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Johnson F, Kloppenburg M, Hofauer B, Wollenberg B, Hoch CC, Stögbauer F, Haller B, Knopf A, Strassen U, Notohamiprodjo S. Novel Detection of Pleomorphic Adenomas via Analysis of 68Ga-DOTATOC PET/CT Imaging. Cancers (Basel) 2024; 16:2624. [PMID: 39123352 PMCID: PMC11311107 DOI: 10.3390/cancers16152624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 07/14/2024] [Accepted: 07/19/2024] [Indexed: 08/12/2024] Open
Abstract
INTRODUCTION Currently, the diagnosis of salivary gland tumors using imaging techniques is unreliable. METHODS In this monocentric retrospective study, we examined patients who received a 68Ga-DOTATOC PET/CT and subsequently underwent a salivary gland tumor resection between 1 January 2010 and 31 December 2021. PET/CT image assessment was compared with somatostatin receptor (SSTR) expression and histology. RESULTS Thirteen patients (five pleomorphic adenoma (PA) and eight other parotid lesions (OPL)) received a 68Ga-DOTATOC PET/CT. Imaging displayed strong focal tracer uptake in all PA except for one with strong tumor to background discrimination. PA revealed higher SUVmax, SUVmean, liver and blood pool quotients than those of Warthin tumors (WT) and of OPL. In comparison to the contralateral parotid, SUVmax (p = 0.02), SUVmean (p = 0.02), liver quotient (p = 0.03) and blood pool quotient (p = 0.03) were all significantly higher. In contrast, WT and OPL showed in relation to the contralateral parotid no significant differences of SUVmax (WT p = 0.79; OPL p = 0.11), SUVmean (WT p = 1.0; OPL p = 0.08), liver quotient (WT p = 0.5; OPL p = 0.08) and blood pool quotient (WT p = 0.8; OPL p = 0.19). Two PA and one granuloma were not available for examination. In the immunohistochemal analysis, all PA demonstrated the highest intensity of SSTR2 expression (grade 3). Furthermore, PA had a high percentage of cells expressing SSTR2 (20%, 80% and 55%). CONCLUSIONS A strong tracer uptake in PA was shown in 68Ga-DOTATOC PET/CT. This may allow physicians to utilize radioligated somatostatin analogue PET CT/MR imaging to accurately diagnose PA. Additionally, it may be possible in the future to treat the PA with a noninvasive peptide receptor radionuclide therapy or with somatostatin analogues.
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Affiliation(s)
- Felix Johnson
- Department of Otorhinolaryngology, Medical University of Innsbruck, Anichstraße 35, A-6020 Innsbruck, Austria
| | - Marcel Kloppenburg
- Department of Otorhinolaryngology, Medical University of Innsbruck, Anichstraße 35, A-6020 Innsbruck, Austria
| | - Benedikt Hofauer
- Department of Otorhinolaryngology, Medical University of Innsbruck, Anichstraße 35, A-6020 Innsbruck, Austria
| | - Barbara Wollenberg
- Department of Otorhinolaryngology, Klinikum rechts der Isar, TUM School of Medicine and Health, Ismaninger Str. 22, 81675 Munich, Germany
| | - Cosima C. Hoch
- Department of Otorhinolaryngology, Klinikum rechts der Isar, TUM School of Medicine and Health, Ismaninger Str. 22, 81675 Munich, Germany
| | - Fabian Stögbauer
- Institute of General and Surgical Pathology, Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany
| | - Bernhard Haller
- Institut für KI und Informatik in der Medizin, Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany
| | - Andreas Knopf
- Department of Otorhinolaryngology, Head and Neck Surgery, Albert-Ludwigs-Universität Freiburg, 79106 Freiburg, Germany
| | - Ulrich Strassen
- Department of Otorhinolaryngology, Klinikum rechts der Isar, TUM School of Medicine and Health, Ismaninger Str. 22, 81675 Munich, Germany
| | - Susan Notohamiprodjo
- Department of Nuclear Medicine, Klinikum rechts der Isar, TUM School of Medicine and Health, 81675 Munich, Germany
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Abe H, Kawahara A, Akiba J, Yamaguchi R. Advances in diagnostic liquid-based cytology. Cytopathology 2024. [PMID: 38837293 DOI: 10.1111/cyt.13405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/09/2024] [Accepted: 05/20/2024] [Indexed: 06/07/2024]
Abstract
Liquid-based cytology (LBC) has changed the landscape of gynaecological cytology. A growing demand exists for LBC in diagnostic cytology, particularly for ancillary testing, such as immunocytochemistry and molecular testing. Ancillary testing solely based on conventional preparation (CP) methods remains challenging. Recently, the increased demand for specialist testing and minimally invasive techniques, such as endoscopic ultrasonography fine-needle aspiration, to obtain cellular samples has led to an increasing demand for ancillary testing on cytology LBC supernatant, slides and cell block (CB). This facilitates the diagnosis and prognosis in cytology samples enabling personalized treatment. An understanding of the history and future prospects of LBC is crucial for its application in routine diagnostics by cytopathologists and cytotechnologists. In this review, we initiated an internet search using the keyword 'liquid-based cytology', and we conducted a literature review to discuss the usefulness of combined diagnosis of LBC and CP, immunocytochemistry and molecular testing and assessed the quality of nucleic acids in diagnostic LBC. High-quality and cell-rich diagnostic LBC surpassed the CP method alone in terms of reliability and versatility of ancillary testing in cytological diagnosis. Conclusively, diagnostic LBC lends itself to various new technologies and is expected to continue evolving with innovations in the future.
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Affiliation(s)
- Hideyuki Abe
- Department of Diagnostic Pathology, Kurume University Hospital, Kurume, Japan
| | - Akihiko Kawahara
- Department of Diagnostic Pathology, Kurume University Hospital, Kurume, Japan
| | - Jun Akiba
- Department of Diagnostic Pathology, Kurume University Hospital, Kurume, Japan
| | - Rin Yamaguchi
- Department of Diagnostic Pathology, Nagasaki University Hospital, Nagasaki, Japan
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Ma H, Jia J, Sun Z, Xiao X, Liang S, Zhao L, Zhang Z. The detection of PD-L1 expression on liquid-based cytology in pleural effusion of lung adenocarcinoma and its prognostic evaluation: Between paired liquid-based cytology and cell block samples. Diagn Cytopathol 2024; 52:235-242. [PMID: 38263766 DOI: 10.1002/dc.25276] [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: 08/08/2023] [Revised: 01/02/2024] [Accepted: 01/08/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND Programmed death-ligand 1 (PD-L1) expression levels measured by immunohistochemistry have been proven to predict the outcome of immunotherapy in lung adenocarcinoma (LUAD). However, data on PD-L1 expression on liquid-based cytology (LBC) in malignant pleural effusion (MPE) is scarce. METHODS This study cohort included 60 cases with MPE suffering from LUAD. PD-L1 SP263 assay was used for immunocytochemistry (ICC) on LBC and matched cell block (CB) to validate ICC protocols on LBC slides. Clinical outcomes were analyzed based on immunotherapy and PD-L1 tumor proportion scores (TPS) on LBC slides and CBs. RESULTS PD-L1 expression with TPS ≥1% was lower in LBCs than in CBs (33 of 60 [55.0%] vs. 35 of 60 [58.3%]; p = .687). Even with the TPS ≥50% threshold, PD-L1 expression was lower in LBCs (10 of 60 [16.7%] vs. 15 of 60 [25%]; p = .125). Epidermal growth factor receptor (EGFR) exon 20 mutation, tumor cell proportion, and pleural fluid neutrophil-to-lymphocyte ratio were related to PD-L1 expression on CBs (p = .013, p = 0.022, and p = .011), respectively. Patients with subsequent immune checkpoint inhibitor therapy remained a better prognostic in subgroups of PD-L1 positive expression on LBC slides (TPS ≥1%, p = .041). CONCLUSIONS LBC specimens had comparable performance to CBs in PD-L1 assessment and predicting treatment response to PD-L1-defined therapy.
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Affiliation(s)
- Haiyue Ma
- Cytopathology Section, Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia Jia
- Cytopathology Section, Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zihan Sun
- Cytopathology Section, Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoyue Xiao
- Cytopathology Section, Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuo Liang
- Cytopathology Section, Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Linlin Zhao
- Cytopathology Section, Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhihui Zhang
- Cytopathology Section, Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Johnson F, Hofauer B, Wirth M, Wollenberg B, Stögbauer F, Notohamiprodjo S, Haller B, Reschke R, Knopf A, Strassen U. Novel Discovery of the Somatostatin Receptor (SSTR2) in Pleomorphic Adenomas via Immunohistochemical Analysis of Tumors of the Salivary Glands. Cancers (Basel) 2023; 15:3917. [PMID: 37568733 PMCID: PMC10417029 DOI: 10.3390/cancers15153917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/09/2023] [Accepted: 07/29/2023] [Indexed: 08/13/2023] Open
Abstract
Reliable preoperative diagnosis between salivary gland tumor entities is difficult. In this monocentric retrospective study, we examined the somatostatin receptor 2 (SSTR2) status of salivary gland tumors after salivary gland tumor resection via immunohistochemistry (IHC), and stains were compared in analogy to the HER2 mamma scale. A total of 42.3% of all pleomorphic adenoma (PA) tumors (42 of 99, 95% confidence interval 32.5-52.8%) demonstrated ≥20% of cells displaying the SSTR2 as compared to just 1% of all other tumors (1/160, 95% CI 0.02-3.4%). The other tumor was a neuroendocrine carcinoma. PA had a higher intensity of SSTR2 staining, with 90.9% staining ≥ an intensity of 2 (moderate). Tumors with an intensity of SSTR2 expression equal to or greater than 2 had an 89.9% likelihood of being a PA (95% CI: 82.2-95.0%, AUC: 0.928). Only one Warthin tumor demonstrated a 'strong' SSTR2 staining intensity. No Warthin tumor showed a percentage of cells staining for SSTR2 above ≥20%. This result demonstrates consistent and strong expression of SSTR2 in PAs as compared to Warthin tumors, which may allow physicians to utilize radioligand-somatostatin analog PET CT/MR imaging to diagnose the PA. SSTR2 positivity, if shown to be clinically relevant, may allow peptide receptor radionuclide therapy in the future.
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Affiliation(s)
- Felix Johnson
- Department of Otorhinolaryngology, University Clinic of Innsbruck, 6020 Innsbruck, Austria
| | - Benedikt Hofauer
- Department of Otorhinolaryngology, University Clinic of Innsbruck, 6020 Innsbruck, Austria
| | - Markus Wirth
- Department of Otorhinolaryngology, Technical University of Munich (TUM), 85354 Freising, Germany
| | - Barbara Wollenberg
- Department of Otorhinolaryngology, Technical University of Munich (TUM), 85354 Freising, Germany
| | - Fabian Stögbauer
- Institute of General and Surgical Pathology, TUM School of Medicine, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Susan Notohamiprodjo
- Department of Nuclear Medicine, Technical University of Munich (TUM), 85354 Freising, Germany
| | - Bernhard Haller
- Institut für KI und Informatik in der Medizin, 81675 München, Germany
| | - Robin Reschke
- Department of Dermatology and Venereology, Universitätsklinikum Hamburg-Eppendorf, Fleur Hiege Center for Skin Cancer Research, 20246 Hamburg, Germany
| | - Andreas Knopf
- Department of Otorhinolaryngology, Head and Neck Surgery, Albert-Ludwigs-Universität Freiburg, 79085 Freiburg, Germany
| | - Ulrich Strassen
- Department of Otorhinolaryngology, Technical University of Munich (TUM), 85354 Freising, Germany
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Chen Y, Fu J, Li Z, Chen Q, Zhang J, Yang Y, Yang P, Wang J, Liu Z, Cao Y, Zhang Y. Cutoff values of PD-L1 expression in urinary cytology samples for predicting response to immune checkpoint inhibitor therapy in upper urinary tract urothelial carcinoma. Cancer Cytopathol 2023; 131:179-187. [PMID: 36397276 DOI: 10.1002/cncy.22661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/08/2022] [Accepted: 09/26/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND The objective of this study was to determine the cutoff value of PD-L1 expression that can predict response to immune checkpoint inhibitor (ICI) immunotherapy for upper tract urothelial carcinoma (UTUC). METHODS The concordance of PD-L1 expression between paired surgical resection specimens (SRSs) and urine cell blocks (UCBs) (cohort 1) was studied in a retrospective set of 58 UTUC patients to determine its suitability as a predictor of ICI immunotherapy efficacy. PD-L1 expression in UCBs obtained before neoadjuvant ICI immunotherapy was verified in a prospective set of 12 UTUC patients (cohort 2). PD-L1 (SP263 clone) expression was assessed for percentage (tumor proportional score) of tumor cell (TC) showing PD-L1 staining. RESULTS The authors found an overall agreement of 94.4% (51 of 54) between UCBs and SRSs in cohort 1 (positive percent agreement = 100%, negative percent agreement = 93.8%, r value = 0.63). PD-L1 expression in <10% and ≥10% of tumor cells (TCs) of UCBs were the best predictors of negative (<25%) and positive (≥25%) expression in TCs of SRSs, respectively (concordance = 98.1%, r value = 0.93). These findings were verified in cohort 2: at the 10% cutoff for PD-L1 expression, the best response predictive value was 83.3% (5 of 6) in PD-L1-positive patients, and the nonresponse predictive value was 50% (3 of 6) in PD-L1-negative patients. The sensitivity, specificity, and area under the receiver operating characteristic curve values for predicting ICI immunotherapy efficacy based on PD-L1-expressing TCs in UCBs were 62.5%, 75%, and 0.688, respectively. CONCLUSIONS Immunocytochemistry of UCBs is reliable for determining PD-L1 expression, which can predict the efficacy of ICI immunotherapy at a cutoff of 10%.
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Affiliation(s)
- Ya Chen
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Pathology, Sun Yat-Sen University Cancer Center, Guangzhou, China.,Department of Pathology, The Eighth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jia Fu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Pathology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Zhiyong Li
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Qunxi Chen
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Pathology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Jing Zhang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Pathology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Yuanzhong Yang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Pathology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Ping Yang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Pathology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Jiayu Wang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Pathology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Zhuowei Liu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Yun Cao
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Pathology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Yijun Zhang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Pathology, Sun Yat-Sen University Cancer Center, Guangzhou, China
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Pinto D, Schmitt FC. Immunohistochemistry Applied to Breast Cytological Material. Pathobiology 2022; 89:343-358. [PMID: 35367980 DOI: 10.1159/000522542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 02/08/2022] [Indexed: 12/19/2022] Open
Abstract
Fine-needle aspiration biopsies (FNABs) of the breast are minimally invasive procedures enabling the diagnosis of suspicious breast lesions. Unfortunately, they are often perceived as inferior to core-needle biopsies, namely because they are supposedly unable to differentiate between high-grade ductal carcinoma in situ and invasive carcinoma or provide material for ancillary testing. Several studies have shown, however, that FNAB samples, when handled properly, are indeed capable of providing sufficient and adequate material for ancillary testing, namely immunocytochemistry (ICC). We reviewed the published literature regarding the use of ICC for both diagnostic and theranostic uses in the different types of cytological samples obtained from FNABs of the breast, including smears, liquid-based cytology samples, and cellblocks. We found that p63 and 34βE12 show promise in aiding in the differential diagnosis between in situ and invasive lesions and that most other diagnostic markers may be used as in tissue. Regarding theranostic ICC markers, results vary between publications, but with care, these can successfully be performed in cytological samples. Air-dried smears should be avoided, and cellblocks are overall more versatile than cytology slides, enabling the evaluation of not only hormonal receptors and HER2 by ICC, but also of Ki-67. Particular attention should be paid to fixation and antigen retrieval procedures in all cases. We recommend that laboratories without experience perform short validation runs before adopting these techniques into clinical practice.
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Affiliation(s)
- Daniel Pinto
- Serviço de Anatomia Patológica, Centro Hospitalar de Lisboa Ocidental, EPE, Lisboa, Portugal.,NOVA Medical School, Lisboa, Portugal.,IPATIMUP-Instituto de Patologia e Imunologia Molecular da Universidade do Porto, Porto, Portugal
| | - Fernando C Schmitt
- IPATIMUP-Instituto de Patologia e Imunologia Molecular da Universidade do Porto, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,RISE (Health Research Network) @ CINTESIS (Center for Health Technology and Services Research), Porto, Portugal
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Sato H, Norimatsu Y, Irino S, Nishikawa T. Efficacy of the Antigenicity-Retaining Ability of Fixative Solutions for Liquid-Based Cytology: Immunocytochemistry of Long-Term Storage. Acta Cytol 2021; 65:510-521. [PMID: 34535585 DOI: 10.1159/000518452] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/11/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION/OBJECTIVE Liquid-based cytology (LBC) is advantageous as multiple stained specimens can be prepared and used for additional assays such as immunocytochemical and molecular-pathological investigations. Two types of preservative-fixative solutions (fixatives) are used for nongynecologic specimens used in the BD SurePath-LBC (SP-LBC) method, and their components vary. However, few studies have evaluated the differences in antigen-retaining ability between these fixatives. Therefore, we investigated and compared the antigen-retaining ability of the fixatives in immunocytochemical staining (ICC) under long-term storage conditions. MATERIALS AND METHODS Sediments of cultured RAJI cells (derived from Burkitt's lymphoma) were added to each fixative (red and blue) and stored at room temperature for a specified period (1 h; 1 week; and 1, 3, and 6 months). The specimens were then prepared using the SP-LBC method and subjected to ICC. Positivity rate was calculated using the specimens fixed at room temperature for 1 h as a control. Antibodies against Ki67 expressed in the nucleus and against CD20 and leukocyte common antigen (LCA) expressed on the cell membrane were used. RESULTS For CD20 and LCA, the positivity rate increased with time in the red fixative compared with that in the control. In the blue fixative, the positivity rate was highest at 1 h and was maintained at a high level throughout the storage period. In contrast, the Ki67 positivity rate was highest at 1 h in both red and blue fixatives and markedly decreased with time. Therefore, although refrigerated (8°C) storage was used, no improvement was noted. CONCLUSIONS Long-term storage is possible for cell membrane antigens at room temperature; however, it is unsuitable for intranuclear antigens. Therefore, we conclude that suitable fixative type and storage temperature differ based on antigen location. Further investigation is warranted.
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Affiliation(s)
- Hiaki Sato
- Department of Medical Technology and Clinical Engineering, Faculty of Health and Medical Sciences, Hokuriku University, Kanazawa, Japan
| | - Yoshiaki Norimatsu
- Department of Medical Technology, Faculty of Health Sciences, Ehime Prefectural University of Health Sciences, Tobe, Japan
| | - Satoshi Irino
- Department of Nursing, Ehime Prefectural University of Health Sciences, Tobe, Japan
| | - Takeshi Nishikawa
- Department of Pathology, Nara Medical University Hospital, Nara, Japan
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