1
|
De Lorenzis E, Wasson CW, Del Galdo F. Alveolar epithelial-to-mesenchymal transition in scleroderma interstitial lung disease: Technical challenges, available evidence and therapeutic perspectives. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2024; 9:7-15. [PMID: 38333528 PMCID: PMC10848925 DOI: 10.1177/23971983231181727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/27/2023] [Indexed: 02/10/2024]
Abstract
The alveolar epithelial-to-mesenchymal transition is the process of transformation of differentiated epithelial cells into mesenchymal-like cells through functional and morphological changes. A partial epithelial-to-mesenchymal transition process can indirectly contribute to lung fibrosis through a paracrine stimulation of the surrounding cells, while a finalized process could also directly enhance the pool of pulmonary fibroblasts and the extracellular matrix deposition. The direct demonstration of alveolar epithelial-to-mesenchymal transition in scleroderma-related interstitial lung disease is challenging due to technical pitfalls and the limited availability of lung tissue samples. Similarly, any inference on epithelial-to-mesenchymal transition occurrence driven from preclinical models should consider the limitations of cell cultures and animal models. Notwithstanding, while the occurrence or the relevance of this phenomenon in scleroderma-related interstitial lung disease have not been directly and conclusively demonstrated until now, pre-clinical and clinical evidence supports the potential role of epithelial-to-mesenchymal transition in the development and progression of lung fibrosis. Evidence consolidation on scleroderma-related interstitial lung disease epithelial-to-mesenchymal transition would pave the way for new therapeutic opportunities to prevent, slow or even reverse lung fibrosis, drawing lessons from current research lines in neoplastic epithelial-to-mesenchymal transition.
Collapse
Affiliation(s)
- Enrico De Lorenzis
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Division of Rheumatology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Francesco Del Galdo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
2
|
Buzan MT, Wetscherek A, Rank CM, Kreuter M, Heussel CP, Kachelrieß M, Dinkel J. Delayed contrast dynamics as marker of regional impairment in pulmonary fibrosis using 5D MRI - a pilot study. Br J Radiol 2020; 93:20190121. [PMID: 32584606 DOI: 10.1259/bjr.20190121] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To analyse delayed contrast dynamics of fibrotic lesions in interstitial lung disease (ILD) using five dimensional (5D) MRI and to correlate contrast dynamics with disease severity. METHODS 20 patients (mean age: 71 years; M:F, 13:7), with chronic fibrosing ILD: n = 12 idiopathic pulmonary fibrosis (IPF) and n = 8 non-IPF, underwent thin-section multislice CT as part of the standard diagnostic workup and additionally MRI of the lung. 2 min after contrast injection, a radial gradient echo sequence with golden-angle spacing was acquired during 5 min of free-breathing, followed by 5D image reconstruction. Disease was categorized as severe or non-severe according to CT morphological regional severity. For each patient, 10 lesions were analysed. RESULTS IPF lesions showed later peak enhancement compared to non-IPF (severe: p = 0.01, non-severe: p = 0.003). Severe lesions showed later peak enhancement compared to non-severe lesions, in non-IPF (p = 0.04), but not in IPF (p = 0.35). There was a tendency towards higher accumulation and washout rates in IPF compared to non-IPF in non-severe disease. Severe lesions had lower washout rate than non-severe ones in both IPF (p = 0.003) and non-IPF (p = 0.005). Continuous contrast agent accumulation, without washout, was found only in IPF lesions. CONCLUSIONS Contrast agent dynamics are influenced by type and severity of pulmonary fibrosis, which might enable a more thorough characterisation of disease burden. The regional impairment is of particular interest in the context of antifibrotic treatments and was characterised using a non-invasive, non-irradiating, free-breathing method. ADVANCES IN KNOWLEDGE Delayed contrast enhancement patterns allow the assessment of regional lung impairment which could represent different disease stages or phenotypes in ILD.
Collapse
Affiliation(s)
- Maria Ta Buzan
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Department of Pneumology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Andreas Wetscherek
- Medical Physics in Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Christopher M Rank
- Medical Physics in Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Michael Kreuter
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,Center for Rare and Interstitial Lung Diseases, Pneumology and respiratory critical care medicine, Thoraxklinik, Heidelberg University Hospital, Heidelberg, Germany
| | - Claus Peter Heussel
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,Center for Rare and Interstitial Lung Diseases, Pneumology and respiratory critical care medicine, Thoraxklinik, Heidelberg University Hospital, Heidelberg, Germany
| | - Marc Kachelrieß
- Medical Physics in Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Julien Dinkel
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Munich, Germany.,Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| |
Collapse
|
3
|
Cottin V, Hirani NA, Hotchkin DL, Nambiar AM, Ogura T, Otaola M, Skowasch D, Park JS, Poonyagariyagorn HK, Wuyts W, Wells AU. Presentation, diagnosis and clinical course of the spectrum of progressive-fibrosing interstitial lung diseases. Eur Respir Rev 2018; 27:180076. [PMID: 30578335 PMCID: PMC9489068 DOI: 10.1183/16000617.0076-2018] [Citation(s) in RCA: 327] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 11/08/2018] [Indexed: 01/22/2023] Open
Abstract
Although these conditions are rare, a proportion of patients with interstitial lung diseases (ILDs) may develop a progressive-fibrosing phenotype. Progressive fibrosis is associated with worsening respiratory symptoms, lung function decline, limited response to immunomodulatory therapies, decreased quality of life and, potentially, early death. Idiopathic pulmonary fibrosis may be regarded as a model for other progressive-fibrosing ILDs. Here we focus on other ILDs that may present a progressive-fibrosing phenotype, namely idiopathic nonspecific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, connective tissue disease-associated ILDs (e.g. rheumatoid arthritis-related ILD), fibrotic chronic hypersensitivity pneumonitis, fibrotic chronic sarcoidosis and ILDs related to other occupational exposures. Differential diagnosis of these ILDs can be challenging, and requires detailed consideration of clinical, radiological and histopathological features. Accurate and early diagnosis is crucial to ensure that patients are treated optimally.
Collapse
Affiliation(s)
- Vincent Cottin
- Louis Pradel Hospital, Reference Center for Rare Pulmonary Diseases, Hospices Civils de Lyon, UMR 754, Université Claude Bernard Lyon 1, Lyon, France
- Co-lead authors of this paper
| | - Nikhil A. Hirani
- Edinburgh Lung Fibrosis Clinic and MRC Centre for Inflammation Research, The Queen's Medical Research Centre, The University of Edinburgh, Edinburgh, UK
| | - David L. Hotchkin
- Division of Pulmonary and Critical Care Medicine, Oregon Clinic, Portland, OR, USA
| | - Anoop M. Nambiar
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, University of Texas Health Science Center San Antonio and the South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Takashi Ogura
- Kanagawa Cardiovascular and Respiratory Center, Kanagawa, Japan
| | - María Otaola
- Fundación FUNEF, Instituto de Rehabilitacion Psicofísica (IREP Hospital), Buenos Aires, Argentina
| | - Dirk Skowasch
- Dept of Internal Medicine II, Cardiology, Pneumology and Angiology, University Hospital Bonn, Bonn, Germany
| | - Jong Sun Park
- Division of Pulmonary and Critical Care Medicine, Dept of Internal Medicine and Lung Institute of Medical Research Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | | | - Wim Wuyts
- Unit for Interstitial Lung Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Athol U. Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
- Co-lead authors of this paper
| |
Collapse
|
4
|
Strouvalis I, Routsi C, Adamopoulou M, Raftogiannis M, Renieris G, Orfanos SE, Kotanidou A, Sabracos L, Giamarellos-Bourboulis EJ. Early increase of VEGF-A is associated with resolution of ventilator-associated pneumonia: Clinical and experimental evidence. Respirology 2018; 23:942-949. [PMID: 29741298 DOI: 10.1111/resp.13320] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 02/12/2018] [Accepted: 03/29/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVE The role of vascular endothelial growth factor (VEGF)-A in the resolution of ventilator-associated pneumonia (VAP) was investigated in clinical and mouse pneumonia models. METHODS VEGF-A was measured for seven consecutive days by an immunosorbent assay in sera of 82 patients with VAP and changes from baseline were correlated with the resolution of VAP. Experimental animals were challenged intratracheally with Pseudomonas aeruginosa. Mouse bronchoalveolar lavage (BAL) samples and segments of lung tissue were obtained at 24, 48 and 124 h after bacterial challenge. Levels of VEGF-A, tumour Necrosis Factor alpha (TNF-α), interleukin (IL)-1β, interferon-gamma (IFNγ) and myeloperoxidase (MPO) activity were measured in these samples. RESULTS VAP resolved in 36.1% of patients with a less than 45% increase of VEGF-A on day 5 compared to 65.2% of patients with a more than 45% increase (P = 0.014). This was also accompanied by an earlier resolution of VAP (log-rank: 7.99; P = 0.005) and it was not pathogen-specific. The increase of VEGF-A was an independent variable associated with VAP resolution in forward logistic regression analysis where Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores were included as independent variables. VEGF-A in mouse BAL and lung tissue increased significantly at 124 h but not with the other mediators. In mice pre-treated with bevacizumab, VEGF-A concentrations decreased while TNF-α and MPO significantly increased. CONCLUSION In patients, an association between increased levels of circulating VEGF-A and VAP resolution was observed. The mouse study suggests that elevated VEGF-A levels may be associated with lung inflammation resolution. CLINICAL TRIAL REGISTRATION NCT00297674 at www.clinicaltrials.gov.
Collapse
Affiliation(s)
- Ioannis Strouvalis
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Christina Routsi
- 1st Department of Critical Care Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Adamopoulou
- Department of Medical Laboratories, Molecular Microbiology Laboratory, Technological Institution of Athens, Athens, Greece
| | - Maria Raftogiannis
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George Renieris
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Stylianos E Orfanos
- 2nd Department of Critical Care Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Kotanidou
- 1st Department of Critical Care Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Labros Sabracos
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | |
Collapse
|
5
|
Montero MA, Osadolor T, Khiroya R, Salcedo MT, Robertus JL, Rice A, Nicholson AG, Roman A, Monforte V. Restrictive allograft syndrome and idiopathic pleuroparenchymal fibroelastosis: do they really have the same histology? Histopathology 2017; 70:1107-1113. [DOI: 10.1111/his.13171] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 01/21/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Maria A Montero
- Histopathology Department; Royal Brompton and Harefield NHS Foundation Trust; London UK
- Biomedical Respiratory Unit; Imperial College London; London UK
| | - Tina Osadolor
- Biomedical Respiratory Unit; Imperial College London; London UK
| | - Reena Khiroya
- Histopathology Department; Royal Brompton and Harefield NHS Foundation Trust; London UK
| | | | - Jan L Robertus
- Histopathology Department; Royal Brompton and Harefield NHS Foundation Trust; London UK
| | - Alexandra Rice
- Histopathology Department; Royal Brompton and Harefield NHS Foundation Trust; London UK
| | - Andrew G Nicholson
- Histopathology Department; Royal Brompton and Harefield NHS Foundation Trust; London UK
| | - Antonio Roman
- Respiratory Medicine; Vall d'Hebron University Hospitals; Barcelona Spain
| | - Victor Monforte
- Respiratory Medicine; Vall d'Hebron University Hospitals; Barcelona Spain
| |
Collapse
|
6
|
Kuehnel M, Maegel L, Vogel-Claussen J, Robertus JL, Jonigk D. Airway remodelling in the transplanted lung. Cell Tissue Res 2016; 367:663-675. [PMID: 27837271 DOI: 10.1007/s00441-016-2529-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 10/12/2016] [Indexed: 12/22/2022]
Abstract
Following lung transplantation, fibrotic remodelling of the small airways has been recognized for almost 5 decades as the main correlate of chronic graft failure and a major obstacle to long-term survival. Mainly due to airway fibrosis, pulmonary allografts currently show the highest attrition rate of all solid organ transplants, with a 5-year survival rate of 58 % on a worldwide scale. The observation that these morphological changes are not just the hallmark of chronic rejection but rather represent a manifestation of a multitude of alloimmune-dependent and -independent injuries was made more recently, as was the discovery that chronic lung allograft dysfunction manifests in different clinical phenotypes of respiratory impairment and corresponding morphological subentities. Although recent years have seen considerable advances in identifying and categorizing these subgroups on the basis of clinical, functional and histomorphological changes, as well as susceptibility to medicinal treatment, this process is far from over. Since the actual pathophysiological mechanisms governing airway remodelling are still only poorly understood, diagnosis and therapy of chronic lung allograft dysfunction presents a major challenge to clinicians, radiologists and pathologists alike. Here, we review and discuss the current state of the literature on chronic lung allograft dysfunction and shed light on classification systems, corresponding clinical and morphological changes, key cellular players and underlying molecular pathways, as well as on emerging diagnostic and therapeutic approaches.
Collapse
Affiliation(s)
- Mark Kuehnel
- Institute of Pathology, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, D-30625, Hanover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease (BREATH), The German Center for Lung Research (Deutsches Zentrum für Lungenforschung, DZL), Hanover, Germany
| | - Lavinia Maegel
- Institute of Pathology, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, D-30625, Hanover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease (BREATH), The German Center for Lung Research (Deutsches Zentrum für Lungenforschung, DZL), Hanover, Germany
| | | | - Jan Lukas Robertus
- Royal Brompton & Harefield NHS Foundation Trust, Department of Histopathology, Hanover, Germany
| | - Danny Jonigk
- Institute of Pathology, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, D-30625, Hanover, Germany.
| |
Collapse
|
7
|
Papp Á, Bene Z, Gáspár I, Nagy B, Kádár L, Márialigeti T, Bánfi A, Baktai G, Balla G, Nagy B. Decreased VEGF Level Is Associated with Elevated Ferritin Concentration in Bronchoalveolar Lavage Fluid of Children with Interstitial Lung Diseases. Respiration 2015; 90:443-450. [PMID: 26473738 DOI: 10.1159/000440888] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 09/01/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A decreased level of vascular endothelial growth factor (VEGF) was previously described in bronchoalveolar lavage fluid (BALF) of adults with interstitial lung diseases (ILD) due to bronchial epithelial cell apoptosis and its proteolytic degradation. Elevated intrapulmonary ferritin was produced by alveolar cells that promoted oxidative injury in such patients. OBJECTIVES In this study, we analyzed the concentrations of VEGF and ferritin in BALF samples of ILD children and studied the relationship between their levels and the degree of inflammation. METHODS BALF and serum concentration of VEGF as well as ferritin and albumin in BALF samples were measured using enzyme-linked immunosorbent assay in children with idiopathic interstitial pneumonia (n = 16), hypersensitivity pneumonitis (n = 11) and idiopathic pulmonary hemosiderosis (n = 3). Twenty-four age- and gender-matched subjects with suspicious foreign body aspiration served as a control group. RESULTS VEGF per albumin levels in BALF were significantly decreased in ILD children compared to controls (1,075 [784-1,415] pg/mg albumin vs. 2,741 [1,131-4,660] pg/mg albumin, p = 0.0008). These values showed a significant negative correlation with inflammatory markers of total immune cell count in BALF (r = -0.411, p = 0.002) and serum C-reactive protein (r = -0.367, p = 0.006). Although serum VEGF was augmented in ILD children versus controls, no difference was observed among the ILD groups. In addition, BALF ferritin/albumin level (688 [188-1,571] ng/mg albumin vs. 256 [178-350] ng/mg albumin, p = 0.022) was significantly higher than normal in ILD individuals, especially in idiopathic pulmonary hemosiderosis. CONCLUSION Depressed VEGF and increased ferritin in BALF may reflect the severity of chronic pulmonary inflammation in altered respiratory epithelium of childhood ILD.
Collapse
Affiliation(s)
- Ágnes Papp
- Department of Pediatrics, Clinical Center, University of Debrecen, Debrecen, Hungary
| | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Yoneshige A, Hagiyama M, Inoue T, Mimae T, Kato T, Okada M, Enoki E, Ito A. Increased ectodomain shedding of cell adhesion molecule 1 as a cause of type II alveolar epithelial cell apoptosis in patients with idiopathic interstitial pneumonia. Respir Res 2015; 16:90. [PMID: 26231557 PMCID: PMC4531801 DOI: 10.1186/s12931-015-0255-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 07/21/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Lung alveolar epithelial cell (AEC) apoptosis has attracted attention as an early pathogenic event in the development of idiopathic interstitial pneumonia (IIP); however, the causative mechanism remains unclear. Cell adhesion molecule 1 (CADM1) is an AEC adhesion molecule in the immunoglobulin superfamily. It generates a membrane-associated C-terminal fragment, αCTF, through protease-mediated ectodomain shedding, termed α-shedding. Increased CADM1 α-shedding contributes to AEC apoptosis in emphysematous lungs. METHODS Formalin-fixed, paraffin-embedded lung lobes (n = 39) from 36 autopsied patients with IIP were classified as acute IIP (n = 10), fibrosing-type nonspecific IIP (f-NSIP, n = 10), cryptogenic organizing IIP (n = 9), and usual IIP (n = 10). CADM1 expression in the lung sections was examined by western blotting and compared with control lungs (n = 10). The rate of CADM1 α-shedding was calculated as the relative amount of αCTF to full-length CADM1, and the full-length CADM1 level was estimated per epithelial cell by normalization to cytokeratin 7, a lung epithelial marker. Apoptotic AECs were detected by immunohistochemistry for single-stranded DNA (ssDNA). NCI-H441 and A549 human lung epithelial cells were transfected with small interfering RNA (siRNA) to silence CADM1 expression and analyzed by terminal nucleotide nick end labeling assays. RESULTS The rate of CADM1 α-shedding was higher in all IIP subtypes than in the control (P ≤ 0.019), and the full-length CADM1 level was lower in f-NSIP (P = 0.007). The α-shedding rate and full-length CADM1 level were correlated with each other (P = 0.015) and with the proportion of ssDNA-positive AECs (P ≤ 0.024). NCI-H441 cells transfected with siRNA exhibited a 61 % lower rate of expression of full-length CADM1 and a 17-fold increased proportion of apoptotic cells. Similar results were obtained with A549 cells. CONCLUSIONS CADM1 α-shedding appeared to be increased in all four IIP subtypes and consequently contributed to AEC apoptosis by decreasing the full-length CADM1 level. This mechanism particularly impacted f-NSIP. The molecular mechanism causing AEC apoptosis may be similar between IIP and emphysema.
Collapse
Affiliation(s)
- Azusa Yoneshige
- Department of Pathology, Faculty of Medicine, Kinki University, Osaka, 589-8511, Japan
| | - Man Hagiyama
- Department of Pathology, Faculty of Medicine, Kinki University, Osaka, 589-8511, Japan
| | - Takao Inoue
- Department of Pathology, Faculty of Medicine, Kinki University, Osaka, 589-8511, Japan
| | - Takahiro Mimae
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Takashi Kato
- Department of Pathology, Faculty of Medicine, Kinki University, Osaka, 589-8511, Japan
| | - Morihito Okada
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Eisuke Enoki
- Department of Pathology, Faculty of Medicine, Kinki University, Osaka, 589-8511, Japan
| | - Akihiko Ito
- Department of Pathology, Faculty of Medicine, Kinki University, Osaka, 589-8511, Japan.
| |
Collapse
|