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Guo Y, Jiang L, Luo S, Hu D, Zhao X, Zhao G, Tang W. Network Analysis and Basic Experiments on the Inhibition of Renal Cancer Proliferation and Migration by Alpinetin through PI3K/AKT/ mTOR Pathway. Curr Mol Med 2024; 24:134-144. [PMID: 37221689 DOI: 10.2174/1566524023666230522145226] [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: 09/08/2022] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Alpinetin, a natural flavonoid, has been shown to have anticancer effects on many tumors. This study investigated the antitumor effect of alpinetin on renal clear cell carcinoma (ccRCC). METHODS Network Pharmacology analysis was carried out on the targets and molecular mechanisms of alpinetin treating ccRCC. The Annexin V PE/7-AAD kit was used to detect apoptosis. Flow cytometry and Cell Counting Kit-8 (CCK-8) were used to detect cell proliferation and cycle. A 24-well transwell chamber and the ibidi scratch insertion performed cell migration analysis. The protein expression of the target molecule was detected by Western blotting. Nude mouse tumorigenesis assays were used to determine the in vivo antitumor effects of alpinetin. RESULTS The network pharmacology revealed that GAPDH, HRAS, SRC, EGFR, and AKT1 are the main targets of alpinetin in treating ccRCC, with the PI3K/AKT signaling pathway being the main pathway of action. We found that alpinetin could significantly inhibit the proliferation and migration of ccRCC cells by inducing apoptosis. In addition, alpinetin also inhibited the cycle progression of ccRCC cells by blocking them in the G1 phase. Furthermore, in vivo and in vitro, alpinetin could inhibit the activation of an important pathway involved in the proliferation and migration of ccRCC cells, namely the PI3K/Akt pathway. CONCLUSION Alpinetin can inhibit the growth of ccRCC cells by inhibiting the activation of the PI3K/Akt pathway and can be a potential anti-cancer drug for ccRCC.
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Affiliation(s)
- Yu Guo
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Li Jiang
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Shengjun Luo
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Daixing Hu
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Xin Zhao
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Guozhi Zhao
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Wei Tang
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
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Bang S, Jee S, Son H, Wi YC, Kim H, Park H, Myung J, Shin SJ, Paik SS. Loss of DUSP4 Expression as a Prognostic Biomarker in Clear Cell Renal Cell Carcinoma. Diagnostics (Basel) 2021; 11:diagnostics11101939. [PMID: 34679636 PMCID: PMC8534388 DOI: 10.3390/diagnostics11101939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/14/2021] [Accepted: 10/16/2021] [Indexed: 11/16/2022] Open
Abstract
Dual-specificity protein phosphatase 4 (DUSP4) is a negative regulator of mitogen-activated protein kinases. The prognostic impact of DUSP4 expression in renal cell carcinoma is not well studied. Therefore, we evaluated the clinicopathological implications of DUSP4 expression in clear cell renal cell carcinoma by performing immunohistochemistry (IHC). The clinical outcome according to DUSP4 expression was evaluated through survival analyses, and the association between mRNA expression and prognosis was confirmed by online analysis (Kaplan-Meier plotter). Loss of DUSP4 expression was noted in most histological subtypes of renal cell carcinoma. Loss of DUSP4 expression in clear cell renal cell carcinoma was significantly correlated with old age (p = 0.033), high histologic grade (p < 0.001), tumor necrosis (p < 0.001), and high pT category (p < 0.001). In survival analysis, loss of DUSP4 expression was associated with poor clinical outcomes in cancer-specific survival and recurrence-free survival (p = 0.010 and p = 0.007, respectively). Upon TCGA data analysis, patients with low DUSP4 mRNA expression showed a shorter overall survival (p = 0.023). These results suggest that loss of DUSP4 expression can be used as a potential biomarker for predicting clinical outcomes in clear cell renal cell carcinoma patients.
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Affiliation(s)
- Seongsik Bang
- Department of Pathology, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul 04763, Korea; (S.B.); (S.J.); (H.S.); (H.K.); (H.P.); (J.M.)
| | - Seungyun Jee
- Department of Pathology, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul 04763, Korea; (S.B.); (S.J.); (H.S.); (H.K.); (H.P.); (J.M.)
| | - Hwangkyu Son
- Department of Pathology, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul 04763, Korea; (S.B.); (S.J.); (H.S.); (H.K.); (H.P.); (J.M.)
| | - Young Chan Wi
- Department of Pathology, Eunpyeong St. Mary’s Hospital, The Catholic University of Korea, Seoul 03312, Korea;
| | - Hyunsung Kim
- Department of Pathology, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul 04763, Korea; (S.B.); (S.J.); (H.S.); (H.K.); (H.P.); (J.M.)
| | - Hosub Park
- Department of Pathology, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul 04763, Korea; (S.B.); (S.J.); (H.S.); (H.K.); (H.P.); (J.M.)
| | - Jaekyung Myung
- Department of Pathology, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul 04763, Korea; (S.B.); (S.J.); (H.S.); (H.K.); (H.P.); (J.M.)
| | - Su-Jin Shin
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea;
| | - Seung Sam Paik
- Department of Pathology, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul 04763, Korea; (S.B.); (S.J.); (H.S.); (H.K.); (H.P.); (J.M.)
- Correspondence: ; Tel.: +82-02-2220-8960
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Zhou S, Zhang H. Synergies of Targeting Angiogenesis and Immune Checkpoints in Cancer: From Mechanism to Clinical Applications. Anticancer Agents Med Chem 2021; 20:768-776. [PMID: 32031076 DOI: 10.2174/1871520620666200207091653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 10/23/2019] [Accepted: 01/12/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Angiogenesis marks key progress in the growth, recurrence, and metastasis of various cancers. Antiangiogenic drugs can improve the blood supply and oxygen content of tumors and enhance the effects of chemotherapy and radiotherapy by normalizing tumor blood vessels and microenvironment. The further recent developments of Immune Checkpoint Inhibitors (ICIs) provide significant progress in cancer immunotherapy. The study focused on programmed cell death protein 1 (PD-1) and Cytotoxic T Lymphocyte Antigen 4 (CTLA-4) blockade, reflecting on the evidence of durable responses among various tumor types. The aim of this review was to sum up present evidence and clarify the rationale behind supporting the benefits of combining antiangiogenic drugs with immunotherapy for cancer treatment as well as list the ongoing clinical trials that are being conducted. METHODS Using PubMed and Web of Science, published articles have been searched and comprehensively reviewed. RESULTS Antiangiogenic agents can trigger antitumor and immunity, and they can also be induced by the immune system. Combining antiangiogenic drugs with immunotherapy may be effective for the treatment of human cancers. CONCLUSION It is evidenced that combining angiogenesis inhibitors with immunotherapy has a synergistic effect thus improving the curative effect of both agents.
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Affiliation(s)
- Shi Zhou
- Department of Oncology, Zhongda Hospital, Medical School of Southeast University, Nanjing 210009, Jiangsu, China
| | - Haijun Zhang
- Department of Oncology, Zhongda Hospital, Medical School of Southeast University, Nanjing 210009, Jiangsu, China
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Cohen J, Meunier R, Jamshed S, Karam AR, Yates J, Wang X, LaFemina J. Metastatic Renal Cell Carcinoma in a Hepatic Hemangioma. Int J Surg Pathol 2016; 24:552-5. [DOI: 10.1177/1066896916634207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report the case of 55-year-old female with biopsy-proven clear cell renal cell carcinoma with a suspicious lesion found in the liver who presented for right radical nephrectomy and partial hepatectomy. Histologic evaluation of the hepatic specimen demonstrated metastatic renal cell carcinoma within a hepatic hemangioma. Herein we provide a review of the literature for this uncommon scenario.
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Affiliation(s)
- Joshua Cohen
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Rashna Meunier
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Sarah Jamshed
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Adib R. Karam
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Jennifer Yates
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Xiaofei Wang
- University of Massachusetts Medical School, Worcester, MA, USA
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Sun P, Wang L, Lu Y, Liu Y, Li L, Yin L, Zhang C, Zhao W, Shen B, Xu W. MicroRNA-195 targets VEGFR2 and has a tumor suppressive role in ACHN cells via PI3K/Akt and Raf/MEK/ERK signaling pathways. Int J Oncol 2016; 49:1155-63. [PMID: 27572273 DOI: 10.3892/ijo.2016.3608] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 06/24/2016] [Indexed: 11/05/2022] Open
Abstract
Increasing evidence indicates that dysregulation of miR-195 may contribute to the occurrence and development of multiple types of human malignancies. However, the function and the mechanism of miR-195 in clear cell renal cell carcinoma (ccRCC) are still not fully understood. In the present study, we used qRT-PCR to detect the expression of miR-195 in ccRCC tissues and normal kidney tissues. MTT assay was performed to detect the cell viability of miR-195. Migration and invasion were evaluated by Transwell migration and Matrigel invasion assays, respectively. Additionally, apoptosis levels were evaluated using TUNEL assays, and signaling pathway changes were determined by western blot analysis. We observed that miR-195 was downregulated in clear cell renal cell carcinoma samples compared with normal renal samples. We identified that overexpression of miR-195 inhibited ACHN cell viability, migration, invasion, and it also induced cell apoptosis by targeting VEGFR2 via PI3K/Akt and Raf/MEK/ERK signaling pathways. These findings indicate that miR-195 has a tumor suppressive role in ACHN cells and miR-195 may be a promising candidate target for prevention and treatment of renal cell carcinoma.
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Affiliation(s)
- Pengcheng Sun
- Department of Urology, The Fourth Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Lu Wang
- Department of Urology, The Fourth Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Yunhan Lu
- Department of Urology, The Fourth Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Yuwei Liu
- Department of Urology, The Fourth Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Lechen Li
- Department of Urology, The Fourth Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Luyao Yin
- Department of Urology, The Fourth Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Cheng Zhang
- Department of Urology, The First Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Weiming Zhao
- Department of Urology, The First Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Baozhong Shen
- Department of Radiology, The Fourth Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Wanhai Xu
- Department of Urology, The Fourth Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
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Zhu X, Zhou W. The Emerging Regulation of VEGFR-2 in Triple-Negative Breast Cancer. Front Endocrinol (Lausanne) 2015; 6:159. [PMID: 26500608 PMCID: PMC4598588 DOI: 10.3389/fendo.2015.00159] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 09/25/2015] [Indexed: 12/21/2022] Open
Abstract
Vascular endothelial growth factor-A (VEGF) signals vascular development and angiogenesis mainly by binding to VEGF receptor family member 2 (VEGFR-2). Adaptor proteins mediate many VEGFR-2's functions in the development of blood vessels. Cancer cells secrete VEGF to activate VEGFR-2 pathway in their neighboring endothelial cells in the process of cancer-related angiogenesis. Interestingly, activation of VEGFR-2 signaling is found in breast cancer cells, but its role and regulation are not clear. We highlighted research advances of VEGFR-2, with a focus on VEGFR-2's regulation by mutant p53 in breast cancer. In addition, we reviewed recent Food and Drug Administration-approved tyrosine kinase inhibitor drugs that can inhibit the function of VEGFR-2. Ongoing preclinical and clinical studies might prove that pharmaceutically targeting VEGFR-2 could be an effective therapeutic strategy in treating triple-negative breast cancer.
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Affiliation(s)
- Xiaoxia Zhu
- Molecular Oncology Program, Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Wen Zhou
- Department of Biological Science, Columbia University, New York, NY, USA
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7
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Mathias J, Rini B. Angiogenesis Inhibitor Therapy in Renal Cell Cancer. KIDNEY CANCER 2015. [DOI: 10.1007/978-3-319-17903-2_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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8
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Iranparast S, Assarehzadegan MA, Heike Y, Hossienzadeh M, Khodadadi A. Wilms' Tumor Gene (WT1) Expression Correlates with Vascular Epithelial Growth Factor (VEGF) in Newly Acute Leukemia Patients Undergoing Chemotherapy. Asian Pac J Cancer Prev 2014; 15:9217-23. [DOI: 10.7314/apjcp.2014.15.21.9217] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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9
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Stewart MW. Review of Aflibercept for the Treatment of Neovascular Age-Related Macular Degeneration. ACTA ACUST UNITED AC 2013. [DOI: 10.4137/cmt.s8921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The treatment of exudative age-related macular degeneration (AMD) has been completely transformed by the development of drugs that bind vascular endothelial growth factor (VEGF). The antibody-based VEGF inhibitors bevacizumab and ranibizumab usually prevent the enlargement of choroidal neovascular membranes, reduce vascular permeability, and improve visual acuity. The newest VEGF inhibitor, aflibercept, is a soluble fusion protein that binds all isoforms of VEGF-A, VEGF-B, and placental growth factor with high affinity. Preclinical studies demonstrated aflibercept's ability to prevent experimental neovascularization and tumor growth in animal models. In phase 3 trials for exudative AMD, patients who received aflibercept avoided moderate vision loss and experienced improved visual acuity comparable to those who received ranibizumab. Additionally, patients who were treated with aflibercept 2 mg every 8 weeks (after 3 monthly loading doses) had similar visual results to those treated every 4 weeks. When treated as needed during the second year of the trials, patients were able to last an average of 3 months between aflibercept injections. Since its regulatory approval, aflibercept has also been found to perform well as a salvage therapy for eyes that respond incompletely to ranibizumab and bevacizumab. Because aflibercept can be administered less frequently than ranibizumab, it promises to decrease the frequency of patients’ visits to physicians’ offices in addition to the overall cost of AMD therapy.
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Ha YS, Chihara Y, Yoon HY, Kim YJ, Kim TH, Woo SH, Yun SJ, Kim IY, Hirao Y, Kim WJ. Downregulation of fumarate hydratase is related to tumorigenesis in sporadic renal cell cancer. Urol Int 2012; 90:233-9. [PMID: 23295344 DOI: 10.1159/000345608] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2012] [Accepted: 11/06/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Although germline mutations of fumarate hydratase (FH) are a useful molecular marker of hereditary leiomyomatosis and renal cell cancer (RCC) syndrome, their clinical significance in sporadic RCC has not been studied in detail. The aim of the present study was to investigate possible correlations between the expression of FH and the clinical implications of sporadic RCC. MATERIALS AND METHODS FH mRNA levels were evaluated in 140 tumor specimens from patients with primary RCC and in 62 specimens of corresponding normal-appearing kidney tissue using real-time quantitative polymerase chain reaction. Immunohistochemical staining was performed on 6 normal surrounding tissues and 71 RCC tissues. RESULTS FH mRNA levels were significantly lower in tumor tissues than in matched normal-appearing kidney tissues (p = 0.031). In all normal tissues, FH staining intensity was strong. However, the expression of FH showed no significant correlation with the pathological and clinical characteristics of patients with sporadic RCC. CONCLUSIONS Our results showed that FH mRNA expression decreased significantly in correlation with the transition from normal renal parenchyma to RCC. FH may be an indicator or tumorigenesis in sporadic RCC and could be a potential target for therapies against RCC in the future.
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Affiliation(s)
- Yun-Sok Ha
- Department of Urology, College of Medicine, Chungbuk National University, Cheongju, South Korea
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Gatson NN, Chiocca EA, Kaur B. Anti-angiogenic gene therapy in the treatment of malignant gliomas. Neurosci Lett 2012; 527:62-70. [PMID: 22906922 DOI: 10.1016/j.neulet.2012.08.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 08/03/2012] [Indexed: 11/15/2022]
Abstract
More than four decades ago, Dr. Judah Folkman hypothesized that angiogenesis was a critical process in tumor growth. Since that time, there have been significant advances in understanding tumor biology and groundbreaking research in cancer therapy that have validated his hypothesis. However, in spite of extensive research, glioblastoma multiforme (GBM), the most common and malignant primary brain tumor, has gained little in the way of improved median survival. There have been several angiogenesis targets that have resulted in drugs that are in clinical trials or FDA approved for clinical use in several cancers. GBM is a highly angiogenic tumor and several drugs are showing promise in clinical trials with one (bevacizumab), clinically approved for use. We will review several possible angiogenic targets in GBM as well as the vector methodologies used for delivery. In addition, GBMs present several therapeutic challenges related to structure, tumor immune microenvironment and resistance to angiogenesis. To overcome these challenges will require novel approaches to improve therapeutic gene expression and vector biodistribution in the glioma.
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Affiliation(s)
- NaTosha N Gatson
- Dardinger Center for Neuro-oncology and Neurosciences, N-1017 Doan Hall, 410 W. 10th Avenue, James Cancer Hospital/Solove Research Institute and The Ohio State University Wexner Medical Center, Columbus, OH 43210-1240, USA
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12
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Sadeghi S, Rini B. Angiogenesis Inhibitor Therapy in Renal Cell Cancer. KIDNEY CANCER 2012. [DOI: 10.1007/978-3-642-21858-3_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Zhou Q, Zhu Y, Deng Z, Long H, Zhang S, Chen X. VEGF and EMMPRIN expression correlates with survival of patients with osteosarcoma. Surg Oncol 2011; 20:13-9. [PMID: 19836228 DOI: 10.1016/j.suronc.2009.09.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Revised: 08/20/2009] [Accepted: 09/01/2009] [Indexed: 01/08/2023]
Abstract
AIM To investigate the clinicopathologic characteristics of Vascular Endothelial Growth Factor (VEGF) and Extracellular Matrix Metalloproteinase Inducer (EMMPRIN) expression in osteosarcoma, and to evaluate the clinical significance of these two markers in the survival of osteosarcoma. METHODS VEGF and EMMPRIN expression in paraffin-embedded specimens gathered from 65 patients with primary osteosarcoma were detected by the method of immunohistochemistry using antibodies against VEGF and EMMPRIN. The correlation of VEGF and EMMPRIN expression with the clinicopathologic features and with the survival of osteosarcoma was subsequently assessed. RESULTS The expression of VEGF and EMMPRIN was detected in 47/65 (72.31%) and 45/65 (69.23%) of patients with osteosarcoma, respectively. Positive expression of VEGF and EMMPRIN was significantly correlated with surgical stage and percentage of dead cells of osteosarcoma. A significant correlation was found between the expression of VEGF and EMMPRIN in osteosarcoma (r=0.89, p=0.01). Additionally, surgical stage, percentage of dead cells, VEGF and EMMPRIN expression showed significant influence on overall survival (OS) and disease-free survival (DFS) in univariate analysis. In multivariate analysis, surgical stage (IIA versus IIB/III) and percentage of dead cells (≤90% versus >90%) were significant for DFS and OS. Those patients with VEGF+/EMMPRIN+ co-expression showed significantly shorter OS and DFS compared with VEGF-/EMMPRIN- expression. CONCLUSION According to our study, the overexpression of VEGF or EMMPRIN may be an important feature of osteosarcoma. A combined detection of VEGF/EMMPRIN co-expression may benefit us in prediction of a poor survival of osteosarcoma.
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Affiliation(s)
- Quan Zhou
- Department of Orthopaedics, Huai'an Hospital, Xuzhou Medical College, Huai'an, People's Republic of China
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Larkin JMG, Pyle LM, Gore ME. Fatigue in renal cell carcinoma: the hidden burden of current targeted therapies. Oncologist 2010; 15:1135-46. [PMID: 21051659 PMCID: PMC3227914 DOI: 10.1634/theoncologist.2010-0078] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Accepted: 10/07/2010] [Indexed: 11/28/2022] Open
Abstract
Fatigue is one of the most common symptoms associated with cancer. Persistent fatigue can impair multiple aspects of daily functioning and quality of life, and patients report that treatment-related fatigue has a greater impact than other symptoms, including pain, nausea, and depression. Thus, management of fatigue is recognized as an important component of care for patients with cancer. Treatment of advanced and metastatic renal cell carcinoma (RCC) was, until recently, limited to cytokine-based therapies, which are associated with modest response rates and significant toxicity, including high rates of treatment-related fatigue. The paradigm for RCC treatment has shifted dramatically in the last 5 years with the advent of efficacious targeted therapies. These agents provide the promise of better tolerability because of their more selective mechanisms of action. However, there is considerable variation in the selectivity of targeted agents for RCC, and a review of randomized clinical trials in patients with advanced and/or metastatic disease reveals that there is considerable variation in the tolerability of these agents. Fatigue remains a prominent toxicity with current targeted therapies. Future agents that show better selectivity and potency than current targeted therapies should help to provide better efficacy and tolerability.
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15
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Hill PA. Recipient origin of vasculature in renal cell carcinoma in a kidney allograft. Pathology 2010; 42:479-80. [DOI: 10.3109/00313025.2010.494284] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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16
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Shimoyamada H, Yazawa T, Sato H, Okudela K, Ishii J, Sakaeda M, Kashiwagi K, Suzuki T, Mitsui H, Woo T, Tajiri M, Ohmori T, Ogura T, Masuda M, Oshiro H, Kitamura H. Early growth response-1 induces and enhances vascular endothelial growth factor-A expression in lung cancer cells. THE AMERICAN JOURNAL OF PATHOLOGY 2010; 177:70-83. [PMID: 20489156 DOI: 10.2353/ajpath.2010.091164] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Vascular endothelial growth factor-A (VEGF-A) is crucial for angiogenesis, vascular permeability, and metastasis during tumor development. We demonstrate here that early growth response-1 (EGR-1), which is induced by the extracellular signal-regulated kinase (ERK) pathway activation, activates VEGF-A in lung cancer cells. Increased EGR-1 expression was found in adenocarcinoma cells carrying mutant K-RAS or EGFR genes. Hypoxic culture, siRNA experiment, luciferase assays, chromatin immunoprecipitation, electrophoretic mobility shift assays, and quantitative RT-PCR using EGR-1-inducible lung cancer cells demonstrated that EGR-1 binds to the proximal region of the VEGF-A promoter, activates VEGF-A expression, and enhances hypoxia inducible factor 1alpha (HIF-1alpha)-mediated VEGF-A expression. The EGR-1 modulator, NAB-2, was rapidly induced by increased levels of EGR-1. Pathology samples of human lung adenocarcinomas revealed correlations between EGR-1/HIF-1alpha and VEGF-A expressions and relative elevation of EGR-1 and VEGF-A expression in mutant K-RAS- or EGFR-carrying adenocarcinomas. Both EGR-1 and VEGF-A expression increased as tumors dedifferentiated, whereas HIF-1alpha expression did not. Although weak correlation was found between EGR-1 and NAB-2 expressions on the whole, NAB-2 expression decreased as tumors dedifferentiated, and inhibition of DNA methyltransferase/histone deacetylase increased NAB-2 expression in lung cancer cells despite no epigenetic alteration in the NAB-2 promoter. These findings suggest that EGR-1 plays important roles on VEGF-A expression in lung cancer cells, and epigenetic silencing of transactivator(s) associated with NAB-2 expression might also contribute to upregulate VEGF-A expression.
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Affiliation(s)
- Hiroaki Shimoyamada
- Department of Pathology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004, Japan
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[Use of sorafenib in patients with hepatocellular or renal carcinoma]. ACTA ACUST UNITED AC 2010; 34:161-7. [PMID: 20181452 DOI: 10.1016/j.gcb.2009.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Revised: 09/14/2009] [Accepted: 12/15/2009] [Indexed: 11/26/2022]
Abstract
Therapeutic approaches of cancers have been recently improved by the development of targeted therapies. Amongst these new drugs, some anti-angiogenic molecules have been approved by either the EMEA or the Food and Drug Administration. Sorafenib, one of these inhibitors of angiogenesis, has been established as the standard of care for advanced hepatocellular and renal carcinoma. This paper reviews the safety profile of sorafenib and presents guidelines for the prevention and the treatment of the main side effects associated with this molecule.
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Chung EK, Stadler WM. Vascular endothelial growth factor pathway-targeted therapy as initial systemic treatment of patients with renal cancer. Clin Genitourin Cancer 2009; 6 Suppl 1:S22-8. [PMID: 19891126 DOI: 10.3816/cgc.2008.s.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Advanced renal cancer is known to be largely refractory to traditional DNA- and DNA repair-targeted chemotherapy. Until recently, immunotherapy had been the mainstay for the treatment; however, it is effective in only a small proportion of patients. Advances in the understanding of the association between the von Hippel-Lindau pathway and angiogenesis and their role in the development of renal cancer has led to the development of highly effective vascular endothelial growth factor (VEGF) pathway-targeted inhibitors. Several such novel agents have demonstrated increased clinical benefit, progression-free survival, and superior quality of life in large, randomized phase III clinical trials, and additional VEGF pathway inhibitors are currently being studied. This review will summarize the major clinical trials and practical recommendations for the most studied VEGF inhibitors, including sunitinib, sorafenib, and bevacizumab; introduce novel VEGF inhibitor agents; outline side effects and toxicities; and discuss sequential and combination therapy with these agents.
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Affiliation(s)
- Elizabeth K Chung
- Department of Medicine, Section of Hematology/Oncology, The University of Chicago Medical Center, IL 60637-1479, USA
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Liang YX, He HC, Han ZD, Bi XC, Dai QS, Ye YK, Qin WJ, Zeng GH, ZHU G, XU CL, Zhong WD. CD147 and VEGF Expression in Advanced Renal Cell Carcinoma and Their Prognostic Value. Cancer Invest 2009; 27:788-93. [PMID: 19548138 DOI: 10.1080/07357900802709167] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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20
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Effets vasculaires et rénaux des médicaments anti-angiogéniques: recommandations françaises pour la pratique. ONCOLOGIE 2009. [DOI: 10.1007/s10269-009-1093-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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21
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Abramovich D, Irusta G, Parborell F, Tesone M. Intrabursal injection of vascular endothelial growth factor trap in eCG-treated prepubertal rats inhibits proliferation and increases apoptosis of follicular cells involving the PI3K/AKT signaling pathway. Fertil Steril 2009; 93:1369-77. [PMID: 19328472 DOI: 10.1016/j.fertnstert.2009.01.127] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 01/20/2009] [Accepted: 01/21/2009] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To investigate the effects of local inhibition of vascular endothelial growth factor A (VEGFA) on proliferation and apoptosis of follicular cells in rat ovaries. To analyze the role of the PI3K/AKT signaling pathway on VEGFA effects. DESIGN Experimental study. SETTING Research laboratory. ANIMAL(S) Female Sprague Dawley rats, 21 days old, treated with equine chorionic gonadotropin (eCG). MAIN OUTCOME MEASURE(S) Follicular cell proliferation, apoptosis, and activation of the PI3K/AKT signaling pathway after intrabursal injection of a VEGFA inhibitor. RESULT(S) Inhibition of VEGFA leads to a decrease in the expression of the proliferation marker proliferating cell nuclear antigen (PCNA) in theca and granulosa cells (GC) and an increase in the activation of caspase 3 in antral follicles. Furthermore, we observed a decrease in the phosphorylation of RAC-alpha serine/threonine-protein kinase (AKT) and its target Bcl2 antagonist of cell death (BAD). No differences were found in the levels of kinase insert domain receptor (KDR) protein or in endothelial cell density. CONCLUSION(S) The VEGFA prevents apoptosis and stimulates proliferation of follicular cells, regulating follicular growth and development. The PI3K/AKT signaling pathway is one of the pathways involved in this mechanism. Therefore, VEGFA has a role as an antiapoptotic and proliferative factor in follicular cells from the rat ovary.
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Affiliation(s)
- Dalhia Abramovich
- Instituto de Biología y Medicina Experimental-CONICET, Buenos Aires, Argentina
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22
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Kwon WA, Park C, Kim EJ, Ha YS, Kim YJ, Yun SJ, Lee SC, Kim WJ. The Relationship between RUNX3 Inactivation and Its Pathological Features in Renal Cell Carcinoma. Korean J Urol 2009. [DOI: 10.4111/kju.2009.50.5.432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Whi-An Kwon
- Department of Urology, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Cheol Park
- Department of Urology, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Eun-Jung Kim
- Department of Urology, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Yun-Sok Ha
- Department of Urology, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Yong-June Kim
- Department of Urology, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Seok-Joong Yun
- Department of Urology, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Sang-Cheol Lee
- Department of Urology, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Wun-Jae Kim
- Department of Urology, College of Medicine, Chungbuk National University, Cheongju, Korea
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Halimi JM, Azizi M, Bobrie G, Bouché O, Deray G, des Guetz G, Lecomte T, Levy B, Mourad JJ, Nochy D, Oudard S, Rieu P, Sahali D. Effets vasculaires et rénaux des médicaments anti-angiogéniques : recommandations françaises pour la pratique (SN, SFHTA, APNET, FFCD). Nephrol Ther 2008; 4:602-15. [DOI: 10.1016/j.nephro.2008.10.002] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 10/03/2008] [Indexed: 11/29/2022]
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Vertical VEGF targeting: A combination of ligand blockade with receptor tyrosine kinase inhibition. Eur J Cancer 2008; 44:1922-30. [PMID: 18691881 DOI: 10.1016/j.ejca.2008.07.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2008] [Revised: 06/18/2008] [Accepted: 07/01/2008] [Indexed: 11/30/2022]
Abstract
The aim of this study was to examine the anti-tumour effects of dual vertical VEGF targeting consisting in the association between bevacizumab, a VEGF-depleting drug, and the VEGF receptor antityrosine kinase AZD2171. Mice bearing human head and neck CAL33 xenografted tumours were treated once daily for 11 d with either vehicle (controls), AZD2171 (2.5mg/kg/day, p.o.), bevacizumab (5mg/kg/day, i.p.) or the bevacizumab-AZD2171 combination. The AZD2171-bevacizumab combination produced additive effects on tumour growth and reduced the number of proliferating cells relative to control. Bevacizumab did not influence tumour vascular necrosis whilst AZD2171 (p=0.01) and the combination (p=0.01) increased it. The number of mature tumour cells decreased significantly with the combination treatment only (p=0.001), which induced the largest increase in the Bax/Bcl2 ratio (up to 25-fold) and a progressive 3-fold decrease in HIF1-alpha expression between 24h and 192h. The present data indicate that there is no redundancy in targeting the same angiogenic pathway with the presently tested clinically applicable drugs. The study provides a strong rationale for future clinical trials.
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Pan J, Jin P, Yan J, Kabelitz D. Anti-angiogenic active immunotherapy: a new approach to cancer treatment. Cancer Immunol Immunother 2008; 57:1105-14. [PMID: 18214475 PMCID: PMC11030112 DOI: 10.1007/s00262-008-0452-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Accepted: 01/08/2008] [Indexed: 01/19/2023]
Abstract
Tumor angiogenesis plays an important role in tumor growth, aggression and metastasis. Many molecules have been demonstrated as positive regulators of angiogenesis, including vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF), epidermal growth factor (EGF), and others. In recent years, significant progress has been made in the research on anti-angiogenic strategies for tumor therapies. In this review, anti-angiogenic active immunotherapies for tumors based on vaccination with xenogeneic homologous molecules and non-xenogeneic homologous molecules are discussed.
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Affiliation(s)
- Jianping Pan
- Department of Medical Microbiology and Parasitology, Zhejiang University School of Medicine, 388 Yuhangtang Road, Hangzhou, 310058, People's Republic of China.
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Abraham JM, Cheng Y, Hamilton JP, Paun B, Jin Z, Agarwal R, Kan T, David S, Olaru A, Yang J, Ito T, Selaru FM, Mori Y, Meltzer SJ. Generation of small 32P-labeled peptides as a potential approach to colorectal cancer therapy. PLoS One 2008; 3:e2508. [PMID: 18575578 PMCID: PMC2423481 DOI: 10.1371/journal.pone.0002508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2008] [Accepted: 05/06/2008] [Indexed: 11/18/2022] Open
Abstract
Cancers have been revealed to be extremely heterogenous in terms of the frequency and types of mutations present in cells from different malignant tumors. Thus, it is likely that uniform clinical treatment is not optimal for all patients, and that the development of individualized therapeutic regimens may be beneficial. We describe the generation of multiple, unique small peptides nine to thirty-four amino acids in length which, when labeled with the radioisotope (32)P, bind with vastly differing efficiencies to cell lines derived from different colon adenocarcinomas. In addition, the most effective of these peptides permanently transfers the (32)P radioisotope to colorectal cancer cellular proteins within two hours at a rate that is more than 150 times higher than in cell lines derived from other cancers or from the normal tissues tested. Currently, the only two FDA-approved radioimmunotherapeutic agents in use both employ antibodies directed against the B cell marker CD20 for the treatment of non-Hodgkin's lymphoma. By using the method described herein, large numbers of different (32)P-labeled peptides can be readily produced and assayed against a broad spectrum of cancer types. This report proposes the development and use of (32)P-labeled peptides as potential individualized peptide-binding therapies for the treatment of colon adenocarcinoma patients.
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Affiliation(s)
- John M Abraham
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America.
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Moreno-Vinasco L, Gomberg-Maitland M, Maitland ML, Desai AA, Singleton PA, Sammani S, Sam L, Liu Y, Husain AN, Lang RM, Ratain MJ, Lussier YA, Garcia JGN. Genomic assessment of a multikinase inhibitor, sorafenib, in a rodent model of pulmonary hypertension. Physiol Genomics 2008; 33:278-91. [PMID: 18303084 PMCID: PMC3616402 DOI: 10.1152/physiolgenomics.00169.2007] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Pulmonary hypertension (PH) and cancer pathology share growth factor- and MAPK stress-mediated signaling pathways resulting in endothelial and smooth muscle cell dysfunction and angioproliferative vasculopathy. In this study, we assessed sorafenib, an antineoplastic agent and inhibitor of multiple kinases important in angiogenesis [VEGF receptor (VEGFR)-1-3, PDGF receptor (PDGFR)-beta, Raf-1 kinase] as a potential PH therapy. Two PH rat models were used: a conventional hypoxia-induced PH model and an augmented PH model combining dual VEGFR-1 and -2 inhibition (SU-5416, single 20 mg/kg injection) with hypoxia. In addition to normoxia-exposed control animals, four groups were maintained at 10% inspired O(2) fraction for 3.5 wk (hypoxia/vehicle, hypoxia/SU-5416, hypoxia/sorafenib, and hypoxia/SU-5416/sorafenib). Compared with normoxic control animals, rats exposed to hypoxia/SU-5416 developed hemodynamic and histological evidence of severe PH while rats exposed to hypoxia alone displayed only mild elevations in hemodynamic values (pulmonary vascular and right ventricular pressures). Sorafenib treatment (daily gavage, 2.5 mg/kg) prevented hemodynamic changes and demonstrated dramatic attenuation of PH-associated vascular remodeling. Compared with normoxic control rats, expression profiling (Affymetrix platform) of lung RNA obtained from hypoxia [false discovery rate (FDR) 6.5%]- and hypoxia/SU-5416 (FDR 1.6%)-challenged rats yielded 1,019 and 465 differentially regulated genes (fold change >1.4), respectively. A novel molecular signature consisting of 38 differentially expressed genes between hypoxia/SU-5416 and hypoxia/SU-5416/sorafenib (FDR 6.7%) was validated by either real-time RT-PCR or immunoblotting. Finally, immunoblotting studies confirmed the upregulation of the MAPK cascade in both PH models, which was abolished by sorafenib. In summary, sorafenib represents a novel potential treatment for severe PH with the MAPK cascade a potential canonical target.
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Affiliation(s)
- Liliana Moreno-Vinasco
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, Pritzker School of Medicine, University of Chicago, Chicago, Illinois 60637, USA
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Szabo Z, Xia J, Mathews WB. Radiopharmaceuticals for renal positron emission tomography imaging. Semin Nucl Med 2008; 38:20-31. [PMID: 18096461 DOI: 10.1053/j.semnuclmed.2007.09.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Radiopharmaceuticals for functional renal imaging, including renal blood flow, renal blood volume, glomerular excretion, and metabolism have been available for some time. This review outlines radiopharmaceuticals for functional renal imaging as well as those that target pertinent molecular constituents of renal injury and repair. The angiotensin and endothelin receptors are particularly appealing molecular targets for renal imaging because of their association with renal physiology and pathology. Other targets such as the vascular endothelial growth factor (VEGF) receptor, integrin, or phosphatidylserine have been investigated at length for cancer imaging, but they are just as important constituents of the renal injury/repair process. Various diseases can involve identical mechanisms, such as angiogenesis and apoptosis, and radiopharmaceuticals developed for these processes in other organs can also be used for renal imaging. The sensitivity and spatial resolution of positron emission tomography makes it an ideal tool for molecular and functional kidney imaging. Radiopharmaceutical development for the kidneys must focus on achieving high target selectivity and binding affinity, stability and slow metabolism in vivo, and minimal nonspecific accumulation and urinary excretion.
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Affiliation(s)
- Zsolt Szabo
- Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Abraham JM, Sato F, Cheng Y, Paun B, Kan T, Olaru A, Jin Z, Yang J, Agarwal R, David S, Hamilton JP, Ito T, Mori Y, Meltzer SJ. Novel decapeptides that bind avidly and deliver radioisotope to colon cancer cells. PLoS One 2007; 2:e964. [PMID: 17912343 PMCID: PMC1978517 DOI: 10.1371/journal.pone.0000964] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2007] [Accepted: 09/12/2007] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The rapidly growing field of targeted tumor therapy often utilizes an antibody, sometimes tagged with a tumor-ablating material such as radioisotope, directed against a specific molecule. METHODOLOGY/PRINCIPAL FINDINGS This report describes the discovery of nine novel decapeptides which can be radioactively labeled, bind to, and deliver (32)P to colon cancer cells. The decapeptides vary from one another by one to three amino acids and demonstrate vastly different binding abilities. The most avidly binding decapeptide can permanently deliver very high levels of radioisotope to the adenocarcinoma cancer cell lines at an efficiency 35 to 150 times greater than to a variety of other cell types, including cell lines derived from other types of cancer or from normal tissue. CONCLUSIONS/SIGNIFICANCE This experimental approach represents a new example of a strategy, termed peptide binding therapy, for the potential treatment of colorectal and other adenocarcinomas.
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Affiliation(s)
- John M Abraham
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America.
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Kwon NS, Jo MK, Lee HM. Serum Levels of Vascular Endothelial Growth Factor (VEGF) as a Prognostic Factor in Renal Cell Carcinoma. Korean J Urol 2007. [DOI: 10.4111/kju.2007.48.12.1219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Nam Sung Kwon
- Department of Urology, Korea Cancer Center Hospital, Seoul, Korea
| | - Moon Ki Jo
- Department of Urology, Korea Cancer Center Hospital, Seoul, Korea
| | - Hyun Moo Lee
- Department of Urology, College of Medicine, Sungkyunkwan University, Seoul, Korea
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