Spontaneous rupture­induced life­threatening mediastinal mixed germ cell tumor: A case report and therapeutic considerations.

Spontaneous rupture and hemorrhage of mediastinal germ cell tumors is a rare occurrence. In the current report, the case of a 20-year-old male patient who was admitted with chest tightness and dyspnea is presented. An urgent chest CT scan revealed a large tumor in the right anterior mediastinum, measuring ~12 cm in diameter, with associated intratumoral hemorrhage. An emergency thoracotomy was performed to excise the lesion, which revealed that the bleeding was caused by a ruptured tumor. Postoperative pathological findings revealed a mediastinal mixed germ cell tumor consisting of four pathological types: Embryonal carcinoma, seminoma, yolk sac tumor and immature teratoma. Postoperatively, the patient showed marked improvement in the symptoms of dyspnea. However, the follow-up outcome was poor, and the patient succumbed 2 months after surgery. To the best of our knowledge, there are no reports of rupture and hemorrhage involving >4 mixed germ cell tumors. In the present report, the experience of the treatment of the patient is summarized, and literature was reviewed to improve clinicians' awareness of the disease.

Potential role of glutathione S­transferase M1 gene polymorphism in kidney calcium oxalate stone formation.

BACKGROUND: The purpose of this study was to look into the effects of glutathione S-transferase M1 (GSTM1) gene polymorphism on the formation of kidney calcium oxalate stones. METHODS: A total of 159 patients with kidney calcium oxalate stones were included in this study as a case group. One hundred and three healthy individuals were included in the control group. The age, gender, and levels of calcium (Ca), uric acid (UA), creatinine (Cr), and urinary creatinine (Ucr) are tracked. Peripheral blood samples are used to perform a polymerase chain reaction to identify the glutathione S-transferase (GST) gene polymorphism (PCR). A commercial kit was used in this study to measure the levels of malondialdehyde (MDA), nitric oxide (NO), total antioxidant capacity (T-AOC), and 8-hydroxydeoxyguanosine (8-OHdG) in peripheral blood. RESULTS: There was no difference in age or gender distribution between the case and control groups (P > 0.05). The Cr, Ucr, Ca, UA, 8-OHdG, MDA, NO, and T-AOC in the case group were significantly higher than those in the control group (P < 0.001). The Hardy-Weinberg genetic equilibrium test showed no difference between the case group (P = 0.23) and the control group (P = 0.09). In the case group, the 8-OHdG and NO in GSTM1 null genotype were significantly higher than those in GSTM1 genotype (P < 0.05), but there was no significant difference in MDA and T-AOC (P > 0.05). Multivariate regression analysis showed that the GSTM1 null genotype was positively correlated with 8-OHdG (P < 0.001) and NO (P < 0.001). CONCLUSIONS: GSTM1 gene polymorphism might be a detecting risk factor for kidney calcium oxalate stone formation. TRIAL REGISTRATION: ChiCTR2100051300.

Dendrobium officinale polysaccharides improved reproductive oxidative stress injury in male mice treated with cyclophosphamide.

Polysaccharides from Dendrobium officinale polysaccharides (DOPs) are the main bioactive components of Dendrobium officinale, which have the functions of antioxidation and immune regulation. However, it is not clear whether DOPs have any effect on the prevention of reproductive disorders induced by oxidative stress. The purpose of this study was to explore the protective effect of DOPs on reproductive oxidative stress injury in male mice and its possible mechanism. In this study, the mouse model of reproductive injury was established by intraperitoneal injection of cyclophosphamide (CTX). The reproductive function was evaluated by relative testicular mass, sperm parameters, and sex hormone levels. The oxidative stress level of male mice with reproductive injury treated with DOPs was analyzed by the levels of 8-hydroxydeoxyguanosine (8-OHdG), malondialdehyde (MDA), and nitric oxide (NO) in sperm. The expression of follicle-stimulating hormone receptor (FSHR) mRNA, androgen-binding (ABP) mRNA, and c-kit mRNA was detected by quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) to explore its mechanism. After CTX administration, the sperm density, sperm motility, normal sperm morphology, and sex hormone levels in mice were significantly lower than those in the control group (P < 0.05). At the same time, the expression of p53 protein was upregulated, and the expression of Bcl-2 protein was downregulated (P < 0.05). In addition, the expression of FSHR and ABP mRNA on Sertoli cells was also significantly inhibited (P < 0.05). DOPs can effectively reduce the oxidative stress injury of testicular tissue. After DOP treatment, the sperm quality and sex-related hormone levels of mice were significantly improved and positively correlated with the dose of DOPs (P < 0.05). Administration of DOPs can reduce the damage caused by oxidative stress by reducing the level of oxidative stress, improving the hormone environment in testes, and regulating the expression of specific genes in Sertoli cells and spermatogenic cells.

Potential role of gut microbiota in prostate cancer: immunity, metabolites, pathways of action?

The gut microbiota helps to reveal the relationship between diseases, but the role of gut microbiota in prostate cancer (PCa) is still unclear. Recent studies have found that the composition and abundance of specific gut microbiota are significantly different between PCa and non-PCa, and the gut microbiota may have common and unique characteristics between different diseases. Intestinal microorganisms are affected by various factors and interact with the host in a variety of ways. In the complex interaction model, the regulation of intestinal microbial metabolites and the host immune system is particularly important, and they play a key role in maintaining the ecological balance of intestinal microorganisms and metabolites. However, specific changes in the composition of intestinal microflora may promote intestinal mucosal immune imbalance, leading to the formation of tumors. Therefore, this review analyzes the immune regulation of intestinal flora and the production of metabolites, as well as their effects and mechanisms on tumors, and briefly summarizes that specific intestinal flora can play an indirect role in PCa through their metabolites, genes, immunity, and pharmacology, and directly participate in the occurrence, development, and treatment of tumors through bacterial and toxin translocation. We also discussed markers of high risk PCa for intestinal microbiota screening and the possibility of probiotic ingestion and fecal microbiota transplantation, in order to provide better treatment options for clinic patients. Finally, after summarizing a number of studies, we found that changes in immunity, metabolites.

Pregnancy complicated with adrenal adenoma causing ACTH-independent Cushing's syndrome, accompanied by obstetric antiphospholipid syndrome and severe pre-eclampsia: case report and literature review.

This case report shares the management experience of a patient with pregnancy combined with adrenal adenoma causing ACTH-independent Cushing's syndrome (CS), accompanied by obstetric antiphospholipid syndrome (OAPS) and severe pre-eclampsia. The case was a 26-year-old that presented with typical clinical symptoms and signs of CS. The patient had a history of 4 spontaneous abortions in the last 4 years. The 24-hour urinary free cortisol was significantly increased, an abnormal cortisol circadian rhythm was demonstrated by a high late-night salivary cortisol, blood ACTH was suppressed (< 1ng/dL), anticardiolipin antibody was positive, and imaging examination showed an adrenal tumor. The patient underwent laparoscopic adrenal tumor resection under general anesthesia at 23 weeks of gestation. The tumor was pathologically confirmed to be an adrenocortical adenoma. The patient underwent a cesarean section at 39 weeks of gestation to give birth to a healthy baby girl with an Apgar score of 10. Pregnancy complicated by CS is clinically rare, easily masked by normal physiological changes of pregnancy, and is difficult to diagnose. The determination of 24-hour urinary free cortisol, the circadian rhythm of serum cortisol, ultrasound, and MRI can be helpful in the diagnosis of CS during pregnancy. Surgery is the first choice for the treatment of CS during pregnancy. As a subtype of antiphospholipid syndrome, patients with OAPS are prone to thrombotic events and recurrent miscarriages if not treated accordingly. To our knowledge no cases of CS with OAPS and severe pre-eclampsia have been reported. We summarize the experience of the treatment of this patient and review the literature to improve clinicians' awareness of this disease.

Bacterial lipopolysaccharide-related genes are involved in the invasion and recurrence of prostate cancer and are related to immune escape based on bioinformatics analysis.

Background: The composition of the tumor microbial microenvironment participates in the whole process of tumor disease. However, due to the limitations of the current technical level, the depth and breadth of the impact of microorganisms on tumors have not been fully recognized, especially in prostate cancer (PCa). Therefore, the purpose of this study is to explore the role and mechanism of the prostate microbiome in PCa based on bacterial lipopolysaccharide (LPS)-related genes by means of bioinformatics. Methods: The Comparative Toxicogenomics Database (CTD) was used to find bacterial LPS- related genes. PCa expression profile data and clinical data were acquired from TCGA, GTEx, and GEO. The differentially expressed LPS-related hub genes (LRHG) were obtained by Venn diagram, and gene set enrichment analysis (GSEA) was used to investigate the putative molecular mechanism of LRHG. The immune infiltration score of malignancies was investigated using single-sample gene set enrichment analysis (ssGSEA). Using univariate and multivariate Cox regression analysis, a prognostic risk score model and nomogram were developed. Results: 6 LRHG were screened. LRHG were involved in functional phenotypes such as tumor invasion, fat metabolism, sex hormone response, DNA repair, apoptosis, and immunoregulation. And it can regulate the immune microenvironment in the tumor by influencing the antigen presentation of immune cells in the tumor. And a prognostic risk score and the nomogram, which were based on LRHG, showed that the low-risk score has a protective effect on patients. Conclusion: Microorganisms in the PCa microenvironment may use complex mechanism and networks to regulate the occurrence and development of PCa. Bacterial lipopolysaccharide-related genes can help build a reliable prognostic model and predict progression-free survival in patients with prostate cancer.

Effects of mild/asymptomatic COVID-19 on semen parameters and sex-related hormone levels in men: a systematic review and meta-analysis.

Coronavirus disease 2019 (COVID-19) has yet to be proven to alter male reproductive function, particularly in the majority of mild/asymptomatic patients. The purpose of this study was to explore whether mild/asymptomatic COVID-19 affects semen quality and sex-related hormone levels. To find suitable comparative studies, a systematic review and meta-analysis was done up to January 22, 2022, by using multiple databases (Web of Science, PubMed, and Embase). Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to identify and choose the studies. Meta-analysis was used to examine the semen parameters and sex-related hormones of mild/asymptomatic COVID-19 patients before and after infection. The effects of semen collection time, fever, and intensity of verification on semen following infection were also investigated. A total of 13 studies (n = 770) were included in the analysis, including three case-control studies, six pre-post studies, and four single-arm studies. A meta-analysis of five pre-post studies showed that after infection with COVID-19, sperm concentration (I2 = 0; P = 0.003), total sperm count (I2 = 46.3%; P = 0.043), progressive motility (I2 = 50.0%; P < 0.001), total sperm motility (I2 = 76.1%; P = 0.047), and normal sperm morphology (I2 = 0; P = 0.001) decreased. Simultaneously, a systematic review of 13 studies found a significant relationship between semen collection time after infection, inflammation severity, and semen parameter values, with fever having only bearing on semen concentration. Furthermore, there was no significant difference in sex-related hormone levels before and after infection in mild/asymptomatic patients. Mild/asymptomatic COVID-19 infection had a significant effect on semen quality in the short term. It is recommended to avoid initiating a pregnancy during this period of time.

Primary urethral carcinoma with variant histology: A case report and literature review.

Primary urethral carcinoma (PUC) has rarely been reported, notably with variant histology. The present case reports a 68-year-old male patient with a 3-month history of difficulty voiding urine accompanied by a burning sensation in the urinary tract and hematuria. Urethrography and computed tomography (CT) indicated a mass localized in the urethral bulb. A fine needle biopsy revealed the mass to be a malignant tumor of the urethra. Partial penectomy was eventually performed and postoperative histopathological examination confirmed that the lesion was PUC, with mixed characteristics of urothelial and squamous differentiation. The patient was postoperatively followed up and at 9 months, a repeat CT scan revealed local recurrence and metastases. The patient rejected further treatment and eventually succumbed to the disease three months later. The present case report demonstrates an example in which urothelial and squamous differentiation simultaneously exist in the pathological report. The clinical features, diagnosis and treatment status of PUC were also summarized and analyzed to improve the clinical understanding of this unique disease.

Molecular Mechanism of Tanshinone against Prostate Cancer.

Prostate cancer (PCa) is the most common malignant tumor of the male urinary system in Europe and America. According to the data in the World Cancer Report 2020, the incidence rate of PCa ranks second in the prevalence of male malignant tumors and varies worldwide between regions and population groups. Although early PCa can achieve good therapeutic results after surgical treatment, due to advanced PCa, it can adapt and tolerate androgen castration-related drugs through a variety of mechanisms. For this reason, it is often difficult to achieve effective therapeutic results in the treatment of advanced PCa. Tanshinone is a new fat-soluble phenanthraquinone compound derived from Salvia miltiorrhiza that can play a therapeutic role in different cancers, including PCa. Several studies have shown that Tanshinone can target various molecular pathways of PCa, including the signal transducer and activator of transcription 3 (STAT3) pathway, androgen receptor (AR) pathway, phosphatidylinositol-3-kinase (PI3K)/protein kinase B (Akt)/mammalian target of rapamycin (mTOR) pathway, and mitogen-activated protein kinase (MAPK) pathway, which will affect the release of pro-inflammatory cytokines and affect cell proliferation, apoptosis, tumor metabolism, genomic stability, and tumor drug resistance. Thus, the occurrence and development of PCa cells are inhibited. In this review, we summarized the in vivo and in vitro evidence of Tanshinone against prostate cancer and discussed the effect of Tanshinone on nuclear factor kappa-B (NF-κB), AR, and mTOR. At the same time, we conducted a network pharmacology analysis on the four main components of Tanshinone to further screen the possible targets of Tanshinone against prostate cancer and provide ideas for future research.

Clinical presentation, management, and research progress of adrenal schwannoma.

Objective: This study shares our experience in managing adrenal schwannoma (AS). Methods: The clinical data of eight patients with AS in our hospital from April 2007 to April 2022 were analyzed retrospectively. Results: A total of 1309 patients with adrenal lesions were treated in the affiliated hospital of Guizhou Medical University for 15 years, of which only 8 cases were diagnosed as AS, accounting for 0.61%. Among the eight patients with AS, there were five females and three males, with an average age of 48.63 ± 12.05 years, and the average maximum diameter of the tumor was 6.96 ± 1.83 cm. All patients underwent adrenalectomy and were pathologically diagnosed as AS after the operation. The average follow-up time of eight patients with AS was 60.13 ± 22.33 months, and there was no recurrence or metastasis. Conclusion: The retroperitoneum is an uncommon site for schwannoma tumors, and among adrenal incidentalomas, the schwannoma is rare. The disease lacks specific clinical and imaging features, but correct diagnosis before the pathological examination is very important for clinical management and surgical decision. When imaging examination indicates a slow-growing retroperitoneal mass, schwannoma should be considered. Surgical resection is the main treatment. Pathology is the gold standard for diagnosis. Most of the tumors are benign and have a good prognosis. There is a risk of recurrence after the operation, and it should be monitored actively.

Comprehensive treatment for primary right renal diffuse large B-cell lymphoma with a renal vein tumor thrombus: A case report.

BACKGROUND: Renal involvement in lymphoma is commonly associated with widespread nodal or extranodal lymphoma. Primary renal diffuse large B-cell lymphoma is an extremely rare extranodal lymphoma, accounting for fewer than 1% of all renal masses. Interestingly, the patient in this study had a renal vein tumor thrombus that was observed after laparoscopic radical nephrectomy. CASE SUMMARY: We report the case of a 56-year-old female patient with primary renal lymphoma and a renal vein tumor thrombus whose first symptom was right pain in the back and gross hematuria. Histopathology revealed primary renal diffuse large B-cell lymphoma. The patient received 8 standard cycles of rituximab with cyclophosphamide, doxorubicin, vincristine, and prednisone chemotherapy after surgery, and no obvious signs of recurrence were observed during the one-year follow-up. CONCLUSION: We evaluated comprehensive treatment of primary renal diffuse large B-cell lymphoma and multidisciplinary management of this malignancy.

GSTT1, an increased risk factor for prostate cancer in patients with metabolic syndrome.

BACKGROUND: Glutathione S-transferase (GSTs) gene polymorphism and metabolic syndrome (Mets) are generally considered to be risk factors for prostate cancer (PCa). However, this conclusion is still controversial. There is a close relationship between GSTs gene polymorphism and Mets. We suspect that the effect of GSTs gene polymorphism and Mets on PCa may be the result of their joint action. As a result, the purpose of this study was to investigate the potential effect of GSTs gene polymorphism on PCa in patients with Mets. METHODS: We collected blood samples from 128 patients with PCa and 200 controls. The GSTs gene polymorphism was detected by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Age, characteristics of Mets, frequencies of GSTs gene polymorphism, total prostate volume (TPV), Gleason score, and prostate-specific antigen (PSA) were recorded and analyzed. RESULTS: There were significant differences in BMI, TG, LDL-C, FBG, SBP, DBP, and HDL-C among the control group, N-PCa group, and Mets-PCa group (p < 0.05). GSTT1 null genotype (OR = 2.844, 95% CI: 1.791-4.517), GSTM1 null genotype (OR = 2.192, 95% CI: 1.395-3.446), and GSTP1 (A/G + G/G) genotype (OR = 2.315, 95% CI: 1.465-3.657) were associated with PCa susceptibility and malignancy. Only the GSTT1 null genotype in Mets patients was positively correlated with PCa. CONCLUSIONS: Our study suggests that GSTs gene polymorphism may be a risk factor for PCa and can predict the susceptibility and malignancy of PCa. Secondly, in Mets patients, GSTT1 null genotype significantly increased the risk of PCa. GSTM1 null genotype and the effect of GSTP1 (AG + GG) on PCa were not significantly related to Mets.

Prostate Microbiota and Prostate Cancer: A New Trend in Treatment.

Although the incidence and mortality of prostate cancer have gradually begun to decline in the past few years, it is still one of the leading causes of death from malignant tumors in the world. The occurrence and development of prostate cancer are affected by race, family history, microenvironment, and other factors. In recent decades, more and more studies have confirmed that prostate microflora in the tumor microenvironment may play an important role in the occurrence, development, and prognosis of prostate cancer. Microorganisms or their metabolites may affect the occurrence and metastasis of cancer cells or regulate anti-cancer immune surveillance. In addition, the use of tumor microenvironment bacteria in interventional targeting therapy of tumors also shows a unique advantage. In this review, we introduce the pathway of microbiota into prostate cancer, focusing on the mechanism of microorganisms in tumorigenesis and development, as well as the prospect and significance of microorganisms as tumor biomarkers and tumor prevention and treatment.

Comparison of Sutureless Versus Suture Partial Nephrectomy for Clinical T1 Renal Cell Carcinoma: A Meta-Analysis of Retrospective Studies.

BACKGROUND: Partial nephrectomy (PN) is the recommended treatment for T1 renal cell carcinoma (RCC). Compared with suture PN, sutureless PN reduces the difficulty and time of operation, but the safety and feasibility have been controversial. This meta-analysis was conducted to compare the function and perioperative outcomes of suture and sutureless PN for T1 RCC. METHODS: Systematic literature review was performed up to April 2021 using multiple databases to identify eligible comparative studies. According to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria, identification and selection of the studies were conducted. Meta-analysis was performed for studies comparing suture to sutureless PN for both T1a and T1b RCC. In addition, subgroup analysis was performed on operation time, warm ischemia time, estimated blood loss, and postoperative complications. Sensitivity analysis was used in analysis with high heterogeneity (operation time and estimated blood loss). RESULTS: Eight retrospective studies were included with a total of 1,156 patients; of the 1,156 patients, 499 received sutureless PN and 707 received suture PN. The results showed that sutureless PN had shorter operative time (I2 = 0%, P < 0.001), warm ischemia time (I2 = 97.5%, P < 0.001), and lower clamping rate (I2 = 85.8%, P = 0.003), but estimated blood loss (I2 = 76.6%, P = 0.064) had no difference. In the comparison of perioperative outcomes, there was no significant difference in postoperative complications (I2 = 0%, P = 0.999), positive surgical margins (I2 = 0%, P = 0.356), postoperative estimated glomerular filtration rat (eGFR) (I2 = 0%, P = 0.656), and tumor recurrence (I2 = 0%, P = 0.531). CONCLUSIONS: In T1a RCC with low RENAL score, sutureless PN is a feasible choice, whereas it should not be overestimated in T1b RCC.

Adult adrenal neuroblastoma: A case report.

Adrenal neuroblastoma (NB) is very rare in adults. According to the literature, <100 cases have been reported worldwide to date, with >90% of the patients aged <10 years. As the early symptoms of the disease are not obvious, distant metastasis has often already occurred when the patients develop clinical symptoms. This lack of obvious symptoms may lead to misdiagnosis and inadequate treatment. Imaging and laboratory examinations are crucial for the diagnosis of NB, but reaching a definitive diagnosis prior to surgery is challenging, as the final diagnosis ultimately depends on histopathological examination. The aim of the present study was to report the rare case of a 40-year-old woman with adrenal left NB who underwent tumor resection. No tumor recurrence was observed at the 3-month and 1-year postoperative follow-up, but a repeat computed tomography at the 3-year postoperative follow-up indicated metastases; the patient refused further treatment and eventually succumbed to the disease within 1 month. The aim of the present case was to emphasize the importance of individualized therapy and long-term, close follow-up of the patients. The clinical characteristics and treatment of this case of adrenal NB were also summarized and analyzed in order to raise clinical awareness of this rare disease.

Potential role of glutathione S-transferase P1 gene polymorphism and metabolic syndrome in lower urinary tract symptoms attributed to benign prostatic hyperplasia.

OBJECTIVE: The aim of the study is to investigate the effects of glutathione S-transferase P1 (GSTP1) gene polymorphism and metabolic syndrome (MS) on lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia (BPH). METHODS: This study included 195 patients diagnosed with LUTS secondary to BPH as case group, divided into simple BPH group (S-BPH group) and combined with MS group (MS-BPH group). Control group included 200 healthy elderly men without LUTS. Use peripheral blood samples detected the GSTP1 gene polymorphism (Ile 105 Val A → G polymorphism) by polymerase chain reaction-restriction fragment length polymorphism. Recorded age, GSTP1 gene polymorphism, international prostate symptom score (IPSS), prostate volume (PV), residual urine volume (RV), maximal urinary flowrate (Qmax), and prostate-specific antigen (PSA) to statistical analysis. RESULTS: Pairwise compared between control group, S-BPH group and MS-BPH, the PV (P < 0.001), PSA (P < 0.001), RV (P < 0.001), Qmax (P < 0.001), IPSS (P < 0.001), frequencies of GSTP1 gene (P < 0.05) were shown significant different, and MS-BPH group had larger PV, and more severe LUTS. In case group, variation genotypes (GSTP1 A/G + G/G) always had larger PV, higher PSA and IPSS, more RV and lower Qmax than homozygote (GSTP1 A/A) and the comparison were significant different (P < 0.05). Variation genotypes were positively correlated with PV (ß = 0.092, P < 0.001), RV (ß = 0.228, P = 0.004), IPSS (ß = 0.274, P = 0.038), PSA (ß = 1.243, P < 0.001) and negatively correlated with Qmax (ß = -0.362, P = 0.025). CONCLUSION: In patients with BPH, GSTP1 variation genotypes and MS might be potential risk factors for faster progression of benign prostatic enlargement and LUTS, which might increase the surgical rate. TRIAL REGISTRATION: ChiCTR-IPR-14005580.

Induction of Mesenchymal-Epithelial Transitions in Sarcoma Cells.

Phenotypic plasticity refers to a phenomenon in which cells transiently gain traits of another lineage. During carcinoma progression, phenotypic plasticity drives invasion, dissemination and metastasis. Indeed, while most of the studies of phenotypic plasticity have been in the context of epithelial-derived carcinomas, it turns out sarcomas, which are mesenchymal in origin, also exhibit phenotypic plasticity, with a subset of sarcomas undergoing a phenomenon that resembles a mesenchymal-epithelial transition (MET). Here, we developed a method comprising the miR-200 family and grainyhead-like 2 (GRHL2) to mimic this MET-like phenomenon observed in sarcoma patient samples.We sequentially express GRHL2 and the miR-200 family using cell transduction and transfection, respectively, to better understand the molecular underpinnings of these phenotypic transitions in sarcoma cells. Sarcoma cells expressing miR-200s and GRHL2 demonstrated enhanced epithelial characteristics in cell morphology and alteration of epithelial and mesenchymal biomarkers. Future studies using these methods can be used to better understand the phenotypic consequences of MET-like processes on sarcoma cells, such as migration, invasion, metastatic propensity, and therapy resistance.