1
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Lu X, Zhong L, Lindell E, Veanes M, Guo J, Zhao M, Salehi M, Swartling FJ, Chen X, Sjöblom T, Zhang X. Identification of ATF3 as a novel protective signature of quiescent colorectal tumor cells. Cell Death Dis 2023; 14:676. [PMID: 37833290 PMCID: PMC10576032 DOI: 10.1038/s41419-023-06204-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/20/2023] [Accepted: 09/28/2023] [Indexed: 10/15/2023]
Abstract
Colorectal cancer (CRC) is the third most common cancer and the second leading cause of death in the world. In most cases, drug resistance and tumor recurrence are ultimately inevitable. One obstacle is the presence of chemotherapy-insensitive quiescent cancer cells (QCCs). Identification of unique features of QCCs may facilitate the development of new targeted therapeutic strategies to eliminate tumor cells and thereby delay tumor recurrence. Here, using single-cell RNA sequencing, we classified proliferating and quiescent cancer cell populations in the human colorectal cancer spheroid model and identified ATF3 as a novel signature of QCCs that could support cells living in a metabolically restricted microenvironment. RNA velocity further showed a shift from the QCC group to the PCC group indicating the regenerative capacity of the QCCs. Our further results of epigenetic analysis, STING analysis, and evaluation of TCGA COAD datasets build a conclusion that ATF3 can interact with DDIT4 and TRIB3 at the transcriptional level. In addition, decreasing the expression level of ATF3 could enhance the efficacy of 5-FU on CRC MCTS models. In conclusion, ATF3 was identified as a novel marker of QCCs, and combining conventional drugs targeting PCCs with an option to target QCCs by reducing ATF3 expression levels may be a promising strategy for more efficient removal of tumor cells.
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Affiliation(s)
- Xi Lu
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Lei Zhong
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Department of Pharmacy, Personalized Drug Therapy Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, Sichuan, China
| | - Emma Lindell
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Margus Veanes
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Jing Guo
- Centre for Computational Biology, Duke-NUS Medical School, 8 College Road, 169857, Singapore, Singapore
| | - Miao Zhao
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Maede Salehi
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Fredrik J Swartling
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Xingqi Chen
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Tobias Sjöblom
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Xiaonan Zhang
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.
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2
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Chatterji S, Krzoska E, Thoroughgood CW, Saganty J, Liu P, Elsberger B, Abu-Eid R, Speirs V. Defining genomic, transcriptomic, proteomic, epigenetic, and phenotypic biomarkers with prognostic capability in male breast cancer: a systematic review. Lancet Oncol 2023; 24:e74-e85. [PMID: 36725152 DOI: 10.1016/s1470-2045(22)00633-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/15/2022] [Accepted: 10/10/2022] [Indexed: 02/02/2023]
Abstract
Although similar phenotypically, there is evidence that male and female breast cancer differ in their molecular landscapes. In this systematic review, we consolidated all existing prognostic biomarker data in male breast cancer spanning genetics, transcriptomics, proteomics, and epigenetics, and phenotypic features of prognostic value from articles published over a 29-year period (March 16, 1992, to May 1, 2021). We identified knowledge gaps in the existing literature, discussed limitations of the included studies, and outlined potential approaches for translational biomarker discovery and validation in male breast cancer. We also recognised STC2, DDX3, and DACH1 as underexploited markers of male-specific prognostic value in breast cancer. Finally, beyond describing the cumulative knowledge on the extensively researched markers oestrogen receptor-α, progesterone receptor, HER2, androgen receptor, and BRCA2, we highlighted ATM, CCND1, FGFR2, GATA3, HIF1-α, MDM2, TP53, and c-Myc as well studied predictors of poor survival that also aligned with several hallmarks of cancer.
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Affiliation(s)
- Subarnarekha Chatterji
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK; Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Emma Krzoska
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | | | - John Saganty
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Peng Liu
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK; Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | | | - Rasha Abu-Eid
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK; Institute of Dentistry, University of Aberdeen, Aberdeen, UK
| | - Valerie Speirs
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK; Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK.
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3
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Ito K, Kitajima Y, Kai K, Matsufuji S, Yamada K, Egawa N, Kitagawa H, Okuyama K, Tanaka T, Noshiro H. Matrix metalloproteinase‑1 expression is regulated by HIF‑1‑dependent and epigenetic mechanisms and serves a tumor‑suppressive role in gastric cancer progression. Int J Oncol 2021; 59:102. [PMID: 34738626 PMCID: PMC8577796 DOI: 10.3892/ijo.2021.5282] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/11/2021] [Indexed: 02/05/2023] Open
Abstract
The matrix metalloproteinase (MMP) family is associated with degradation of the extracellular matrix and is known to promote cancer invasion. The present study aimed to investigate the biological role of MMP-1 in gastric cancer cells and analyze the association between MMP-1 expression and the clinical outcomes of gastric cancer patients. In the present study, hypoxia accelerated invasion, accompanied by elevated MMP-1 expression in the gastric cancer cell line 58As9. Additionally, hypoxia-inducible factor-1α (HIF-1α) knock- down in 58As9 cells reduced MMP-1 expression under hypoxic conditions. Treatment with 5-aza-2-deoxycytidine and trichostatin A restored MMP-1 expression in the MMP-1-deficient cell lines MKN45 and MKN74. These results indicated that MMP-1 expression was controlled by both HIF-1α-dependent and epigenetic mechanisms in gastric cancer cell lines. In addition, MMP-1 knockdown impaired the hypoxia-induced invasiveness of 58As9 cells, implicating MMP-1 in the elevated invasion. By contrast, knockdown enhanced the proliferative ability of 58As9 cells, whereby expression of cell cycle-related genes was subsequently altered. In nude mouse models, the knockdown accelerated the growth of xenograft tumor and the development of peritoneal dissemination. In an immunohistochemical study using 161 surgically resected cancer tissues, the Ki67 score was significantly higher in the group with low MMP-1 expression (P<0.001). Disease-free survival (DFS) and disease-specific survival (DSS) were both significantly reduced in patients with low MMP-1 expression (log-rank test; DFS: P=0.005; DSS: P=0.022). Multivariate analysis demonstrated that MMP-1 expression was an independent prognostic factor for DFS and DSS [DFS: HR=2.11 (1.22–3.92) P=0.005, DSS: HR=2.90 (1.23–8.50) P=0.012]. In conclusion, the present study indicated that MMP-1 may serve as a tumor-suppressive factor that inhibits gastric cancer progression, although it promoted invasion in vitro.
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Affiliation(s)
- Kotaro Ito
- Department of Surgery, Saga University Faculty of Medicine, Saga 849‑8501, Japan
| | - Yoshihiko Kitajima
- Department of Surgery, National Hospital Organization Higashisaga Hospital, Miyaki, Saga 849‑0101, Japan
| | - Keita Kai
- Department of Pathology, Saga University Hospital, Saga 849‑8501, Japan
| | - Shohei Matsufuji
- Department of Surgery, Saga University Faculty of Medicine, Saga 849‑8501, Japan
| | - Kohei Yamada
- Department of Surgery, Saga University Faculty of Medicine, Saga 849‑8501, Japan
| | - Noriyuki Egawa
- Department of Surgery, Saga University Faculty of Medicine, Saga 849‑8501, Japan
| | - Hiroshi Kitagawa
- Department of Surgery, Saga University Faculty of Medicine, Saga 849‑8501, Japan
| | - Keiichiro Okuyama
- Department of Surgery, Saga University Faculty of Medicine, Saga 849‑8501, Japan
| | - Tomokazu Tanaka
- Department of Surgery, Saga University Faculty of Medicine, Saga 849‑8501, Japan
| | - Hirokazu Noshiro
- Department of Surgery, Saga University Faculty of Medicine, Saga 849‑8501, Japan
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4
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André S, Pinto AE, Silva GL, Silva F, Serpa J, Félix A. Male Breast Cancer-Immunohistochemical Patterns and Clinical Relevance of FASN, ATF3, and Collagen IV. BREAST CANCER-BASIC AND CLINICAL RESEARCH 2021; 15:11782234211002496. [PMID: 33888988 PMCID: PMC8040573 DOI: 10.1177/11782234211002496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/24/2021] [Indexed: 11/16/2022]
Abstract
Background Male breast carcinoma (male BC) is an uncommon neoplasia without individualized strategies for diagnosis and therapeutics. Low overall survival (OS) rates have been reported, mostly associated with patients' advanced stage and older age. Intratumoral heterogeneity versus homogeneity of malignant epithelial cells seems to be an important factor to consider for the development of combination therapies with curative intention. Objective In this preliminary study, we aim to provide valuable insight into the distinct clinicopathologic features of male BC. Material and methods In a series of 40 male BC patients, we evaluated by immunohistochemistry androgen receptor; activating transcription factor 3 (ATF3); p16; cyclin D1; fatty acid synthase (FASN); fatty acid transport protein 1 (FATP1); β1, β3, β4, and β6 integrins; collagen I and collagen IV; and their interactions. Kaplan-Meier survival curves and log-rank tests were assessed for statistical analysis. Results Homogeneous epithelial staining of p16, ATF3, β6 integrin, FASN, and FATP1 was found to be significantly intercorrelated, and associated with high Ki67. These markers also stained tumor stromal fibroblasts. The prognostic analysis showed statistically significant associations of FASN with disease-free survival (DFS) and OS, as well as of ATF3 with OS and collagen IV with DFS. Conclusions This study highlights, as a novel finding, the relevance of FASN, ATF3, and collagen IV immunophenotypes, which may have innovative application in the clinical management of male BC.
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Affiliation(s)
- Saudade André
- Department of Pathology, Portuguese Institute of Oncology of Lisbon, Lisbon, Portugal
| | - António E Pinto
- Department of Pathology, Portuguese Institute of Oncology of Lisbon, Lisbon, Portugal
| | - Giovani L Silva
- Department of Mathematics of Higher Technical Institute (Instituto Superior Técnico), Faculty of Sciences (Faculdade de Ciências), University of Lisbon, Lisbon, Portugal.,Statistics and Applications Center of University of Lisbon (CEAUL), Lisbon, Portugal
| | - Fernanda Silva
- CEDOC, NOVA Medical School, NOVA University, Lisbon, Portugal
| | - Jacinta Serpa
- CEDOC, NOVA Medical School, NOVA University, Lisbon, Portugal
| | - Ana Félix
- Department of Pathology, Portuguese Institute of Oncology of Lisbon, Lisbon, Portugal.,CEDOC, NOVA Medical School, NOVA University, Lisbon, Portugal
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5
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Abstract
No national data have been available on descriptive epidemiology of mammary Paget's disease (MPD) in China. This population-based study aimed to estimate the prevalence of MPD and its pattens by sex, age and area in China. We conducted a population-based study using data in 2016 from China's Urban Employee Basic Medical Insurance and Urban Resident Basic Medical Insurance, covering approximately 0.43 billion residents. MPD cases were identified based on the diagnostic names and codes in claim data. A total of 825 patients of confirmed diagnosis of MPD were found during the study period. The prevalence of MPD in 2016 was 0.42 per 100,000 population (95% CI 0.19 to 0.73), with marked female predominance. The prevalence rates peaked at 40-59 years and ≥ 80 years in females and males, respectively. The prevalence rates varied among different regions, ranging from 0.06 (95% CI 0.00 to 0.23) in Northeast China to 1.21 (95% CI 0.07 to 3.72) in Northwest China. MPD showed marked female predominance in China. Chinese female patients were much younger, with lower prevalence than that in the United States. Obvious sex difference in the age pattern of MPD prevalence was also observed in China.
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6
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Controversies in clinicopathological characteristics and treatment strategies of male breast cancer: A review of the literature. Crit Rev Oncol Hematol 2017; 113:283-291. [DOI: 10.1016/j.critrevonc.2017.03.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 02/17/2017] [Accepted: 03/11/2017] [Indexed: 01/01/2023] Open
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7
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Martín-Ibáñez R, Pardo M, Giralt A, Miguez A, Guardia I, Marion-Poll L, Herranz C, Esgleas M, Garcia-Díaz Barriga G, Edel MJ, Vicario-Abejón C, Alberch J, Girault JA, Chan S, Kastner P, Canals JM. Helios expression coordinates the development of a subset of striatopallidal medium spiny neurons. Development 2017; 144:1566-1577. [PMID: 28289129 PMCID: PMC5399659 DOI: 10.1242/dev.138248] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 03/03/2017] [Indexed: 12/25/2022]
Abstract
Here, we unravel the mechanism of action of the Ikaros family zinc finger protein Helios (He) during the development of striatal medium spiny neurons (MSNs). He regulates the second wave of striatal neurogenesis involved in the generation of striatopallidal neurons, which express dopamine 2 receptor and enkephalin. To exert this effect, He is expressed in neural progenitor cells (NPCs) keeping them in the G1/G0 phase of the cell cycle. Thus, a lack of He results in an increase of S-phase entry and S-phase length of NPCs, which in turn impairs striatal neurogenesis and produces an accumulation of the number of cycling NPCs in the germinal zone (GZ), which end up dying at postnatal stages. Therefore, He−/− mice show a reduction in the number of dorso-medial striatal MSNs in the adult that produces deficits in motor skills acquisition. In addition, overexpression of He in NPCs induces misexpression of DARPP-32 when transplanted in mouse striatum. These findings demonstrate that He is involved in the correct development of a subset of striatopallidal MSNs and reveal new cellular mechanisms for neuronal development. Summary: The transcription factor Helios regulates G1-S transition to promote neuronal differentiation of a striatopallidal neuronal subpopulation involved in motor skill acquisition.
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Affiliation(s)
- Raquel Martín-Ibáñez
- Stem Cells and Regenerative Medicine Laboratory, Production and Validation Center of Advanced Therapies (Creatio), Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, 08036 Barcelona, Spain.,Neuroscience Institute, University of Barcelona, 08036 Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), 08036 Barcelona, Spain.,Networked Biomedical Research Centre for Neurodegenerative Disorders (CIBERNED), Spain.,Research and Development Unit, Production and Validation Center of Advanced Therapies (Creatio), Faculty of Medicine and Health Sciences, University of Barcelona, 08036 Barcelona, Spain
| | - Mónica Pardo
- Stem Cells and Regenerative Medicine Laboratory, Production and Validation Center of Advanced Therapies (Creatio), Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, 08036 Barcelona, Spain.,Neuroscience Institute, University of Barcelona, 08036 Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), 08036 Barcelona, Spain.,Networked Biomedical Research Centre for Neurodegenerative Disorders (CIBERNED), Spain
| | - Albert Giralt
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), 08036 Barcelona, Spain.,Networked Biomedical Research Centre for Neurodegenerative Disorders (CIBERNED), Spain.,Pathophysiology of Neurodegenerative Diseases Laboratory, Production and Validation Center of Advanced Therapies (Creatio), Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, 08036 Barcelona, Spain
| | - Andrés Miguez
- Stem Cells and Regenerative Medicine Laboratory, Production and Validation Center of Advanced Therapies (Creatio), Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, 08036 Barcelona, Spain.,Neuroscience Institute, University of Barcelona, 08036 Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), 08036 Barcelona, Spain.,Networked Biomedical Research Centre for Neurodegenerative Disorders (CIBERNED), Spain
| | - Inés Guardia
- Stem Cells and Regenerative Medicine Laboratory, Production and Validation Center of Advanced Therapies (Creatio), Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, 08036 Barcelona, Spain.,Neuroscience Institute, University of Barcelona, 08036 Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), 08036 Barcelona, Spain.,Networked Biomedical Research Centre for Neurodegenerative Disorders (CIBERNED), Spain
| | - Lucile Marion-Poll
- Inserm UMR-S839; Université Pierre et Marie Curie (UPMC, Paris 6), Sorbonne Universités; Institut du Fer à Moulin, 75005 Paris, France
| | - Cristina Herranz
- Stem Cells and Regenerative Medicine Laboratory, Production and Validation Center of Advanced Therapies (Creatio), Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, 08036 Barcelona, Spain.,Neuroscience Institute, University of Barcelona, 08036 Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), 08036 Barcelona, Spain.,Networked Biomedical Research Centre for Neurodegenerative Disorders (CIBERNED), Spain.,Research and Development Unit, Production and Validation Center of Advanced Therapies (Creatio), Faculty of Medicine and Health Sciences, University of Barcelona, 08036 Barcelona, Spain
| | - Miriam Esgleas
- Stem Cells and Regenerative Medicine Laboratory, Production and Validation Center of Advanced Therapies (Creatio), Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, 08036 Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), 08036 Barcelona, Spain.,Networked Biomedical Research Centre for Neurodegenerative Disorders (CIBERNED), Spain
| | - Gerardo Garcia-Díaz Barriga
- Neuroscience Institute, University of Barcelona, 08036 Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), 08036 Barcelona, Spain.,Networked Biomedical Research Centre for Neurodegenerative Disorders (CIBERNED), Spain.,Pathophysiology of Neurodegenerative Diseases Laboratory, Production and Validation Center of Advanced Therapies (Creatio), Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, 08036 Barcelona, Spain
| | - Michael J Edel
- Control of Pluripotency Laboratory, Department of Biomedical Sciences, Faculty of Medicine and Health Science, University of Barcelona, 08036 Barcelona, Spain.,Victor Chang Cardiac Research Institute, Sydney, New South Wales, 2010 Australia.,School of Medicine and Pharmacology, Anatomy, Physiology and Human Biology, CCTRM, University of Western Australia, Western Australia, 6009 Australia
| | - Carlos Vicario-Abejón
- Networked Biomedical Research Centre for Neurodegenerative Disorders (CIBERNED), Spain.,Departamento de Neurobiología Molecular, Celular y del Desarrollo, Instituto Cajal, Consejo Superior de Investigaciones Científicas (CSIC), 28002 Madrid, Spain
| | - Jordi Alberch
- Neuroscience Institute, University of Barcelona, 08036 Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), 08036 Barcelona, Spain.,Networked Biomedical Research Centre for Neurodegenerative Disorders (CIBERNED), Spain
| | - Jean-Antoine Girault
- Inserm UMR-S839; Université Pierre et Marie Curie (UPMC, Paris 6), Sorbonne Universités; Institut du Fer à Moulin, 75005 Paris, France
| | - Susan Chan
- Stem Cells and Regenerative Medicine Laboratory, Production and Validation Center of Advanced Therapies (Creatio), Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, 08036 Barcelona, Spain.,Neuroscience Institute, University of Barcelona, 08036 Barcelona, Spain
| | - Philippe Kastner
- Department of Functional Genomics and Cancer, Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), Inserm U964, Centre National de la Recherche Scientifique (CNRS) UMR 7104, 67400 Illkirch-Graffenstaden, France.,Faculté de Médecine, Université de Strasbourg, 67081 Strasbourg, France
| | - Josep M Canals
- Stem Cells and Regenerative Medicine Laboratory, Production and Validation Center of Advanced Therapies (Creatio), Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, 08036 Barcelona, Spain .,Neuroscience Institute, University of Barcelona, 08036 Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), 08036 Barcelona, Spain.,Networked Biomedical Research Centre for Neurodegenerative Disorders (CIBERNED), Spain.,Research and Development Unit, Production and Validation Center of Advanced Therapies (Creatio), Faculty of Medicine and Health Sciences, University of Barcelona, 08036 Barcelona, Spain
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8
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Paget's disease of the male breast in the 21st century: A systematic review. Breast 2016; 29:14-23. [DOI: 10.1016/j.breast.2016.06.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/13/2016] [Accepted: 06/14/2016] [Indexed: 11/23/2022] Open
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9
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Male breast cancer is not congruent with the female disease. Crit Rev Oncol Hematol 2016; 101:119-24. [PMID: 26989051 DOI: 10.1016/j.critrevonc.2016.02.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 12/28/2015] [Accepted: 02/25/2016] [Indexed: 12/21/2022] Open
Abstract
It has become customary to extrapolate from the results of treatment trials for female breastcancer and apply them to males with the disease. In the absence of results from national and international randomised trials for male breast cancer (MBC) this appears superficially to be an appropriate response. Closer examination of available data reveals that aspects of the aetiology and treatment of MBC do not fit the simplistic model that men usually have endocrine sensitive tumours which behave like those in postmenopausal women. Most females and males with breast cancer have none of the recognised risk factors, indicating the gaps in our knowledge of the epidemiology of this disease. Several studies have compared epidemiological risk factors for MBC and female breast cancer (FBC) but many have been blighted by small numbers. In comparison with FBC there is a larger proportion of BRCA2 tumours, (occurring in 10% of MBC), and underrepresentation of BRCA1 tumours (found in only 1%), suggesting significant differences in the genetic aetiology of MBC and FBC. Genome-wide association studies in FBC reported single nucleotide polymorphisms (SNPs) in 12 novel independent loci were consistently associated with disease but for MBC 2 SNPs had a significantly increased risk. Molecular profiles of matched cancers in males and females showed a gender-associated modulation of major processes including energy metabolism, regulation of translation, matrix remodelling and immune recruitment. Immunohistochemistry for kinase inhibitor proteins (KIPs) p27Kip1 and p21Waf1 indicate a significant difference in the immunostaining of tumours from male patients compared with females. MBC is almost always estrogen receptor positive (ER+ve) and so systemic treatment is usually endocrine. With evidence in FBC that aromatase inhibitors are more effective than tamoxifen in the postmenopausal it was seemingly logical that the same would be true for MBC. Results however suggest less efficacy with AIs and an increase in risk of mortality compared to tamoxifen. The overall survival in male breast cancer was significantly better after adjuvant treatment with tamoxifen compared to an aromatase inhibitor. These important biological differences point the way to the development of new therapies for MBC based on differences rather than similarities with FBC.
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10
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Biesma HD, Schouten PC, Lacle MM, Sanders J, Brugman W, Kerkhoven R, Mandjes I, van der Groep P, van Diest PJ, Linn SC. Copy number profiling by array comparative genomic hybridization identifies frequently occurring BRCA2-like male breast cancer. Genes Chromosomes Cancer 2015; 54:734-44. [DOI: 10.1002/gcc.22284] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 06/25/2015] [Indexed: 11/08/2022] Open
Affiliation(s)
- Hedde D. Biesma
- Department of Molecular Pathology; Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Philip C. Schouten
- Department of Molecular Pathology; Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Miangela M. Lacle
- Department of Pathology; University Medical Center Utrecht; The Netherlands
| | - Joyce Sanders
- Department of Pathology; Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Wim Brugman
- Genomics Core Facility, Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Ron Kerkhoven
- Genomics Core Facility, Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Ingrid Mandjes
- Data Center, Netherlands Cancer Institute; Amsterdam The Netherlands
| | | | - Paul J. van Diest
- Department of Pathology; University Medical Center Utrecht; The Netherlands
| | - Sabine C. Linn
- Department of Molecular Pathology; Netherlands Cancer Institute; Amsterdam The Netherlands
- Department of Pathology; University Medical Center Utrecht; The Netherlands
- Department of Medical Oncology; Netherlands Cancer Institute; Amsterdam The Netherlands
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11
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Omran OM, Omer OH. The effects of alpha-lipoic acid on breast of female albino rats exposed to malathion: Histopathological and immunohistochemical study. Pathol Res Pract 2015; 211:462-9. [DOI: 10.1016/j.prp.2015.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 02/15/2015] [Accepted: 02/23/2015] [Indexed: 10/23/2022]
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12
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Senger JL, Chandran G, Kanthan R. Is routine pathological evaluation of tissue from gynecomastia necessary? A 15-year retrospective pathological and literature review. Plast Surg (Oakv) 2014. [DOI: 10.1177/229255031402200210] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jenna-Lynn Senger
- College of Medicine; Royal University Hospital, Saskatoon, Saskatchewan
| | - Geethan Chandran
- Department of Plastic Surgery, University of Saskatchewan; Saskatoon, Saskatchewan
| | - Rani Kanthan
- Department of Pathology & Laboratory Medicine, Royal University Hospital, Saskatoon, Saskatchewan
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13
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Johansson I, Killander F, Linderholm B, Hedenfalk I. Molecular profiling of male breast cancer - lost in translation? Int J Biochem Cell Biol 2014; 53:526-35. [PMID: 24842109 DOI: 10.1016/j.biocel.2014.05.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 05/07/2014] [Accepted: 05/09/2014] [Indexed: 02/06/2023]
Abstract
Breast cancer is the most common cancer form in women and it has been extensively studied on the molecular level. Male breast cancer (MBC), on the other hand, is rare and has not been thoroughly investigated in terms of transcriptional profiles or genomic aberrations. Most of our understanding of MBC has therefore been extrapolated from knowledge of female breast cancer. Although differences in addition to similarities with female breast cancer have been reported, the same prognostic and predictive markers are used to determine optimal management strategies for both men and women diagnosed with breast cancer. This review is focused on prognosis for MBC patients, prognostic and predictive factors and molecular subgrouping; comparisons are made with female breast cancer. Information was collected from relevant literature on both male and female breast cancer from the MEDLINE database between 1992 and 2014. MBC is a heterogeneous disease, and on the molecular level many differences compared to female breast cancer have recently been revealed. Two distinct subgroups of MBC, luminal M1 and luminal M2, have been identified which differ from the well-established intrinsic subtypes of breast cancer in women. These novel subgroups of breast cancer therefore appear unique to MBC. Furthermore, several studies report inferior survival for men diagnosed with breast cancer compared to women. New promising prognostic biomarkers for MBC (e.g. NAT1) deserving further attention are reviewed. Further prospective studies aimed at validating the novel subgroups and recently proposed biomarkers for MBC are warranted to provide the basis for optimal patient management in this era of personalized medicine. This article is part of a Directed Issue entitled: Rare Cancers.
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Affiliation(s)
- Ida Johansson
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University Cancer Center, Lund, Sweden; CREATE Health Strategic Center for Translational Cancer Research, Lund University, Lund, Sweden
| | - Fredrika Killander
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University Cancer Center, Lund, Sweden; Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - Barbro Linderholm
- Department of Oncology, Sahlgrenska Academy and University Hospital, Gothenburg, Sweden; Cancer Center Karolinska, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Hedenfalk
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University Cancer Center, Lund, Sweden; CREATE Health Strategic Center for Translational Cancer Research, Lund University, Lund, Sweden.
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14
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He C, Jiang H, Geng S, Sheng H, Shen X, Zhang X, Zhu S, Chen X, Yang C, Gao H. Expression and prognostic value of c-Myc and Fas (CD95/APO1) in patients with pancreatic cancer. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2014; 7:742-750. [PMID: 24551298 PMCID: PMC3925922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 12/12/2013] [Indexed: 06/03/2023]
Abstract
The identification of molecular prognostic markers for pancreatic cancer patients could provide insightful information for their management in the clinic. The aim of the study is to investigate whether or not the expressions of c-Myc and Fas (CD95/APO1) have prognostic relevance for overall survival (OS) in patients with pancreatic cancer. we used immunohistochemistry on tissue microarrays containing 162 pancreatic cancer specimens to assess the protein expression levels of c-Myc and Fas. Kaplan-Meier survival analysis demonstrated that high level of c-Myc cytoplasmic expression was significantly correlated with worse survival in patients with pancreatic cancer (P = 0.012), while high level of Fas cytoplasmic expression was significantly associated with better outcome of pancreatic cancer (P = 0.046). However, multivariate Cox model analysis showed that tumor differentiation, lymph node status and c-Myc cytoplasmic expression were significant independent prognostic factors for OS (P < 0.001, P = 0.023, P = 0.001, respectively). On the contrary, Fas cytoplasmic expression did not independently influence patient's prognosis (P = 0.249). Our data suggested that high level of c-Myc cytoplasmic expression may be considered as a valuable marker for prognosis of pancreatic cancer.
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Affiliation(s)
- Chengzhi He
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of MedicineShanghai 200120, China
- Department of Gastroenterology, Tongji Institute of Digestive Diseases, Tongji Hospital, Tongji University School of MedicineShanghai 200065, China
| | - Hua Jiang
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of MedicineShanghai 200120, China
| | - Shasha Geng
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of MedicineShanghai 200120, China
| | - Haihui Sheng
- Shanghai Engineering Center for Molecular Medicine, National Engineering Center for Biochip at Shanghai201203, China
| | - Xiaoying Shen
- Shanghai Engineering Center for Molecular Medicine, National Engineering Center for Biochip at Shanghai201203, China
| | - Xiaoyan Zhang
- Shanghai Engineering Center for Molecular Medicine, National Engineering Center for Biochip at Shanghai201203, China
| | - Shizhang Zhu
- Shanghai Engineering Center for Molecular Medicine, National Engineering Center for Biochip at Shanghai201203, China
| | - Ximei Chen
- Department of Gastroenterology, Tongji Institute of Digestive Diseases, Tongji Hospital, Tongji University School of MedicineShanghai 200065, China
| | - Changqing Yang
- Department of Gastroenterology, Tongji Institute of Digestive Diseases, Tongji Hospital, Tongji University School of MedicineShanghai 200065, China
| | - Hengjun Gao
- Department of Gastroenterology, Tongji Institute of Digestive Diseases, Tongji Hospital, Tongji University School of MedicineShanghai 200065, China
- Shanghai Engineering Center for Molecular Medicine, National Engineering Center for Biochip at Shanghai201203, China
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15
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Senger JL, Chandran G, Kanthan R. Is routine pathological evaluation of tissue from gynecomastia necessary? A 15-year retrospective pathological and literature review. Plast Surg (Oakv) 2014; 22:112-116. [PMID: 25114624 PMCID: PMC4116310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
OBJECTIVE To reconsider the routine plastic surgical practice of requesting histopathological evaluation of tissue from gynecomastia. METHOD The present study was a retrospective histopathological review (15-year period [1996 to 2012]) involving gynecomastia tissue samples received at the pathology laboratory in the Saskatoon Health Region (Saskatchewan). The Laboratory Information System (LIS) identified all specimens using the key search words "gynecomastia", "gynaecomastia", "gynecomazia" and "gynaecomazia". A literature review to identify all cases of incidentally discovered malignancies in gynecomastia tissue specimens over a 15-year period (1996 to present) was undertaken. RESULTS The 15-year LIS search detected a total of 452 patients that included two cases of pseudogynecomastia (0.4%). Patients' age ranged from five to 92 years and 43% of the cases were bilateral (28% left sided, 29% right sided). The weight of the specimens received ranged from 0.2 g to 1147.2 g. All cases showed no significant histopathological concerns. The number of tissue blocks sampled ranged from one to 42, averaging four blocks/case (approximately $105/case), resulting in a cost of approximately $3,200/year, with a 15-year expenditure of approximately $48,000. The literature review identified a total of 15 incidental findings: ductal carcinoma in situ (12 cases), atypical ductal hyperplasia (two cases) and infiltrating ductal carcinoma (one case). CONCLUSIONS In the context of evidence-based literature, and because no significant pathological findings were detected in this particular cohort of 452 cases with 2178 slides, the authors believe it is time to re-evaluate whether routine histopathological examination of tissue from gynecomastia remains necessary. The current climate of health care budget fiscal restraints warrants reassessment of the current policies and practices of sending tissue samples of gynecomastia incurring negative productivity costs on routine histopathological examination.
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Affiliation(s)
| | | | - Rani Kanthan
- Department of Pathology & Laboratory Medicine, Royal University Hospital, Saskatoon, Saskatchewan
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16
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Zhou L, Kang D, Xu C, Zhao W, Tian B, Chen L. Expression of cyclin D1 and cyclin E significantly associates with human papillomavirus subtypes in Bowenoid papulosis. Acta Histochem 2013; 115:339-43. [PMID: 23044415 DOI: 10.1016/j.acthis.2012.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 09/07/2012] [Accepted: 09/10/2012] [Indexed: 11/19/2022]
Abstract
Human papillomavirus (HPV) incorporates high-risk HPV (hrHPV) and low-risk HPV (lrHPV) subtypes according to its contribution to oncogenesis. Different HPV subtypes could regulate the cell cycle of infected cells at different levels. To date, the expression of cyclin D1 and cyclin E in Bowenoid papulosis (BP) tissues and its association with HPV infection still remains elusive. In the present study, genotyping was performed to identify the HPV subtypes in 44 BP specimens. In addition, immunohistochemistry was performed to detect the expression of cell cycle related proteins cyclin D1 and cyclin E in BP tissues as well as normal tissues. We found that there were 20 patients with hrHPV subtypes, 6 patients with lrHPV subtypes, and 18 patients with combined high and low (hr/lr) HPV subtypes. Cyclin D1 expression in patients with hrHPV subtypes (P=0.0408), in patients with lrHPV subtypes (P=0.0002) and in patients with hr/lr HPV subtypes (P=0.0047) was significantly higher than that in normal controls, respectively. Cyclin D1 expression in patients with hr/lr HPV subtypes (P<0.0001) and in patients with lrHPV subtypes (P=0.0244) was significantly higher than that in patients with hrHPV subtypes, respectively. Cyclin E expression in patients with hrHPV subtypes (P<0.0001), in patients with lrHPV subtypes (P=0.0005), and in patients with hr/lr HPV subtypes (P<0.0001) was significantly higher than that in normal controls, respectively. Cyclin E expression in patients with hrHPV subtypes was significantly higher than that in patients with lrHPV subtypes (P=0.0032). Our data suggest that HPV infection is strongly associated with the pathogenesis of BP, and further support the notion that HPV may be involved in the regulation of the expression of cell cycle related proteins, cyclin D1 and cyclin E, in the pathogenesis of BP.
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Affiliation(s)
- Lailai Zhou
- Department of Dermatology, The Third Affiliated Hospital of Suzhou University, Jiangsu, Changzhou 213003, China
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17
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Ruddy KJ, Winer EP. Male breast cancer: risk factors, biology, diagnosis, treatment, and survivorship. Ann Oncol 2013; 24:1434-43. [PMID: 23425944 DOI: 10.1093/annonc/mdt025] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The causes, optimal treatments, and medical/psychosocial sequelae of breast cancer in men are poorly understood. DESIGN A systematic review of the English language literature was conducted to identify studies relevant to male breast cancer between 1987 and 2012 and including at least 20 patients. Searches were carried out on PubMed using the title terms 'male breast cancer' or 'male breast carcinoma'. RESULTS Relevant published data regarding risk factors, biological characteristics, presentation and prognosis, appropriate evaluation and treatment, and survivorship issues in male breast cancer patients are presented. BRCA2 mutations, age, conditions that alter the estrogen/androgen ratio, and radiation are proven risk factors. Disease biology is distinct in men, but diagnostic approaches and treatments for men are generally extrapolated from those in women due to inadequate research in men. Survivorship issues in men may include sexual and hormonal side-effects of endocrine therapies as well as unique psychosocial impacts of the disease. CONCLUSION Further research is needed to address gaps in knowledge pertaining to care of male breast cancer patients and survivors.
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Affiliation(s)
- K J Ruddy
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA.
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18
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Abstract
Assessment of proliferation is important in female breast cancer and individual treatment decisions are based upon its results, especially in the luminal subgroups. Gene expression analyses fail to group male breast cancer into the intrinsic subgroups previously established in female breast cancer. Even though proliferation has been shown to divide male breast cancer into molecular subgroups with different prognoses, the clinical importance of proliferation markers has not yet been elucidated. Previous studies in male breast cancer have demonstrated contradictory results regarding the prognostic impact of histological grade and Ki-67, parameters strongly associated with proliferation. The aim of the present project was to study proliferation in male breast cancer by assessing other proliferation-related markers viz. cyclins A, B, D1 and mitotic count. A total of 197 male breast cancer cases with accessible paraffin-embedded material and outcome data were investigated. Immunohistochemical stainings were performed on tissue microarrays. Kaplan-Meier estimates and the Cox proportional regression models were used for survival analyses with breast cancer death as the event. The subset of patients with high expression of cyclin A (hazard ratio (HR) 3.7; P=0.001) and B (HR 2.7; P=0.02) demonstrated a poorer survival. Furthermore, high mitotic count was associated with an increased risk of breast cancer death (HR 2.5; P=0.01). In contrast, cyclin D1 overexpression was predictive of better breast cancer survival (HR 0.3; P=0.001). In conclusion, high levels of cyclin A and B expression and an elevated mitotic count result in a two to threefold higher risk for breast cancer death, whereas cyclin D1 overexpression halves the risk. The clinical utility of these proliferation markers needs further elucidation.
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19
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Nilsson C, Johansson I, Ahlin C, Thorstenson S, Amini RM, Holmqvist M, Bergkvist L, Hedenfalk I, Fjällskog ML. Molecular subtyping of male breast cancer using alternative definitions and its prognostic impact. Acta Oncol 2013; 52:102-9. [PMID: 22928693 DOI: 10.3109/0284186x.2012.711952] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Male breast cancer (MBC) is an uncommon disease and there is limited information on the prognostic impact of routinely used clinicopathological parameters. MATERIAL AND METHODS In a retrospective setting, we reviewed 197 MBC patients with accessible paraffin-embedded tumor tissue and clinicopathological data. Immunohistochemical (IHC) stainings were performed on tissue microarrays and histological grading on conventional slides. Cox proportional regression models were applied for uni- and multivariate analyses using breast cancer death as the event. RESULTS Estrogen receptor (ER) and progesterone receptor positivity were demonstrated in 93% and 77% of patients, respectively. Nottingham histologic grade (NHG) III was seen in 41% and HER2 positivity in 11%. Classification into molecular subtypes using IHC markers according to three alternative definitions revealed luminal A and luminal B in 81% vs. 11%; 48% vs. 44% and 41% vs. 42% of cases. Two cases of basal-like were identified, but no cases of HER2-like. Factors associated with an increased risk of breast cancer death were node positivity (HR 4.5; 95% CI 1.8-11.1), tumor size > 20 mm (HR 3.3; 95% CI 1.4-7.9) and ER negativity (HR 10.9; 95% CI 3.2-37.9). No difference in breast cancer death between the luminal subgroups was demonstrated, regardless of definition. CONCLUSION MBC tumors were more often of high grade, whereas HER2 overexpression was as frequent as in FBC. Lymph nodes, tumor size and ER status were independent predictors of breast cancer death. The prognostic impact of molecular subtyping in MBC seems to differ from that previously established in FBC.
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Affiliation(s)
- Cecilia Nilsson
- Center for Clinical Research, Västmanland County Hospital, Västerås, Sweden.
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20
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Kornegoor R, Verschuur-Maes AHJ, Buerger H, Hogenes MC, de Bruin PC, Oudejans JJ, Hinrichs B, van Diest PJ. Immunophenotyping of male breast cancer. Histopathology 2012; 61:1145-55. [DOI: 10.1111/j.1365-2559.2012.04330.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Guo H, Nan K, Hu T, Meng J, Hui W, Zhang X, Qin H, Sui C. Prognostic significance of co-expression of nm23 and p57 protein in hepatocellular carcinoma. Hepatol Res 2010; 40:1107-16. [PMID: 20880063 DOI: 10.1111/j.1872-034x.2010.00721.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM To investigate the unbalance of proliferation and apoptosis and the functions of cell-cycle proteins and apoptotic factor in metastasis of hepatocellular carcinoma (HCC) and their effect in prognosis. METHODS Proliferation index and apoptosis index, as well as seven relatively molecular markers, namely p15, p34, p53, p57, p73, survivin and nm23, were evaluated by immunohistochemistry and TUNEL in HCC tissues and compared to adjacent non-cancerous tissues and normal liver tissues. Furthermore, the prognostic significance by follow-up and mutual relationships for each clinicopathologic factor and molecular marker were analysed. RESULTS The dysregulation between proliferation and apoptosis and the abnormal expression of seven molecular markers were observed in HCC tissues. The unbalance of proliferation and apoptosis and abnormal expressions of p15, p34, p57 and nm23 were correlated with TNM stage and extrahepatic metastasis. In particular, the abnormal co-expression of nm23/p57 correlated with advanced TNM stage and bigger tumor size and was an independent prognostic factor of HCC. CONCLUSION The unbalance of proliferation and apoptosis and abnormal expression of cell-cycle proteins promote metastasis of HCC. Moreover, the abnormal co-expression of nm23/p57 may be a useful molecular marker for metastasis and unfavourable prognosis for HCC.
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Affiliation(s)
- Hui Guo
- Department of Oncology, The First Affiliated HospitalThe Second Affiliated Hospital, College Of Medicine of Xi'an Jiaotong University, Xi'an, Shaanxi Department of Oncology, The First People Hospital, Changzhou, Jiangsu Department of Pulmonary Medicine, Kiang Wu Hospital, Macao, China
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