Supramolecular Assembly Based on Calix(4)arene and Aggregation-Induced Emission Photosensitizer for Phototherapy of Drug-Resistant Bacteria and Skin Flap Transplantation.

Photodynamic therapy as a burgeoning and non-invasive theranostic technique has drawn great attention in the field of antibacterial treatment but often encounters undesired phototoxicity of photosensitizers during systemic circulation. Herein, a supramolecular substitution strategy is proposed for phototherapy of drug-resistant bacteria and skin flap repair by using macrocyclic p-sulfonatocalix(4)arene (SC4A) as a host, and two cationic aggregation-induced emission luminogens (AIEgens), namely TPE-QAS and TPE-2QAS, bearing quaternary ammonium group(s) as guests. Through host-guest assembly, the obtained complex exhibits obvious blue fluorescence in the solution due to the restriction of free motion of AIEgens and drastically inhibits efficient type I ROS generation. Then, upon the addition of another guest 4,4'-benzidine dihydrochloride, TPE-QAS can be competitively replaced from the cavity of SC4A to restore its pristine ROS efficiency and photoactivity in aqueous solution. The dissociative TPE-QAS shows a high bacterial binding ability with an efficient treatment for methicillin-resistant Staphylococcus aureus (MRSA) in dark and light irradiation. Meanwhile, it also exhibits an improved survival rate for MRSA-infected skin flap transplantation and largely accelerates the healing process. Thus, such cascaded host-guest assembly is an ideal platform for phototheranostics research.

Carbonized Polymer Dots Assemble in Proton-Conducting Channels to Enhance the Conductivity and Selectivity Simultaneously for High-Performance Fuel Cells.

Fabricating polymer electrolyte membranes (PEMs) simultaneously with high ion conductivity and selectivity has always been an ultimate goal in many membrane-integrated systems for energy conversion and storage. Constructing broader ion-conducting channels usually enables high-efficient ion conductivity while often bringing increased crossover of other ions or molecules simultaneously, resulting in decreased selectivity. Here, the ultra-small carbon dots (CDs) with the selective barriers are self-assembled within proton-conducting channels of PEMs through electrostatic interaction to enhance the proton conductivity and selectivity simultaneously. The functional CDs regulate the nanophase separation of PEMs and optimize the hydration proton network enabling higher-efficient proton transport. Meanwhile, the CDs within proton-conducting channels prevent fuel from permeating selectively due to their repelling and spatial hindrance against fuel molecules, resulting in highly enhanced selectivity. Benefiting from the improved conductivity and selectivity, the open-circuit voltage and maximum power density of the direct methanol fuel cell (DMFC) equipped with the hybrid membranes raised by 23% and 93%, respectively. This work brings new insight to optimize polymer membranes for efficient and selective transport of ions or small molecules, solving the trade-off of conductivity and selectivity.

Hybrid Liquid-Crystalline Electrolytes with High-Temperature-Stable Channels for Anhydrous Proton Conduction.

Modern electrochemical and electronic devices require advanced electrolytes. Liquid crystals have emerged as promising electrolyte candidates due to their good fluidity and long-range order. However, the mesophase of liquid crystals is variable upon heating, which limits their applications as high-temperature electrolytes, e.g., implementing anhydrous proton conduction above 100 °C. Here, we report a highly stable thermotropic liquid-crystalline electrolyte based on the electrostatic self-assembly of polyoxometalate (POM) clusters and zwitterionic polymer ligands. These electrolytes can form a well-ordered mesophase with sub-10 nm POM-based columnar domains, attributed to the dynamic rearrangement of polymer ligands on POM surfaces. Notably, POMs can serve as both electrostatic cross-linkers and high proton conductors, which enable the columnar domains to be high-temperature-stable channels for anhydrous proton conduction. These nanochannels can maintain constant columnar structures in a wide temperature range from 90 to 160 °C. This work demonstrates the unique role of POMs in developing high-performance liquid-crystalline electrolytes, which can provide a new route to design advanced ion transport systems for energy and electronic applications.

Block-copolymer-like self-assembly behavior of mobile-ligand grafted ultra-small nanoparticles.

We use coarse-grained molecular dynamics simulations to study the self-assembly behavior of polyoxometalate (POM) nanoparticles (NPs) decorated with mobile polymer ligands under melt conditions. We demonstrate that due to the mobile nature of the grafted ligands on the NP surface, NPs have the ability to expose a part of their surfaces, leading to a block-copolymer-like self-assembly behavior. The exposed NP surface serves as one block and the grafted ligand polymers as another. This system has a strong ability to self-assemble into long-range ordered structures such as block copolymers due to large incompatibility between POM and ligand polymers, i.e., POM NPs can form lamellar, cylindrical, and spherical structures, which are consistent with previous experimental results. More importantly, these ordered structures are on the sub-10 nm scale, which is an important requirement for many applications. At low graft density, we find a new inverse-cylindrical structure formation where polymers form cylinders and POMs form a continuous network structure. A full self-assembly phase diagram is constructed which illustrates rules to manipulate the self-assembly structures of NPs decorated with mobile polymer ligands. We hope that these computational results will be useful for the new design of nanostructures with improved optical or electronic functions.

Pyrotinib versus trastuzumab emtansine for HER2-positive metastatic breast cancer after previous trastuzumab and lapatinib treatment: a real-world study.

BACKGROUND: To compare the efficacy and safety of pyrotinib and trastuzumab emtansine (T-DM1) in patients who experienced disease progression on trastuzumab and lapatinib treatment. METHODS: This was a real-world study that included cases of metastatic breast cancer (MBC) with trastuzumab and lapatinib failure. One group of patients received pyrotinib monotherapy or combination therapy, whereas the other group received T-DM1 monotherapy. The primary study endpoint was progression-free survival (PFS); secondary endpoints were the objective response rate (ORR), clinical benefit rate (CBR) and safety. RESULTS: Between January 2013 and November 2019, 105 patients were enrolled in the pyrotinib group (n=55) or T-DM1 group (n=50). The median PFS was 6.0 months (95% CI, 4.7 to 7.3 months) with pyrotinib and 4.2 months (95% CI, 3.6 to 4.8 months) with T-DM1 (P=0.044). ORR values were 16.3% and 20.0% in the pyrotinib and T-DM1 groups, respectively (P=0.629); CBR values were 45.5% and 40.0% in the pyrotinib and T-DM1 groups, respectively (P=0.573). Subgroup analysis of those benefitting from lapatinib revealed a median PFS of 8.1 months (95% CI, 4.8 to 11.4 months) in the pyrotinib group, whereas that of the T-DM1 group was 4.4 months (95% CI, 3.8 to 5.0 months, P=0.013). Moreover, the median PFS of patients without liver metastases was 6.9 months (95% CI, 3.7 to 10.1 months) in the pyrotinib group and 4.1 months (95% CI, 3.1 to 5.1 months) in the T-DM1 group (P=0.010). The main common adverse events (AEs) were diarrhea (98.2%) and nausea (49.1%) in the pyrotinib group and thrombocytopenia (42.0%) and nausea (40.0%) in the T-DM1 group. The percentages of grade 3 to 4 AEs in the pyrotinib and T-DM1 groups were 34.5% and 40.0%, respectively. CONCLUSIONS: The results of this study suggest that patients with HER2-positive MBC with trastuzumab and lapatinib failure can benefit from subsequent pyrotinib treatment and tolerate this treatment well, especially those who have benefited from previous lapatinib treatment or those who have no liver metastasis.

Effect of an Artificial Intelligence Clinical Decision Support System on Treatment Decisions for Complex Breast Cancer.

PURPOSE: To examine the impact of a clinical decision support system (CDSS) on breast cancer treatment decisions and adherence to National Comprehensive Cancer Center (NCCN) guidelines. PATIENTS AND METHODS: A cross-sectional observational study was conducted involving 1,977 patients at high risk for recurrent or metastatic breast cancer from the Chinese Society of Clinical Oncology. Ten oncologists provided blinded treatment recommendations for an average of 198 patients before and after viewing therapeutic options offered by the CDSS. Univariable and bivariable analyses of treatment changes were performed, and multivariable logistic regressions were estimated to examine the effects of physician experience (years), patient age, and receptor subtype/TNM stage. RESULTS: Treatment decisions changed in 105 (5%) of 1,977 patients and were concentrated in those with hormone receptor (HR)-positive disease or stage IV disease in the first-line therapy setting (73% and 58%, respectively). Logistic regressions showed that decision changes were more likely in those with HR-positive cancer (odds ratio [OR], 1.58; P < .05) and less likely in those with stage IIA (OR, 0.29; P < .05) or IIIA cancer (OR, 0.08; P < .01). Reasons cited for changes included consideration of the CDSS therapeutic options (63% of patients), patient factors highlighted by the tool (23%), and the decision logic of the tool (13%). Patient age and oncologist experience were not associated with decision changes. Adherence to NCCN treatment guidelines increased slightly after using the CDSS (0.5%; P = .003). CONCLUSION: Use of an artificial intelligence-based CDSS had a significant impact on treatment decisions and NCCN guideline adherence in HR-positive breast cancers. Although cases of stage IV disease in the first-line therapy setting were also more likely to be changed, the effect was not statistically significant (P = .22). Additional research on decision impact, patient-physician communication, learning, and clinical outcomes is needed to establish the overall value of the technology.

Endocrine therapy combined with targeted therapy in hormone receptor-positive metastatic breast cancer.

Increasing numbers of targeted drugs are used in hormone receptor (HR)-positive metastatic breast cancer (MBC) to overcome or delay resistance to endocrine therapy. This study will systemically review the progress made in endocrine therapy combined with targeted therapy in the treatment of HR-positive MBC. From the "AI (aromatase inhibitor) era" represented by aromatase inhibitors, we have gradually entered the "post-AI era" represented by fulvestrant. Under the guidance of research on the molecular mechanism of endocrine therapy resistance, the "combination of endocrine therapy and targeted therapy" era is approaching. The development of drugs that target endocrine therapy resistance has concentrated on cyclin-dependent kinase 4/6 inhibitors, histone deacetylase inhibitors, and inhibitors of drug targets in the phosphatidylinositol 3 kinase-protein kinase B-mammalian target of rapamycin (PI3K-AKT-mTOR) pathway, providing new strategies for HR-positive MBC. Exploring biomarkers to guide the more precise use of targeted drugs in endocrine therapy for MBC is the focus of current and future research.

Effectiveness of second-line anti-HER2 treatment in HER2-positive metastatic breast cancer patients previously treated with trastuzumab: A real-world study.

OBJECTIVE: Several studies have demonstrated different benefits for patients whose disease progressed despite previous trastuzumab treatment. Due to limited real-world data, we evaluate the effectiveness of anti-human epidermal growth factor receptor 2 (HER2) therapy (lapatinib or trastuzumab) plus chemotherapy or chemotherapy alone in patients who were previously treated with trastuzumab-containing regimens and investigate factors associated with effectiveness. And we further show the effectiveness of the two anti-HER2 therapy groups. METHODS: A total of 342 HER2-positive metastatic breast cancer (MBC) patients whose disease progressed during prior anti-HER2 (trastuzumab) and standard chemotherapy therapy from Department of Breast Oncology, the Fifth Medical Center of Chinese PLA General Hospital, from August 2010 to December 2016 were included. Seventy-eight patients received standard chemotherapy only, 148 patients continued to receive trastuzumab and switched to other chemotherapy drugs, and 116 patients received tyrosine-kinase inhibitors (TKIs; lapatinib) and chemotherapy. The main outcome measures were progression-free survival (PFS), overall response rate (ORR), and clinical benefit rate (CBR). Subgroup analyses were conducted to identify patient characteristics associated with the greatest clinical benefit. RESULTS: After a median follow-up of 26.2 (range, 2.0-56.0) months, PFS significantly improved with anti-HER2 therapy compared with chemotherapy alone: median 6.0 months with lapatinib [95% confidence interval (95% CI), 4.53-7.47], 4.5 months with trastuzumab (95% CI, 3.99-5.01)vs. 3.0 months with chemotherapy alone (95% CI, 2.42-3.58); stratified hazard ratio (HR)=0.70, 95% CI, 0.60-0.81; P<0.0001. The ORR values were 33.6%, 25.0% and 12.8 %, respectively, the CBR values were 60.3%, 48.6% and 26.9%, respectively. The effectiveness of lapatinib group and trastuzumab group were further analyzed. In multivariate analysis, lapatinib group was associated with a longer PFS, after controlling other potential confounders (HR=0.68, 95% CI, 0.52-0.90; P=0.006). CONCLUSIONS: The combination of TKIs and chemotherapy was effective in this cohort previously treated with trastuzumab treatment. Therefore, TKIs combined with chemotherapy is an option for Chinese HER2-positive MBC patients previously treated with trastuzumab treatment.

Erratum to prophylaxis of breast cancer chemotherapy for bone marrow toxicity: more individualized and safer.

[This corrects the article DOI: 10.21037/atm.2019.12.50.].

Erratum to a right atrium metastasis of breast cancer after long-term endocrine therapy.

[This corrects the article DOI: 10.21037/atm.2019.09.36.].

Erratum to efficacy and safety of mecapegfilgrastim for prophylaxis of chemotherapy-induced neutropenia in patients with breast cancer: a randomized, multicenter, active-controlled phase III trial.

[This corrects the article DOI: 10.21037/atm.2019.07.95.].

Efficacy and safety of mecapegfilgrastim for prophylaxis of chemotherapy-induced neutropenia in patients with breast cancer: a randomized, multicenter, active-controlled phase III trial.

BACKGROUND: Neutropenia is a common complication from chemotherapy. Mecapegfilgramtim (code name HHPG-19K), a long-acting recombinant human granulocyte colony-stimulating factor (rhG-CSF), has been developed. This study was to evaluate the efficacy and safety of mecapegfilgrastim for reducing neutropenia compared with filgrastim. METHODS: This was a randomized, controlled non-inferiority study. A total of 339 breast cancer patients who were eligible for (neo) adjuvant chemotherapy were randomized assigned into three groups to receive mecapegfilgrastim 100 µg/kg, mecapegfilgrastim fixed dose of 6 mg or filgrastim 5 µg/kg/day in the first cycle of chemotherapy. The primary endpoint was the duration of grade ≥3 neutropenia in cycle 1. The secondary endpoints included the duration of grade ≥3 neutropenia in cycles 2-4, incidence of grade ≥3 neutropenia, and febrile neutropenia (FN). The safety profile was also evaluated. RESULTS: The mean duration of grade ≥3 neutropenia was 1.06 [95% confidence interval (CI): 0.65, 1.26] days in mecapegfilgrastim 100 µg/kg group, 1.23 (95% CI: 0.84, 1.88) days in mecapegfilgrastim 6 mg group, and 2.06 (95% CI: 1.66, 2.46) days in the filgrastim group. The mean difference between mecapegfilgrastim 100 µg/kg and filgrastim was -1.00 (95% CI: -1.52, -0.48), the mean difference between mecapegfilgrastim 6 mg and filgrastim was -0.83 (95% CI: -1.36, -0.30). The upper bounds of 95% CI for the difference between mecapegfilgrastim and filgrastim were all <1 day (the predefined non-inferiority margin). For the incidence of grade ≥3 and grade 4 neutropenia, the mean duration of grade 4 neutropenia, mecapegfilgrastim showed better performance compared with filgrastim. For the incidence of FN, there was no difference between patients treated with mecapegfilgrastim and filgrastim. For safety profile, mecapegfilgrastim of two doses groups were all well-tolerated. Fixed 6 mg dose of mecapegfilgrastim exhibited comparable efficacy and safety in comparison with 100 µg/kg during 4 cycles. CONCLUSIONS: Long-acting mecapegfilgrastim (100 µg/kg and fixed 6 mg) is very effective and well tolerated when administered in the primary prophylaxis of chemotherapy induced neutropenia and in consecutive-cycle treatment. In some clinical parameters, mecafilgrastim is non-inferior and even superior to filgrastim. The fixed 6 mg-dose regimen showed similar efficacy and safety profile compared with 100 µg/kg regimen, and would be the preference in clinical practice, due to the convenient once-per-cycle administration and high-degree treatment compliance for the patients. This study provided new evidence for the novel long-acting rhG-CSF, mecapegfilgrastim, which would be a new alternative for clinical practice for prophylaxis of chemotherapy induced neutropenia.

SERS Substrate with Silk Nanoribbons as Interlayer Template.

The formation of hot spots is an effective approach to improve the performance of surface-enhanced Raman scattering (SERS). Silk nanoribbons (SNRs), with a height of about 1-2 nm, and Au nanoparticles (AuNPs) were assembled by electrostatic interactions to introduce sandwich hot spot structures. These sandwich structures were optimized by tuning the ratio of SNRs and AuNPs, resulting in strong SERS signals with a sensitivity of 10-13 M and enhancement factor (EF) of 5.8 × 106. Improved SERS spectrum uniformity with relative standard deviation (RSD) about 11.2% was also achieved due to the homogeneous distribution of these hot spot structures. The inherent biocompatibility of SNRs and facile fabrication processes utilized endowed the SERS substrates significant benefits toward biomedical applications, confirmed by cytocompatibility and improved SERS bioimaging capacity in vitro. The results of this study suggest the feasibility of forming high performance bioimaging systems through the use of naturally derived materials with special nanostructures.

Artificial Intelligence Treatment Decision Support For Complex Breast Cancer Among Oncologists With Varying Expertise.

PURPOSE: The aim of the current study was to assess treatment concordance and adherence to National Comprehensive Cancer Network breast cancer treatment guidelines between oncologists and an artificial intelligence advisory tool. PATIENTS AND METHODS: Study cases of patients (N = 1,977) who were at high risk for recurrence or who had metastatic disease and cell types for which the advisory tool was trained were obtained from the Chinese Society for Clinical Oncology cancer database (2012 to 2017). A cross-sectional observational study was performed to examine treatment concordance and guideline adherence among an artificial intelligence advisory tool and 10 oncologists with varying expertise-three fellows, four attending physicians, and three chief physicians. In a blinded fashion, each oncologist provided treatment advice on an average of 198 cases and the advisory tool on all cases (N = 1,977). Results are reported as rates and logistic regression odds ratios. RESULTS: Concordance for the recommended treatment was 0.56 for all physicians and higher for fellows compared with chief and attending physicians (0.68 v 0.54; 0.49; P = .001). Concordance differed by hormone receptor subtype-TNM stage, with the lowest for hormone receptor-positive human epidermal growth factor receptor 2/neu-positive cancers (0.48) and highest for triple-negative breast cancers (0.71) across most TNM stages. Adherence to National Comprehensive Cancer Network guidelines was higher for oncologists compared with the advisory tool (0.96 v 0.82; P < .003) and lower for fellows compared with attending physicians (0.93 v 0.98; 0.96; P = .04). CONCLUSION: Study findings reflect a complex breast cancer case mix, the limits of medical knowledge regarding optimum treatment, clinician practice patterns, and use of a tool that reflects expertise from one cancer center. Additional research in different practice settings is needed to understand the tool's scalability and its impact on treatment decisions and clinical and health services outcomes.

Multiscale Self-Assembly of Mobile-Ligand Molecular Nanoparticles for Hierarchical Nanocomposites.

Multiscale hierarchical morphologies are greatly desired for fabricating nanocomposites with tunable macroscopic properties, but challenges remain in precisely manipulating the spatial arrangement of nanoparticles in polymer matrices across multiple length scales. Here, we demonstrate a class of mobile-ligand nanoparticle system built upon 1 nm anionic polyoxometalate molecular nanoparticles and cationic terminated polymer chains by electrostatic interaction. The highly rearrangeable polymer chains can serve as mobile ligands to direct the polyoxometalates to align into sub-10 nm anisotropic superlattice-like nanoarrays in the bulk state. Moreover, these nanoarrays can further serve as structural units to assemble into hierarchically ordered morphologies in polymer matrices, e.g., percolated networks over hundreds of micrometers which are comprised of cylindrically packed polyoxometalate superlattices down to sub-10 nm scale. These hierarchical morphologies enable the nanocomposites with reinforced mechanical performance. The presented mobile-ligand approach can provide a paradigm to design functional polymer nanocomposites with improved properties such as mechanical reinforcement and collective optical and electronic functions.

A right atrium metastasis of breast cancer after long-term endocrine therapy.

We report a case of right atrial metastasis in a 66-year-old female patient with breast cancer. The patient presented with palpitation and dyspnea after long-term endocrine therapy. A large echo-dense mass was found in the right atrium after the examination. In order to relieve the symptoms, the patient underwent a resection of the atrial lesion, and the pathology confirmed that it was metastatic breast cancer. Next-generation sequencing (NGS) of the entire exon was taken to explore the gene expression of the metastatic lesion. Forty-eighty genes were identified with mutations, and the mutations of ATM and ESR1 were considered to be associated with the development and metastasis of breast cancer in this case.

Subtle Regulation of Scaffold Stiffness for the Optimized Control of Cell Behavior.

The rigidity of extracellular matrices can impact cell fate, guide tissue development, and initiate tumor formation. Scaffolds such as hydrogels with tunable levels of stiffness have been developed to control cell adhesion, migration, and differentiation, providing suitable microenvironments for different tissue outcomes. However, studies of cell-material interactions are largely confined to biomaterials with stiffness values that are coarsely regulated, so refinements in sensitive cellular responses and optimal stiffness values that determine cell fate remain elusive. Here, a freezing temperature, as a tunable regulating factor, was introduced to freeze-drying processes to form silk fibroin (SF) scaffolds with refined control of stiffness values. Due to this control of intermediate structural conformations of SF, the scaffolds exhibited differences in stiffness values to permit refined assessments of impact on cell behavior on cell-friendly surfaces. Both in vitro and in vivo results with these scaffolds exhibited gradually changeable cell migration and differentiation outcomes, as well as differences in tissue ingrowth, demonstrating the sensitivity of cellular responses to such refined mechanical cues. The optimal vascularization capacity of these SF scaffolds was in the 3-7.4 kPa range, suggesting a key range to develop bioactive biomaterials. Systematic fine regulation of scaffold rigidity based on the present strategy provides a platform for an improved understanding of cell-material interactions and also for generating optimized microenvironments for tissue regeneration.

The way to precision medicine of our team.

In the past few years, the treatment model of breast cancer (BC) has undergone a variety of changes and the change of eras. Whether the classification treatment which is currently dominant, or the precision medicine which is extremely promising in the future are both carrying out the concept of individual treatment. Through retrospect the research and clinical achievement of our team in the past three decades, we share our experience and exertion on the exploration of a road to BC precision medicine in this paper and make a prospect of the future development direction of research and treatment.