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1.
Mol Ther ; 32(1): 84-102, 2024 Jan 03.
Article En | MEDLINE | ID: mdl-37952087

So far, the mechanisms that impede AAV transduction, especially in the human heart, are poorly understood, hampering the introduction of new, effective gene therapy strategies. Therefore, the aim of this study was to identify and overcome the main cellular barriers to successful transduction in the heart, using induced pluripotent stem cell (iPSC)-derived cardiomyocytes (iPSC-CMs), iPSC-derived cardiac fibroblasts (iPSC-CFs), and primary endothelial cells to model vector-host interactions. Through phosphoproteome analysis we established that casein kinase 2 (CK2) signaling is one of the most significantly affected pathways upon AAV exposure. Transient inhibition of CK2 activity substantially enhanced the transduction rate of AAV2, AAV6, and AAV9 in all tested cell types. In particular, CK2 inhibition improved the trafficking of AAVs through the cytoplasm, impaired DNA damage response through destabilization of MRE11, and altered the RNA processing pathways, which were also highly responsive to AAV transduction. Also, it augmented transgene expression in already transduced iPSC-CFs, which retain AAV genomes in a functional, but probably silent form. In summary, the present study provides new insights into the current understanding of the host-AAV vector interaction, identifying CK2 activity as a key barrier to efficient transduction and transgene expression, which may translate to improving the outcome of AAV-based therapies in the future.


Casein Kinase II , Endothelial Cells , Humans , Transduction, Genetic , Casein Kinase II/genetics , Casein Kinase II/metabolism , Genetic Therapy , Transgenes , Dependovirus/genetics , Dependovirus/metabolism , Genetic Vectors/genetics
2.
Front Immunol ; 14: 1249379, 2023.
Article En | MEDLINE | ID: mdl-37965327

Nuclear factor erythroid 2-related factor 2 (Nrf2) is a transcriptional regulator of antioxidant and anti-inflammatory response in all cell types. It also activates the transcription of genes important for macrophage function. Nrf2 activity declines with age and has been closely linked to atherosclerosis, but its specific role in this vascular pathology is not clear. Atherosclerotic plaques contain several macrophage subsets with distinct, yet not completely understood, functions in the lesion development. The aim of this study was to analyze the transcriptome of diverse Nrf2-deficient macrophage subpopulations from murine atherosclerotic aortas. Mice with transcriptionally inactive Nrf2 in Cdh5-expressing cells (Nrf2 Cdh5tKO) were used in the experiments. These mice lack transcriptional Nrf2 activity in endothelial cells, but also in a proportion of leukocytes. We confirmed that the bone marrow-derived and tissue-resident macrophages isolated from Nrf2 Cdh5tKO mice exhibit a significant decline in Nrf2 activity. Atherosclerosis was induced in Nrf2 Cdh5tKO and appropriate control mice via adeno-associated viral vector (AAV)-mediated overexpression of murine proprotein convertase subtilisin/kexin type 9 (Pcsk9) in the liver and high-fat diet feeding. After 21 weeks, live aortic cells were sorted on FACS and single-cell RNA sequencing (scRNA-seq) was performed. Unsupervised clustering singled out 13 distinct aortic cell types. Among macrophages, 9 subclusters were identified. Differential gene expression analysis revealed cell subtype-specific expression patterns. A subset of inflammatory macrophages from atherosclerotic Nrf2 Cdh5tKO mice demonstrated downregulation of DNA replication genes (e.g. Mcm7, Lig1, Pola1) concomitant with upregulation of DNA damage sensor Atr gene. Atherosclerotic Nrf2 Cdh5tKO Lyve1+ resident macrophages showed strong upregulation of IFN-stimulated genes, as well as changes in the expression of death pathways-associated genes (Slc40a1, Bcl2a1). Furthermore, we observed subtype-specific expression of core ferroptosis genes (e.g. Cp, Hells, Slc40a1) in inflammatory versus tissue resident macrophages. This observation suggested a link between ferroptosis and inflammatory microenvironment appearing at a very early stage of atherogenesis. Our findings indicate that Nrf2 deficiency in aortic macrophages leads to subtype-specific transcriptomic changes associated with inflammation, iron homeostasis, cell injury or death pathways. This may help understanding the role of aging-associated decline of Nrf2 activity and the function of specific macrophage subtypes in atherosclerotic lesion development.


Atherosclerosis , Proprotein Convertase 9 , Animals , Mice , Aorta/pathology , Atherosclerosis/metabolism , Endothelial Cells/metabolism , Gene Expression Profiling , Macrophages/metabolism , NF-E2-Related Factor 2/genetics , NF-E2-Related Factor 2/metabolism , Proprotein Convertase 9/metabolism , Transcriptome
3.
Free Radic Biol Med ; 205: 188-201, 2023 08 20.
Article En | MEDLINE | ID: mdl-37302617

Kidneys are pivotal organ in iron redistribution and can be severely damaged in the course of hemolysis. In our previous studies, we observed that induction of hypertension with angiotensin II (Ang II) combined with simvastatin administration results in a high mortality rate or the appearance of signs of kidney failure in heme oxygenase-1 knockout (HO-1 KO) mice. Here, we aimed to address the mechanisms underlying this effect, focusing on heme and iron metabolism. We show that HO-1 deficiency leads to iron accumulation in the renal cortex. Higher mortality of Ang II and simvastatin-treated HO-1 KO mice coincides with increased iron accumulation and the upregulation of mucin-1 in the proximal convoluted tubules. In vitro studies showed that mucin-1 hampers heme- and iron-related oxidative stress through the sialic acid residues. In parallel, knock-down of HO-1 induces the glutathione pathway in an NRF2-depedent manner, which likely protects against heme-induced toxicity. To sum up, we showed that heme degradation during heme overload is not solely dependent on HO-1 enzymatic activity, but can be modulated by the glutathione pathway. We also identified mucin-1 as a novel redox regulator. The results suggest that hypertensive patients with less active HMOX1 alleles may be at higher risk of kidney injury after statin treatment.


Heme Oxygenase-1 , Hypertension , Mice , Animals , Heme Oxygenase-1/genetics , Heme Oxygenase-1/metabolism , Angiotensin II/metabolism , Mucin-1/metabolism , Heme Oxygenase (Decyclizing)/metabolism , Simvastatin/adverse effects , Simvastatin/metabolism , Kidney/metabolism , Iron/metabolism , Hypertension/chemically induced , Hypertension/genetics , Hypertension/metabolism , Heme/metabolism , Glutathione/metabolism
4.
Cells ; 10(3)2021 03 15.
Article En | MEDLINE | ID: mdl-33804125

Heme oxygenase-1 (HO-1) plays a vital role in the catabolism of heme and yields equimolar amounts of biliverdin, carbon monoxide, and free iron. We report that macrophages engulfing either the low amount of heme-containing apoptotic thymocytes or the high amount of heme-containing eryptotic red blood cells (eRBCs) strongly upregulate HO-1. The induction by apoptotic thymocytes is dependent on soluble signals, which do not include adenylate cyclase activators but induce the p38 mitogen-activated protein (MAP) kinase pathway, while in the case of eRBCs, it is cell uptake-dependent. Both pathways might involve the regulation of BTB and CNC homology 1 (BACH1), which is the repressor transcription regulator factor of the HO-1 gene. Long-term continuous efferocytosis of apoptotic thymocytes is not affected by the loss of HO-1, but that of eRBCs is inhibited. This latter is related to an internal signaling pathway that prevents the efferocytosis-induced increase in Rac1 activity. While the uptake of apoptotic cells suppressed the basal pro-inflammatory cytokine production in wild-type macrophages, in the absence of HO-1, engulfing macrophages produced enhanced amounts of pro-inflammatory cytokines. Our data demonstrate that HO-1 is required for both the engulfment and the anti-inflammatory response parts of the efferocytosis program.


Anti-Inflammatory Agents/pharmacology , Heme Oxygenase-1/drug effects , Heme Oxygenase-1/metabolism , Inflammation/drug therapy , Macrophages/drug effects , Animals , Gene Expression Regulation/drug effects , Inflammation/metabolism , Macrophages/metabolism , Mice, Inbred C57BL , NF-E2-Related Factor 2/metabolism , Phagocytosis/drug effects , Signal Transduction/drug effects , Up-Regulation/drug effects
5.
Biomedicines ; 8(12)2020 Dec 07.
Article En | MEDLINE | ID: mdl-33297443

Cell therapies are extensively tested to restore heart function after myocardial infarction (MI). Survival of any cell type after intracardiac administration, however, may be limited due to unfavorable conditions of damaged tissue. Therefore, the aim of this study was to evaluate the therapeutic effect of adipose-derived stromal cells (ADSCs) and human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) overexpressing either the proangiogenic SDF-1α or anti-inflammatory heme oxygenase-1 (HO-1) in a murine model of MI. ADSCs and hiPSCs were transduced with lentiviral vectors encoding luciferase (Luc), GFP and either HO-1 or SDF-1α. hiPSCs were then differentiated to hiPSC-CMs using small molecules modulating the WNT pathway. Genetically modified ADSCs were firstly administered via intracardiac injection after MI induction in Nude mice. Next, ADSCs-Luc-GFP and genetically modified hiPSC-CMs were injected into the hearts of the more receptive NOD/SCID strain to compare the therapeutic effect of both cell types. Ultrasonography, performed on days 7, 14, 28 and 42, revealed a significant decrease of left ventricular ejection fraction (LVEF) in all MI-induced groups. No improvement of LVEF was observed in ADSC-treated Nude and NOD/SCID mice. In contrast, administration of hiPSC-CMs resulted in a substantial increase of LVEF, occurring between 28 and 42 days after MI, and decreased fibrosis, regardless of genetic modification. Importantly, bioluminescence analysis, as well as immunofluorescent staining, confirmed the presence of hiPSC-CMs in murine tissue. Interestingly, the luminescence signal was strongest in hearts treated with hiPSC-CMs overexpressing HO-1. Performed experiments demonstrate that hiPSC-CMs, unlike ADSCs, are effective in improving heart function after MI. Additionally, long-term evaluation of heart function seems to be crucial for proper assessment of the effect of cell administration.

6.
PLoS One ; 15(10): e0240691, 2020.
Article En | MEDLINE | ID: mdl-33057437

Adeno-associated viral (AAV) vectors are characterised by low immunogenicity, although humoral and cellular responses may be triggered upon infection. Following systemic administration high levels of vector particles accumulate within the liver. Kupffer cells (KCs) are liver resident macrophages and an important part of the liver innate immune system. Decreased functional activity of KCs can contribute to exaggerated inflammatory response upon antigen exposure. Heme oxygenase-1 (HO-1) deficiency is associated with considerably reduced numbers of KCs. In this study we aimed to investigate the inflammatory responses in liver and to characterise two populations of hepatic macrophages in adult wild type (WT) and HO-1 knockout (KO) mice following systemic administration of one or two doses (separated by 3 months) of self-complementary (sc)AAV9 vectors. At steady state, the livers of HO-1 KO mice contained significantly higher numbers of monocyte-derived macrophages (MDMs), but significantly less KCs than their WT littermates. Three days after re-administration of scAAV9 we observed increased mRNA level of monocyte chemoattractant protein-1 (Mcp-1) in the livers of both WT and HO-1 KO mice, but the protein level and the macrophage infiltration were not affected. Three days after the 1st and 3 days after the 2nd vector dose the numbers of AAV genomes in the liver were comparable between both genotypes indicating similar transduction efficiency, but the percentage of transgene-expressing MDMs and KCs was higher in WT than in HO-1 KO mice. In the primary culture, KCs were able to internalize AAV9 particles without induction of TLR9-mediated immune responses, but no transgene expression was observed. In conclusion, in vivo and in vitro cultured KCs have different susceptibility to scAAV9 vectors. Regardless of the presence or absence of HO-1 and initial numbers of KCs in the liver, scAAV9 exhibits a low potential to stimulate inflammatory response at the analysed time points.


Genetic Vectors/metabolism , Heme Oxygenase-1/deficiency , Inflammation/pathology , Liver/pathology , Macrophages/pathology , Animals , Cells, Cultured , Chemokine CCL2/metabolism , Dependovirus/metabolism , Gene Expression Regulation , Green Fluorescent Proteins/metabolism , HEK293 Cells , Heme Oxygenase-1/metabolism , Humans , Inflammation/blood , Inflammation/genetics , Interleukin-6/blood , Kupffer Cells/pathology , Mice, Inbred C57BL , Mice, Knockout , Phenotype , Signal Transduction/genetics , Toll-Like Receptor 9/metabolism , Transgenes
7.
Int J Mol Sci ; 21(20)2020 Oct 20.
Article En | MEDLINE | ID: mdl-33092142

In most mammals, neonatal intravascular hemolysis is a benign and moderate disorder that usually does not lead to anemia. During the neonatal period, kidneys play a key role in detoxification and recirculation of iron species released from red blood cells (RBC) and filtered out by glomeruli to the primary urine. Activity of heme oxygenase 1 (HO1), a heme-degrading enzyme localized in epithelial cells of proximal tubules, seems to be of critical importance for both processes. We show that, in HO1 knockout mouse newborns, hemolysis was prolonged despite a transient state and exacerbated, which led to temporal deterioration of RBC status. In neonates lacking HO1, functioning of renal molecular machinery responsible for iron reabsorption from the primary urine (megalin/cubilin complex) and its transfer to the blood (ferroportin) was either shifted in time or impaired, respectively. Those abnormalities resulted in iron loss from the body (excreted in urine) and in iron retention in the renal epithelium. We postulate that, as a consequence of these abnormalities, a tight systemic iron balance of HO1 knockout neonates may be temporarily affected.


Heme Oxygenase-1/deficiency , Hemolysis , Iron/metabolism , Kidney/metabolism , Renal Insufficiency/metabolism , Anemia/blood , Anemia/therapy , Animals , Animals, Newborn , Erythrocyte Count , Female , Heme/metabolism , Heme Oxygenase-1/genetics , Iron/urine , Kidney/pathology , Male , Mice, Inbred C57BL , Mice, Knockout , Renal Insufficiency/genetics , Renal Insufficiency/therapy
8.
Mol Ther Methods Clin Dev ; 17: 1190-1201, 2020 Jun 12.
Article En | MEDLINE | ID: mdl-32518806

Systemically delivered adeno-associated viral vector serotype 9 (AAV9) effectively transduces murine heart, but provides transgene expression also in liver and skeletal muscles. Improvement of the selectivity of transgene expression can be achieved through incorporation of target sites (TSs) for miRNA-122 and miRNA-206 into the 3' untranslated region (3' UTR) of the expression cassette. Here, we aimed to generate such miRNA-122- and miRNA-206-regulated AAV9 vector for a therapeutic, heart-specific overexpression of heme oxygenase-1 (HO-1). We successfully validated the vector functionality in murine cell lines corresponding to tissues targeted by AAV9. Next, we evaluated biodistribution of transgene expression following systemic vector delivery to HO-1-deficient mice of mixed C57BL/6J × FVB genetic background. Although AAV genomes were present in the hearts of these animals, HO-1 protein expression was either absent or significantly impaired. We found that miRNA-122, earlier described as liver specific, was present also in the hearts of C57BL/6J × FVB mice. Various levels of miRNA-122 expression were observed in the hearts of other mouse strains, in heart tissues of patients with cardiomyopathy, and in human induced pluripotent stem cell-derived cardiomyocytes in which we also confirmed such posttranscriptional regulation of transgene expression. Our data clearly indicate that therapeutic utilization of miRNA-based regulation strategy needs to consider inter-individual variability.

9.
Vascul Pharmacol ; 112: 79-90, 2019 01.
Article En | MEDLINE | ID: mdl-30213580

Upon myocardial infarction (MI) immune system becomes activated by extensive necrosis of cardiomyocytes releasing intracellular molecules called damage-associated molecular patterns. Overactive and prolonged immune responses are likely to be responsible for heart failure development and progression in patients surviving the ischemic episode. Heme oxygenase-1 (HO-1) plays a crucial role in heme degradation and in this way releases carbon monoxide, free iron, and biliverdin. This stress-inducible enzyme is induced by various oxidative and inflammatory signals. Consequently, biological actions of HO-1 are not limited to degradation of a toxic heme released from hemoproteins, but also provide an adaptive cellular response against chronic inflammation and oxidative injury. Indeed, the immunomodulatory and anti-inflammatory properties of HO-1 were demonstrated in several experimental studies, as well as in human cases of genetic HO-1 deficiency. HO-1 was shown to suppress the production, myocardial infiltration and inflammatory properties of monocytes and macrophages what resulted in limitation of post-MI cardiac damage. This review specifically addresses the role of HO-1, heme and its degradation products in macrophage biology and post-ischemic cardiac repair. A more complete understanding of these mechanisms is essential to develop new therapeutic approaches.


Cardiovascular Agents/pharmacology , Genetic Therapy/methods , Heme Oxygenase-1/metabolism , Macrophages/drug effects , Monocytes/drug effects , Myocardium/enzymology , Animals , Gene Expression Regulation, Enzymologic/drug effects , Heart Failure/enzymology , Heart Failure/genetics , Heart Failure/immunology , Heart Failure/pathology , Heme Oxygenase-1/genetics , Humans , Inflammation Mediators/metabolism , Macrophages/enzymology , Macrophages/immunology , Molecular Targeted Therapy , Monocytes/enzymology , Monocytes/immunology , Myocardium/immunology , Myocardium/pathology , Necrosis , Oxidative Stress/drug effects , Signal Transduction/drug effects
10.
Basic Res Cardiol ; 112(4): 39, 2017 07.
Article En | MEDLINE | ID: mdl-28534119

Heme oxygenase-1 (Hmox1) is a stress-inducible protein crucial in heme catabolism. The end products of its enzymatic activity possess anti-oxidative, anti-apoptotic and anti-inflammatory properties. Cardioprotective effects of Hmox1 were demonstrated in experimental models of myocardial infarction (MI). Nevertheless, its importance in timely resolution of post-ischemic inflammation remains incompletely understood. The aim of this study was to determine the role of Hmox1 in the monocyte/macrophage-mediated cardiac remodeling in a mouse model of MI. Hmox1 knockout (Hmox1-/-) and wild-type (WT, Hmox1+/+) mice were subjected to a permanent ligation of the left anterior descending coronary artery. Significantly lower incidence of left ventricle (LV) free wall rupture was noted between 3rd and 5th day after MI in Hmox1-/- mice resulting in their better overall survival. Then, starting from 7th until 21st day post-MI a more potent deterioration of LV function was observed in Hmox1-/- than in the surviving Hmox1+/+ mice. This was accompanied by higher numbers of Ly6Chi monocytes in peripheral blood, as well as higher expression of monocyte chemoattractant protein-1 and adhesion molecules in the hearts of MI-operated Hmox1-/- mice. Consequently, a greater post-MI monocyte-derived myocardial macrophage infiltration was noted in Hmox1-deficient individuals. Splenectomy decreased the numbers of circulating inflammatory Ly6Chi monocytes in blood, reduced the numbers of proinflammatory cardiac macrophages and significantly improved the post-MI LV function in Hmox1-/- mice. In conclusion, Hmox1 deficiency has divergent consequences in MI. On the one hand, it improves early post-MI survival by decreasing the occurrence of cardiac rupture. Afterwards, however, the hearts of Hmox1-deficient mice undergo adverse late LV remodeling due to overactive and prolonged post-ischemic inflammatory response. We identified spleen as an important source of these cardiovascular complications in Hmox1-/- mice.


Antigens, Ly/metabolism , Heme Oxygenase-1/deficiency , Membrane Proteins/deficiency , Monocytes/enzymology , Myocardial Infarction/enzymology , Myocardium/enzymology , Spleen/enzymology , Ventricular Function, Left , Ventricular Remodeling , Animals , Antigens, Ly/immunology , Bone Marrow Cells/enzymology , Disease Models, Animal , Female , Genotype , Heart Rupture, Post-Infarction/enzymology , Heart Rupture, Post-Infarction/pathology , Heart Rupture, Post-Infarction/physiopathology , Hematopoiesis , Heme Oxygenase-1/genetics , Macrophages/enzymology , Macrophages/immunology , Membrane Proteins/genetics , Mice, Knockout , Monocytes/immunology , Myocardial Infarction/immunology , Myocardial Infarction/pathology , Myocardial Infarction/physiopathology , Myocardium/pathology , Phenotype , Spleen/immunology , Time Factors , Ventricular Dysfunction, Left/enzymology , Ventricular Dysfunction, Left/pathology , Ventricular Dysfunction, Left/physiopathology
11.
Chem Commun (Camb) ; (39): 4935-7, 2005 Oct 21.
Article En | MEDLINE | ID: mdl-16205805

The first magnesium and zinc alkyls derived from N-(iso-propyl)-pyrrolylaldimine have been synthesised and structurally characterised: both tBuM(N,N')-type compounds exist as three-coordinate monomers in benzene solution, but in the solid state the magnesium complex is a centrosymmetric dimer with Mg2(mu-N)2 bridges, whereas the zinc complex is a Zn...pi bonded dimer with a pi-coordinated pyrrole unit.

12.
Chest ; 123(4): 1054-9, 2003 Apr.
Article En | MEDLINE | ID: mdl-12684293

STUDY OBJECTIVES: The relationship between smoking and COPD has been well-documented. We investigated the impact of cigarette smoking on airway inflammation in COPD patients. DESIGN: Changes in cell profiles in induced sputum (IS) samples from smokers with COPD and patients who ceased smoking were compared. SETTING: Department of pneumonology in a university hospital. PATIENTS: IS samples were collected from 17 smokers and 17 ex-smokers with COPD. INTERVENTIONS: We examined IS samples for differential cell counts and macrophage phenotypes determined by immunocytochemistry with monoclonal antibodies anti-CD11b, anti-CD14, anti-CD54, and anti-CD71. MEASUREMENTS AND RESULTS: The median IS volume was greater and the total cell count was higher in smokers than in ex-smokers. The difference, however, was not significant. We did not find any significant differences in the proportions of cells and in the phenotypes of macrophages between the two groups, with the proportion of eosinophils being slightly higher in the group of smokers. We found, however, a significant positive correlation between the decrease in pulmonary function parameters and the number of pack-years smoked, an inverse correlation of pulmonary function test results with the number of lymphocytes in IS, and a correlation between some changes in the expression of macrophage surface markers and smoking history. There was no correlation between the time from smoking cessation and any cellular component found in IS samples. CONCLUSIONS: The analysis of IS samples in patients with COPD revealed no significant differences in cell count and macrophage phenotypes between active smokers and ex-smokers.


Lung/pathology , Macrophages/metabolism , Pulmonary Disease, Chronic Obstructive/pathology , Smoking/pathology , Sputum/cytology , Aged , Antigens, CD/metabolism , Cell Count , Female , Humans , Immunohistochemistry , Inflammation/pathology , Male , Middle Aged , Phenotype , Prospective Studies , Respiratory Function Tests , Specimen Handling
13.
Wiad Lek ; 55(9-10): 510-5, 2002.
Article Pl | MEDLINE | ID: mdl-12607404

The term radial segmentation (RS) is applied to a characteristic nuclear deformation observed in peripheral blood in vitro in some neoplastic and normal cells. It concerns al mononuclear cells. RS positive lymphocytes were found as CD 4 cells. Different conditions and substances, i.e. anticoagulant or cyclosporin can induce the formation of RS nuclei in vitro. Elevated ratio of RS nuclei in peripheral blood has been observed in patients with some autoimmunological diseases i.e. rheumatoid arthritis, diabetes mellitus insulin-dependent, sarcoidosis. Reduced ratio of RS nuclei was observed in neoplastic diseases. The aim of the study was to analyze the incidence of RS nuclei of lymphocytes in vitro in peripheral blood (induced by cyclosporin) in patients with non-small cell lung cancer (NSCLC). Heparinized peripheral blood was obtained from controls and patients with primary NSCLC. The blood was incubated with cyclosporin, and then lymphocytes were isolated by Lymphoprep. RS positive lymphocytes were counted in smears stained with MGG stain. In peripheral blood from healthy donors the average incidence of lymphocytes RS was 3.314% and in patients with NSCLC 4.481% respectively. The difference between controls and patients with NSCLC was not significant. No correlation was found between incidence of RS and stadium of lung cancer.


Carcinoma, Non-Small-Cell Lung/blood , Cell Nucleus/ultrastructure , Cell Transformation, Neoplastic/ultrastructure , Lung Neoplasms/blood , T-Lymphocytes/ultrastructure , Adult , Aged , Aged, 80 and over , Carcinoma, Non-Small-Cell Lung/diagnostic imaging , Carcinoma, Non-Small-Cell Lung/pathology , Case-Control Studies , Cell Nucleus/pathology , Female , Humans , In Vitro Techniques , Leukocytes/ultrastructure , Lung Neoplasms/diagnostic imaging , Lung Neoplasms/pathology , Male , Middle Aged , Ultrasonography
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