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Farmer W, Hannon G, Ghosh S, Prina-Mello A. Thermal ablation in pancreatic cancer: A scoping review of clinical studies. Front Oncol 2022; 12:1066990. [DOI: 10.3389/fonc.2022.1066990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/11/2022] [Indexed: 11/30/2022] Open
Abstract
BackgroundPancreatic cancer is a deadly cancer with a 5-year survival rate less than 10%. Only 20% of patients are eligible to receive surgery at diagnosis. Hence, new therapies are needed to improve outcomes for non-surgical candidates. Thermal ablation techniques can offer a non-invasive alternative to surgery.AimThe aim of this review is to map the literature for the use of thermal ablative techniques: Radiofrequency ablation (RFA), High-intensity focused ultrasound (HIFU), Microwave ablation (MWA), and Laser ablation (LA) in the management of patients with PC.MethodsA search strategy was applied to PUBMED and EMBASE using keywords concerning pancreatic cancer, radiofrequency ablation, ultrasound ablation, laser ablation, and microwave ablation. The studies that fit this inclusion criteria were summarized in table format and results reviewed for interpretation.Results72 clinical studies were included. Most of the included studies related to RFA (n=35) and HIFU (n=27). The most common study design was retrospective (n=33). Only 3 randomized control trials (RCT) were included, all of which related to RFA. Safety outcomes were reported in 53 of the 72 studies, and survival outcomes were reported in 39. Statistically significant survival benefits were demonstrated in 11 studies.ConclusionThe evidence for the benefit of MWA and LA in PC patients is limited. RFA and HIFU are safe and feasible therapies to be used in PC patients. Further RCTs where thermal techniques are standardized and reported are necessary in the future to elucidate thermal ablation’s clinical utility, and before an evidence-based decision on its routine use in PC management can be considered.
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deSouza NM, Gedroyc W, Rivens I, ter Haar G. Tissue specific considerations in implementing high intensity focussed ultrasound under magnetic resonance imaging guidance. Front Oncol 2022; 12:1037959. [PMID: 36387108 PMCID: PMC9663991 DOI: 10.3389/fonc.2022.1037959] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/17/2022] [Indexed: 11/29/2022] Open
Abstract
High-intensity focused ultrasound can ablate a target permanently, leaving tissues through which it passes thermally unaffected. When delivered under magnetic resonance (MR) imaging guidance, the change in tissue relaxivity on heating is used to monitor the temperatures achieved. Different tissue types in the pre-focal beam path result in energy loss defined by their individual attenuation coefficients. Furthermore, at interfaces with different acoustic impedances the beam will be both reflected and refracted, changing the position of the focus. For complex interfaces this effect is exacerbated. Moreover, blood vessels proximal to the focal region can dissipate heat, altering the expected region of damage. In the target volume, the temperature distribution depends on the thermal conductivity (or diffusivity) of the tissue and its heat capacity. These are different for vascular tissues, water and fat containing tissues and bone. Therefore, documenting the characteristics of the pre-focal and target tissues is critical for effective delivery of HIFU. MR imaging provides excellent anatomic detail and characterization of soft tissue components. It is an ideal modality for real-time planning and monitoring of HIFU ablation, and provides non-invasive temperature maps. Clinical applications involve soft-tissue (abdomino-pelvic applications) or bone (brain applications) pre-focally and at the target (soft-tissue tumors and bone metastases respectively). This article addresses the technical difficulties of delivering HIFU effectively when vascular tissues, densely cellular tissues, fat or bone are traversed pre-focally, and the clinical applications that target these tissues. The strengths and limitations of MR techniques used for monitoring ablation in these tissues are also discussed.
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Affiliation(s)
- Nandita M. deSouza
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Wladyslaw Gedroyc
- Faculty of Medicine, St. Mary’s Hospital, Imperial College, London, United Kingdom
| | - Ian Rivens
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Gail ter Haar
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
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Sofuni A, Asai Y, Mukai S, Yamamoto K, Itoi T. High-intensity focused ultrasound therapy for pancreatic cancer. J Med Ultrason (2001) 2022:10.1007/s10396-022-01208-4. [PMID: 35551555 DOI: 10.1007/s10396-022-01208-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/01/2022] [Indexed: 11/28/2022]
Abstract
Pancreatic cancer (PC) has one of the poorest prognoses among solid cancers, and its incidence has increased recently. Satisfactory outcomes are not achieved with current therapies; thus, novel treatments are urgently needed. High-intensity focused ultrasound (HIFU) is a novel therapy for ablating tissue from the outside of the body by focusing ultrasonic waves from multiple sources on the tumor. In this therapy, only the focal area is heated to 80-100 ºC, which causes coagulative necrosis of the tissue, with hardly any impact on the tissue outside the focal area. Although HIFU is a minimally invasive treatment and is expected to be useful, it is not yet generally known. Here, we discuss the usefulness of HIFU treatment for un-resectable advanced PC using the results of previous research, meta-analyses, and systematic reviews on its efficacy and safety. HIFU therapy for un-resectable PC is useful for its anti-tumor effect and pain relief, and is expected to prolong survival time and improve quality of life. Although HIFU for PC has several limitations and further study is needed, this technique can be safely performed on un-resectable advanced PC. In future, HIFU could be utilized as a minimally invasive treatment strategy for PC patients with a poor prognosis.
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Affiliation(s)
- Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Yasutsugu Asai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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Pre-Exposure to Stress-Inducing Agents Increase the Anticancer Efficacy of Focused Ultrasound against Aggressive Prostate Cancer Cells. Antioxidants (Basel) 2022; 11:antiox11020341. [PMID: 35204223 PMCID: PMC8868501 DOI: 10.3390/antiox11020341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 02/01/2023] Open
Abstract
Despite the initial success in treatment of localized prostate cancer (PCa) using surgery, radiation or hormonal therapy, recurrence of aggressive tumors dictates morbidity and mortality. Focused ultrasound (FUS) is being tested as a targeted, noninvasive approach to eliminate the localized PCa foci, and strategies to enhance the anticancer potential of FUS have a high translational value. Since aggressive cancer cells utilize oxidative stress (Ox-stress) and endoplasmic reticulum stress (ER-stress) pathways for their survival and recurrence, we hypothesized that pre-treatment with drugs that disrupt stress-signaling pathways in tumor cells may increase FUS efficacy. Using four different PCa cell lines, i.e., LNCaP, C4-2B, 22Rv1 and DU145, we tested the in vitro effects of FUS, alone and in combination with two clinically tested drugs that increase Ox-stress (i.e., CDDO-me) or ER-stress (i.e., nelfinavir). As compared to standalone FUS, significant (p < 0.05) suppressions in both survival and recurrence of PCa cells were observed following pre-sensitization with low-dose CDDO-me (100 nM) and/or nelfinavir (2 µM). In drug pre-sensitized cells, significant anticancer effects were evident at a FUS intensity of as low as 0.7 kW/cm2. This combined mechanochemical disruption (MCD) approach decreased cell proliferation, migration and clonogenic ability and increased apoptosis/necrosis and reactive oxygen species (ROS) production. Furthermore, although activated in cells that survived standalone FUS, pre-sensitization with CDDO-me and/or nelfinavir suppressed both total and activated (phosphorylated) NF-κB and Akt protein levels. Thus, a combined MCD therapy may be a safe and effective approach towards the targeted elimination of aggressive PCa cells.
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Mouratidis PXE, ter Haar G. Latest Advances in the Use of Therapeutic Focused Ultrasound in the Treatment of Pancreatic Cancer. Cancers (Basel) 2022; 14:638. [PMID: 35158903 PMCID: PMC8833696 DOI: 10.3390/cancers14030638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 02/07/2023] Open
Abstract
Traditional oncological interventions have failed to improve survival for pancreatic cancer patients significantly. Novel treatment modalities able to release cancer-specific antigens, render immunologically "cold" pancreatic tumours "hot" and disrupt or reprogram the pancreatic tumour microenvironment are thus urgently needed. Therapeutic focused ultrasound exerts thermal and mechanical effects on tissue, killing cancer cells and inducing an anti-cancer immune response. The most important advances in therapeutic focused ultrasound use for initiation and augmentation of the cancer immunity cycle against pancreatic cancer are described. We provide a comprehensive review of the use of therapeutic focused ultrasound for the treatment of pancreatic cancer patients and describe recent studies that have shown an ultrasound-induced anti-cancer immune response in several tumour models. Published studies that have investigated the immunological effects of therapeutic focused ultrasound in pancreatic cancer are described. This article shows that therapeutic focused ultrasound has been deemed to be a safe technique for treating pancreatic cancer patients, providing pain relief and improving survival rates in pancreatic cancer patients. Promotion of an immune response in the clinic and sensitisation of tumours to the effects of immunotherapy in preclinical models of pancreatic cancer is shown, making it a promising candidate for use in the clinic.
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Affiliation(s)
- Petros X. E. Mouratidis
- Department of Physics, Division of Radiotherapy and Imaging, The Institute of Cancer Research: Royal Marsden Hospital, Sutton, London SM25NG, UK;
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Fergadi MP, Magouliotis DE, Rountas C, Vlychou M, Athanasiou T, Symeonidis D, Pappa PA, Zacharoulis D. A meta-analysis evaluating the role of high-intensity focused ultrasound (HIFU) as a fourth treatment modality for patients with locally advanced pancreatic cancer. Abdom Radiol (NY) 2022; 47:254-264. [PMID: 34718835 DOI: 10.1007/s00261-021-03334-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/20/2021] [Accepted: 10/22/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND This study aimed to evaluate the outcomes of high-intensity focused ultrasound (HIFU) on patients with advanced pancreatic cancer. METHODS A literature search was performed in PubMed, Scopus and Cochrane databases, in accordance with the PRISMA guidelines. The Odds Ratio, Weighted Mean Difference, and 95% Confidence Interval were evaluated by means of the Random-Effects model. RESULTS Nineteen articles met the inclusion criteria, incorporating 939 patients. This study reveals that patients in the HIFU group presented increased median overall survival (OS), along with higher OS at 6 and 12 months after treatment compared with the control group (p < 0.05). Furthermore, patients treated with HIFU in conjunction with chemotherapy presented reduced levels of pain (p < 0.05) compared to the traditional treatment group. In addition, HIFU contributed to significant tumor responsiveness, in terms of CA19-9 reduction (p < 0.05). Finally, HIFU was a considerably safe treatment modality with a low incidence of complications. CONCLUSION These outcomes suggest that HIFU is a feasible and safe treatment modality for patients with advanced pancreatic cancer and provides enhanced outcomes regarding survival and quality of life. Given the lack of a significant number of randomized clinical trials, this meta-analysis represents the best currently available evidence. New randomized trials assessing HIFU are necessary to further evaluate their outcomes.
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Affiliation(s)
- Maria P Fergadi
- Department of Radiology, University of Thessaly, 41110, Biopolis, Larissa, Greece
| | - Dimitrios E Magouliotis
- Department of Radiology, University of Thessaly, 41110, Biopolis, Larissa, Greece
- Division of Surgery and Interventional Sciences, UCL, London, UK
| | - Christos Rountas
- Department of Radiology, University of Thessaly, 41110, Biopolis, Larissa, Greece
| | - Marianna Vlychou
- Department of Radiology, University of Thessaly, 41110, Biopolis, Larissa, Greece
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, W2 1NY, UK
| | - Dimitris Symeonidis
- Department of Surgery, University of Thessaly, 41110, Biopolis, Larissa, Greece
| | - Polyxeni A Pappa
- Department of Radiology, University of Thessaly, 41110, Biopolis, Larissa, Greece
| | - Dimitris Zacharoulis
- Department of Surgery, University of Thessaly, 41110, Biopolis, Larissa, Greece.
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Sofuni A, Asai Y, Tsuchiya T, Ishii K, Tanaka R, Tonozuka R, Honjo M, Mukai S, Nagai K, Yamamoto K, Matsunami Y, Kurosawa T, Kojima H, Homma T, Minami H, Nakatsubo R, Hirakawa N, Miyazawa H, Nagakawa Y, Tsuchida A, Itoi T. Novel Therapeutic Method for Unresectable Pancreatic Cancer-The Impact of the Long-Term Research in Therapeutic Effect of High-Intensity Focused Ultrasound (HIFU) Therapy. Curr Oncol 2021; 28:4845-4861. [PMID: 34898585 PMCID: PMC8628685 DOI: 10.3390/curroncol28060409] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/18/2021] [Accepted: 11/17/2021] [Indexed: 11/16/2022] Open
Abstract
High-intensity focused ultrasound (HIFU) is a novel advanced therapy for unresectable pancreatic cancer (PC). HIFU therapy with chemotherapy is being promoted as a novel method to control local advancement by tumor ablation. We evaluated the therapeutic effects of HIFU therapy in locally advanced and metastatic PC. PC patients were treated with HIFU as an optional local therapy and systemic chemotherapy. The FEP-BY02 (Yuande Bio-Medical Engineering) HIFU device was used under ultrasound guidance. Of 176 PC patients, 89 cases were Stage III and 87 were Stage IV. The rate of complete tumor ablation was 90.3%, while that of symptom relief was 66.7%. The effectiveness on the primary lesions were as follows: complete response (CR): n = 0, partial response (PR): n = 21, stable disease (SD): n = 106, and progressive disease (PD): n = 49; the primary disease control rate was 72.2%. Eight patients underwent surgery. The median survival time (MST) after diagnosis for HIFU with chemotherapy compared to chemotherapy alone (100 patients in our hospital) was 648 vs. 288 days (p < 0.001). Compared with chemotherapy alone, the combination of HIFU therapy and chemotherapy demonstrated significant prolongation of prognosis. This study suggests that HIFU therapy has the potential to be a novel combination therapy for unresectable PC.
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Affiliation(s)
- Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Yasutsugu Asai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Kentaro Ishii
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Reina Tanaka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Mitsuyoshi Honjo
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Kazumasa Nagai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Yukitoshi Matsunami
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Takashi Kurosawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Hiroyuki Kojima
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Toshihiro Homma
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Hirohito Minami
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Ryosuke Nakatsubo
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Noriyuki Hirakawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Hideaki Miyazawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.N.); (A.T.)
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.N.); (A.T.)
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan; (Y.A.); (T.T.); (K.I.); (R.T.); (R.T.); (M.H.); (S.M.); (K.N.); (K.Y.); (Y.M.); (T.K.); (H.K.); (T.H.); (H.M.); (R.N.); (N.H.); (H.M.); (T.I.)
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