Increased coexpression of PD-L1 and IDO1 is associated with poor overall survival in patients with NK/T-cell lymphoma.

Immunotherapy with programmed cell death 1 ligand 1 (PD-L1) blockade was effective in patients with NK/T-cell lymphoma. In addition to PD-L1, indoleamine 2,3-dioxygenase-1 (IDO1) is one of the most promising immunotherapeutic targets. High proportions of PD-L1 and IDO1 proteins were observed by immunohistochemistry (IHC) from 230 newly diagnosed patients with NK/T lymphoma with tissue samples from three cancer centers and were associated with poor overall survival (OS) in patients with NK/T lymphoma. Importantly, the coexpression of PD-L1 and IDO1 was related to poor OS and short restricted mean survival time in patients with NK/T lymphoma and was an independent prognostic factor in the training cohorts, and which was also validated in 58 NK/T lymphoma patients (GSE90597). Moreover, a nomogram model constructed with PD-L1 and IDO1 expression together with age could provide concise and precise predictions of OS rates and median survival time. The high-risk group in the nomogram model had a positive correlation with CD4 + T-cell infiltration in the validation cohort, as did the immunosuppressive factor level. Therefore, high PD-L1 and IDO1 expression was associated with poor OS in patients with NK/T lymphoma. PD-L1 and IDO1 might be potential targets for future immune checkpoint blockade (ICB) therapy for NK/T lymphoma.

Research progress of extracellular vesicles in the treatment of ovarian diseases (Review).

The ovary is an essential reproductive organ in the female organism and its development seriously affects the physical and mental health of female patients. Ovarian diseases include ovarian cancer, premature ovarian insufficiency (POI) and polycystic ovary syndrome (PCOS). Women should pay attention to the most effective treatments for this condition because it is one of the most prevalent gynecological illnesses at present. Extracellular vesicles (EVs), which are smaller vesicles that mediate the exchange of cellular information, include the three categories of exosomes, microvesicles and apoptotic bodies. They are able to transport proteins, RNA and other substances to adjacent or distal cells, thus allowing cellular and tissue homeostasis to be maintained. Numerous previous studies have revealed that EVs are crucial for the treatment of ovarian diseases. They are known to transport its contents to ovarian cancer cells as well as other ovarian cells such as granulosa cells, affecting the development of ovarian disease processes. Therefore, this extracellular vesicle may be involved as a target in the therapeutic process of ovarian disease and may have great potential in the treatment of ovarian disease. In the present review, the role of EVs in the development of three ovarian diseases, including ovarian cancer, POI and PCOS, was mainly summarizes. It is expected that this will provide some theoretical support for the treatment of ovarian disease.

Prognostic value of hyperthermic intraperitoneal chemotherapy in gastric cancer with synchronous peritoneal metastases: a real-world retrospective study.

PURPOSE: Peritoneal metastasis in gastric cancer (GC) is a late-stage condition with a poor prognosis. Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a popular treatment for peritoneal metastases. Here, we aim to investigate the real-world application and efficacy of HIPEC alone for GC patients with synchronous peritoneal metastases. METHODS: We conducted a retrospective analysis on GC patients with synchronous peritoneal metastasis at the Sixth Affiliated Hospital of Sun Yat-sen University between January 2011 and December 2022. Survival analyses and Cox regression models were performed based on overall survival (OS) and cancer-specific survival (CSS), and subgroup analysis was used to determine the prognostic value of HIPEC across different treatment. RESULTS: We enrolled 250 patients, of whom 120 (48%) received HIPEC while 130 (52%) did not. HIPEC showed no survival benefit for GC patients (P = 0.220 for OS and P = 0.370 for CSS). However, subgroup analysis found that HIPEC can only improve OS and CSS when combined with primary tumor resection (P = 0.034 for OS and P = 0.036 for CSS). Moreover, survival analyses also demonstrated that HIPEC independently improved OS (HR for OS = 0.58, 95% CI 0.37-0.92, P = 0.020) and CSS (HR for CSS = 0.58, 95% CI 0.37-0.93, P = 0.024) for patients who underwent primary site resection, but not for those who did not. CONCLUSION: HIPEC can improve survival in GC patients with synchronous peritoneal metastases who have primary tumor resection, but not in those without primary tumor resection.

Mechanisms for enhanced lignin humification with reduced organic matter loss by goethite in biogas residue composting.

In this study, effects of three iron (oxyhydr)oxides on the biogas residue composting, i.e., composting with goethite (CFe1), hematite (CFe2) or magnetite (CFe3), were investigated. Results showed that composting performance of CFe1 was much better than those of CFe2 and CFe3. Addition of goethite increased temperature of CFe1 and enhanced lignin humification. More than 31.49% of Fe(III) in goethite was reduced to amorphous Fe(II) during the composting, suggesting that goethite worked as electron acceptor for microbial metabolism and heat generation. The functional bacteria Chloroflexi and Actinobacteria, and genes encoding key enzymes (AA1 family), which play essential roles in humification of lignin, were enriched in CFe1. Besides, goethite reduced 10.96% organic matter (OM) loss probably by increasing the molecular size and aggregation of OM for its protection during the composting. This study shows that adding goethite is an efficient strategy to enhancing the humification of lignin-rich biowaste.

Elderly patients with stage II gastric cancer do not benefit from adjuvant chemotherapy.

BACKGROUND: With the aging of the population, the burden of elderly gastric cancer (EGC) increases worldwide. However, there is no consensus on the definition of EGC and the efficacy of adjuvant chemotherapy in patients with stage II EGC. Here, we investigated the effectiveness of adjuvant chemotherapy in defined EGC patients. METHODS: We enrolled 5762 gastric cancer patients of three independent cohorts from the Sixth Affiliated Hospital of Sun Yat-sen University (local), the Surveillance, Epidemiology, and End Results (SEER), and the Asian Cancer Research Group (ACRG). The optimal age cutoff for EGC was determined using the K-adaptive partitioning algorithm. The defined EGC group and the efficacy of adjuvant chemotherapy for them were confirmed by Cox regression and Kaplan-Meier survival analyses. Furthermore, gene set variation analyses (GSVA) were performed to reveal pathway enrichment between groups. RESULTS: The optimal age partition value for EGC patients was 75. In the local, SEER, and ACRG cohorts, the EGC group exhibited significantly worse overall survival and cancer-specific survival than the non-EGC group (P < 0.05) and was an independent risk factor. Stratified analyses based on chemotherapy showed that EGC patients derived little benefit from adjuvant chemotherapy. Furthermore, GSVA analysis revealed the activation of DNA repair-related pathways and downregulation of the p53 pathway, which may partially contribute to the observed findings. CONCLUSION: In this retrospective, international multi-center study, 75 years old was identified as the optimal age cutoff for EGC definition, and adjuvant chemotherapy proved to be unbeneficial for stage II EGC patients.

Research progress of the Fanconi anemia pathway and premature ovarian insufficiency†.

The Fanconi anemia pathway is a key pathway involved in the repair of deoxyribonucleic acidinterstrand crosslinking damage, which chiefly includes the following four modules: lesion recognition, Fanconi anemia core complex recruitment, FANCD2-FANCI complex monoubiquitination, and downstream events (nucleolytic incision, translesion synthesis, and homologous recombination). Mutations or deletions of multiple Fanconi anemia genes in this pathway can damage the interstrand crosslinking repair pathway and disrupt primordial germ cell development and oocyte meiosis, thereby leading to abnormal follicular development. Premature ovarian insufficiency is a gynecological clinical syndrome characterized by amenorrhea and decreased fertility due to decreased oocyte pool, accelerated follicle atresia, and loss of ovarian function in women <40 years old. Furthermore, in recent years, several studies have detected mutations in the Fanconi anemia gene in patients with premature ovarian insufficiency. In addition, some patients with Fanconi anemia exhibit symptoms of premature ovarian insufficiency and infertility. The Fanconi anemia pathway and premature ovarian insufficiency are closely associated.

Luteolin regulates the distribution and function of organelles by controlling SIRT1 activity during postovulatory oocyte aging.

The quality of oocytes determines their development competence, which will be rapidly lost if the oocytes are not fertilized at the proper time after ovulation. SIRT1, one of the sirtuin family members, has been proven to protect the quality of oocytes during postovulatory oocyte aging. However, evidence of the effect of SIRT1 on the activity of organelles including the mitochondria, the endoplasmic reticulum (ER), the Golgi apparatus, and the lysosomes in postovulatory aging oocyte is lacking. In this study, we investigated the distribution and function of organelles in postovulatory aged oocytes and discovered abnormalities. Luteolin, which is a natural flavonoid contained in vegetables and fruits, is an activator of SIRT1. When the oocytes were treated with luteolin, the abnormal distribution of mitochondria, ER, and Golgi complex were restored during postovulatory oocyte aging. The ER stress protein GRP78 and the lysosome protein LAMP1 increased, while the mitochondrial membrane potential and the Golgi complex protein GOLPH3 decreased in aged oocytes, and these were restored by luteolin treatment. EX-527, an inhibitor of SIRT1, disrupted the luteolin-mediated normal distribution and function of mitochondria, ER, Golgi apparatus, and lysosomes. In conclusion, we demonstrate that luteolin regulates the distribution and function of mitochondria, ER, Golgi apparatus, and lysosomes during postovulatory oocyte aging by activating SIRT1.

Rapid synthesis of Palladium-Platinum-Nickel ultrathin porous nanosheets with high catalytic performance for alcohol electrooxidation.

Bimetallic two-dimensional (2D) nanomaterials are widely used in electrocatalysis owing to their unique physicochemical properties, while trimetallic 2D materials of porous structures with large surface area are rarely reported. In this paper, a one-pot hydrothermal synthesis of ternary ultra-thin PdPtNi nanosheets is developed. By adjusting the volume ratio of the mixed solvents, PdPtNi with porous nanosheets (PNSs) and ultrathin nanosheets (UNSs) was prepared. The growth mechanism of PNSs was investigated through a series of control experiments. Notably, thanks to the high atom utilization efficiency and fast electron transfer, the PdPtNi PNSs have remarkable activity of methanol oxidation reaction (MOR) and ethanol oxidation reaction (EOR). The mass activities of the well-tuned PdPtNi PNSs for MOR and EOR were 6.21 A mg-1 and 5.12 A mg-1, respectively, much higher than those of commercial Pt/C and Pd/C. In addition, after durability test, the PdPtNi PNSs exhibited desirable stability with the highest retained current density. Therefore, this work provides a significant guidance for designing and synthesizing a new 2D material with excellent catalytic performance toward direct fuel cells applications.

Potential Therapeutic Options for Premature Ovarian Insufficiency: Experimental and Clinical Evidence.

Premature ovarian insufficiency (POI) is a condition in which a woman experiences premature decline in ovarian function before the age of 40 years, manifested by menstrual disorders, decreased fertility, and possibly postmenopausal symptoms such as insomnia, hot flashes, and osteoporosis, and is one of the predominant clinical syndromes leading to female infertility. Genetic, immunologic, iatrogenic and other factors, alone or in combination, have been reported to trigger POI, yet the etiology remains unknown in most cases. The main methods currently used clinically to ameliorate menopausal symptoms due to hypoestrogenemia in POI patients are hormone replacement therapy, while the primary methods available to address infertility in POI patients are oocyte donation and cryopreservation techniques, both of which have limitations to some degree. In recent years, researchers have continued to explore more efficient and safe therapies, and have achieved impressive results in preclinical trials. In this article, we will mainly review the three most popular therapies and their related signaling pathways published in the past ten years, with the aim of providing ideas for clinical applications.

Induction of filopodia formation by α-Actinin-2 via RelA with a feedforward activation loop promoting overt bone marrow metastasis of gastric cancer.

BACKGROUND: Bone marrow metastasis (BMM) is underestimated in gastric cancer (GC). GC with BMM frequently complicate critical hematological abnormalities like diffused intravascular coagulation and microangiopathic hemolytic anemia, which constitute a highly aggressive GC (HAGC) subtype. HAGC present a very poor prognosis with peculiar clinical and pathological features when compared with not otherwise specified advanced GC (NAGC). But the molecular mechanisms underlying BMM from GC remain rudimentary. METHODS: The transcriptomic difference between HAGC and NAGC were analyzed. Genes that were specifically upregulated in HAGC were identified, and their effect on cell migration and invasion was studied. The function of ACTN2 gene were confirmed by GC cell lines, bone-metastatic animal model and patients' tissues. Furthermore, the molecular mechanism of ACTN2 derived-BMM was explored by multiple immunofluorescence staining, western blot, chromatin immunoprecipitation, and luciferase reporter assays. RESULTS: We elucidated the key mechanisms of BMM depending on the transcriptomic difference between HAGC and NAGC. Five genes specifically upregulated in HAGC were assessed their effect on cell migration and invasion. The ACTN2 gene encoding protein α-Actinin-2 was detected enhanced the metastatic capability and induced BMM of GC cells in mouse models. Mechanically, α-Actinin-2 was involved in filopodia formation where it promoted the Actin filament cross-linking by replacing α-Actinin-1 to form α-Actinin-2:α-Actinin-4 complexes in GC cells. Moreover, NF-κB subunit RelA and α-Actinin-2 formed heterotrimers in the nuclei of GC cells. As a direct target of RelA:α-Actinin-2 heterotrimers, the ACTN2 gene was a positive auto-regulatory loop for α-Actinin-2 expression. CONCLUSIONS: We demonstrated a link between filopodia, BMM and ACTN2 activation, where a feedforward activation loop between ACTN2 and RelA is established via actin in response to distant metastasis. Given the novel filopodia formation function and the new mechanism of BMM in GC, we propose ACTN2 as a druggable molecular vulnerability that may provide potential therapeutic benefit against BMM of GC.

Alkalization-induced disintegration increased redox activity of solid humic acids and its soil biogeochemical implications.

Solid humic acids (HAsolid) plays a significant role in maintaining soil ecosystem services, especially in alkaline soil. The unique chemical structures and electrochemical properties are the cores that HAsolid works. In this study, the alkalization-induced variations of particle morphology, functional groups and redox activity of HAsolid were investigated and its soil biogeochemical implications were discussed. Atomic force microscopy (AFM) deflection images and zeta potential results showed that alkalization induced disintegration of HAsolid, with particle size reducing to 200 nm when pH value reached 10.0. This result suggested that HAsolid could exist in alkaline soil. AFM-IR along with fluorescence intensity of HAsolid at different pH further proved that the supramolecular aggregation of HAsolid became loose and dispersive with more redox-active functional groups exposure after alkalization, which could lead to HAsolid susceptible to degradation in alkaline soil. Conductivity of HAsolid decreased 42.86 % when pH increased from 5.0 to 10.0, while electron exchange capacity (EEC) of HAsolid increased 45.30 %, indicating the increase of redox activity of HAsolid. Increase of redox activity of HAsolid by alkalization-induced disintegration not only can accelerate organic pollutant degradation via enhancing microbial co-metabolism, but also speed up the organic carbon loss. This study contributes to a better understanding of the role of HAsolid in organic carbon stocks and fluxes of alkaline soils and has great implications for soil biogeochemical process.

Affinity-based alleviation of dissolved organic matter (DOM) on tetracycline toxicity to photosynthesis of green algae Chlorella vulgaris: roles of hydrophilic and hydrophobic DOM.

The environmental fate and toxic effects of antibiotics such as tetracycline (TC) could be influenced by the ubiquitous dissolved organic matter (DOM). However, DOM from different origins has different hydrophilic and hydrophobic properties. It is still unknown the effects of hydrophilic and hydrophobic DOM on the toxic effect of TC. In this study, DOM with hydrophilicity and hydrophobicity was separated and used to investigate their roles in affecting TC toxicity to the photosynthesis of green algae Chlorella vulgaris. Results showed that 10 mg L-1 TC inhibited the efficiency of photosystem II (PSII) of C. vulgaris using light by hindering electron transfer from QA- to QB/QB-, and the O2 release rate of C. vulgaris decreased by a third after 12-h treatment of 10 mg L-1 TC, while both hydrophilic and hydrophobic DOM (20 mg L-1 TOC) alleviated TC toxicity to the photosynthesis of C. vulgaris. In the presence of hydrophilic or hydrophobic DOM, stable complex of TC-hydrophilic DOM or TC-hydrophobic DOM was formed immediately, due to the good affinity of both DOM for TC. Fourier transform infrared spectroscopy result showed that both hydrophilic and hydrophobic DOM could reduce C=O in TC to C-O, and isothermal titration calorimetry result suggested that reactions of both DOM with TC were exothermic (△H < 0) and spontaneous (△G < 0). Thereinto, the reaction constant (Ka) of TC reacting with hydrophobic DOM (Ka=9.70) was higher than that with hydrophilic DOM (Ka=8.93), indicating hydrophobic DOM with more chemical binding sites and accessible fractions for TC. The present study suggests that DOM, especially the hydrophobic DOM, is an important consideration in the environmental impact assessment of antibiotics.

Electrochemical properties of humic acid and its novel applications: A tip of the iceberg.

The widely existed humic acid (HA) with abundant redox-active groups has been considered to play an important role in biogeochemistry in sediments and soils. Recent studies reported that HA showed great performance in terms of electron transfer capacity (up to HAEDC = 94 mmol e-/mol C, HAEAC = 42 mmol e-/mol C). Since HA is widely available, inexpensive and environmentally friendly, the electrochemistry of HA has been explored to apply in many fields, such as environmental remediation, detection sensor and energy storage. Whereas, these prospective applications of HA and their electrochemical principles were lack of a comprehensive summary. In this review, the electrochemical properties and the prospective electrochemical applications of HA were summarized. Simultaneously, the existing problems like shortages of traditional electrochemical characterization of HA, and future research directions about HA electrochemistry were prospected. This review provides a deeper understanding of HA electrochemistry, and also inspires ideas for environmental remediation, detection sensor and energy storage by exploring the potential application values of HA.

Effects of PFOS at ng/L levels on photostability of extracellular polymeric substances under solar irradiation by fluorescence and infrared spectroscopy.

The ubiquitous EPS (extracellular polymeric substances), as a type of dissolved organic carbon, plays a key role in carbon cycling in water environment. When EPS meet the omnipresent PFOS (perfluorooctane sulfonate), they must interact with each other and exert profound effect on behavior and fate of both, which is still not well known. We hypothesized that the highly persistent PFOS at real environmental levels may significantly influence behavior of EPS under solar irradiation which may retard carbon turnover. In this study, 3D-EEM fluorescence spectroscopy and FTIR spectroscopy were used to probe responses of composition and structure of EPS under solar irradiation in the absence and presence of PFOS (5-500 ng/L). The experimental results showed that PFOS at ng/L levels significantly affected responses of EPS to sunlight irradiation and the effects were dependent on the components in EPS. Photostability of humic-like substances was significantly increased in the presence of PFOS; Degradation and unfolding of proteins induced by solar light were reduced by PFOS. In addition, degradation of both hydrophilic and hydrophobic functional groups by sunlight was inhibited by PFOS. The novel findings provide new insights for assessing the environmental behavior of EPS and PFOS and understanding the effect of PFOS on carbon cycling in water environments.

Protective-mechanism-exclusive thermal stability modes of soil organic matter: Novel implication for wildfire effect on soil organic carbon.

Stability of soil organic matter (SOM) is considered to be governed by different protection mechanisms including physical protection (PP), biochemical protection (BCP) and physical plus biochemical protection (PBCP). The thermostability of SOM protected by different mechanisms is unknown, despite its importance for understanding the stability of soil organic carbon (SOC) under frequently occurred wildfires. In this study, we reported for the first time that pyrolysis of SOM under different protection mechanisms in three types of soil (shrub soil, cultivated soil, and meadow soil) followed their own distinct modes regardless of soil type. Specifically, SOM-PP, SOM-PBCP and SOM-BCP from each type of soil were pyrolyzed in the double-step-shape, the mono-step-shape and the linear modes, respectively, when they were heated from room temperature to 800 °C by thermogravimeter. There were more thermolabile organic fractions (pyrolysis temperature < 200 °C) enriched in SOM-PP, while more thermostable organic fractions enriched in SOM-BCP and SOM-PBCP. These findings are of great importance for deeper insight into stability responses of SOM with different occurrence of wildfire.

Environmental concentration PFOS as a light shield for lake exopolymers against photodegradation by formation of sandwiched supramolecular nanostructures.

EPS (exopolymers) play a central role in global carbon cycling due to huger amount in aquatic environment, and PFOS (Perfluorooctane sulfonate) is also ubiquitous and persistent pollutant. Whether and how can PFOS of environmental concentrations affect behavior and fate of EPS was unclear. In this study, for the first time interaction between lake EPS and PFOS of environmental concentrations was visually probed by AFM-IR technique. It was found that EPS could effectively trap PFOS and the latter of environmental concentrations could trigger nanoscale reassembly of the former. Sandwiched PFOS-EPS nanostructures were formed via supramolecular interaction between EPS and PFOS, confirmed by fluorescence quenching titration and FTIR spectroscopy. The PFOS microlayers sandwiched in EPS was proven to be a light shield that could protect EPS from photodegradation because of its high reflectivity and nearly zero absorbance of UV-Vis light. The light shielding effect of PFOS was confirmed by evidences from photodegradation experiments, including change of concentrations of ions released and molecular weight distribution patterns. These novel findings provided valuable information for deep insight into environmental behavior of PFOS and its effects on biogeochemical carbon cycle of biopolymers in global waters.

Temporospatial nano-heterogeneity of self-assembly of extracellular polymeric substances on microplastics and water environmental implications.

Environmental behavior and ecotoxicity of microplastics (MPs) are significantly influenced by the omnipresent self-assembly of microbial extracellular polymeric substances (EPS) on them. However, mechanisms of EPS self-assembly onto MPs at nanoscale resolution and effects of aging are unclear. For the first time, temporospatial nano-heterogeneity of self-assembly of EPS onto fresh and one-year aged polypropylene (PP) MPs were investigated by atomic-force-microscopy-infrared-spectroscopy (AFM-IR). Natural aging caused high degree nanoscale fragmentation of MPs physically and chemically. Self-assembly of EPS on MPs was aging-dependent. Polysaccharides were assembled on MP surface faster than proteins. Initially, regardless of the fresh or aged MPs, polysaccharides and proteins, with the former being predominant, were successively and separately assembled to different nanospaces because of their competition for binding sites. More and more proteins and polysaccharides were superimposed on each other with assembly time due to intermolecular forces. The nanochemical textural analysis showed that the nano-heterogeneity of EPS assembly to MPs was clearly correlated with the aging-induced nanochemical and nanomechanical heterogeneity of MP surface. The spontaneous self-assembly of EPS with temporospatial nano-heterogeneity on MPs have multiple impacts on behavior, ecotoxicity and fate of MPs and their associated pollutants as well as other key ecological processes in aquatic environment.

Chemical structure and nanomechanics relevant electrochemistry of solid-phase humic acid along a typical forest-river-paddy landscape section in eastern China and its environmental implications.

Solid-phase humic acid (HAsolid) plays a critical role in global carbon cycle and redox biogeochemistry of topsoil, because of its unique physicochemical properties, including electrochemical property. In this study, topsoil HAsolid along a typical forest-river-paddy landscape section in eastern China was investigated in the aspects of electrochemical property, chemical structure and nanomechanics, and their relationship. Nano-size HAsolid particles were extracted from topsoil of paddy soil (PS-HAsolid), forest soil (FS-HAsolid) and riverside sediment (RS-HAsolid). Results showed that all the HAsolid were conductive and played an important role in conductivity of topsoil suspension. HAsolid contained both reversible and irreversible redox peaks, with redox activity of PS-HAsolid > RS-HAsolid > FS-HAsolid. Owing to limited humification, electron exchange capacity (EEC) values of topsoil HAsolid suspensions were modest (3.18-4.45 µmol e-g-1 HAsolid). Compared with RS-HAsolid and FS-HAsolid, PS-HAsolid showed higher aromaticity and higher degree of humification with simple and even nanomechanical property. Long-term cultivation (human activities) as well as high content of polyvalent metals in paddy soil were supposed to facilitate formation of aromatic carbon and improve humification of HAsolid. The results suggested that aromatic carbon and high humification degree of PS-HAsolid contributed to simple and even nanomechanics, which further optimized its electrochemical property. This study not only provides novel insight into the mechanism of HAsolid mediating electron transfer, but also inspires ideas for soil and environmental management with different purposes based on regulation of HAsolid.

Phase II Study of Gemcitabine, Peg-Asparaginase, Dexamethasone and Methotrexate Regimen for Newly Diagnosed Extranodal Natural Killer/T-Cell Lymphoma, Nasal Type: Final Analysis With Long-Term Follow-Up and Rational Research for the Combination.

Patients with extranodal natural killer/T-cell lymphoma (ENKTL), nasal type are benefit from peg-asparaginase, gemcitabine, and methotrexate. Therefore, we conducted a prospective phase II trial using a combination of these drugs as GAD-M regimen in naïve ENKTL patients, simultaneously, explored the combinational mechanism. The GAD-M regimen was administered for 6 cycles sandwiched by radiotherapy for stage I/II and 6 cycles for stage III/IV patients. After 6 cycles, the overall response rate of 36 patients was 91.6%, and the complete remission rate increased to 83.3%. The 3-year progression-free survival (PFS) and overall survival (OS) rates were 74.8% and 77.8%, respectively. The 5-year PFS and OS were 68.3% and 77.8%. No patient suffered from the central nervous system (CNS) relapse. Most patients experienced recoverable liver dysfunction and anemia in this study. The plasma MTX concentration ratio at 12 to 24 hr during the first cycle could be an early predictor of outcomes in ENKTL (PFS, P=0.005; OS, P=0.002). Additionally, we found that high dose MTX (HD-MTX) and gemcitabine had the synergistic effect of ENKTL cell in vitro. Mechanistically, we demonstrated that the combination could lead to obviously apoptosis in ENKTL cell with extremely release of reactive oxygen spices (ROS), which mediated by endoplasmic reticulum stress. In conclusion, the GAD-M regimen could be a new choice to newly diagnosed ENKTL, especially for stage I/II patients. Furthermore, our results showed the synergy effect of HD-MTX with gemcitabine in ENKTL. CLINICAL TRIAL REGISTRATION: This trial was registered at www.clinicaltrials.gov as #NCT01991158.