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Sun S, Zhang G, Lv S, Sun J. Potential mechanisms of traditional Chinese medicine in the treatment of liver cirrhosis: a focus on gut microbiota. Front Microbiol 2024; 15:1407991. [PMID: 39234554 PMCID: PMC11371771 DOI: 10.3389/fmicb.2024.1407991] [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: 03/27/2024] [Accepted: 07/29/2024] [Indexed: 09/06/2024] Open
Abstract
Cirrhosis, a pathological stage that develops from various chronic liver diseases, is characterized by liver fibrosis, pseudolobular formation, and chronic inflammation. When it progresses to the decompensated phase, the mortality rate of cirrhosis can reach 80%. The role of gut microbiota in the progression of liver diseases has received significant attention. Numerous studies have shown that regulating gut microbiota has significant therapeutic effects on preventing and reversing liver cirrhosis. This article reviewed the mechanisms by which gut microbiota influence liver cirrhosis, explaining the effective therapeutic effects of traditional Chinese medicine. Through multi-directional regulation involving signaling pathways, gut microbiota diversity, and restoration of intestinal barrier function, traditional Chinese medicine has been promising in ameliorating liver cirrhosis, providing treatment options and pharmacological guidance for the occurrence and development of liver cirrhosis.
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Affiliation(s)
- Siyuan Sun
- First Clinical Medical College, Beijing University of Chinese Medicine, Beijing, China
| | - Guangheng Zhang
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Shimeng Lv
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Jinhui Sun
- Gastroenterology Department, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
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2
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Kirschner SK, Ghane P, Park JK, Simbo SY, Ivanov I, Braga-Neto UM, Ten Have GAM, Thaden JJ, Engelen MPKJ, Deutz NEP. Short-chain fatty acid production in accessible and inaccessible body pools as assessed by novel stable tracer pulse approach is reduced by aging independent of presence of COPD. Metabolism 2023; 141:155399. [PMID: 36642114 DOI: 10.1016/j.metabol.2023.155399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Production rates of the short-chain fatty acids (SCFA) acetate, propionate, and butyrate, which are beneficial metabolites of the intestinal microbiota, are difficult to measure in humans due to inaccessibility of the intestine to perform measurements, and the high first-pass metabolism of SCFAs in colonocytes and liver. We developed a stable tracer pulse approach to estimate SCFA whole-body production (WBP) in the accessible pool representing the systemic circulation and interstitial fluid. Compartmental modeling of plasma enrichment data allowed us to additionally calculate SCFA kinetics and pool sizes in the inaccessible pool likely representing the intestine with microbiota. We also studied the effects of aging and the presence of Chronic Obstructive Pulmonary Disease (COPD) on SCFA kinetics. METHODS In this observational study, we designed a two-compartmental model to determine SCFA kinetics in 31 young (20-29 y) and 71 older (55-87 y) adults, as well as in 33 clinically stable patients with moderate to very severe COPD (mean (SD) FEV1, 46.5 (16.2)% of predicted). Participants received in the fasted state a pulse containing stable tracers of acetate, propionate, and butyrate intravenously and blood was sampled four times over a 30 min period. We measured tracer-tracee ratios by GC-MS and used parameters obtained from two-exponential curve fitting to calculate non-compartmental SCFA WBP and perform compartmental analysis. Statistics were done by ANCOVA. RESULTS Acetate, propionate, and butyrate WBP and fluxes between the accessible and inaccessible pools were lower in older than young adults (all q < 0.0001). Moreover, older participants had lower acetate (q < 0.0001) and propionate (q = 0.019) production rates in the inaccessible pool as well as smaller sizes of the accessible and inaccessible acetate pools (both q < 0.0001) than young participants. WBP, compartmental SCFA kinetics, and pool sizes did not differ between COPD patients and older adults (all q > 0.05). Overall and independent of the group studied, calculated production rates in the inaccessible pool were on average 7 (acetate), 11 (propionate), and 16 (butyrate) times higher than non-compartmental WBP, and sizes of inaccessible pools were 24 (acetate), 31 (propionate), and 55 (butyrate) times higher than sizes of accessible pools (all p < 0.0001). CONCLUSION Non-compartmental production measurements of SCFAs in the accessible pool (i.e. systemic circulation) substantially underestimate the SCFA production in the inaccessible pool, which likely represents the intestine with microbiota, as assessed by compartmental analysis.
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Affiliation(s)
- Sarah K Kirschner
- Center for Translational Research in Aging & Longevity, Texas A&M University, College Station, TX, USA
| | - Parisa Ghane
- Center for Translational Research in Aging & Longevity, Texas A&M University, College Station, TX, USA; Department of Electrical & Computer Engineering, Texas A&M University, College Station, TX, USA
| | - Jaekwan K Park
- Center for Translational Research in Aging & Longevity, Texas A&M University, College Station, TX, USA
| | - Sunday Y Simbo
- Center for Translational Research in Aging & Longevity, Texas A&M University, College Station, TX, USA
| | - Ivan Ivanov
- Department of Electrical & Computer Engineering, Texas A&M University, College Station, TX, USA; Department of Veterinary Physiology & Pharmacology, Texas A&M University, College Station, TX, USA
| | - Ulisses M Braga-Neto
- Department of Electrical & Computer Engineering, Texas A&M University, College Station, TX, USA
| | - Gabriëlla A M Ten Have
- Center for Translational Research in Aging & Longevity, Texas A&M University, College Station, TX, USA
| | - John J Thaden
- Center for Translational Research in Aging & Longevity, Texas A&M University, College Station, TX, USA
| | - Mariëlle P K J Engelen
- Center for Translational Research in Aging & Longevity, Texas A&M University, College Station, TX, USA
| | - Nicolaas E P Deutz
- Center for Translational Research in Aging & Longevity, Texas A&M University, College Station, TX, USA.
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Zheng M, Yang X, Wu Q, Gong Y, Pang N, Ge X, Nagaratnam N, Jiang P, Zhou M, Hu T, Hua H, Zheng K, Huang X, Yu Y. Butyrate Attenuates Hepatic Steatosis Induced by a High-Fat and Fiber-Deficient Diet via the Hepatic GPR41/43-CaMKII/HDAC1-CREB Pathway. Mol Nutr Food Res 2023; 67:e2200597. [PMID: 36382553 PMCID: PMC10078002 DOI: 10.1002/mnfr.202200597] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Indexed: 11/17/2022]
Abstract
SCOPE Hepatic steatosis is a major health issue that can be attenuated by a healthy diet. This study investigates the effects and molecular mechanisms of butyrate, a dietary fiber metabolite of gut microbiota, on lipid metabolism in hepatocytes. METHODS AND RESULTS This study examines the effects of butyrate (0-8 mM) on lipid metabolism in primary hepatocytes. The results show that butyrate (2 mM) consistently inhibits lipogenic genes and activates lipid oxidation-related gene expression in hepatocytes. Furthermore, butyrate modulates lipid metabolism genes, reduces fat droplet accumulation, and activates the calcium/calmodulin-dependent protein kinase II (CaMKII)/histone deacetylase 1 (HDAC1)-cyclic adenosine monophosphate response element binding protein (CREB) signaling pathway in the primary hepatocytes and liver of wild-type (WT) mice, but not in G-protein-coupled receptor 41 (GPR41) knockout and 43 (GPR43) knockout mice. This suggests that butyrate regulated hepatic lipid metabolism requires GPR41 and GPR43. Finally, the study finds that dietary butyrate supplementation (5%) ameliorates hepatic steatosis and abnormal lipid metabolism in the liver of mice fed a high-fat and fiber-deficient diet for 15 weeks. CONCLUSION This work reveals that butyrate improves hepatic lipid metabolism through the GPR41/43-CaMKII/HDAC1-CREB pathway, providing support for consideration of butyrate as a dietary supplement to prevent the progression of NAFLD induced by the Western-style diet.
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Affiliation(s)
- Mingxuan Zheng
- Jiangsu Key Laboratory of Immunity and MetabolismDepartment of Pathogen Biology and ImmunologyXuzhou Medical UniversityXuzhouJiangsu221004P. R. China
| | - Xiaoying Yang
- Jiangsu Key Laboratory of Immunity and MetabolismDepartment of Pathogen Biology and ImmunologyXuzhou Medical UniversityXuzhouJiangsu221004P. R. China
| | - Qingyuan Wu
- Jiangsu Key Laboratory of Immunity and MetabolismDepartment of Pathogen Biology and ImmunologyXuzhou Medical UniversityXuzhouJiangsu221004P. R. China
| | - Yuying Gong
- Jiangsu Key Laboratory of Immunity and MetabolismDepartment of Pathogen Biology and ImmunologyXuzhou Medical UniversityXuzhouJiangsu221004P. R. China
| | - Ning Pang
- Tianjin Third Central HospitalTianjin300170P. R. China
| | - Xing Ge
- Jiangsu Key Laboratory of Immunity and MetabolismDepartment of Pathogen Biology and ImmunologyXuzhou Medical UniversityXuzhouJiangsu221004P. R. China
| | - Nathan Nagaratnam
- Illawarra Health and Medical Research Institute(IHMRI) and School of MedicineUniversity of WollongongWollongongNSW2522Australia
| | - Pengfei Jiang
- Jiangsu Key Laboratory of Immunity and MetabolismDepartment of Pathogen Biology and ImmunologyXuzhou Medical UniversityXuzhouJiangsu221004P. R. China
| | - Menglu Zhou
- Jiangsu Key Laboratory of Immunity and MetabolismDepartment of Pathogen Biology and ImmunologyXuzhou Medical UniversityXuzhouJiangsu221004P. R. China
| | - Tao Hu
- Jiangsu Key Laboratory of Immunity and MetabolismDepartment of Pathogen Biology and ImmunologyXuzhou Medical UniversityXuzhouJiangsu221004P. R. China
| | - Hui Hua
- Jiangsu Key Laboratory of Immunity and MetabolismDepartment of Pathogen Biology and ImmunologyXuzhou Medical UniversityXuzhouJiangsu221004P. R. China
| | - Kuiyang Zheng
- Jiangsu Key Laboratory of Immunity and MetabolismDepartment of Pathogen Biology and ImmunologyXuzhou Medical UniversityXuzhouJiangsu221004P. R. China
- National Experimental Demonstration Center for Basic Medicine EducationXuzhou Medical UniversityXuzhouJiangsu221004P. R. China
| | - Xu‐Feng Huang
- Illawarra Health and Medical Research Institute(IHMRI) and School of MedicineUniversity of WollongongWollongongNSW2522Australia
| | - Yinghua Yu
- Jiangsu Key Laboratory of Immunity and MetabolismDepartment of Pathogen Biology and ImmunologyXuzhou Medical UniversityXuzhouJiangsu221004P. R. China
- Illawarra Health and Medical Research Institute(IHMRI) and School of MedicineUniversity of WollongongWollongongNSW2522Australia
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Hjorth M, Galigniana NM, Ween O, Ulven SM, Holven KB, Dalen KT, Sæther T. Postprandial Effects of Salmon Fishmeal and Whey on Metabolic Markers in Serum and Gene Expression in Liver Cells. Nutrients 2022; 14:1593. [PMID: 35458155 PMCID: PMC9027870 DOI: 10.3390/nu14081593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/29/2022] [Accepted: 04/09/2022] [Indexed: 12/13/2022] Open
Abstract
Fish is considered an important part of a healthy diet, in part due to the content of long chain omega-3 fatty acids. However, both lean and fatty fish have beneficial health effects, suggesting that micronutrients and proteins may play a role. In a randomised, controlled, cross-over trial, five healthy male participants consumed 5.2 g of protein from either salmon fishmeal or whey. Blood samples were taken before and 30 and 60 min after intake. The concentration of glucose, lipids, hormones and metabolites, including 28 different amino acids and derivatives, were measured in serum or plasma. Cultured HepG2 cells were incubated with or without serum from the participants, and transcriptomic profiling was performed using RNA sequencing. The ingestion of both salmon fishmeal and whey reduced the glucose and triglyceride levels in serum. Protein intake, independent of the source, increased the concentration of 22 amino acids and derivatives in serum. Fishmeal increased the concentration of arginine, methionine, serine, glycine, cystathionine and 2-aminobutyric acid more than whey did. Incubation with postprandial serum resulted in large transcriptomic alterations in serum-fasted HepG2 cells, with the differential expression of >4500 protein coding genes. However, when comparing cells cultivated in fasting serum to postprandial serum after the ingestion of fishmeal and whey, we did not detect any differentially regulated genes, neither with respect to the protein source nor with respect to the time after the meal. The comparable nutrigenomic effects of fishmeal and whey do not change the relevance of fish by-products as an alternative food source.
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Affiliation(s)
- Marit Hjorth
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Sognsvannsveien 9, Domus Medica, 0372 Oslo, Norway; (M.H.); (S.M.U.); (K.B.H.); (K.T.D.)
| | - Natalia M. Galigniana
- Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Sognsvannsveien 9, Domus Medica, 0372 Oslo, Norway;
| | - Ola Ween
- Møreforskning AS, Borgundvegen 340, 6009 Ålesund, Norway;
| | - Stine M. Ulven
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Sognsvannsveien 9, Domus Medica, 0372 Oslo, Norway; (M.H.); (S.M.U.); (K.B.H.); (K.T.D.)
| | - Kirsten B. Holven
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Sognsvannsveien 9, Domus Medica, 0372 Oslo, Norway; (M.H.); (S.M.U.); (K.B.H.); (K.T.D.)
- Norwegian National Advisory Unit on Familial Hypercholesterolemia, Oslo University Hospital, P.O. Box 4959, Nydalen, 0424 Oslo, Norway
| | - Knut Tomas Dalen
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Sognsvannsveien 9, Domus Medica, 0372 Oslo, Norway; (M.H.); (S.M.U.); (K.B.H.); (K.T.D.)
| | - Thomas Sæther
- Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Sognsvannsveien 9, Domus Medica, 0372 Oslo, Norway;
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Rode J, Yang L, König J, Hutchinson AN, Wall R, Venizelos N, Brummer RJ, Rangel I, Vumma R. Butyrate Rescues Oxidative Stress-Induced Transport Deficits of Tryptophan: Potential Implication in Affective or Gut-Brain Axis Disorders. Neuropsychobiology 2021; 80:253-263. [PMID: 33075780 DOI: 10.1159/000510886] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 07/03/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Butyrate is a short-chain fatty acid metabolite produced by microbiota in the colon. With its antioxidant properties, butyrate has also been shown to alter the neurological functions in affective disorder models, suggesting it as a key mediator in gut-brain interactions. OBJECTIVE Here, we evaluated the negative effect of oxidative stress on the transport of the serotonin precursor tryptophan as present in affective disorders. Butyrate was hypothesized to be able to rescue these deficits due to its antioxidative capacities and its effect on transmembrane transport of tryptophan. Human skin-derived fibroblasts were used as cellular models to address these objectives. METHODS Human fibroblasts were treated with hydrogen peroxide to induce oxidative stress. Stressed as well as control cells were treated with different concentrations of butyrate. Tryptophan (3H) was used as a tracer to measure the transport of tryptophan across the cell membranes (n = 6). Furthermore, gene expression profiles of different amino acid transporters were analyzed (n = 2). RESULTS As hypothesized,oxidative stress significantly decreased the uptake of tryptophan in fibroblast cells, while butyrate counteracted this effect. Oxidative stress did not alter the gene expression profile of amino acid transporters. However, treatment of stressed and control cells with different concentrations of butyrate differentially regulated the gene expression of large amino acid transporters 1 and 2, which are the major transporters of tryptophan. CONCLUSIONS Gut microbiota-derived butyrate may have therapeutic potential in affective disorders characterized by either aberrant serotonergic activity or neuroinflammation due to its role in rescuing the oxidative stress-induced perturbations of tryptophan transport.
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Affiliation(s)
- Julia Rode
- Nutrition-Gut-Brain Interactions Research Centre, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Lin Yang
- Department of Chemistry and Biomedical Sciences, Linnaeus University, Kalmar, Sweden
| | - Julia König
- Nutrition-Gut-Brain Interactions Research Centre, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Ashley Nicole Hutchinson
- Nutrition-Gut-Brain Interactions Research Centre, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Rebecca Wall
- Nutrition-Gut-Brain Interactions Research Centre, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Nikolaos Venizelos
- Nutrition-Gut-Brain Interactions Research Centre, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Robert-Jan Brummer
- Nutrition-Gut-Brain Interactions Research Centre, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Ignacio Rangel
- Nutrition-Gut-Brain Interactions Research Centre, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Ravi Vumma
- Department of Chemistry and Biomedical Sciences, Linnaeus University, Kalmar, Sweden,
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Kirschner SK, Ten Have GAM, Engelen MPKJ, Deutz NEP. Transorgan short-chain fatty acid fluxes in the fasted and postprandial state in the pig. Am J Physiol Endocrinol Metab 2021; 321:E665-E673. [PMID: 34605248 DOI: 10.1152/ajpendo.00121.2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The short-chain fatty acids (SCFAs) acetate, propionate, butyrate, isovalerate, and valerate are end products of intestinal bacterial fermentation and important mediators in the interplay between the intestine and peripheral organs. To unravel the transorgan fluxes and mass balance comparisons of SCFAs, we measured their net fluxes across several organs in a translational pig model. In multicatheterized conscious pigs [n = 12, 25.6 (95% CI [24.2, 26.9]) kg, 8-12 wk old], SCFA fluxes across portal-drained viscera (PDV), liver, kidneys, and hindquarter (muscle compartment) were measured after an overnight fast and in the postprandial state, 4 h after administration of a fiber-free, mixed meal. PDV was the main releasing compartment of acetate, propionate, butyrate, isovalerate, and valerate during fasting and in the postprandial state (all P = 0.001). Splanchnic acetate release was high due to the absence of hepatic clearance. All other SCFAs were extensively taken up by the liver (all P < 0.05). Even though only 7% [4, 10] (propionate), 42% [23, 60] (butyrate), 26% [12, 39] (isovalerate), and 3% [0.4, 5] (valerate) of PDV release were excreted from the splanchnic area in the fasted state, splanchnic release of all SCFAs was significant (all P values ≤0.01). Splanchnic propionate, butyrate, isovalerate, and valerate release remained low but significant in the postprandial state (all P values <0.01). We identified muscle and kidneys as main peripheral SCFA metabolizing organs, taking up the majority of all splanchnically released SCFAs in the fasted state and in the postprandial state. We conclude that the PDV is the main SCFA releasing and the liver the main SCFA metabolizing organ. Splanchnically released SCFAs appear to be important energy substrates to peripheral organs not only in the fasted but also in the postprandial state.NEW & NOTEWORTHY Using a multicatheterized pig model, we identified the portal-drained viscera as the main releasing compartment of the short-chain fatty acids acetate, propionate, butyrate, isovalerate, and valerate in the fasted and postprandial states. Low hepatic acetate metabolism resulted in a high splanchnic release, whereas all other SCFAs were extensively cleared resulting in low but significant splanchnic releases. Muscle and kidneys are the main peripheral SCFA metabolizing organs during fasting and in the postprandial state.
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Affiliation(s)
- Sarah K Kirschner
- Center for Translational Research in Aging & Longevity, Department of Health & Kinesiology, Texas A&M University, College Station, Texas
| | - Gabriëlla A M Ten Have
- Center for Translational Research in Aging & Longevity, Department of Health & Kinesiology, Texas A&M University, College Station, Texas
| | - Mariëlle P K J Engelen
- Center for Translational Research in Aging & Longevity, Department of Health & Kinesiology, Texas A&M University, College Station, Texas
| | - Nicolaas E P Deutz
- Center for Translational Research in Aging & Longevity, Department of Health & Kinesiology, Texas A&M University, College Station, Texas
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Kubota N, Ojima H, Hatano M, Yamazaki K, Masugi Y, Tsujikawa H, Fujii-Nishimura Y, Ueno A, Kurebayashi Y, Shinoda M, Kitago M, Abe Y, Kitagawa Y, Sakamoto M. Clinicopathological features of hepatocellular carcinoma with fatty change: Tumors with macrovesicular steatosis have better prognosis and aberrant expression patterns of perilipin and adipophilin. Pathol Int 2020; 70:199-209. [PMID: 31930673 DOI: 10.1111/pin.12889] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 11/26/2019] [Indexed: 12/19/2022]
Abstract
The clinicopathological characteristics of steatosis in hepatocellular carcinoma (HCC) remain unclear. Here, we elucidate the features of macrovesicular steatosis (MaS) and microvesicular steatosis (MiS) in HCC and their relationships with background liver steatosis. A total of 165 HCC lesions were classified as MaS-HCC, MiS-HCC, or conventional HCC (cHCC) according to the cutoff value of 30% MaS or MiS in tumor cells. We analyzed the clinicopathological differences among these groups. MaS-HCC had less portal vein invasion, a higher proportion of HCC with intratumoral fibrosis, and a lower cumulative risk of recurrence than MiS-HCC or cHCC. Moreover, both MaS-HCC and MiS-HCC had lower incidences of hepatitis virus infection and higher levels of HbA1c than cHCC. Background liver steatosis was also higher in MaS-HCC than in cHCC. Immunohistochemical expression of perilipin (Plin1) and adipophilin (ADRP), major proteins expressed on lipid droplet membranes, revealed that almost all lipid droplets in HCC were Plin1 negative, whereas those in background liver were positive. In contrast, ADRP was expressed on lipid droplets in both HCC and background liver. We concluded that MaS-HCC and MiS-HCC were associated with metabolic abnormalities but exhibited different biologic behaviors. Furthermore, lipid droplets in HCC were pathophysiologically different from those in background liver.
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Affiliation(s)
- Naoto Kubota
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Hidenori Ojima
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Mami Hatano
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan.,Department of Pathology, National Hospital Organization, Tokyo Medical Center, Tokyo, Japan
| | - Ken Yamazaki
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Masugi
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Hanako Tsujikawa
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | | | - Akihisa Ueno
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Yutaka Kurebayashi
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Shinoda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Michiie Sakamoto
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
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