicity and endometriosis. These findings allow for the exploration of unique and specific treatments for OCCC. Two major mutated genes in OCCC are PIK3CA and ARID1A, which are frequently coexistent with each other. Other genes' alterations also contribute to activation of the PI3K (e.g. PIK3R1 and PTEN) and dysregulation of the chromatin remodeling complex (e.g. ARID1B, and SMARKA4). Although the number of focal copy number variations is small in OCCC, amplification is recurrently detected at chromosome 20q13.2 (including ZNF217), 8q, and 17q. Both expression and methylation profiling highlight the significance of adjustments to oxidative stress and inflammation. In particular, up-regulation of HNF-1β resulting from hypomethylation contributes to the switch from anaerobic to aerobic glucose metabolism. Additionally, up-regulation of HNF-1β activates STAT3 and NF-κB signaling, and leads to immune suppression via production of IL-6 and IL-8. Immune suppression may also be induced by the increased expression of PD-1, Tim-3 and LAG3. Mismatch repair deficient (microsatellite instable) tumors as found in Lynch syndrome also induce immune suppression in some OCCC. In a recent phase II clinical trial in heavily-treated platinum-resistant ovarian cancer, two out of twenty cases with a complete response to the anti-PD-1 antibody, nivolumab, were OCCC subtypes. Thus, the immune-suppressive state resulting from both genetic alterations and the unique tumor microenvironment may be associated with sensitivity to immune checkpoint inhibitors in OCCC. In this review, we highlight recent update and progress in OCCC from both the genomic and immunologic points of view, addressing the future candidate therapeutic options.
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Affiliation(s)
- Katsutoshi Oda
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Junzo Hamanishi
- Department of Obstetrics and Gynecology, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Kosei Hasegawa
- Department of Gynecologic Oncology, Saitama Medical University International Medical Center, Saitama, Japan
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Shen Y, Wang X, Xu J, Lu L. SerpinE2, a poor biomarker of endometrial cancer, promotes the proliferation and mobility of EC cells. Cancer Biomark 2018; 19:271-278. [PMID: 28453461 DOI: 10.3233/cbm-160442] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The SerpinE2 pathway is evolutionarily conserved and plays an important role in tumorigenesis. SerpinE2 (a small ubiquitin-related modifier), like ubiquitin, conjugates SerpinE2 proteins onto lysine residues of target proteins. SerpinE2 over-expression has been found in several tumors. Here, we detected the level of SerpinE2 in 72 samples of EC tissue using immunohistochemistry to assess the role of SerpinE2 in EC prognosis. Meanwhile, we knocked down SerpinE2 by siRNA in the HTB-111 and Ishikawa EC cell lines and analyzed the viability and mobility change using an MTT assay, an annexin V/PI apoptosis assay, a wound scratch test and a transwell assay. A Kaplan-Meier analysis indicated a negative correlation between the level of SerpinE2 and the EC prognosis. Silencing SerpinE2 induced cell apoptosis and reduced the migration ability. Our data suggest SerpinE2 works as an oncogene in EC.
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Affiliation(s)
- Yuan Shen
- Gynecology and Obstetrics Department of the First Affiliated Hospital of Jinan University, Guangzhou 510630, Guangdong, China
| | - Xiaoyu Wang
- Gynecology and Obstetrics Department of the First Affiliated Hospital of Jinan University, Guangzhou 510630, Guangdong, China
| | - Jianping Xu
- Gynecology and Obstetrics Department of the First Affiliated Hospital of Jinan University, Guangzhou 510630, Guangdong, China
| | - Lin Lu
- Gynecology and Obstetrics Department, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong, China
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10
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The NCI-MATCH trial and precision medicine in gynecologic cancers. Gynecol Oncol 2018; 148:585-590. [DOI: 10.1016/j.ygyno.2018.01.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/10/2018] [Accepted: 01/11/2018] [Indexed: 12/20/2022]
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Yahya MA, Sharon SM, Hantisteanu S, Hallak M, Bruchim I. The Role of the Insulin-Like Growth Factor 1 Pathway in Immune Tumor Microenvironment and Its Clinical Ramifications in Gynecologic Malignancies. Front Endocrinol (Lausanne) 2018; 9:297. [PMID: 29922232 PMCID: PMC5996273 DOI: 10.3389/fendo.2018.00297] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 05/17/2018] [Indexed: 12/12/2022] Open
Abstract
Treatment of patients with gynecologic malignancies diagnosed at advanced stages remains a therapeutic challenge. Survival rates of these patients remain significantly low, despite surgery and chemotherapy. Advances in understanding the role of the immune system in the pathogenesis of cancer have led to the rapid evolution of immunotherapeutic approaches. Immunotherapeutic strategies, including targeting specific immune checkpoints, as well as dendritic cell (DC) immunotherapy are being investigated in several malignancies, including gynecological cancers. Another important approach in cancer therapy is to inhibit molecular pathways that are crucial for tumor growth and maintenance, such as the insulin-like growth factor-1 (IGF1) pathway. The IGF axis has been shown to play a significant role in carcinogenesis of several types of tissue, including ovarian cancer. Preclinical studies reported significant anti-proliferative activity of IGF1 receptor (IGF1R) inhibitors in gynecologic malignancies. However, recent clinical studies have shown variable response rates with advanced solid tumors. This study provides an overview on current immunotherapy strategies and on IGF-targeted therapy for gynecologic malignancies. We focus on the involvement of IGF1R signaling in DCs and present our preliminary results which imply that the IGF axis contributes to an immunosuppressive tumor microenvironment (TME). For the long term, we believe that restoring the TME function by IGF1R targeting in combination with immunotherapy can serve as a new clinical approach for gynecological cancers.
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Affiliation(s)
- Muna Alemi Yahya
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
- Gynecology Laboratory, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center (Affiliated with the Technion Israel Institute of Technology), Hadera, Israel
| | - Shilhav Meisel Sharon
- Gynecology Laboratory, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center (Affiliated with the Technion Israel Institute of Technology), Hadera, Israel
| | - Shay Hantisteanu
- Gynecology Laboratory, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center (Affiliated with the Technion Israel Institute of Technology), Hadera, Israel
| | - Mordechai Hallak
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
- Gynecology Laboratory, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center (Affiliated with the Technion Israel Institute of Technology), Hadera, Israel
| | - Ilan Bruchim
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
- Gynecology Laboratory, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center (Affiliated with the Technion Israel Institute of Technology), Hadera, Israel
- Department of Human Molecular Genetics and Biochemistry, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- *Correspondence: Ilan Bruchim,
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12
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Kamińska I, Bar JK. The association between p53 protein phosphorylation at serine 15, serine 20 and sensitivity of cells isolated from patients with ovarian cancer and cell lines to chemotherapy in in vitro study. Pharmacol Rep 2017; 70:570-576. [PMID: 29684847 DOI: 10.1016/j.pharep.2017.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 12/06/2017] [Accepted: 12/14/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND The association between p53 protein phosphorylated at serine 15 (Ser15), serine 20 (Ser20) and ovarian tumor cell sensitivity after chemotherapy was analyzed in order to define the influence of p53 activation on tumor cell sensitivity to chemotherapy. METHODS The study was performed on ovarian cancer cell line (OvBH-1), colon adenocarcinoma metastasis to ovary (SW626) and on cells isolated from ascitic fluids from patients with ovarian cancer: with (p53+) or without (p53-) p53 nuclear protein accumulation. p53 protein, Ser15, Ser20, Bax, Noxa and PgP protein expression was evaluated by means of immunocytochemical staining before and after chemotherapy. Cell viability after treatment was estimated using MTT assay. RESULTS Cell lines and tumor cells p53+, p53- revealed a significant decrease in cell survival after camptothecin, paclitaxel, cisplatin treatment, compared to the control group (p < 0.01). In p53+ group, the expression of Ser20 significantly increased after camptothecin and paclitaxel (p < 0.05). Ser15, Ser20, Bax, Noxa expression correlated with MTT and depended on p53+, p53- tumor cell and the drug used (p < 0.05). Expression of Bax and Noxa were dependent on the type of tumor cells and drug used. The correlation between Ser15, Ser20 and Bax, Noxa expression was found in cell lines and tumor cells (p < 0.05). CONCLUSIONS Our study suggests that the relation between Ser15 or Ser20 and tumor cell viability might reflect their role in tumor sensitivity on chemotherapy in dependent p53 protein status. Revealed association between p53 protein phosphorylated at Ser15, Ser20 and Bax, Noxa protein expression determined the apoptotic activity of tumor cells.
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Affiliation(s)
- Iwona Kamińska
- Department of Immunopathology and Molecular Biology, Medical University, Wrocław, Poland.
| | - Julia K Bar
- Department of Immunopathology and Molecular Biology, Medical University, Wrocław, Poland.
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Oda K, Tanikawa M, Sone K, Mori-Uchino M, Osuga Y, Fujii T. Recent advances in targeting DNA repair pathways for the treatment of ovarian cancer and their clinical relevance. Int J Clin Oncol 2017; 22:611-618. [DOI: 10.1007/s10147-017-1137-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 04/28/2017] [Indexed: 11/24/2022]
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Chuwa AH, Sone K, Oda K, Ikeda Y, Fukuda T, Wada-Hiraike O, Inaba K, Makii C, Takeuchi M, Oki S, Miyasaka A, Kashiyama T, Arimoto T, Kuramoto H, Kawana K, Yano T, Osuga Y, Fujii T. Significance of survivin as a prognostic factor and a therapeutic target in endometrial cancer. Gynecol Oncol 2016; 141:564-569. [PMID: 27079211 DOI: 10.1016/j.ygyno.2016.04.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/31/2016] [Accepted: 04/02/2016] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Survivin is an anti-apoptotic protein encoded by the baculoviral inhibitor of apoptosis repeat-containing (BIRC5) gene and is upregulated in 83% of endometrial cancers. We aimed to elucidate the prognostic importance of BIRC5 expression, and evaluate survivin as a therapeutic target for endometrial cancer, by knock-down of BIRC5 and using the survivin inhibitor-YM155. METHODS RNA sequencing data in 234 patients with endometrial carcinoma was obtained from The Cancer Genome Atlas database, and analyzed using Kaplan-Meier method, log-rank test and Cox proportional hazard model. Expressions of survivin in 16 endometrial cancer cell lines were analyzed by western blotting. Knocking down effect on survivin expression was evaluated using a small interfering RNA (siRNA). The anti-proliferative and pro-apoptotic effects of YM155 were assessed with cell viability, flow cytometry, and annexin V/propidium iodide assays. RESULTS High expression of BIRC5 was associated with poor progression free survival (P=0.006), and shown to be an independent prognostic factor (HR=1.97, 95% CI=1.29-4.5, P=0.045). Survivin was upregulated in 14 of 16 (87.5%) endometrial cancer cell lines, compared with endometrial immortalized cells. Apoptosis was induced by knockdown of BIRC5 in all 3 cell lines examined. YM155 showed increased population of sub-G1 cells (P<0.001) in all 16 cell lines, and IC50 values to YM155 were <50nm in 15 cell lines. YM155 dose-dependently and significantly increased the apoptotic cell population in all 16 cell lines (P<0.001). CONCLUSIONS Present study indicated that survivin expression is a significant prognostic factor and that survivin is a promising therapeutic target for endometrial cancer.
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Affiliation(s)
- Agapiti Hipoliti Chuwa
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan
| | - Kenbun Sone
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan
| | - Katsutoshi Oda
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan.
| | - Yuji Ikeda
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan
| | - Tomohiko Fukuda
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan
| | - Osamu Wada-Hiraike
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan
| | - Kanako Inaba
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan
| | - Chinami Makii
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan
| | - Makoto Takeuchi
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan
| | - Shinya Oki
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan
| | - Aki Miyasaka
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan
| | - Tomoko Kashiyama
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan
| | - Takahide Arimoto
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan
| | | | - Kei Kawana
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan
| | - Tetsu Yano
- Department of Obstetrics and Gynecology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan
| | - Tomoyuki Fujii
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo, Tokyo 113-8655, Japan
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