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Beckers C, Pruschy M, Vetrugno I. Tumor hypoxia and radiotherapy: A major driver of resistance even for novel radiotherapy modalities. Semin Cancer Biol 2024; 98:19-30. [PMID: 38040401 DOI: 10.1016/j.semcancer.2023.11.006] [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: 09/19/2023] [Revised: 11/16/2023] [Accepted: 11/22/2023] [Indexed: 12/03/2023]
Abstract
Hypoxia in solid tumors is an important predictor of poor clinical outcome to radiotherapy. Both physicochemical and biological processes contribute to a reduced sensitivity of hypoxic tumor cells to ionizing radiation and hypoxia-related treatment resistances. A conventional low-dose fractionated radiotherapy regimen exploits iterative reoxygenation in between the individual fractions, nevertheless tumor hypoxia still remains a major hurdle for successful treatment outcome. The technological advances achieved in image guidance and highly conformal dose delivery make it nowadays possible to prescribe larger doses to the tumor as part of single high-dose or hypofractionated radiotherapy, while keeping an acceptable level of normal tissue complication in the co-irradiated organs at risk. However, we insufficiently understand the impact of tumor hypoxia to single high-doses of RT and hypofractionated RT. So-called FLASH radiotherapy, which delivers ionizing radiation at ultrahigh dose rates (> 40 Gy/sec), has recently emerged as an important breakthrough in the radiotherapy field to reduce normal tissue toxicity compared to irradiation at conventional dose rates (few Gy/min). Not surprisingly, oxygen consumption and tumor hypoxia also seem to play an intriguing role for FLASH radiotherapy. Here we will discuss the role of tumor hypoxia for radiotherapy in general and in the context of novel radiotherapy treatment approaches.
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Affiliation(s)
- Claire Beckers
- Laboratory for Applied Radiobiology, Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Martin Pruschy
- Laboratory for Applied Radiobiology, Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - Irene Vetrugno
- Laboratory for Applied Radiobiology, Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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2
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Martínez-Alonso M, Gandioso A, Thibaudeau C, Qin X, Arnoux P, Demeubayeva N, Guérineau V, Frochot C, Jung AC, Gaiddon C, Gasser G. A Novel Near-IR Absorbing Ruthenium(II) Complex as Photosensitizer for Photodynamic Therapy and its Cetuximab Bioconjugates. Chembiochem 2023; 24:e202300203. [PMID: 37017905 DOI: 10.1002/cbic.202300203] [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: 03/14/2023] [Revised: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 04/06/2023]
Abstract
A novel Ru(II) cyclometalated photosensitizer (PS), Ru-NH2 , for photodynamic therapy (PDT) of formula [Ru(appy)(bphen)2 ]PF6 (where appy=4-amino-2-phenylpyridine and bphen=bathophenanthroline) and its cetuximab (CTX) bioconjugates, Ru-Mal-CTX and Ru-BAA-CTX (where Mal=maleimide and BAA=benzoylacrylic acid) were synthesised and characterised. The photophysical properties of Ru-NH2 revealed absorption maxima around 580 nm with an absorption up to 725 nm. The generation of singlet oxygen (1 O2 ) upon light irradiation was confirmed with a 1 O2 quantum yield of 0.19 in acetonitrile. Preliminary in vitro experiments revealed the Ru-NH2 was nontoxic in the dark in CT-26 and SQ20B cell lines but showed outstanding phototoxicity when irradiated, reaching interesting phototoxicity indexes (PI) >370 at 670 nm, and >150 at 740 nm for CT-26 cells and >50 with NIR light in SQ20B cells. The antibody CTX was successfully attached to the complexes in view of the selective delivery of the PS to cancer cells. Up to four ruthenium fragments were anchored to the antibody (Ab), as confirmed by MALDI-TOF mass spectrometry. Nonetheless, the bioconjugates were not as photoactive as the Ru-NH2 complex.
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Affiliation(s)
- Marta Martínez-Alonso
- Chimie ParisTech, PSL University, CNRS, Institute of Chemistry for Life and Health Sciences, Laboratory for Inorganic Chemical Biology, 75005, Paris, France
| | - Albert Gandioso
- Chimie ParisTech, PSL University, CNRS, Institute of Chemistry for Life and Health Sciences, Laboratory for Inorganic Chemical Biology, 75005, Paris, France
| | - Chloé Thibaudeau
- Laboratoire de Biologie Tumorale, Institut de cancérologie Strasbourg Europe, 67200, Strasbourg, France
- Université de Strasbourg-Inserm, UMR_S 1113 IRFAC, Laboratory « Streinth », 67200, Strasbourg, France
| | - Xue Qin
- Laboratoire de Biologie Tumorale, Institut de cancérologie Strasbourg Europe, 67200, Strasbourg, France
- Université de Strasbourg-Inserm, UMR_S 1113 IRFAC, Laboratory « Streinth », 67200, Strasbourg, France
| | - Philippe Arnoux
- Reactions and Chemical Engineering Laboratory, Université de Lorraine, LRGP-CNRS, 54000, Nancy, France
| | - Nurikamal Demeubayeva
- Reactions and Chemical Engineering Laboratory, Université de Lorraine, LRGP-CNRS, 54000, Nancy, France
| | - Vincent Guérineau
- Université Paris-Saclay, CNRS, Institut de Chimie des Substances Naturelles, UPR 2301, 91198, Gif-sur-Yvette, France
| | - Céline Frochot
- Reactions and Chemical Engineering Laboratory, Université de Lorraine, LRGP-CNRS, 54000, Nancy, France
| | - Alain C Jung
- Laboratoire de Biologie Tumorale, Institut de cancérologie Strasbourg Europe, 67200, Strasbourg, France
- Université de Strasbourg-Inserm, UMR_S 1113 IRFAC, Laboratory « Streinth », 67200, Strasbourg, France
| | - Christian Gaiddon
- Université de Strasbourg-Inserm, UMR_S 1113 IRFAC, Laboratory « Streinth », 67200, Strasbourg, France
| | - Gilles Gasser
- Chimie ParisTech, PSL University, CNRS, Institute of Chemistry for Life and Health Sciences, Laboratory for Inorganic Chemical Biology, 75005, Paris, France
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Kao TW, Bai GH, Wang TL, Shih IM, Chuang CM, Lo CL, Tsai MC, Chiu LY, Lin CC, Shen YA. Novel cancer treatment paradigm targeting hypoxia-induced factor in conjunction with current therapies to overcome resistance. J Exp Clin Cancer Res 2023; 42:171. [PMID: 37460927 DOI: 10.1186/s13046-023-02724-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/29/2023] [Indexed: 07/20/2023] Open
Abstract
Chemotherapy, radiotherapy, targeted therapy, and immunotherapy are established cancer treatment modalities that are widely used due to their demonstrated efficacy against tumors and favorable safety profiles or tolerability. Nevertheless, treatment resistance continues to be one of the most pressing unsolved conundrums in cancer treatment. Hypoxia-inducible factors (HIFs) are a family of transcription factors that regulate cellular responses to hypoxia by activating genes involved in various adaptations, including erythropoiesis, glucose metabolism, angiogenesis, cell proliferation, and apoptosis. Despite this critical function, overexpression of HIFs has been observed in numerous cancers, leading to resistance to therapy and disease progression. In recent years, much effort has been poured into developing innovative cancer treatments that target the HIF pathway. Combining HIF inhibitors with current cancer therapies to increase anti-tumor activity and diminish treatment resistance is one strategy for combating therapeutic resistance. This review focuses on how HIF inhibitors could be applied in conjunction with current cancer treatments, including those now being evaluated in clinical trials, to usher in a new era of cancer therapy.
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Affiliation(s)
- Ting-Wan Kao
- Department of Pathology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 110301, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, 110301, Taiwan
| | - Geng-Hao Bai
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, 100225, Taiwan
| | - Tian-Li Wang
- Departments of Pathology, Oncology and Gynecology and Obstetrics, Johns Hopkins Medical Institutions, 1550 Orleans StreetRoom 306, Baltimore, MD, CRB221231, USA
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ie-Ming Shih
- Departments of Pathology, Oncology and Gynecology and Obstetrics, Johns Hopkins Medical Institutions, 1550 Orleans StreetRoom 306, Baltimore, MD, CRB221231, USA
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chi-Mu Chuang
- Faculty of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei, 112304, Taiwan
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, 112201, Taiwan
- Department of Midwifery and Women Health Care, National Taipei University of Nursing and Health Sciences, Taipei, 112303, Taiwan
| | - Chun-Liang Lo
- Department of Biomedical Engineering, National Yang-Ming Chiao Tung University, Taipei, 112304, Taiwan
- Medical Device Innovation and Translation Center, National Yang Ming Chiao Tung University, Taipei, 112304, Taiwan
| | - Meng-Chen Tsai
- Department of General Medicine, Taipei Medical University Hospital, Taipei, 110301, Taiwan
| | - Li-Yun Chiu
- Department of General Medicine, Mackay Memorial Hospital, Taipei, 104217, Taiwan
| | - Chu-Chien Lin
- Department of Pathology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 110301, Taiwan
- School of Medicine, College of Medicine, Taipei Medical University, Taipei City, 110301, Taiwan
| | - Yao-An Shen
- Department of Pathology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 110301, Taiwan.
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, 110301, Taiwan.
- International Master/Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, 110301, Taiwan.
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De Azevedo J, Mourtada J, Bour C, Devignot V, Schultz P, Borel C, Pencreach E, Mellitzer G, Gaiddon C, Jung AC. The EXTREME Regimen Associating Cetuximab and Cisplatin Favors Head and Neck Cancer Cell Death and Immunogenicity with the Induction of an Anti-Cancer Immune Response. Cells 2022; 11:cells11182866. [PMID: 36139440 PMCID: PMC9496761 DOI: 10.3390/cells11182866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 12/24/2022] Open
Abstract
(1) Background: The first line of treatment for recurrent/metastatic Head and Neck Squamous Cell Carcinoma (HNSCC) has recently evolved with the approval of immunotherapies that target the anti-PD-1 immune checkpoint. However, only about 20% of the patients display a long-lasting objective tumor response. The modulation of cancer cell immunogenicity via a treatment-induced immunogenic cell death is proposed to potentially be able to improve the rate of patients who respond to immune checkpoint blocking immunotherapies. (2) Methods: Using human HNSCC cell line models and a mouse oral cancer syngeneic model, we have analyzed the ability of the EXTREME regimen (combination therapy using the anti-EGFR cetuximab antibody and platinum-based chemotherapy) to modify the immunogenicity of HNSCC cells. (3) Results: We showed that the combination of cetuximab and cisplatin reduces cell growth through both cell cycle inhibition and the induction of apoptotic cell death independently of p53. In addition, different components of the EXTREME regimen were found to induce, to a variable extent, and in a cell-dependent manner, the emission of mediators of immunogenic cell death, including calreticulin, HMGB1, and type I Interferon-responsive chemokines. Interestingly, cetuximab alone or combined with the IC50 dose of cisplatin can induce an antitumor immune response in vivo, but not when combined with a high dose of cisplatin. (4) Conclusions: Our observations suggest that the EXTREME protocol or cetuximab alone are capable, under conditions of moderate apoptosis induction, of eliciting the mobilization of the immune system and an anti-tumor immune response in HNSCC.
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Affiliation(s)
- Justine De Azevedo
- Laboratory Streinth, Université de Strasbourg-Inserm, UMR_S 1113 IRFAC, 67200 Strasbourg, France
| | - Jana Mourtada
- Laboratory Streinth, Université de Strasbourg-Inserm, UMR_S 1113 IRFAC, 67200 Strasbourg, France
| | - Cyril Bour
- Laboratory Streinth, Université de Strasbourg-Inserm, UMR_S 1113 IRFAC, 67200 Strasbourg, France
- Laboratoire de Biologie Tumorale, Institut de Cancérologie Strasbourg Europe, 67200 Strasbourg, France
| | - Véronique Devignot
- Laboratory Streinth, Université de Strasbourg-Inserm, UMR_S 1113 IRFAC, 67200 Strasbourg, France
| | - Philippe Schultz
- Laboratory Streinth, Université de Strasbourg-Inserm, UMR_S 1113 IRFAC, 67200 Strasbourg, France
- Department of Otorhinolaryngology and Head and Neck Surgery, Hôpitaux Universitaires de Strasbourg, 67200 Strasbourg, France
| | - Christian Borel
- Laboratory Streinth, Université de Strasbourg-Inserm, UMR_S 1113 IRFAC, 67200 Strasbourg, France
- Department of Medical Oncology, Institut de Cancérologie Strasbourg Europe, 67200 Strasbourg, France
| | - Erwan Pencreach
- Laboratory Streinth, Université de Strasbourg-Inserm, UMR_S 1113 IRFAC, 67200 Strasbourg, France
- Laboratoire de Biochimie et Biologie Moléculaire, Hôpitaux Universitaires de Strasbourg, 67200 Strasbourg, France
| | - Georg Mellitzer
- Laboratory Streinth, Université de Strasbourg-Inserm, UMR_S 1113 IRFAC, 67200 Strasbourg, France
| | - Christian Gaiddon
- Laboratory Streinth, Université de Strasbourg-Inserm, UMR_S 1113 IRFAC, 67200 Strasbourg, France
- Correspondence: (C.G.); (A.C.J.)
| | - Alain C. Jung
- Laboratory Streinth, Université de Strasbourg-Inserm, UMR_S 1113 IRFAC, 67200 Strasbourg, France
- Laboratoire de Biologie Tumorale, Institut de Cancérologie Strasbourg Europe, 67200 Strasbourg, France
- Correspondence: (C.G.); (A.C.J.)
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Hill RM, Rocha S, Parsons JL. Overcoming the Impact of Hypoxia in Driving Radiotherapy Resistance in Head and Neck Squamous Cell Carcinoma. Cancers (Basel) 2022; 14:4130. [PMID: 36077667 PMCID: PMC9454974 DOI: 10.3390/cancers14174130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 12/24/2022] Open
Abstract
Hypoxia is very common in most solid tumours and is a driving force for malignant progression as well as radiotherapy and chemotherapy resistance. Incidences of head and neck squamous cell carcinoma (HNSCC) have increased in the last decade and radiotherapy is a major therapeutic technique utilised in the treatment of the tumours. However, effectiveness of radiotherapy is hindered by resistance mechanisms and most notably by hypoxia, leading to poor patient prognosis of HNSCC patients. The phenomenon of hypoxia-induced radioresistance was identified nearly half a century ago, yet despite this, little progress has been made in overcoming the physical lack of oxygen. Therefore, a more detailed understanding of the molecular mechanisms of hypoxia and the underpinning radiobiological response of tumours to this phenotype is much needed. In this review, we will provide an up-to-date overview of how hypoxia alters molecular and cellular processes contributing to radioresistance, particularly in the context of HNSCC, and what strategies have and could be explored to overcome hypoxia-induced radioresistance.
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Affiliation(s)
- Rhianna M. Hill
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool L7 8TX, UK
| | - Sonia Rocha
- Department of Molecular Physiology and Cell Signalling, University of Liverpool, Liverpool L69 7ZB, UK
| | - Jason L. Parsons
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool L7 8TX, UK
- Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Bebington CH63 4JY, UK
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HIF-1α Inhibition Improves Anti-Tumor Immunity and Promotes the Efficacy of Stereotactic Ablative Radiotherapy (SABR). Cancers (Basel) 2022; 14:cancers14133273. [PMID: 35805044 PMCID: PMC9265101 DOI: 10.3390/cancers14133273] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/24/2022] [Accepted: 06/29/2022] [Indexed: 01/10/2023] Open
Abstract
Simple Summary Stereotactic ablative radiotherapy (SABR), which irradiates tumors with high-dose radiation per fraction, promotes anti-tumor immunity by stimulating various immune processes. SABR also induces vascular damage and obstructs blood flow, thereby increasing tumor hypoxia and upregulation of hypoxia-inducible factors HIF-1α and HIF-2α, master transcription factors for the cellular response to hypoxia. HIF-1α and HIF-2α are key players in the upregulation of immune suppression in hypoxia. Therefore, the radiation-induced increase in anti-tumor immunity is masked by the HIF-mediated immune suppression. Pre-clinical experiments show that inhibition of HIF-1α effectively prevents immune suppression and improves anti-tumor immunity. A combination of HIF-1α inhibitors with immunotherapy with checkpoint blocking antibodies may represent a novel approach to boost anti-tumor immunity and enhance the efficacy of SABR. Abstract High-dose hypofractionated radiation such as SABR (stereotactic ablative radiotherapy) evokes an anti-tumor immune response by promoting a series of immune-stimulating processes, including the release of tumor-specific antigens from damaged tumor cells and the final effector phase of immune-mediated lysis of target tumor cells. High-dose hypofractionated radiation also causes vascular damage in tumors, thereby increasing tumor hypoxia and upregulation of hypoxia-inducible factors HIF-1α and HIF-2α, the master transcription factors for the cellular response to hypoxia. HIF-1α and HIF-2α are critical factors in the upregulation of immune suppression and are the master regulators of immune evasion of tumors. Consequently, SABR-induced increase in anti-tumor immunity is counterbalanced by the increase in immune suppression mediated by HIFα. Inhibition of HIF-1α with small molecules such as metformin downregulates immunosuppressive pathways, including the expression of immune checkpoints, and it improves or restores the anti-tumor immunity stimulated by irradiation. Combinations of HIFα inhibitors, particularly HIF-1α inhibitors, with immune checkpoint blocking antibodies may represent a novel approach to boost the overall anti-tumor immune profile in patients and thus enhance outcomes after SABR.
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EGFR Mutations in Head and Neck Squamous Cell Carcinoma. Int J Mol Sci 2022; 23:ijms23073818. [PMID: 35409179 PMCID: PMC8999014 DOI: 10.3390/ijms23073818] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/25/2022] [Accepted: 03/25/2022] [Indexed: 12/16/2022] Open
Abstract
EGFR is a prototypical receptor tyrosine kinase that is overexpressed in multiple cancers including head and neck squamous cell carcinoma (HNSCC). The standard of care for HNSCC remains largely unchanged despite decades of research. While EGFR blockade is an attractive target in HNSCC patients and anti-EGFR strategies including monoclonal antibodies and kinase inhibitors have shown some clinical benefit, efficacy is often due to the eventual development of resistance. In this review, we discuss how the acquisition of mutations in various domains of the EGFR gene not only alter drug binding dynamics giving rise to resistance, but also how mutations can impact radiation response and overall survival in HNSCC patients. A better understanding of the EGFR mutational landscape and its dynamic effects on treatment resistance hold the potential to better stratify patients for targeted therapies in order to maximize therapeutic benefits.
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Kałafut J, Czerwonka A, Anameriç A, Przybyszewska-Podstawka A, Misiorek JO, Rivero-Müller A, Nees M. Shooting at Moving and Hidden Targets-Tumour Cell Plasticity and the Notch Signalling Pathway in Head and Neck Squamous Cell Carcinomas. Cancers (Basel) 2021; 13:6219. [PMID: 34944837 PMCID: PMC8699303 DOI: 10.3390/cancers13246219] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 12/15/2022] Open
Abstract
Head and Neck Squamous Cell Carcinoma (HNSCC) is often aggressive, with poor response to current therapies in approximately 40-50% of the patients. Current therapies are restricted to operation and irradiation, often combined with a small number of standard-of-care chemotherapeutic drugs, preferentially for advanced tumour patients. Only very recently, newer targeted therapies have entered the clinics, including Cetuximab, which targets the EGF receptor (EGFR), and several immune checkpoint inhibitors targeting the immune receptor PD-1 and its ligand PD-L1. HNSCC tumour tissues are characterized by a high degree of intra-tumour heterogeneity (ITH), and non-genetic alterations that may affect both non-transformed cells, such as cancer-associated fibroblasts (CAFs), and transformed carcinoma cells. This very high degree of heterogeneity likely contributes to acquired drug resistance, tumour dormancy, relapse, and distant or lymph node metastasis. ITH, in turn, is likely promoted by pronounced tumour cell plasticity, which manifests in highly dynamic and reversible phenomena such as of partial or hybrid forms of epithelial-to-mesenchymal transition (EMT), and enhanced tumour stemness. Stemness and tumour cell plasticity are strongly promoted by Notch signalling, which remains poorly understood especially in HNSCC. Here, we aim to elucidate how Notch signal may act both as a tumour suppressor and proto-oncogenic, probably during different stages of tumour cell initiation and progression. Notch signalling also interacts with numerous other signalling pathways, that may also have a decisive impact on tumour cell plasticity, acquired radio/chemoresistance, and metastatic progression of HNSCC. We outline the current stage of research related to Notch signalling, and how this pathway may be intricately interconnected with other, druggable targets and signalling mechanisms in HNSCC.
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Affiliation(s)
- Joanna Kałafut
- Department of Biochemistry and Molecular Biology, Medical University of Lublin, ul. Chodzki 1, 20-093 Lublin, Poland; (J.K.); (A.C.); (A.A.); (A.P.-P.); (A.R.-M.)
| | - Arkadiusz Czerwonka
- Department of Biochemistry and Molecular Biology, Medical University of Lublin, ul. Chodzki 1, 20-093 Lublin, Poland; (J.K.); (A.C.); (A.A.); (A.P.-P.); (A.R.-M.)
| | - Alinda Anameriç
- Department of Biochemistry and Molecular Biology, Medical University of Lublin, ul. Chodzki 1, 20-093 Lublin, Poland; (J.K.); (A.C.); (A.A.); (A.P.-P.); (A.R.-M.)
| | - Alicja Przybyszewska-Podstawka
- Department of Biochemistry and Molecular Biology, Medical University of Lublin, ul. Chodzki 1, 20-093 Lublin, Poland; (J.K.); (A.C.); (A.A.); (A.P.-P.); (A.R.-M.)
| | - Julia O. Misiorek
- Department of Molecular Neurooncology, Institute of Bioorganic Chemistry Polish Academy of Sciences, ul. Noskowskiego 12/14, 61-704 Poznan, Poland;
| | - Adolfo Rivero-Müller
- Department of Biochemistry and Molecular Biology, Medical University of Lublin, ul. Chodzki 1, 20-093 Lublin, Poland; (J.K.); (A.C.); (A.A.); (A.P.-P.); (A.R.-M.)
| | - Matthias Nees
- Department of Biochemistry and Molecular Biology, Medical University of Lublin, ul. Chodzki 1, 20-093 Lublin, Poland; (J.K.); (A.C.); (A.A.); (A.P.-P.); (A.R.-M.)
- Western Finland Cancer Centre (FICAN West), Institute of Biomedicine, University of Turku, 20101 Turku, Finland
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Elmusrati A, Wang J, Wang CY. Tumor microenvironment and immune evasion in head and neck squamous cell carcinoma. Int J Oral Sci 2021; 13:24. [PMID: 34341329 PMCID: PMC8329257 DOI: 10.1038/s41368-021-00131-7] [Citation(s) in RCA: 105] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 02/07/2023] Open
Abstract
Head and neck squamous cell carcinoma (HNSCC), an aggressive malignancy, is characterized by high morbidity and low survival rates with limited therapeutic options outside of regional surgery, conventional cytotoxic chemotherapy, and irradiation. Increasing studies have supported the synergistic role of the tumor microenvironment (TME) in cancer advancement. The immune system, in particular, plays a key role in surveillance against the initiation, development, and progression of HNSCC. The understanding of how neoplastic cells evolve and evade the immune system whether through self-immunogenicity manipulation, or expression of immunosuppressive mediators, provides the foundation for the development of advanced therapies. Furthermore, the crosstalk between cancer cells and the host immune system have a detrimental effect on the TME promoting angiogenesis, proliferation, and metastasis. This review provides a recent insight into the role of the key inflammatory cells infiltrating the TME, with a focus on reviewing immunological principles related to HNSCC, as cancer immunosurveillance and immune escape, including a brief overview of current immunotherapeutic strategies and ongoing clinical trials.
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Affiliation(s)
- Areeg Elmusrati
- grid.19006.3e0000 0000 9632 6718Laboratory of Molecular Signaling, Division of Oral Biology and Medicine, School of Dentistry, UCLA, Los Angeles, CA USA
| | - Justin Wang
- grid.19006.3e0000 0000 9632 6718Laboratory of Molecular Signaling, Division of Oral Biology and Medicine, School of Dentistry, UCLA, Los Angeles, CA USA ,grid.19006.3e0000 0000 9632 6718Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA USA
| | - Cun-Yu Wang
- grid.19006.3e0000 0000 9632 6718Laboratory of Molecular Signaling, Division of Oral Biology and Medicine, School of Dentistry, UCLA, Los Angeles, CA USA ,grid.19006.3e0000 0000 9632 6718Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA USA
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10
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Muraro E, Fanetti G, Lupato V, Giacomarra V, Steffan A, Gobitti C, Vaccher E, Franchin G. Cetuximab in locally advanced head and neck squamous cell carcinoma: Biological mechanisms involved in efficacy, toxicity and resistance. Crit Rev Oncol Hematol 2021; 164:103424. [PMID: 34245856 DOI: 10.1016/j.critrevonc.2021.103424] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 06/02/2021] [Accepted: 07/04/2021] [Indexed: 12/17/2022] Open
Abstract
Since its introduction, the use of cetuximab in the treatment of head and neck squamous cell carcinoma (HNSCC) has experienced an evolution. Currently, cetuximab associated with radiotherapy is limited to the treatment of patients affected by a locally advanced malignancy and unfit for cisplatin. However, reliable biomarkers of cetuximab efficacy in this cancer setting are still lacking. This review focuses on the mechanisms of action of cetuximab, highlighting, in particular, the consequences of the binding to EGFR, and the pathways involved in the development of adverse events or acquired resistance. Indeed, adverse events, such as skin rash, have been associated with cetuximab efficacy in HNSCC several times. Acquired resistance is associated with microenvironment plasticity, which is, in turn, characterized by an increased immune infiltrate. The better definition of patients eligible for this kind of therapy could improve HNSCC management, possibly proposing a combined treatment with radiotherapy, cetuximab and immune checkpoint inhibitors as recently investigated.
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Affiliation(s)
- Elena Muraro
- Immunopathology and Cancer Biomarkers Unit, Department of Translational Research, CRO Aviano National Cancer Institute, Aviano, PN, Italy.
| | - Giuseppe Fanetti
- Department of Radiation Oncology, CRO Aviano National Cancer Institute, Aviano, PN, Italy
| | - Valentina Lupato
- Unit of Otolaryngology, General Hospital "S. Maria degli Angeli", Pordenone, Italy
| | - Vittorio Giacomarra
- Unit of Otolaryngology, General Hospital "S. Maria degli Angeli", Pordenone, Italy
| | - Agostino Steffan
- Immunopathology and Cancer Biomarkers Unit, Department of Translational Research, CRO Aviano National Cancer Institute, Aviano, PN, Italy
| | - Carlo Gobitti
- Department of Radiation Oncology, CRO Aviano National Cancer Institute, Aviano, PN, Italy
| | - Emanuela Vaccher
- Department of Medical Oncology, CRO Aviano National Cancer Institute, Aviano, PN, Italy
| | - Giovanni Franchin
- Department of Radiation Oncology, CRO Aviano National Cancer Institute, Aviano, PN, Italy
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Lei X, Ma N, Du L, Liang Y, Zhang P, Han Y, Qu B. PP2A and tumor radiotherapy. Hereditas 2020; 157:36. [PMID: 32847617 PMCID: PMC7450598 DOI: 10.1186/s41065-020-00149-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/13/2020] [Indexed: 02/07/2023] Open
Abstract
Protein phosphatase 2A (PP2A) is a serine/threonine phosphatase that serves as a key regulator of cellular physiology in the context of apoptosis, mitosis, and DNA damage responses. Canonically, PP2A functions as a tumor suppressor gene. However, recent evidence suggests that inhibiting PP2A activity in tumor cells may represent a viable approach to enhancing tumor sensitivity to chemoradiotherapy as such inhibition can cause cells to enter a disordered mitotic state that renders them more susceptible to cell death. Indeed, there is evidence that inhibiting PP2A can slow tumor growth following radiotherapy in a range of cancer types including ovarian cancer, liver cancer, malignant glioma, pancreatic cancer, and nasopharyngeal carcinoma. In the present review, we discuss current understanding of the role of PP2A in tumor radiotherapy and the potential mechanisms whereby it may influence this process.
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Affiliation(s)
- Xiao Lei
- The First Medical Center of Chinese PLA General Hospital, Department of Radiation Oncology, Beijing, P. R. China
| | - Na Ma
- The First Medical Center of Chinese PLA General Hospital, Department of Radiation Oncology, Beijing, P. R. China
| | - Lehui Du
- The First Medical Center of Chinese PLA General Hospital, Department of Radiation Oncology, Beijing, P. R. China
| | - Yanjie Liang
- The First Medical Center of Chinese PLA General Hospital, Department of Radiation Oncology, Beijing, P. R. China
| | - Pei Zhang
- The First Medical Center of Chinese PLA General Hospital, Department of Radiation Oncology, Beijing, P. R. China
| | - Yanan Han
- The First Medical Center of Chinese PLA General Hospital, Department of Radiation Oncology, Beijing, P. R. China
| | - Baolin Qu
- The First Medical Center of Chinese PLA General Hospital, Department of Radiation Oncology, Beijing, P. R. China.
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12
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Midkine Is a Potential Therapeutic Target of Tumorigenesis, Angiogenesis, and Metastasis in Non-Small Cell Lung Cancer. Cancers (Basel) 2020; 12:cancers12092402. [PMID: 32847073 PMCID: PMC7563676 DOI: 10.3390/cancers12092402] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/03/2020] [Accepted: 08/20/2020] [Indexed: 12/17/2022] Open
Abstract
Hypoxia-inducible factors (HIFs) induced by reduced O2 availability activate the transcription of target genes encoding proteins that play important roles in communication between cancer and stromal cells. Cancer cells were incubated under hypoxic conditions: H1299, A549 (NSCLC); Hep3B, HepG2 (HCC); HCT116, CT26 (Colon cancer); MCF-7, MDAMB231 (Breast cancer); MKN1, MKN5 (Gastric cancer); U87MG, SHSY5Y (Brain cancer); and SKOV3, SNU840 (Ovary cancer). All cells expressed HIF-1α and HIF-2α mRNA and proteins. However, cell proliferation of NSCLC, breast, gastric, and brain cancer cells under hypoxia was more dependent on HIF-1α except for HCC cells where it was more dependent on HIF-2α. Among HIF-1α dependent cells H1299 was the most affected in terms of cell proliferation by HIF-1α knockdown. To examine which cytokines are secreted in NSCLC cells by HIF-1α to communicate with stromal cells, we performed a cytokine-profiling array with H1299. We screened the top 14 cytokines which were dependent on the HIF-1α expression pattern. Among them, midkine (MDK) expression was affected the most in response to HIF-1α. MDK is a heparin-binding growth factor that promotes angiogenesis and carcinogenesis. Indeed, MDK significantly increased HUVEV endothelial cell migration and neo- vascularization in chick chorioallantoic membrane assay (CAM) assay via paracrine signaling. In addition, MDK secreted from NSCLC cells interacted with Notch2 which activated the Notch signaling pathway and induced EMT, upregulated NF-κB, and increased cancer promotion. However, in response to MDK knock down, siRNA or the MDK inhibitor, iMDK treatment not only decreased MDK-induced migration and angiogenesis of endothelial cells but also abrogated the progression and metastasis of NSCLC cells in in vitro and in vivo orthotopic and spontaneous lung metastasis models. Consequently, iMDK treatment significantly increased mice survival rates compared with the control or MDK expression group. MDK plays a very important role in the progression and metastasis of NSCLC cells. Moreover, the MDK targeting strategy provides a potential therapeutic target for the treatment of MDK-expressing lung cancers.
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Begg K, Tavassoli M. Inside the hypoxic tumour: reprogramming of the DDR and radioresistance. Cell Death Discov 2020; 6:77. [PMID: 32864165 PMCID: PMC7434912 DOI: 10.1038/s41420-020-00311-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/27/2020] [Accepted: 04/09/2020] [Indexed: 12/19/2022] Open
Abstract
The hypoxic tumour is a chaotic landscape of struggle and adaption. Against the adversity of oxygen starvation, hypoxic cancer cells initiate a reprogramming of transcriptional activities, allowing for survival, metastasis and treatment failure. This makes hypoxia a crucial feature of aggressive tumours. Its importance, to cancer and other diseases, was recognised by the award of the 2019 Nobel Prize in Physiology or Medicine for research contributing to our understanding of the cellular response to oxygen deprivation. For cancers with limited treatment options, for example those that rely heavily on radiotherapy, the results of hypoxic adaption are particularly restrictive to treatment success. A fundamental aspect of this hypoxic reprogramming with direct relevance to radioresistance, is the alteration to the DNA damage response, a complex set of intermingling processes that guide the cell (for good or for bad) towards DNA repair or cell death. These alterations, compounded by the fact that oxygen is required to induce damage to DNA during radiotherapy, means that hypoxia represents a persistent obstacle in the treatment of many solid tumours. Considerable research has been done to reverse, correct or diminish hypoxia's power over successful treatment. Though many clinical trials have been performed or are ongoing, particularly in the context of imaging studies and biomarker discovery, this research has yet to inform clinical practice. Indeed, the only hypoxia intervention incorporated into standard of care is the use of the hypoxia-activated prodrug Nimorazole, for head and neck cancer patients in Denmark. Decades of research have allowed us to build a picture of the shift in the DNA repair capabilities of hypoxic cancer cells. A literature consensus tells us that key signal transducers of this response are upregulated, where repair proteins are downregulated. However, a complete understanding of how these alterations lead to radioresistance is yet to come.
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Affiliation(s)
- Katheryn Begg
- Head and Neck Oncology Group, Centre for Host Microbiome Interaction, King’s College London, Hodgkin Building, London, SE1 1UL UK
| | - Mahvash Tavassoli
- Head and Neck Oncology Group, Centre for Host Microbiome Interaction, King’s College London, Hodgkin Building, London, SE1 1UL UK
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Alonso-González C, González A, Menéndez-Menéndez J, Martínez-Campa C, Cos S. Melatonin as a Radio-Sensitizer in Cancer. Biomedicines 2020; 8:biomedicines8080247. [PMID: 32726912 PMCID: PMC7460067 DOI: 10.3390/biomedicines8080247] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/15/2020] [Accepted: 07/22/2020] [Indexed: 02/07/2023] Open
Abstract
Radiotherapy is one of the treatments of choice in many types of cancer. Adjuvant treatments to radiotherapy try, on one hand, to enhance the response of tumor cells to radiation and, on the other hand, to reduce the side effects to normal cells. Radiosensitizers are agents that increase the effect of radiation in tumor cells by trying not to increase side effects in normal tissues. Melatonin is a hormone produced mainly by the pineal gland which has an important role in the regulation of cancer growth, especially in hormone-dependent mammary tumors. Different studies have showed that melatonin administered with radiotherapy is able to enhance its therapeutic effects and can protect normal cells against side effects of this treatment. Several mechanisms are involved in the radiosensitization induced by melatonin: increase of reactive oxygen species production, modulation of proteins involved in estrogen biosynthesis, impairment of tumor cells to DNA repair, modulation of angiogenesis, abolition of inflammation, induction of apoptosis, stimulation of preadipocytes differentiation and modulation of metabolism. At this moment, there are very few clinical trials that study the therapeutic usefulness to associate melatonin and radiotherapy in humans. All findings point to melatonin as an effective adjuvant molecule to radiotherapy in cancer treatment.
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Affiliation(s)
| | - Alicia González
- Correspondence: (A.G.); (C.M.-C.); Tel.: +34-942-201965 (A.G.); +34-942-201963 (C.M.-C.)
| | | | - Carlos Martínez-Campa
- Correspondence: (A.G.); (C.M.-C.); Tel.: +34-942-201965 (A.G.); +34-942-201963 (C.M.-C.)
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15
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Tsai YM, Wu KL, Chang YY, Chang WA, Huang YC, Jian SF, Tsai PH, Lin YS, Chong IW, Hung JY, Hsu YL. Loss of miR-145-5p Causes Ceruloplasmin Interference with PHD-Iron Axis and HIF-2α Stabilization in Lung Adenocarcinoma-Mediated Angiogenesis. Int J Mol Sci 2020; 21:ijms21145081. [PMID: 32708433 PMCID: PMC7404111 DOI: 10.3390/ijms21145081] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 12/18/2022] Open
Abstract
For decades, lung cancer has been the leading cause of cancer-related death worldwide. Hypoxia-inducible factors (HIFs) play critical roles in mediating lung cancer development and metastasis. The present study aims to clarify how HIF’s over-activation affects lung cancer angiogenesis not only in a normoxic condition, but also a hypoxic niche. Our study shows that human lung cancer exhibits elevated levels of ceruloplasmin (CP), which has a negative impact on the prognosis of patients. CP affects the cellular Fe2+ level, which inactivates prolyl hydroxylase (PHD) 1 and 2, resulting in HIF-2α enhancement. Increased HIF-2α leads to vascular endothelial growth factor-A (VEGF-A) secretion and angiogenesis. The expression of CP is under the epigenetic control of miR-145-5p. Restoration of miR-145-5p by miRNA mimics transfection decreases CP expression, increases Fe2+ and PHD1/2 levels and HIF hydroxylation while reduced HIF-2α levels resulting in the inhibition of tumor angiogenesis. In contrast, inhibition of miR-145-5p by miRNA inhibitors increases the expression of CP and VEGF-A in lung cancer cells. Significantly, miR-145-5p expression is lost in the tumor samples of lung cancer patients, and low miR-145-5p expression is strongly correlated with a shorter overall survival time. In conclusion, the current study reveals the clinical importance and prognostic value of miR-145-5p and CP. It identifies a unique mechanism of HIF-2α over-activation, which is mediated by iron imbalance of the iron-PHD coupling that modulates tumor angiogenesis.
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Affiliation(s)
- Ying-Ming Tsai
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-M.T.); (K.-L.W.); (Y.-C.H.); (S.-F.J.); (P.-H.T.); (Y.-S.L.); (I.-W.C.); (Y.-L.H.)
- Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-Y.C.); (W.-A.C.)
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Respiratory Care, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Kuan-Li Wu
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-M.T.); (K.-L.W.); (Y.-C.H.); (S.-F.J.); (P.-H.T.); (Y.-S.L.); (I.-W.C.); (Y.-L.H.)
- Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-Y.C.); (W.-A.C.)
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Yung-Yun Chang
- Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-Y.C.); (W.-A.C.)
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Wei-An Chang
- Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-Y.C.); (W.-A.C.)
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Yung-Chi Huang
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-M.T.); (K.-L.W.); (Y.-C.H.); (S.-F.J.); (P.-H.T.); (Y.-S.L.); (I.-W.C.); (Y.-L.H.)
| | - Shu-Fang Jian
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-M.T.); (K.-L.W.); (Y.-C.H.); (S.-F.J.); (P.-H.T.); (Y.-S.L.); (I.-W.C.); (Y.-L.H.)
| | - Pei-Hsun Tsai
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-M.T.); (K.-L.W.); (Y.-C.H.); (S.-F.J.); (P.-H.T.); (Y.-S.L.); (I.-W.C.); (Y.-L.H.)
| | - Yi-Shiuan Lin
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-M.T.); (K.-L.W.); (Y.-C.H.); (S.-F.J.); (P.-H.T.); (Y.-S.L.); (I.-W.C.); (Y.-L.H.)
| | - Inn-Wen Chong
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-M.T.); (K.-L.W.); (Y.-C.H.); (S.-F.J.); (P.-H.T.); (Y.-S.L.); (I.-W.C.); (Y.-L.H.)
- Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-Y.C.); (W.-A.C.)
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Respiratory Care, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Jen-Yu Hung
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-M.T.); (K.-L.W.); (Y.-C.H.); (S.-F.J.); (P.-H.T.); (Y.-S.L.); (I.-W.C.); (Y.-L.H.)
- Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-Y.C.); (W.-A.C.)
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Respiratory Care, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Correspondence: ; Tel.: +886-7-3121101 (ext. 2136); Fax: +886-7-3161210
| | - Ya-Ling Hsu
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (Y.-M.T.); (K.-L.W.); (Y.-C.H.); (S.-F.J.); (P.-H.T.); (Y.-S.L.); (I.-W.C.); (Y.-L.H.)
- Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan
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