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Wang Y, Peng J, Yang D, Xing Z, Jiang B, Ding X, Jiang C, Ouyang B, Su L. From metabolism to malignancy: the multifaceted role of PGC1α in cancer. Front Oncol 2024; 14:1383809. [PMID: 38774408 PMCID: PMC11106418 DOI: 10.3389/fonc.2024.1383809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/16/2024] [Indexed: 05/24/2024] Open
Abstract
PGC1α, a central player in mitochondrial biology, holds a complex role in the metabolic shifts seen in cancer cells. While its dysregulation is common across major cancers, its impact varies. In some cases, downregulation promotes aerobic glycolysis and progression, whereas in others, overexpression escalates respiration and aggression. PGC1α's interactions with distinct signaling pathways and transcription factors further diversify its roles, often in a tissue-specific manner. Understanding these multifaceted functions could unlock innovative therapeutic strategies. However, challenges exist in managing the metabolic adaptability of cancer cells and refining PGC1α-targeted approaches. This review aims to collate and present the current knowledge on the expression patterns, regulators, binding partners, and roles of PGC1α in diverse cancers. We examined PGC1α's tissue-specific functions and elucidated its dual nature as both a potential tumor suppressor and an oncogenic collaborator. In cancers where PGC1α is tumor-suppressive, reinstating its levels could halt cell proliferation and invasion, and make the cells more receptive to chemotherapy. In cancers where the opposite is true, halting PGC1α's upregulation can be beneficial as it promotes oxidative phosphorylation, allows cancer cells to adapt to stress, and promotes a more aggressive cancer phenotype. Thus, to target PGC1α effectively, understanding its nuanced role in each cancer subtype is indispensable. This can pave the way for significant strides in the field of oncology.
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Affiliation(s)
- Yue Wang
- Department of Surgery, Nanjing Central Hospital, Nanjing, China
| | - Jianing Peng
- Division of Biosciences, University College London, London, United Kingdom
| | - Dengyuan Yang
- Department of Surgery, Nanjing Central Hospital, Nanjing, China
| | - Zhongjie Xing
- Department of Surgery, Nanjing Central Hospital, Nanjing, China
| | - Bo Jiang
- Department of General Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China
| | - Xu Ding
- Department of Surgery, Nanjing Central Hospital, Nanjing, China
| | - Chaoyu Jiang
- Department of General Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China
| | - Bing Ouyang
- Department of Surgery, Nanjing Central Hospital, Nanjing, China
| | - Lei Su
- Department of General Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China
- Department of General Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
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Ganesan K, Xu C, Liu Q, Sui Y, Chen J. Unraveling the Role of Hepatic PGC1α in Breast Cancer Invasion: A New Target for Therapeutic Intervention? Cells 2023; 12:2311. [PMID: 37759533 PMCID: PMC10529029 DOI: 10.3390/cells12182311] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/15/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
Breast cancer (BC) is the most common cancer among women worldwide and the main cause of cancer deaths in women. Metabolic components are key risk factors for the development of non-alcoholic fatty liver disease (NAFLD), which may promote BC. Studies have reported that increasing PGC1α levels increases mitochondrial biogenesis, thereby increasing cell proliferation and metastasis. Moreover, the PGC1α/ERRα axis is a crucial regulator of cellular metabolism in various tissues, including BC. However, it remains unclear whether NAFLD is closely associated with the risk of BC. Therefore, the present study aimed to determine whether hepatic PGC1α promotes BC cell invasion via ERRα. Various assays, including ELISA, western blotting, and immunoprecipitation, have been employed to explore these mechanisms. According to the KM plot and TCGA data, elevated PGC1α expression was highly associated with a shorter overall survival time in patients with BC. High concentrations of palmitic acid (PA) promoted PGC1α expression, lipogenesis, and inflammatory processes in hepatocytes. Conditioned medium obtained from PA-treated hepatocytes significantly increased BC cell proliferation. Similarly, recombinant PGC1α in E0771 and MCF7 cells promoted cell proliferation, migration, and invasion in vitro. However, silencing PGC1α in both BC cell lines resulted in a decrease in this trend. As determined by immunoprecipitation assay, PCG1a interacted with ERRα, thereby facilitating the proliferation of BC cells. This outcome recognizes the importance of further investigations in exploring the full potential of hepatic PGC1α as a prognostic marker for BC development.
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Affiliation(s)
- Kumar Ganesan
- School of Chinese Medicine, LKS Faculty of Medicine, The University of Hong Kong, Sassoon Road, Hong Kong, China; (K.G.); (C.X.); (Q.L.); (Y.S.)
| | - Cong Xu
- School of Chinese Medicine, LKS Faculty of Medicine, The University of Hong Kong, Sassoon Road, Hong Kong, China; (K.G.); (C.X.); (Q.L.); (Y.S.)
| | - Qingqing Liu
- School of Chinese Medicine, LKS Faculty of Medicine, The University of Hong Kong, Sassoon Road, Hong Kong, China; (K.G.); (C.X.); (Q.L.); (Y.S.)
| | - Yue Sui
- School of Chinese Medicine, LKS Faculty of Medicine, The University of Hong Kong, Sassoon Road, Hong Kong, China; (K.G.); (C.X.); (Q.L.); (Y.S.)
| | - Jianping Chen
- School of Chinese Medicine, LKS Faculty of Medicine, The University of Hong Kong, Sassoon Road, Hong Kong, China; (K.G.); (C.X.); (Q.L.); (Y.S.)
- Shenzhen Institute of Research and Innovation, The University of Hong Kong, Shenzhen 518057, China
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Orofiamma LA, Vural D, Antonescu CN. Control of cell metabolism by the epidermal growth factor receptor. BIOCHIMICA ET BIOPHYSICA ACTA. MOLECULAR CELL RESEARCH 2022; 1869:119359. [PMID: 36089077 DOI: 10.1016/j.bbamcr.2022.119359] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 08/24/2022] [Accepted: 09/01/2022] [Indexed: 06/15/2023]
Abstract
The epidermal growth factor receptor (EGFR) triggers the activation of many intracellular signals that control cell proliferation, growth, survival, migration, and differentiation. Given its wide expression, EGFR has many functions in development and tissue homeostasis. Some of the cellular outcomes of EGFR signaling involve alterations of specific aspects of cellular metabolism, and alterations of cell metabolism are emerging as driving influences in many physiological and pathophysiological contexts. Here we review the mechanisms by which EGFR regulates cell metabolism, including by modulation of gene expression and protein function leading to control of glucose uptake, glycolysis, biosynthetic pathways branching from glucose metabolism, amino acid metabolism, lipogenesis, and mitochondrial function. We further examine how this regulation of cell metabolism by EGFR may contribute to cell proliferation and differentiation and how EGFR-driven control of metabolism can impact certain diseases and therapy outcomes.
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Affiliation(s)
- Laura A Orofiamma
- Department of Chemistry and Biology, Toronto Metropolitan University, Toronto, Ontario M5B 2K3, Canada; Graduate Program in Molecular Science, Toronto Metropolitan University, Toronto, Ontario M5B 2K3, Canada
| | - Dafne Vural
- Department of Chemistry and Biology, Toronto Metropolitan University, Toronto, Ontario M5B 2K3, Canada; Graduate Program in Molecular Science, Toronto Metropolitan University, Toronto, Ontario M5B 2K3, Canada
| | - Costin N Antonescu
- Department of Chemistry and Biology, Toronto Metropolitan University, Toronto, Ontario M5B 2K3, Canada; Graduate Program in Molecular Science, Toronto Metropolitan University, Toronto, Ontario M5B 2K3, Canada.
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Targeting PGC1α to wrestle cancer: a compelling therapeutic opportunity. J Cancer Res Clin Oncol 2022; 148:767-774. [PMID: 35032216 DOI: 10.1007/s00432-021-03912-z] [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: 11/18/2021] [Accepted: 12/28/2021] [Indexed: 10/19/2022]
Abstract
Metabolic adaptation is an emerging hallmark of cancer, as it provides tumor cells sufficient energy and metabolic intermediates. Although tumor cells are believed to highly rely on Warburg effect to satisfy their energy demand, more studies have pointed out that various types of tumor cells are highly dependent on oxidative phosphorylation to drive the tumorigenesis. Peroxisome proliferator-activated receptor-c coactivator 1α (PGC1α), the crucial member of PGC1 family, is aberrantly expressed in several cancer types, implicating its role in tumor proliferation, migration, invasion, metastasis, and chemoresistance. Numerous studies have reported that PGC1α participates in the regulation of tumor development by altering the transcriptional programs as well as the metabolic phenotypes. Thus, PGC1α-targeted therapy is therapeutically exploitable to target the metabolic vulnerabilities in tumor cells. This review mainly focuses on the current underlying mechanisms for its roles in regulating metabolic adaptation of tumor cells and its upstream regulators; how PGC1α participates in the regulation of the tumor proliferation, migration, invasion, metastasis, therapy resistance; and the feasibility of PGC1α-targeted therapy for cancer treatment.
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STAT1 potentiates oxidative stress revealing a targetable vulnerability that increases phenformin efficacy in breast cancer. Nat Commun 2021; 12:3299. [PMID: 34083537 PMCID: PMC8175605 DOI: 10.1038/s41467-021-23396-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 04/28/2021] [Indexed: 12/14/2022] Open
Abstract
Bioenergetic perturbations driving neoplastic growth increase the production of reactive oxygen species (ROS), requiring a compensatory increase in ROS scavengers to limit oxidative stress. Intervention strategies that simultaneously induce energetic and oxidative stress therefore have therapeutic potential. Phenformin is a mitochondrial complex I inhibitor that induces bioenergetic stress. We now demonstrate that inflammatory mediators, including IFNγ and polyIC, potentiate the cytotoxicity of phenformin by inducing a parallel increase in oxidative stress through STAT1-dependent mechanisms. Indeed, STAT1 signaling downregulates NQO1, a key ROS scavenger, in many breast cancer models. Moreover, genetic ablation or pharmacological inhibition of NQO1 using β-lapachone (an NQO1 bioactivatable drug) increases oxidative stress to selectively sensitize breast cancer models, including patient derived xenografts of HER2+ and triple negative disease, to the tumoricidal effects of phenformin. We provide evidence that therapies targeting ROS scavengers increase the anti-neoplastic efficacy of mitochondrial complex I inhibitors in breast cancer. Complex I inhibition induces oxidative stress leading to cancer cell cytotoxicity. Here, the authors show, in breast cancer models, that inflammatory mediators can potentiate complex I inhibitor phenformin cytotoxicity through STAT1-mediated downregulation of the reactive oxygen species scavenger NQO1.
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Cancer Stem Cell-Associated Pathways in the Metabolic Reprogramming of Breast Cancer. Int J Mol Sci 2020; 21:ijms21239125. [PMID: 33266219 PMCID: PMC7730588 DOI: 10.3390/ijms21239125] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/25/2020] [Accepted: 11/26/2020] [Indexed: 02/07/2023] Open
Abstract
Metabolic reprogramming of cancer is now considered a hallmark of many malignant tumors, including breast cancer, which remains the most commonly diagnosed cancer in women all over the world. One of the main challenges for the effective treatment of breast cancer emanates from the existence of a subpopulation of tumor-initiating cells, known as cancer stem cells (CSCs). Over the years, several pathways involved in the regulation of CSCs have been identified and characterized. Recent research has also shown that CSCs are capable of adopting a metabolic flexibility to survive under various stressors, contributing to chemo-resistance, metastasis, and disease relapse. This review summarizes the links between the metabolic adaptations of breast cancer cells and CSC-associated pathways. Identification of the drivers capable of the metabolic rewiring in breast cancer cells and CSCs and the signaling pathways contributing to metabolic flexibility may lead to the development of effective therapeutic strategies. This review also covers the role of these metabolic adaptation in conferring drug resistance and metastasis in breast CSCs.
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Xiang Y, Fang B, Liu Y, Yan S, Cao D, Mei H, Wang Q, Hu Y, Guo T. SR18292 exerts potent antitumor effects in multiple myeloma via inhibition of oxidative phosphorylation. Life Sci 2020; 256:117971. [PMID: 32553925 DOI: 10.1016/j.lfs.2020.117971] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/29/2020] [Accepted: 06/11/2020] [Indexed: 12/30/2022]
Abstract
AIMS Multiple myeloma (MM) was recently reported to rely on increased oxidative phosphorylation (OXPHOS) for survival, providing a potential opportunity for MM therapy. Herein, we aimed to propose a novel targeted drug for MM treatment, followed by the exploration of reason for OXPHOS enhancement in MM cells. MATERIALS AND METHODS The expression of OXPHOS genes and peroxisome proliferator-activated receptor gamma coactivator-1 alpha (PGC-1α) was analyzed using bioinformatics analyses, followed by verification in MM cell lines. The effects of SR18292 on OXPHOS were measured by qRT-PCR, Western blot, transmission electron microscopy, oxygen consumption rate and so on. The proliferation and apoptosis were evaluated by CCK-8, flow cytometry and Western blot. The efficiency and safety of SR18292 were assessed in a mouse model of MM. KEY FINDINGS The OXPHOS genes were generally overexpressed in MM cells, which was associated with poorer prognosis of MM patients. PGC-1α, a transcriptional coactivator, was upregulated in MM cells, and MM patients with higher PGC-1α expression exhibited increased enrichment of the OXPHOS gene set. Treatment with SR18292 (an inhibitor of PGC-1α) significantly impaired the proliferation and survival of MM cells due to OXPHOS metabolism dysfunction, which leads to energy exhaustion and oxidative damage. Besides, SR18292 potently inhibited tumor growth at a well-tolerated dose in MM model mice. SIGNIFICANCE The overexpression of OXPHOS gene set mediated by upregulated PGC-1α provides a structural basis for enhanced OXPHOS in MM cells, and SR18292 (a PGC-1α inhibitor) exerts potent antimyeloma effects, offering a potential tangible avenue for MM therapy.
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Affiliation(s)
- Yu Xiang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Collaborative Innovation Center of Hematology, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Bin Fang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yilin Liu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Siqi Yan
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Dedong Cao
- Department of Oncology, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Huiling Mei
- Department of Rheumatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Qiuguo Wang
- Pediatrics Department of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Collaborative Innovation Center of Hematology, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - Tao Guo
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Collaborative Innovation Center of Hematology, Huazhong University of Science and Technology, Wuhan 430022, China.
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Läsche M, Emons G, Gründker C. Shedding New Light on Cancer Metabolism: A Metabolic Tightrope Between Life and Death. Front Oncol 2020; 10:409. [PMID: 32300553 PMCID: PMC7145406 DOI: 10.3389/fonc.2020.00409] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 03/09/2020] [Indexed: 12/13/2022] Open
Abstract
Since the earliest findings of Otto Warburg, who discovered the first metabolic differences between lactate production of cancer cells and non-malignant tissues in the 1920s, much time has passed. He explained the increased lactate levels with dysfunctional mitochondria and aerobic glycolysis despite adequate oxygenation. Meanwhile, we came to know that mitochondria remain instead functional in cancer cells; hence, metabolic drift, rather than being linked to dysfunctional mitochondria, was found to be an active act of direct response of cancer cells to cell proliferation and survival signals. This metabolic drift begins with the use of sugars and the full oxidative phosphorylation via the mitochondrial respiratory chain to form CO2, and it then leads to the formation of lactic acid via partial oxidation. In addition to oncogene-driven metabolic reprogramming, the oncometabolites themselves alter cell signaling and are responsible for differentiation and metastasis of cancer cells. The aberrant metabolism is now considered a major characteristic of cancer within the past 15 years. However, the proliferating anabolic growth of a tumor and its spread to distal sites of the body is not explainable by altered glucose metabolism alone. Since a tumor consists of malignant cells and its tumor microenvironment, it was important for us to understand the bilateral interactions between the primary tumor and its microenvironment and the processes underlying its successful metastasis. We here describe the main metabolic pathways and their implications in tumor progression and metastasis. We also portray that metabolic flexibility determines the fate of the cancer cell and ultimately the patient. This flexibility must be taken into account when deciding on a therapy, since singular cancer therapies only shift the metabolism to a different alternative path and create resistance to the medication used. As with Otto Warburg in his days, we primarily focused on the metabolism of mitochondria when dealing with this scientific question.
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Affiliation(s)
- Matthias Läsche
- Department of Gynecology and Obstetrics, University Medicine Göttingen, Göttingen, Germany
| | - Günter Emons
- Department of Gynecology and Obstetrics, University Medicine Göttingen, Göttingen, Germany
| | - Carsten Gründker
- Department of Gynecology and Obstetrics, University Medicine Göttingen, Göttingen, Germany
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Dai K, Radin DP, Leonardi D. PINK1 depletion sensitizes non-small cell lung cancer to glycolytic inhibitor 3-bromopyruvate: Involvement of ROS and mitophagy. Pharmacol Rep 2019; 71:1184-1189. [PMID: 31669882 DOI: 10.1016/j.pharep.2019.08.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 07/24/2019] [Accepted: 08/13/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Despite significant strides in understanding the pathophysiology of non-small cell lung cancer (NSCLC), these neoplasms typically present with intrinsic chemo- and radiotherapeutic resistance. Transcriptomic analyses of patient NSCLC tumors stratified by survival times have identified the PTEN-induced putative kinase 1 (PINK1) as a molecular governor of tumor aggressiveness and patient survival time. PINK1 has been shown to confer neuroprotection in models of Parkinson Disease by ensuring proper mitochondrial turnover (mitophagy), the upkeep of ATP production and sequestering of reactive oxygen species (ROS). METHODS We utilized an shRNA against PINK1 and the glycolytic inhibitor 3-BP to assess effects on NSCLC viability via MTS cell viability assay. ATP levels, caspase-9 activation, mitophagy and ROS production were determined with standardly available kits. Cytochrome c cellular localization and phosphorylated parkin levels were determined using an ELISA. RESULTS Our results demonstrate that PINK1 depletion in the NSCLC cell line A549 via shRNA, reduced cancer cell proliferation, increased cell death, reduced ATP production, inhibited mitophagy and increased ROS and caspase-9-dependent apoptosis. PINK1 depleted cells were more susceptible to the glycolytic inhibitor 3-bromopyruvate (3-BP), which further perturbed ATP production. PINK1 depletion and 3-BP synergistically increased ROS production, caspase-9-dependent apoptosis and additively repressed mitophagy. CONCLUSIONS These results suggest that PINK1 depletion alters energetic metabolism and confers sensitivity to agents that inhibit glycolysis. Targeting accelerated tumor cell metabolism may prove useful in the clinical setting while sparing non-malignant tissue.
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Affiliation(s)
- Katherine Dai
- Bergen County Academies, Hackensack, NJ, United States
| | - Daniel P Radin
- Department of Pharmacology, Stony Brook University School of Medicine, Stony Brook, NY, United States.
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Avagliano A, Ruocco MR, Aliotta F, Belviso I, Accurso A, Masone S, Montagnani S, Arcucci A. Power in nursing: a collaborative approach. Nurs Outlook 1984; 8:cells8050401. [PMID: 31052256 PMCID: PMC6562467 DOI: 10.3390/cells8050401] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/26/2019] [Accepted: 04/28/2019] [Indexed: 01/09/2023]
Abstract
Breast cancers are very heterogeneous tissues with several cell types and metabolic pathways together sustaining the initiation and progression of disease and contributing to evasion from cancer therapies. Furthermore, breast cancer cells have an impressive metabolic plasticity that is regulated by the heterogeneous tumour microenvironment through bidirectional interactions. The structure and accessibility of nutrients within this unstable microenvironment influence the metabolism of cancer cells that shift between glycolysis and mitochondrial oxidative phosphorylation (OXPHOS) to produce adenosine triphosphate (ATP). In this scenario, the mitochondrial energetic pathways of cancer cells can be reprogrammed to modulate breast cancer’s progression and aggressiveness. Moreover, mitochondrial alterations can lead to crosstalk between the mitochondria and the nucleus, and subsequently affect cancer tissue properties. This article reviewed the metabolic plasticity of breast cancer cells, focussing mainly on breast cancer mitochondrial metabolic reprogramming and the mitochondrial alterations influencing nuclear pathways. Finally, the therapeutic strategies targeting molecules and pathways regulating cancer mitochondrial alterations are highlighted.
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Affiliation(s)
- Angelica Avagliano
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy.
| | - Maria Rosaria Ruocco
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80131 Naples, Italy.
| | - Federica Aliotta
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80131 Naples, Italy.
| | - Immacolata Belviso
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy.
| | - Antonello Accurso
- Department of General, Oncological, Bariatric and Endocrine-Metabolic Surgery, University of Naples Federico II, 80131 Naples, Italy.
| | - Stefania Masone
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80131 Naples, Italy.
| | - Stefania Montagnani
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy.
| | - Alessandro Arcucci
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy.
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