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Ogasawara N, Kikuchi D, Tanaka M, Ochiai Y, Okamura T, Hayasaka J, Suzuki Y, Mitsunaga Y, Nomura K, Odagiri H, Yamashita S, Matsui A, Watanabe K, Takeda H, Hoteya S. Long-term outcome of cervical lymph node metastasis in superficial pharyngeal squamous cell carcinoma after endoscopic submucosal dissection. Gastrointest Endosc 2023; 98:524-533.e2. [PMID: 37150414 DOI: 10.1016/j.gie.2023.04.2095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 04/07/2023] [Accepted: 04/24/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND AND AIMS Superficial pharyngeal squamous cell carcinoma (PSCC) has received increasing attention as a therapeutic target in the GI field with recent innovations in endoscopic submucosal dissection (ESD). However, there are currently no defined criteria for the application of ESD to superficial PSCC. One of the problems encountered during follow-up after ESD is cervical lymph node metastasis (LNM). Identifying the clinicopathologic predictors of cervical LNM can help to provide a basis for the refinement of therapeutic strategies for superficial PSCC. METHODS The risk of cervical LNM was evaluated in 331 patients with superficial PSCC who underwent initial ESD between 2008 and 2021. Since tumor size, rather than depth, is the dominant factor in the current TNM classification for PSCC, the correlation between tumor size and thickness was investigated. RESULTS The median follow-up period was 4.8 years. The cumulative 5-year cervical LNM rate was 6.1%. Multivariate Cox proportional hazards regression analysis identified tumor thickness ≥1000 μm and lymphatic invasion as significant independent predictors. Among 204 cases with subepithelial invasion, both factors were also revealed to be significant independent predictors, suggesting that tumor thickness was superior to tumor size in predicting cervical LNM. Despite the positive correlation between tumor thickness and size, there was noticeable variability in the values (R = .20), and the current staging was inadequate to identify groups at high risk for cervical LNM. CONCLUSIONS Tumor thickness and lymphatic invasion are validated as significant independent predictors for cervical LNM and can be useful indicators to optimize the therapeutic strategies for superficial PSCC.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Kenta Watanabe
- Department of Otolaryngology, Toranomon Hospital, Tokyo, Japan
| | - Hidehiko Takeda
- Department of Otolaryngology, Toranomon Hospital, Tokyo, Japan
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Yamaguchi H, Kawai T, Fukuzawa M, Nemoto D, Kagawa Y, Kono S, Naito S, Sato H, Nagata N, Sugimoto M, Tsukahara K, Itoi T. Prediction of depth of invasion and lymph node metastasis in superficial pharyngeal cancer by magnifying endoscopy using the Japan Esophageal Society classification. DEN Open 2023; 3:e151. [PMID: 35898848 PMCID: PMC9307742 DOI: 10.1002/deo2.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/27/2022] [Accepted: 06/19/2022] [Indexed: 11/16/2022]
Abstract
Backgrounds The pharynx has no muscularis mucosae, so it is unclear whether diagnostic techniques used for the esophagus can be applied to the pharynx. This study investigated the usefulness of magnifying endoscopy with narrowband imaging using the Japan Esophageal Society (JES) classification for predicting the depth of invasion and lymph node metastasis (LNM) in pharyngeal cancer. Methods A total of 123 superficial pharyngeal carcinoma lesions that had been observed preoperatively with magnifying endoscopy with narrowband imaging between January 2014 and June 2021 were analyzed. Predictors of subepithelial invasion (SEP) and LNM were sought based on endoscopic findings, including microvascular morphology, using the JES classification. Results The lesions were divided into carcinoma in situ (n = 41) and SEP (n = 82). Multivariate analysis identified B2–B3 vessels (odds ratio [OR] 6.54, 95% confidence interval [CI] 1.74–24.61, p = 0.005) and a middle/large avascular area (OR 4.15, 95% CI 1.18–14.62, p = 0.027) as independent predictors of SEP. Significant predictors of LNM were protruding type, B2–B3 vessels, middle/large avascular area, SEP, venous invasion, lymphatic invasion, and tumor thickness > 1000 μm. Median tumor thickness increased significantly in the order of B1 < B2 < B3 vessels (B1, 305 μm; B2, 1045 μm; B3, 4043 μm; p < 0.001). The LNM rates for B1, B2, and B3 vessels were 1.6% (1/63), 4.8% (2/42), and 55.6% (10/18), respectively (p < 0.001). Conclusions Magnifying endoscopy with narrowband imaging using the JES classification could predict the depth of invasion in superficial pharyngeal carcinoma. The JES classification may contribute to the prediction of LNM, suggesting that it could serve as an alternative to tumor thickness.
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Affiliation(s)
- Hayato Yamaguchi
- Department of Gastroenterology and Hepatology Tokyo Medical University Tokyo Japan
| | - Takashi Kawai
- Department of Gastroenterological Endoscopy Tokyo Medical University Hospital Tokyo Japan
| | - Masakatsu Fukuzawa
- Department of Gastroenterology and Hepatology Tokyo Medical University Tokyo Japan
| | - Daiki Nemoto
- Department of Gastroenterology and Hepatology Tokyo Medical University Tokyo Japan
| | - Yasuyuki Kagawa
- Department of Gastroenterology and Hepatology Tokyo Medical University Tokyo Japan
| | - Shin Kono
- Department of Gastroenterology and Hepatology Tokyo Medical University Tokyo Japan
| | - Sakiko Naito
- Department of Gastroenterology and Hepatology Tokyo Medical University Tokyo Japan
| | - Hiroki Sato
- Department of Otorhinolaryngology, Head, and Neck Surgery Tokyo Medical University Tokyo Japan
| | - Naoyoshi Nagata
- Department of Gastroenterological Endoscopy Tokyo Medical University Hospital Tokyo Japan
| | - Mitsushige Sugimoto
- Department of Gastroenterological Endoscopy Tokyo Medical University Hospital Tokyo Japan
| | - Kiyoaki Tsukahara
- Department of Otorhinolaryngology, Head, and Neck Surgery Tokyo Medical University Tokyo Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology Tokyo Medical University Tokyo Japan
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Okabe R, Ueki Y, Ohashi R, Takeuchi M, Hashimoto S, Takahashi T, Shodo R, Yamazaki K, Matsuyama H, Umezu H, Terai S, Ajioka Y, Horii A. Predicting Cervical Lymph Node Metastasis Following Endoscopic Surgery in Superficial Head and Neck Carcinoma. Front Surg 2022; 8:813260. [PMID: 35223969 PMCID: PMC8878680 DOI: 10.3389/fsurg.2021.813260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 12/17/2021] [Indexed: 11/27/2022] Open
Abstract
Background Early detection of head and neck carcinoma (HNC) as superficial HNC (SHNC) identified using recently developed optical techniques, such as magnifying endoscopy and narrow-band imaging (NBI), in combination with endoscopic surgeries enables minimally invasive treatment with favorable outcomes for HNC. This study aimed to identify the predictive factors for the rare but important clinical issue of SHNC, namely cervical lymph node metastasis (CLNM), following endoscopic resection. Methods Sixty-nine patients with SHNC who underwent endoscopic resection were enrolled in the study. Clinical data, preoperative endoscopic findings, pathological findings, and treatment outcomes were retrospectively reviewed. Because the pharyngeal mucosa lacks the muscularis mucosa, we measured tumor thickness in permanent pathology as an alternative to the depth of invasion. Correlations with the occurrence of CLNM were statistically examined. Results The 5-year disease-specific survival rate was 100%. Of 69 patients, 3 (4.3%) developed CLNM. All had subepithelial but not epithelial tumors. The 0-IIa type in the macroscopic findings, type B2/B3 vessels in narrow-band imaging, tumors ≥ pathological stage T2, lymphatic invasion, positive surgical margins, and tumor thickness >1,000 μm showed significant correlations with CLNM following endoscopic resection. Furthermore, the classification of type B vessels was significantly associated with tumor thickness. Conclusion The treatment outcomes following endoscopic resection for SHNC were favorable. The risk of CLNM following endoscopic resection in SHNC can be predicted by several preoperative endoscopic and postoperative pathological findings. Among them, the classification of type B vessels, which correlated with both tumor thickness and CLNM, might be a useful predictive factor.
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Affiliation(s)
- Ryuichi Okabe
- Department of Otolaryngology-Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
- Department of Otorhinolaryngology, Nagaoka Red Cross Hospital, Niigata, Japan
| | - Yushi Ueki
- Department of Otolaryngology-Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
- *Correspondence: Yushi Ueki ; orcid.org/0000-0002-1699-7891
| | - Riuko Ohashi
- Division of Molecular and Diagnostic Pathology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
- Histopathology Core Facility, Niigata University Faculty of Medicine, Niigata, Japan
| | - Manabu Takeuchi
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
- Division of Gastroenterology, Nagaoka Red Cross Hospital, Niigata, Japan
| | - Satoru Hashimoto
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takeshi Takahashi
- Department of Otolaryngology-Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Ryusuke Shodo
- Department of Otolaryngology-Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Keisuke Yamazaki
- Department of Otolaryngology-Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hiroshi Matsuyama
- Department of Otolaryngology-Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
- Department of Otorhinolaryngology, Niigata City General Hospital, Niigata, Japan
| | - Hajime Umezu
- Division of Pathology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yoichi Ajioka
- Division of Molecular and Diagnostic Pathology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Arata Horii
- Department of Otolaryngology-Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Maeda H, Sasaki F, Kabayama M, Iwaya H, Komaki Y, Arima S, Tanoue S, Hashimoto S, Kanmura S, Miyashita K, Ohori J, Yamashita M, Ido A. Efficacy of endoscopic ultrasonography in evaluating tumor thickness in patients with superficial pharyngeal carcinoma: A pilot study. Auris Nasus Larynx 2021; 49:495-503. [PMID: 34840033 DOI: 10.1016/j.anl.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 11/01/2021] [Accepted: 11/10/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES A histopathological tumor thickness of ≥1000 μm has been reported as one of many risk factors for recurrent lymph node metastasis in superficial pharyngeal cancer (SPC). However, methods for assessing this risk factor preoperatively have not yet been established. Hence, the current study aimed to evaluate the efficacy of endoscopic ultrasonography (EUS) in measuring tumor thickness preoperatively in patients with SPC. METHODS This single-center retrospective study included 44 consecutive patients with 47 lesions who underwent endoscopic submucosal dissection (ESD). Prior to surgery, EUS examination was performed while under general anesthesia. Further, microvascular irregularity in the target lesion was evaluated using the Japan Esophageal Society (JES) magnification endoscopic classification system. RESULTS A significant correlation was noted between histopathological and EUS tumor thickness (Spearman's correlation r == 0.879, p < 0.001). In tumors ≥1000 µm thick on histopathology, the cutoff value for EUS tumor thickness was 2.6 mm, and the following values were obtained: sensitivity, 100%; specificity, 81.8%; positive predictive value (PPV), 70%; negative predictive value (NPV), 100%; and accuracy, 87.2%. In B2 lesions ≥1000-μm thick, the following values were obtained: sensitivity, 85.7%; specificity, 90.9%; PPV, 80%; NPV, 93.8%; and accuracy, 89.4%. The diagnostic accuracy rate of combined EUS and the JES magnifying endoscopic classification system was 95.7%. CONCLUSIONS Tumor thickness assessed using EUS was effective in diagnosing histopathological tumor thickness of ≥1000 μm. The combined use of EUS and the JES magnifying endoscopic classification system may be useful for assessing preoperative risk factors for lymph node metastasis in SPC.
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Affiliation(s)
- Hidehito Maeda
- Digestive and Lifestyle Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Fumisato Sasaki
- Digestive and Lifestyle Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.
| | - Masayuki Kabayama
- Digestive and Lifestyle Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Hiromichi Iwaya
- Digestive and Lifestyle Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Yuga Komaki
- Digestive and Lifestyle Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Shiho Arima
- Digestive and Lifestyle Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Shiroh Tanoue
- Digestive and Lifestyle Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Shinichi Hashimoto
- Digestive and Lifestyle Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Shuji Kanmura
- Digestive and Lifestyle Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Keiichi Miyashita
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Junichiro Ohori
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Masaru Yamashita
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Akio Ido
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
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Chabrillac E, Dupret-Bories A, Vairel B, Woisard V, De Bonnecaze G, Vergez S. Narrow-Band Imaging in oncologic otorhinolaryngology: State of the art. Eur Ann Otorhinolaryngol Head Neck Dis 2021; 138:451-458. [PMID: 33722467 DOI: 10.1016/j.anorl.2021.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To describe the diagnostic performance of Narrow Band Imaging (NBI) combined with White Light Imaging (WLI) in the diagnosis of mucosal lesions at each location of the upper aerodigestive tract, for detection of primary tumor in case of carcinoma of unknown primary, for determination of intraoperative resection margins, and to describe its main diagnostic pitfalls. MATERIAL AND METHODS A PubMed search was carried out according to the PRISMA method. RESULTS Four hundred and seventy-seven articles published between 2007 and 2020 were identified, 133 of which met the study inclusion criteria and were assessed. CONCLUSION The current literature seems to support the use of NBI in diagnosis and/or follow-up of (pre-)malignant head & neck tumors, and in the determination of intraoperative resection margins.
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Affiliation(s)
- E Chabrillac
- Department of ENT-Head and Neck Surgery, University Cancer Institute Toulouse and Toulouse University Hospital, Hôpital Larrey, 24 Chemin de Pouvourville, 31059 Toulouse, France; Department of Surgery, University Cancer Institute Toulouse-Oncopole, 1 Avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - A Dupret-Bories
- Department of Surgery, University Cancer Institute Toulouse-Oncopole, 1 Avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - B Vairel
- Department of ENT-Head and Neck Surgery, University Cancer Institute Toulouse and Toulouse University Hospital, Hôpital Larrey, 24 Chemin de Pouvourville, 31059 Toulouse, France; Department of Surgery, University Cancer Institute Toulouse-Oncopole, 1 Avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - V Woisard
- Department of ENT-Head and Neck Surgery, University Cancer Institute Toulouse and Toulouse University Hospital, Hôpital Larrey, 24 Chemin de Pouvourville, 31059 Toulouse, France; Department of Surgery, University Cancer Institute Toulouse-Oncopole, 1 Avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - G De Bonnecaze
- Department of ENT-Head and Neck Surgery, University Cancer Institute Toulouse and Toulouse University Hospital, Hôpital Larrey, 24 Chemin de Pouvourville, 31059 Toulouse, France
| | - S Vergez
- Department of ENT-Head and Neck Surgery, University Cancer Institute Toulouse and Toulouse University Hospital, Hôpital Larrey, 24 Chemin de Pouvourville, 31059 Toulouse, France; Department of Surgery, University Cancer Institute Toulouse-Oncopole, 1 Avenue Irène Joliot-Curie, 31059 Toulouse, France.
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Hosono H, Katada C, Kano K, Kimura A, Tsutsumi S, Miyamoto S, Ichinoe M, Furue Y, Tanabe S, Koizumi W, Yamashita T. Evaluation of the usefulness of upper gastrointestinal endoscopy and the Valsamouth Ⓡ by an otolaryngologist in patients with Hypopharyngeal cancer. Auris Nasus Larynx 2020; 48:265-273. [PMID: 32950326 DOI: 10.1016/j.anl.2020.07.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/17/2020] [Accepted: 07/29/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this retrospective study is to evaluate the usefulness of upper gastrointestinal endoscopy and the ValsamouthⓇ by an otolaryngologist in patients with hypopharyngeal cancer to assess the risk. METHODS The study group comprised 41 patients with untreated hypopharyngeal cancer that was precisely diagnosed by an otolaryngologist using upper gastrointestinal endoscopy and the ValsamouthⓇ at our hospital from January 2016 to December 2017. With upper gastrointestinal endoscopy and the ValsamouthⓇ, the oral cavity, oropharynx, larynx, hypopharynx, and esophagus were observed in this order. Narrow-band imaging, and subsequently, white-light observation were performed. At the hypopharynx, vocalization, and subsequently, the Valsalva maneuver were performed. After observing the esophagus, Lugol chromoendoscopy of the esophagus was performed. RESULTS The mean age of the 38 men and 3 women included in the study was 69.7 ± 10.0 years (range, 51-94 years). As for the T category of hypopharyngeal cancer, T1 cancer was observed in 9 patients, T2 cancer in 14, T3 cancer in 11, and T4 cancer in 7. With vocalization, the grade of visualization in the hypopharynx was 1 in 30 patients (73.2%), 2 in 11 patients (26.8%), and 3 or more in 0 patients (0.0%). With the Valsalva maneuver, the grade of visualization in the hypopharynx was 1 in 1 patient (2.4%), 2 in 15 patients (36.6%), 3 in 8 patients (19.5%), 4 in 11 patients (26.8%), and 5 in 6 patients (14.6%). The grade of visualization in the hypopharynx on average was 1.27 after vocalization and 3.15 after the Valsalva maneuver (p < 0.001). With vocalization, the percentage of patients in whom the entire image of hypopharyngeal cancer could be observed was 0.0% for grade 1 and 18.2% for grade 2. With the Valsalva maneuver, the percentage of patients in whom the entire image of hypopharyngeal cancer could be observed was 0.0% for grade 1, 40.0% for grade 2, 50.0% for grade 3, 86.1% for grade 4, and 100% for grade 5. Synchronous esophageal cancers were detected in 17.1% (7/41) of the patients. The grade of Lugol-voiding lesions was A in 5.6%, B in 52.8%, and C in 41.7%. CONCLUSION The examination with upper gastrointestinal endoscopy and the ValsamouthⓇ by an otolaryngologist is feasible in patients with hypopharyngeal cancer. This procedure can detect synchronous esophageal cancer, allowing the risk of metachronous cancer in the head and neck or the esophagus to be recognized after the treatment.
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Affiliation(s)
- Hiroshi Hosono
- Department of Otorhinolaryngology-Head and Neck Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Chikatoshi Katada
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Koichi Kano
- Department of Otorhinolaryngology-Head and Neck Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Akari Kimura
- Department of Otorhinolaryngology-Head and Neck Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Shohei Tsutsumi
- Department of Otorhinolaryngology-Head and Neck Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Syunsuke Miyamoto
- Department of Otorhinolaryngology-Head and Neck Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Masaaki Ichinoe
- Department of Pathology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Yasuaki Furue
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Satoshi Tanabe
- Department of Research and Development Center for New Medical Frontiers, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Wasaburo Koizumi
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Taku Yamashita
- Department of Otorhinolaryngology-Head and Neck Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan.
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