A pooled analysis of clinical outcome in driver-gene negative non-small cell lung cancer patients with MET overexpression treated with gumarontinib.

Background: MET overexpression represents the most MET aberration in advanced non-small-cell lung cancer (NSCLC). However, except MET exon 14 (METex14) skipping mutation was recognized as a clinical biomarker, the role of MET overexpression as a predictive factor to MET inhibitor is not clear. Objectives: The purpose of the pooled analysis is to explore the safety and efficiency of gumarontinib, a highly selective oral MET inhibitor, in drive-gene negative NSCLC patients with MET overexpression. Design and methods: NSCLC patients with MET overexpression [immunohistochemistry (IHC) ⩾3+ as determined by central laboratory] not carrying epidermal growth factor receptor mutation, METex14 skipping mutation or other known drive gene alternations who received Gumarontinib 300 mg QD from two single arm studies were selected and pooled for the analysis. The efficacy [objective response rate (ORR), disease control rate (DCR), duration of response, progression-free survival (PFS) and overall survival (OS)] and safety [treatment emergent adverse event (TEAE), treatment related AE (TRAE) and serious AE (SAE) were assessed. Results: A total of 32 patients with MET overexpression were included in the analysis, including 12 treatment naïve patients who refused or were unsuitable for chemotherapy, and 20 pre-treated patients who received ⩾1 lines of prior systemic anti-tumour therapies. Overall, the ORR was 37.5% [95% confidence interval (CI): 21.1-56.3%], the DCR was 81.3% (95% CI: 63.6-92.8%), median PFS (mPFS) and median OS (mOS) were 6.9 month (95% CI: 3.6-9.7) and 17.0 month (95% CI: 10.3-not evaluable), respectively. The most common AEs were oedema (59.4%), hypoalbuminaemia (40.6%), alanine aminotransferase increased (31.3%). Conclusion: Gumarontinib showed promising antitumour activity in driver-gene negative locally advanced or metastatic NSCLC patients with MET overexpression, which warranted a further clinical trial. Trial registration: ClinicalTrials.gov identifier: NCT03457532; NCT04270591.

A novel technique for NO.253 lymph node dissection and left colic artery preservation to avoid potential postoperative internal hernia in laparoscopic radical resection for rectal cancer.

BACKGROUND: The preservation of the left colic artery (LCA) has emerged as a preferred approach in laparoscopic radical resection for rectal cancer. However, preserving the LCA while simultaneously dissecting the NO.253 lymph node can create a mesenteric defect between the inferior mesenteric artery (IMA), the LCA, and the inferior mesenteric vein (IMV). This defect could act as a potential "hernia ring," increasing the risk of developing an internal hernia after surgery. The objective of this study was to introduce a novel technique designed to mitigate the risk of internal hernia by filling mesenteric defects with autologous tissue. METHODS: This new technique was performed on eighteen patients with rectal cancer between January 2022 and June 2022. First of all, dissected the lymphatic fatty tissue on the main trunk of IMA from its origin until the LCA and sigmoid artery (SA) or superior rectal artery (SRA) were exposed and then NO.253 lymph node was dissected between the IMA, LCA and IMV. Next, the SRA or SRA and IMV were sequentially ligated and cut off at an appropriate location away from the "hernia ring" to preserve the connective tissue between the "hernia ring" and retroperitoneum. Finally, after mobilization of distal sigmoid, on the lateral side of IMV, the descending colon was mobilized cephalad. Patients'preoperative baseline characteristics and intraoperative, postoperative complications were examined. RESULTS: All patients' potential "hernia rings" were closed successfully with our new technique. The median operative time was 195 min, and the median intraoperative blood loss was 55 ml (interquartile range 30-90). The total harvested lymph nodes was 13.0(range12-19). The median times to first flatus and liquid diet intake were both 3.0 days. The median number of postoperative hospital days was 8.0 days. One patient had an injury to marginal arterial arch, and after mobolization of splenic region, tension-free anastomosis was achieved. No other severe postoperative complications such as abdominal infection, anastomotic leakage, or bleeding were observed. CONCLUSIONS: This technique is both safe and effective for filling the mesenteric defect, potentially reducing the risk of internal hernia following laparoscopic NO.253 lymph node dissection and preservation of the left colic artery in rectal cancer surgeries.

Gumarontinib in patients with non-small-cell lung cancer harbouring MET exon 14 skipping mutations: a multicentre, single-arm, open-label, phase 1b/2 trial.

Background: Approximately 3-4% of patients with non-small-cell lung cancer (NSCLC) have MET exon 14 (METex14) skipping mutations. We report primary results from the phase 2 stage of a phase 1b/2 study of gumarontinib, a selective, potent, oral MET inhibitor, in patients with METex14 skipping mutation-positive (METex14-positive) NSCLC. Methods: The single-arm, multicentre, open-label, phase 2 stage of the GLORY study was conducted at 42 centres across China and Japan. Adults with locally advanced or metastatic METex14-positive NSCLC received oral gumarontinib 300 mg once daily in continuous 21-day cycles until disease progression, intolerable toxicity, or withdrawal of consent. Eligible patients had failed one or two prior lines of therapy (not including a MET inhibitor), were ineligible for/refused chemotherapy, and had no genetic alterations targetable with standard therapies. The primary endpoint was objective response rate in patients with a valid baseline tumour assessment, by blinded independent review. The study was registered at ClinicalTrials.gov (NCT04270591). Findings: Between Aug 2, 2019 and Apr 28, 2021, 84 patients were enrolled and received gumarontinib (median follow-up 13.5 months [IQR 8.7-17.1]), at data cut-off (Apr 28, 2022) five patients whose METex14 status could not be confirmed by a central laboratory were excluded from the efficacy analysis. The objective response rate was 66% (95% CI 54-76) overall (n = 79), 71% (95% CI 55-83) in treatment-naïve patients (n = 44), and 60% (95% CI 42-76) in previously-treated patients (n = 35). The most common treatment-related adverse events (any grade) were oedema (67/84 patients, 80%) and hypoalbuminuria (32/84, 38%). Grade ≥3 treatment-emergent adverse events occurred in 45 (54%) patients. Treatment-related adverse events leading to permanent discontinuation occurred in 8% (7/84) of patients. Interpretation: Gumarontinib monotherapy had durable antitumour activity with manageable toxicity in patients with locally advanced or metastatic METex14-positive NSCLC when used in first line or later. Funding: Haihe Biopharma Co., Ltd. Supported in part by grants from the National Science and Technology Major Project of China for "Clinical Research of Gumarontinib, a highly selective MET inhibitor" (2018ZX09711002-011-003); the National Natural Science Foundation of China (82030045 to S.L. and 82172633 to YF.Y); Shanghai Municipal Science & Technology Commission Research Project (19411950500 to S.L.); Shanghai Shenkang Action Plan (16CR3005A to S.L.) and Shanghai Chest Hospital Project of Collaborative Innovation (YJXT20190105 to S.L.).

Residues and dietary risk assessment of fluazinam in root mustard after field experiments.

The residue levels of fluazinam in root mustard were investigated by using a quick, easy, cheap, effective, rugged, and safe (QuEChERS) technique with ultra-performance liquid chromatography tandem mass spectrometry. Samples of leaf and root mustard were analyzed. The recoveries of fluazinam were 85.2-110.8% for leaf mustard with the coefficient of variation of 1.0-7.2%, and 88.8-93.3% for root mustard with the coefficient of variation of 1.9-12.4%. The suspension concentrate formulation of fluazinam was applied on root mustard at 262.5 g a.i. ha-1 in accordance with good agricultural practice (GAP), respectively. After the final application, the root mustard samples were collected at 3, 7, and 14 days. Fluazinam residues in root mustard were less than 0.01-0.493 mg kg-1. The dietary risk of fluazinam was predicted by comparing intake amounts with the toxicological data, namely acceptable daily intake (ADI) and acute reference dose (ARfD). The risk quotient (RQ) was 72.2-74.3%, for ordinary consumers, which showed negligible risk. According to the maximum residue limit (MRL) and dietary risk assessment, it is suggested that the pre-harvest interval (PHI) of 3 days; meanwhile, the MRL of 2 mg kg-1 was suggested for fluazinam in root mustard, which indicates that the dietary risk of fluazinam 500 g L-1 suspension concentrate (SC) with the recommended usage on root mustard is negligible. This study provided basic data on the use and safety of fluazinam in root mustard to help the Chinese government formulate a maximum residue level for fluazinam in root mustard.

A Novel Technique With Ileal Mesentery to Reconstruct the Pelvic Peritoneum After Pelvic Dissection With End Colostomy for Rectal Cancer.

BACKGROUND: After abdominoperineal resection, low anterior resection, and end colostomy for lower rectal cancer, it is necessary to reconstruct the pelvic peritoneum to avoid small bowel obstruction, perineal hernia, and radiation enteritis in patients for whom postoperative radiotherapy is planned. However, pelvic peritoneal closure is technically difficult in patients who lack enough peritoneum to cover the defect or have received neoadjuvant radiation and have a rigid pelvis. IMPACT OF INNOVATION: The impact of this innovation is to reconstruct the pelvic peritoneum with the distal ileal mesentery laparoscopically. TECHNOLOGY, MATERIALS AND METHODS: After removal of the tumor, the distal ileal mesentery was selected to completely cover the defect. Subsequently, suturing of the ileal mesentery to the posterior wall of the urinary bladder and all sides of the pelvic cavity was performed. Finally, the patients were returned to the headfirst supine position to ensure that there was no small bowel falling into the pelvic dead space. PRELIMINARY RESULTS: All surgical procedures were successfully performed laparoscopically from January 2019 to April 2021. No perineal complications or intestinal obstructions occurred during the follow-up period. CONCLUSIONS AND FUTURE DIRECTIONS: This novel technique was found to be safe and effective. Moreover, it provided an economical method for the reconstruction of the pelvic peritoneum using autologous material, which could preserve the small intestine in the abdomen to avoid related complications. Additional larger series of patients with longer follow-up are needed to validate the safety and feasibility of this method.

Laparoscopic Complete Mesocolic Excision with Central Vascular Ligation (CME + CVL) for Right-Sided Colon Cancer: A New "Superior Mesenteric Artery First" Approach.

PURPOSE: It remains a technical challenge to perform "superior mesenteric artery (SMA) first" approach for laparoscopic right hemicolectomy with complete mesocolon excision (CME) as the vascular anatomy of the right colon varies a lot, which may cause difficulty in early location of SMA and the risk of vascular damage during central vascular ligation (CVL). The purpose of this study was to describe a new "SMA first" approach for laparoscopic CME with CVL in right hemicolectomy with Treitz's ligament and ileocolic vascular pedicle as the anatomical landmarks for early identification of and exposure of SMA. METHODS: This procedure was performed on 21 patients with right colon cancer between March 2020 and August 2021. To start, the transverse mesocolon was retracted to expose the ligament of Treitz, and the pedicle of ileocolic vessels was anteriorly grasped. Next, the peritoneum near the right border of the ligament of Treitz was divided along the left side of SMA until the peritoneum below the ileocolic vessels. Next, the mesenteric lymphatic adipose tissue outside of the sheath of SMA was dissected from medial to lateral. Then, laparoscopic right hemicolectomy with complete mesocolic excision (CME) was performed. Patients' preoperative baseline characteristics and intraoperative and postoperative complications were examined. RESULTS: The median operative time was 180 min, and the median intraoperative blood loss was 50 ml (interquartile range 40-90). Chylous leakage occurred in four patients, and all the patients resolved with percutaneous drainage. The total harvested lymph nodes was 21.0 (range 16-27). The median times to first flatus and liquid diet intake were both 3.0 days. The median number of postoperative hospital days was 10.0 days. No severe postoperative complications, such as abdominal infection, anastomotic leakage, or bleeding, were observed. CONCLUSIONS: This new "SMA first" approach is safe and technically feasible for laparoscopic CME with CVL in right hemicolectomy.

Identification and evaluation of circulating small extracellular vesicle microRNAs as diagnostic biomarkers for patients with indeterminate pulmonary nodules.

BACKGROUND: The identification of indeterminate pulmonary nodules (IPNs) following a low-dose computed tomography (LDCT) is a major challenge for early diagnosis of lung cancer. The inadequate assessment of IPNs' malignancy risk results in a large number of unnecessary surgeries or an increased risk of cancer metastases. However, limited studies on non-invasive diagnosis of IPNs have been reported. METHODS: In this study, we identified and evaluated the diagnostic value of circulating small extracellular vesicle (sEV) microRNAs (miRNAs) in patients with IPNs that had been newly detected using LDCT scanning and were scheduled for surgery. Out of 459 recruited patients, 109 eligible patients with IPNs were enrolled in the training cohort (n = 47) and the test cohort (n = 62). An external cohort (n = 99) was used for validation. MiRNAs were extracted from plasma sEVs, and assessed using Small RNA sequencing. 490 lung adenocarcinoma samples and follow-up data were used to investigate the role of miRNAs in overall survival. RESULTS: A circulating sEV miRNA (CirsEV-miR) model was constructed from five differentially expressed miRNAs (DEMs), showing 0.920 AUC in the training cohort (n = 47), and further identified in the test cohort (n = 62) and in an external validation cohort (n = 99). Among five DEMs of the CirsEV-miR model, miR-101-3p and miR-150-5p were significantly associated with better overall survival (p = 0.0001 and p = 0.0069). The CirsEV-miR scores were calculated, which significantly correlated with IPNs diameters (p < 0.05), and were able to discriminate between benign and malignant PNs (diameter ≤ 1 cm). The expression patterns of sEV miRNAs in the benign, adenocarcinoma in situ/minimally invasive adenocarcinoma, and invasive adenocarcinoma subgroups were found to gradually change with the increase in aggressiveness for the first time. Among all DEMs of the three subgroups, five miRNAs (miR-30c-5p, miR-30e-5p, miR-500a-3p, miR-125a-5p, and miR-99a-5p) were also significantly associated with overall survival of lung adenocarcinoma patients. CONCLUSIONS: Our results indicate that the CirsEV-miR model could help distinguish between benign and malignant PNs, providing insights into the feasibility of circulating sEV miRNAs in diagnostic biomarker development. TRIAL REGISTRATION: Chinese Clinical Trials: ChiCTR1800019877. Registered 05 December 2018, https://www.chictr.org.cn/showproj.aspx?proj=31346 .

Laparoscopic right hemicolectomy with complete mesocolic excision plus D3 lymphadenectomy (CME + D3): a new medial approach for central vascular ligation.

Due to the high risk of vascular injuries, it remains a technical challenge and time-consuming procedure for surgeons to perform CME and D3 lymph node dissection in laparoscopic right hemicolectomy. To overcome this difficulty, we developed a novel method of the vessel's management for central vascular ligation (CVL). The key feature of this new approach focused on vascular dissection in two aspects. The first one was to expose the superior mesentery vein (SMV) and the branches of the superior mesentery artery (SMA) at their roots from left to right after dividing the peritoneum near the left border of SMV, which has the advantage of exposing SMV and controlling bleeding. The second was to selectively ligate the colic tributaries of gastrocolic trunk of Henle (GTH) after expanding its surrounding spaces. We named this technique the "new approach (NA)". Thirty-eight patients who underwent laparoscopic right hemicolectomy with the new approach (NA) were retrospectively analyzed and compared with data from 35 patients, who underwent the conventional medial approach (TA) performed by the same surgical team from April 2017 to March 2021. There was no significant difference between the two groups in baseline data (all p > 0.05). All 38 operations were completed with this procedure successfully. The NA approach was associated with a shorter operation time (190.5 min vs.215.5 min; P < 0.05) and a smaller blood loss (50 ml vs. 95 ml; P < 0.05) compared with the conventional approach. Two cases of vascular injuries occurred in the TA group and had been managed laparoscopically. The lymph nodes count (15 vs. 16; P > 0.05) was not significantly different; additionally, no difference was observed regarding anastomotic leakage (both n = 0) and postoperative complications (3/31 vs. 3/30; P > 0.05). No mortality was observed. NA is feasible and can be an optional method of vessel's management in laparoscopic CME and D3 lymphadenectomy for right-sided colon cancer.

Blood small extracellular vesicles derived miRNAs to differentiate pancreatic ductal adenocarcinoma from chronic pancreatitis.

BACKGROUND: The differential diagnosis of pancreatic ductal adenocarcinoma (PDAC) from chronic pancreatitis (CP) is clinically challenging due to a lack of minimally invasive diagnosis methods. MicroRNAs (miRNAs) derived from small extracellular vesicles (EVs) in the blood have been reported as a promising diagnosis biomarker for various types of cancer. However, blood small EV miRNA signatures and their diagnostic value to differentiate between PDAC and CP remain to be determined. METHODS: In this study, 107 patients with PDAC or CP were recruited, and 90 patients were finally enrolled for a training cohort (n = 48) and test cohort (n = 42). Small RNA sequencing was used to assess the expression of blood small EV miRNAs in these patients. RESULTS: The linear model from the differentially expressed blood small EV miR-95-3p divided by miR-26b-5p showed an average sensitivity of 84.1% and an average specificity of 96.6% to identify PDAC from CP in the training cohort and the test cohort, respectively. When the model was combined with serum carbohydrate antigen 19-9 (CA19-9), the average sensitivity increased to 96.5%, and the average specificity remained at 96.4% of both cohorts, which demonstrated the best performance of all the published biomarkers for distinguishing between PDAC and CP. The causal analysis performed using the Bayesian network demonstrated that miR-95-3p was associated with a "consequence" of "cancer" and miR-26b-5p as a "cause" of "pancreatitis." A subgroup analysis revealed that blood small EV miR-335-5p/miR-340-5p could predict metastases in both cohorts and was associated with an overall survival (p = 0.020). CONCLUSIONS: This study indicated that blood small EV miR-95-3p/miR-26b-5p and its combination with serum levels of CA19-9 could separate PDAC from CP, and miR-335-5p/miR-340-5p was identified to associate with PDAC metastasis and poor prognosis. These results suggested the potentiality of blood small EV miRNAs as differential diagnosis and metastases biomarkers of PDAC.

Genomic Landscape of Head and Neck Squamous Cell Carcinoma Across Different Anatomic Sites in Chinese Population.

BACKGROUND: The characteristics of head and neck squamous cell carcinoma (HNSCC) across different anatomic sites in the Chinese population have not been studied. To determine the genomic abnormalities underlying HNSCC across different anatomic sites, the alterations of selected cancer-related genes were evaluated. METHODS: Genomic DNA samples obtained from formalin-fixed, paraffin-embedded tissues were analyzed using targeted sequencing in a panel of 383 cancer-related genes to determine the genomic alterations. RESULTS: A total of 317 formalin-fixed, paraffin-embedded HNSCC specimens were collected, and a total of 2,156 protein-coding mutations, including 1,864 single nucleotide variants and 292 insertions and deletions, were identified across more than six different anatomic sites. Mutation loads were distinct across the anatomic sites. Larynx carcinoma was found with the highest mutation loads, whereas nasopharynx carcinoma showed the lowest mutation loads. A total of 1,110 gains and 775 losses were identified in the 317 specimens. Patients who had at least one clinically actionable alteration (levels 1-4 in OncoKB) were identified. One patient had an actionable alteration with level 1 evidence in OncoKB, TEX10-NTRK2 fusion, who may benefit from larotrectinib or entrectinib treatment. CONCLUSION: The genomic profiling of HNSCC using targeted sequencing can identify rational therapeutic candidate genes suitable for the treatment of the HNSCCs.

Benchmarking the Human Leukocyte Antigen Typing Performance of Three Assays and Seven Next-Generation Sequencing-Based Algorithms.

With the great progress made recently in next generation sequencing (NGS) technology, sequencing accuracy and throughput have increased, while the cost for data has decreased. Various human leukocyte antigen (HLA) typing algorithms and assays have been developed and have begun to be used in clinical practice. In this study, we compared the HLA typing performance of three HLA assays and seven NGS-based HLA algorithms and assessed the impact of sequencing depth and length on HLA typing accuracy based on 24 benchmarked samples. The algorithms HISAT-genotype and HLA-HD showed the highest accuracy at both the first field and the second field resolution, followed by HLAscan. Our internal capture-based HLA assay showed comparable performance with whole exome sequencing (WES). We found that the minimal depth was 100X for HISAT-genotype and HLA-HD to obtain more than 90% accuracy at the third field level. The top three algorithms were quite robust to the change of read length. Thus, we recommend using HISAT-genotype and HLA-HD for NGS-based HLA genotyping because of their higher accuracy and robustness to read length. We propose that a minimal sequence depth for obtaining more than 90% HLA typing accuracy at the third field level is 100X. Besides, targeting capture-based NGS HLA typing may be more suitable than WES in clinical practice due to its lower sequencing cost and higher HLA sequencing depth.

Establishment and characterization of 38 novel patient-derived primary cancer cell lines using multi-region sampling revealing intra-tumor heterogeneity of gallbladder carcinoma.

Gallbladder carcinoma (GBC) is a lethal biliary tract malignant neoplasm. Patient-derived primary cancer cell lines (PDPCs) are appropriate models to explore biological characteristics and potential therapeutics; however, there is a lack of PDPCs in GBC. In this study, we aimed to establish and characterize the GBC PDPCs, and further investigated the intra-tumor heterogeneity (ITH). Multi-region sampling (3-9 regions) of the operable tumor tissue samples was used to establish PDPCs. Short tandem repeat genotyping for cell authentication and karyotyping was performed, followed by whole-exome sequencing and RNA sequencing to assess the ITH at the genetic and transcriptional levels, respectively. Thirty-eight PDPCs were successfully established from seven GBC patients and characterized. ITH was observed with a median of 38.3% mutations being heterogeneous (range, 26.6-59.4%) across all patients. Similar with other tumor types, TP53 mutations were always truncal. In addition, there were three genes, KMT2C, CDKN2A, and ARID1A, with truncal mutations in at least two patients. A median of 370 differentially expressed genes (DEGs) was identified per patient. Distinct expression patterns were observed between major histocompatibility complex (MHC) class I and II genes. We found the expression of MHC class II genes in the PDPC samples was closely regulated by CIITA, while that of MHC class I genes were not correlated with CIITA expression. The PDPCs established from GBC patients can serve as novel in vitro models to identify the ITH, which may pave a crucial molecular foundation for enhanced understanding of tumorigenesis and progression.

Predicted CD4+ T cell infiltration levels could indicate better overall survival in sarcoma patients.

OBJECTIVE: The role of tumor-infiltrating lymphocytes (TILs) has not yet been characterized in sarcomas. The aim of this bioinformatics study was to explore the effect of TILs on sarcoma survival and genome alterations. METHODS: Whole-exome sequencing, transcriptome sequencing, and survival data of sarcoma were obtained from The Cancer Genome Atlas. Immune infiltration scores were calculated using the Tumor Immune Estimation Resource. Potential associations between abundance of infiltrating TILs and survival or genome alterations were examined. RESULTS: Levels of CD4+ T cell infiltration were associated with overall survival of patients with pan-sarcomas, and higher CD4+ T cell infiltration levels were associated with better survival. Somatic copy number alterations, rather than mutations, were found to correlate with CD4+ T cell infiltration levels. CONCLUSIONS: This data mining study indicated that CD4+ T cell infiltration levels predicted from RNA sequencing could predict sarcoma prognosis, and higher levels of CD4+ T cells infiltration indicated a better chance of survival.

Determination of thiamethoxam and its metabolite clothianidin residue and dissipation in cowpea by QuEChERS combining with ultrahigh-performance liquid chromatography-tandem mass spectrometry.

The dissipation and residue levels of thiamethoxam and its metabolite clothianidin in cowpea were investigated under field conditions. Samples of cowpea were analyzed using a QuEChERS technique with ultra-performance liquid chromatography tandem mass spectrometry. The recoveries were 86.5-118.9% for thiamethoxam and 75.6-104.1% for clothianidin, with the coefficient of variation of < 13%. The water dispersible granule formulation of thiamethoxam was applied on cowpea at 30 and 45 g active ingredient ha-1 in accordance with good agricultural practice. The half-life of thiamethoxam in cowpea was 0.8-1.6 days. The cowpea samples were gathered at 3, 7, and 10 days after the last application, and the residues of thiamethoxam in cowpea were < 0.005-0.054 mg kg-1, while those of clothianidin were < 0.005-0.008 mg kg-1. The final residues of thiamethoxam and clothianidin were below the European Union (EU) maximum residue level (0.3 mg kg-1 for thiamethoxam; 0.2 mg kg-1 for clothianidin) in cowpea after a preharvest interval (PHI) of 7 days. This study provided basic data on the use and safety of thiamethoxam and clothianidin in cowpea to help the Chinese government formulate a maximum residue level for thiamethoxam in cowpea.

Development and Validation of an RNA Sequencing Assay for Gene Fusion Detection in Formalin-Fixed, Paraffin-Embedded Tumors.

RNA sequencing (RNA-seq) is a well-validated tool for detecting gene fusions in fresh-frozen tumors; however, RNA-seq is much more challenging to use with formalin-fixed, paraffin-embedded (FFPE) tumor samples. We evaluated the performance of RNA-seq to detect gene fusions in clinical FFPE tumor samples. Our assay identified all 15 spiked-in NTRK fusions from RNA reference material and six known fusions from five cancer cell lines. Limit of detection for the assay was assessed with a series of dilutions of RNA from the cell line H2228. These fusions can be detected when the dilution is down to 10%. Good intra-assay and interassay reproducibility was observed in three specimens. For clinical validation, the assay detected 10 of 12 fusions initially identified by a DNA panel (covering 23 gene fusions) in clinical specimens (83.3% sensitivity), whereas one fusion (MET fusion) was identified in another 34 fusion-negative tumor specimens as determined by the DNA panel (negative prediction value of 94.3%). This MET fusion was confirmed by RT-PCR and Sanger sequencing, which found that this is a false-negative result for the DNA panel. The assay also identified 26 extra fusions not covered by the DNA panel, 20 (76.9%) of which were validated by RT-PCR and Sanger sequencing. Therefore, this RNA assay has reasonable performance and could complement DNA-based next-generation sequencing assays.

A New Medial-to-Lateral Approach for Laparoscopic D3 Lymphadenectomy plus Complete Mesocolic Excision (D3 + CME) for Right-Sided Colon Cancer.

BACKGROUND: D3 lymphadenectomy is important for accurate staging and provides long-term benefits, especially for T3-4/N + tumors.1,2 Both D3 lymphadenectomy as well as complete mesocolic excision (CME) require central ligation of vessels at their origins to ensure radical resection.3 Currently, superior mesentery vein (SMV) is navigated by ileocolic vessels while its sheath is dissected stepwise from caudal to cranial.4-6 This report describes a new medial-to-lateral approach for laparoscopic right hemicolectomy with D3 + CME. METHODS: The patient was a 47-year-old man with diagnosis of hepatic flexure cancer (cT4N1M0). First, the pedicle of the middle colic vessels and ileocolic vessels were both grasped, then the sheath of SMV was dissected at its left side as there are fewer blood vessels entering here compared with its right side. Second, after identification of middle colic artery (MCA), SMV was skeletonized from medial to lateral and no. 213 and no. 203 lymph nodes were dissected. Third, MCA and ileocolic vein and artery (ICV and ICA) were ligated at their roots. After separating the transverse mesocolon from the duodenum, the branches of the Henle trunk were exposed and no. 223 lymph nodes were dissected. Accessory right colic vein, right colic vein, and middle colic vein were ligated respectively. Fourth, the ascending mesocolon was separated from the retroperitoneal tissues through the front side of Toldt's fascia, the mesocolon was mobilized completely, and the tumor was removed en bloc. RESULTS: The operation time was 175 min, with estimated blood loss of 50 ml. The patient recovered well without bleeding complications and was discharged on postoperative day 7. Histology revealed moderately differentiated adenocarcinoma with 5 of 24 lymph nodes involved (pT3N2M0). CONCLUSIONS: The medial-to-lateral approach presented in the video might be helpful for standardization of laparoscopic D3 + CME for right-sided colon cancer.

Blood exosomal micro ribonucleic acid profiling reveals the complexity of hepatocellular carcinoma and identifies potential biomarkers for differential diagnosis.

BACKGROUND: Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related deaths worldwide, but there is a shortage of effective biomarkers for its diagnosis. AIM: To explore blood exosomal micro ribonucleic acids (miRNAs) as potential biomarkers for HCC diagnosis. RESULTS: The principal component analysis suggested that daily alcohol consumption could alter the blood exosomal miRNA profiles of hepatitis B virus positive non-HCC patients through miR-3168 and miR-223-3p. The miRNA profiles also revealed the tumor stages of HCC patients. High expression of miR-455-5p and miR-30c-5p, which significantly correlated with better overall survival in tumor tissues, could also be detected in blood exosomes. Two pairs of miRNAs (miR-584-5p/miR-106-3p and miR-628-3p/miR-941) showed a 94.1% sensitivity and 68.4% specificity to differentiate HCC patients from non-HCC patients. The specificity of the combination was substantially influenced by alcohol consumption habits. CONCLUSION: This study suggested that blood exosomal miRNAs can be used as new non-invasive diagnostic tools for HCC. However, their accuracy could be affected by tumor stage and alcohol consumption habits.

Mechanisms of Increased Indoxacarb Toxicity in Methoxyfenozide-Resistant Cotton Bollworm Helicoverpa armigera (Lepidoptera: Noctuidae).

Indoxacarb is an important insecticide for the selective control of Helicoverpa armigera. It can be bioactivated to the more effective N-decarbomethoxylated indoxacarb (DCJW) by esterases in pests. It was observed that both field and laboratory selected populations of H. armigera showed negative cross-resistance between indoxacarb and methoxyfenozide. The Handan population exhibited moderate resistance to indoxacarb, but was susceptible to methoxyfenozide; the Baoding and Yishui populations exhibited moderate resistance to methoxyfenozide, but they were susceptible to indoxacarb. Moreover, the toxicity of indoxacarb was enhanced 1.83-fold in the laboratory methoxyfenozide-resistant H. armigera, and susceptibility to methoxyfenozide was increased 2.81-fold in the laboratory indoxacarb-resistant H. armigera. In vivo, DCJW concentrations in the susceptible and methoxyfenozide-selected (laboratory methoxyfenozide-resistant) populations were 4.59- and 4.31-fold greater than in the indoxacarb-resistant Handan population 1 h after dosing. After 2 h, the highest concentrations of DCJW and indoxacarb appeared in the methoxyfenozide-selected population. Meanwhile, increased carboxyl esterase (CarE) and decreased glutathione S-transferase (GST) activities were observed in the methoxyfenozide-selected population. However, the indoxacarb-selected (laboratory indoxacarb-resistant) and Handan populations showed a higher disappearance of indoxacarb and DCJW, and the activity of cytochrome P450 mono-oxygenase in these populations were significantly increased. This study showed that the improved toxicity of indoxacarb, as observed in the methoxyfenozide-selected H. armigera, was correlated with increased CarE activity, decreased GST activity, and the in vivo accumulation of indoxacarb and DCJW. The significantly increased cytochrome P450 activity and higher disappearance of indoxacarb and DCJW in indoxacarb-resistant H. armigera resulted in the decreased toxicity of indoxacarb.

Targeted deep sequencing contributes to guiding personalized targeted therapy for advanced biliary tract cancer patients with non­radical resection: A real­world study.

Targeted therapy based on specific genetic alterations has been proven to be an effective treatment for various types of cancer. In the present study, we aimed to explore the efficacy of personalized targeted therapy guided by targeted deep sequencing for patients with advanced biliary tract cancer (BTC) after non­radical resection. Targeted deep sequencing was performed on 49 patients with BTC, to whom biologic agents were recommended. Among 32 patients with stage IV and R2 resection (a non­radical resection), 21 patients underwent conventional chemotherapy (mGEMOX), while the remaining 11 patients received a personalized targeted agent. The genomic landscape of the 49 patients with BTC was determined and the results showed that genetic alterations were enriched in the ERBB family and cell cycle pathway. After a median follow­up of 12 months, the 11 BTC patients with personalized targeted therapy showed a median progression­free survival (PFS) of 4.5 months (2.5­20.5 months), a median overall survival (OS) of 12.9 months (4.7­24.8 months) and a disease control rate (DCR) of 63.6%. In the other 21 BTC patients, who were undergoing conventional chemotherapy, the BTC patients had a median PFS of 1.5 months (0.5­11.6 months), a median OS of 4.1 months (1.3­18.4 months), and a DCR of 33.3%. In addition, 36.4% of the patients in the personalized targeted therapy group experienced grade >2 treatment­related toxicity vs. 19.0% of patients in the conventional chemotherapy group. This real­world study suggests that targeted deep sequencing contributes to the guidance of personalized targeted therapy based on individual actionable mutations, which may benefit advanced BTC patients undergoing non­radical resection.

A Modified Side-to-Side Anastomosis Using a Circular Stapler Reduces Anastomotic Leakage in Colonic Surgery.

Background. Anastomotic leakage (AL) remains one of the serious complications after colonic surgery. Method. A prospective interventional study to assess a modified technique of creating the ileocolic, colic-colic, and colorectal side-to-side anastomoses using a circular stapler. The primary endpoint was to evaluate the safety and efficacy of this technique in the reduction of AL. Computed tomography scan was performed when AL was clinically suspected. Result. One hundred and forty-five patients who underwent colonic resection between January 2015 and August 2018 were included. One patient underwent surgery for severe inflammatory bowel disease, and the others underwent surgery for colonic cancer. The procedures were open surgeries, including right hemicolectomy (n = 79 [54.5%]), left hemicolectomy (n = 29 [20%]), sigmoidectomy (n = 30 [20.7%]), and transverse colectomy (n = 7 [4.8%]). In 23 patients with ascending colonic obstruction, emergency right colectomy with primary anastomosis was performed. Two surgeons performed the operations (52.4% and 47.6%, respectively), and intraoperative blood loss was 50 to 100 mL. The operative time was 160 to 240 minutes. There was no mortality postoperatively, and 26 (17.9%) patients developed complications. One patient who underwent transverse colonic cancer resection developed a clinical AL (0.7%). After ileostomy, the patient was discharged with no other serious complication. The median of postoperative hospital stay was 8 days (range = 5-18 days). Conclusion. This modified technique is a safe and efficient method for anastomotic configuration in colonic surgery.