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Adult wild-type (WT) and MT-TGFα mice received zinc sulfate (25 mM ZnSO4) in the drinking water for 2 weeks before sacrifice. The stomachs of WT mice appeared normal, grossly and histologically. In marked contrast, the stomachs of MT-TGFα were grossly thickened (Figure 2A). Microscopically, these stomachs showed massive foveolar hyperplasia with loss of both parietal and chief cells (Figure 2B-D), recapitulating the histological features of Ménétrier's disease (MD). Loss of chief cells can occur in two different ways: death of chief cells or spasmolytic polypeptide-expressing metaplasia (SPEM) arising from chief cells. To distinguish these two possibilities, we performed lineage tracing of chief cells by intercrossing Mist1-CreERT2; R26-LSL-mTmG mice with MT-TGFα mice. These mice were treated first with low dose tamoxifen (37.5 mg/kg intraperitoneally for 7 consecutive days) to label chief cells with GFP and then with ZnSO4 in the drinking water to induce TGFα overexpression. We observed rare GFP-labeled cells in the MT-TGFα mice (data not shown). In addition, there were no gross and histological differences in the MT-TGFα mice in the presence or absence of ZnSO4 (Figure 3A-C). One possible explanation for this finding was that TGFα may have reduced the expression of Mist1, an essential transcription factor for chief cells18, and subverting the usefulness of the Mist1-CreERT2 allele. In fact, immunohistochemical staining for Mist1 was lost in MT-TGFα mice without ZnSO4 treatment (Figure 3D).
To overcome the leakiness of the MT-TGFα mouse model, we turned to a doxycycline-inducible Doxi-TGFa transgenic model. This was achieved by intercrossing TetO-TGFα mice14 to a CMV-rtTA mouse line13; it has been reported previously that rtTA is expressed in the stomach. We confirmed that 2 weeks of doxycycline treatment induces foveolar hyperplasia and decreased numbers of parietal and chief cells in this new MD mouse model (Figure 4A-C). Compared to histomorphologic features in MT-TGFα mice, Doxi-TGFα mice showed less severe mucosal thickness and foveolar hyperplasia, as well as less of a decrease in parietal cells (Supplementary Figure 2). Nevertheless, we were able to lineage trace chief cells using the Mist1-CreERT2 mouse line and confirmed that chief cell lineages are also labeled with GSII and CD44v920,21, confirming that TGFα overexpression induces SPEM from chief cells (Figure 4D).
The current study shows that the MT-TGFα mouse model phenocopies the histopathological features of MD in the absence of heavy metal treatment, likely due to the intrinsic leakiness of the promoter/enhancer and/or the inability to avoid heavy metal exposure (Figure 3 and Supplementary Figure 2). Because TGFα suppresses Mist1 expression, the Mist1-CreERT2 mouse line cannot be used in the MT-TGFα mouse model. We generated a new MD mouse model in which TGFα expression can be induced by doxycycline treatment. Using this new Doxi-TGFα MD mouse model, we were able to confirm that TGFα overexpression induces SPEM derived from chief cells. The Doxi-TGFα MD mouse model will be useful when precise control of TGFα expression is necessary and also when genetic alteration in chief cells is required using the Mist1-CreERT2 mouse line.
Data availability:
All raw data are available as supplementary files.

Figure 1: Workflow for fixation and preparation of gastric tissue embedding. (A) Dissect the stomach along with a short segment (3-5 mm) of the duodenum. (B) Remove luminal content by instilling PBS from the duodenum using a syringe with a pipette tip and squeezing it with fingers 3x. (C) Inflate the stomach with formalin from the duodenum using a syringe and pinch the gastroduodenal junction to retain the formalin. (D) Submerge the stomach in formalin and fix overnight at 4 °C with shaking. (E) Remove the forestomach and the duodenum with a razor blade and rinse with PBS. (F) Cut the gastric body and antrum into 3-4 rings in a cross-sectional manner and embed them in 2% agarose to maintain the orientation of stomach tissue rings. (G) Place the agarose-embedded tissue in cassettes. Please click here to view a larger version of this figure.

Figure 2: Gross and microscopic phenotypes of MT-TGFα mice treated with heavy metal ZnSO4. (A) The gastric wall is thicker in the MT-TGFα mice (right) compared to the control mice (left). (B) Stomach from MT-TGFα mice (right) shows massive foveolar hyperplasia and loss of parietal cells. Yellow arrowheads indicate parietal cells, and green arrowheads indicate foveolar cells. Scale bars represent 100 µm. (C) Immunofluorescent staining confirms that the MT-TGFα mouse stomach (right) shows increased numbers of foveolar cells (UEA1 positive) and SPEM cells (GIF and GSII double positive) and decreased numbers of parietal cells (H+/K+-ATPase positive) and chief cells (GIF single positive) compared to control mouse stomach (left). Scale bars represent 100 µm. (D) Quantification of different epithelial cell types and mucosal thickness in wild-type (WT) mice treated with ZnSO4 (n = 5) and MT-TGFα mice with ZnSO4 (n = 3). Error bars indicate standard deviation (**p < 0.01, ***p < 0.001, ****p < 0.0001). Please click here to view a larger version of this figure.

Figure 3: MT-TGFα mice develop gastric phenotypes without heavy metal treatment. (A) Stomach from MT-TGFα mice (right) shows massive foveolar hyperplasia and loss of parietal cells without heavy metal treatment. Yellow arrowheads indicate parietal cells, and green arrowheads indicate foveolar cells. Scale bars represent 100 µm. (B) Immunofluorescent staining confirms MT-TGFα mouse stomach (right) without heavy metal treatment shows increased numbers of foveolar cells (UEA1 positive) and SPEM cells (GIF and GSII double positive), and decreased numbers of parietal cells (H+/K+-ATPase positive) and chief cells (GIF single positive) compared to control mouse stomach (left). Scale bars represent 100 µm. (C) Quantification of different epithelial cell types and mucosal thickness in WT mice without ZnSO4 (n = 5) and MT-TGFα mice ZnSO4 (n = 3). Error bars indicate standard deviation (***p < 0.001, ****p < 0.0001). (D) Stomach from MT-TGFα mice (right) shows loss of Mist1 expression, which is normally expressed in the chief cells (left). GSII is a marker for mucous neck cells. Scale bars represent 100 µm. Please click here to view a larger version of this figure.

Figure 4: Doxycycline inducible TGFα mouse model (Doxi-TGFα) recapitulates Ménétrier's disease phenotypes, and SPEM formation is confirmed in this mouse model. (A) Stomach from CMV-rtTA; TetO-TGFα mice (Doxi-TGFα; right) shows massive foveolar hyperplasia and decreased number of parietal cells. Yellow arrowheads indicate parietal cells, and green arrowheads indicate foveolar cells. Scale bars represent 100 µm. (B) Immunofluorescent staining confirms Doxi-TGFα mouse stomach (right) shows increased numbers of foveolar cells (UEA1 positive) and SPEM cells (GIF and GSII double positive), and decreased numbers of parietal cells (H+/K+-ATPase positive) and chief cells (GIF single positive) compared to control mouse stomach (left). Scale bars represent 100 µm. (C) Quantification of different epithelial cell types and mucosal thickness in WT mice (n = 5) and Doxi-TGFα mice (n = 5). Error bars indicate standard deviation (*p < 0.05, **p < 0.01, ***p < 0.001). (D) Lineage tracing of chief cells (GFP positive) using Mist1-CreERT2; R26-LSL-mTmG mouse line reveals GFP positive cells are also positive for GSII and CD44v9 in the Doxi-TGFα mouse stomach, confirming SPEM formation derived from chief cells whereas control stomach (left) shows almost no GFP positive cells are also positive for GSII or CD44v9. Scale bars represent 100 µm. Please click here to view a larger version of this figure.
Supplementary Figure 1: Low dose tamoxifen (TMX) treatment does not induce gastric mucosal injury. Seven consecutive days of low-dose TMX treatment (37.5 mg/kg) does not induce gastric mucosal injury, exemplified by the maintenance of parietal cell number. (A) Representative H&E images without TMX treatment (left panel) and with TMX treatment (right panel). Scale bars represent 100 µm. (B) Quantification of parietal cell number per gastric unit in WT mice (n = 5) and WT with TMX treatment (n = 5). Please click here to download this File.
Supplementary Figure 2: Comparison of phenotypes among different Ménétrier's disease (MD) mouse models. (A) MT-TGFα with ZnSO4 treatment, MT-TGFα without ZnSO4 treatment, and Doxi-TGFα MD mouse models show foveolar hyperplasia, loss of parietal and chief cells, increased spasmolytic polypeptide-expressing metaplasia (SPEM) cells (GIF and GSII co-localized cells), and thickened mucosa. There are no phenotypic differences between MT-TGFα with and without ZnSO4 treatment groups. Doxi-TGFα mouse model shows less severe phenotypes than MT-TGFα mouse model. Please click here to download this File.