First-line penpulimab (an anti-PD1 antibody) and anlotinib (an angiogenesis inhibitor) with nab-paclitaxel/gemcitabine (PAAG) in metastatic pancreatic cancer: a prospective, multicentre, biomolecular exploratory, phase II trial.

Metastatic pancreatic cancer (mPC) has a dismal prognosis. Herein, we conducted a prospective, multicentre, single-arm, phase II trial evaluating the efficacy and safety of penpulimab and anlotinib in combination with nab-paclitaxel/gemcitabine (PAAG) in patients with first-line mPC (NCT05493995). The primary endpoints included the objective response rate (ORR) and disease control rate (DCR), while secondary endpoints encompassed progression-free survival (PFS), overall survival (OS), and safety. In 66 patients analysed for efficacy, the best response, indicated by the ORR, was recorded at 50.0% (33/66) (95% CI, 37.4-62.6%), with 33 patients achieving partial response (PR). Notably, the DCR was 95.5% (63/66, 95% CI, 87.3-99.1%). The median PFS (mPFS) and OS (mOS) were 8.8 (95% CI, 8.1-11.6), and 13.7 (95% CI, 12.4 to not reached) months, respectively. Grade 3/4 treatment-related adverse events (TRAEs) were reported in 39.4% of patients (26/66). In prespecified exploratory analysis, patients with altered SWI/SNF complex had a poorer PFS. Additionally, low serum CA724 level, high T-cell recruitment, low Th17 cell recruitment, and high NK CD56dim cell scores at baseline were potential predicative biomarkers for more favourable efficacy. In conclusion, PAAG as a first-line therapy demonstrated tolerability with promising clinical efficacy for mPC. The biomolecular findings identified in this study possess the potential to guide the precise clinical application of the triple-combo regimen.

Molecular and immunological characteristics of postoperative relapse in lymph node-positive esophageal squamous cell cancer.

BACKGROUND: The molecular and immunological characteristics of primary tumors and positive lymph nodes in esophageal squamous cell carcinoma (ESCC) are unknown and the relationship with recurrence is unclear, which this study attempted to explore. METHODS: A total of 30 ESCC patients with lymph node positive (IIB-IVA) were enrolled. Among them, primary tumor and lymph node specimens were collected from each patient, and subjected to 551-tumor-targeted DNA sequencing and 289-immuno-oncology RNA panel sequencing to identify the different molecular basis and immunological features, respectively. RESULTS: The primary tumors exhibited a higher mutation burden than lymph nodes (p < 0.001). One-year recurrent ESCC exhibited a higher Mucin16 (MUC16) mutation rate (p = 0.038), as well as univariate and multivariate analysis revealed that MUC16 mutation is independent genetic factor associated with reduced relapse-free survival (univariate, HR: 5.39, 95% CI: 1.67-17.4, p = 0.005; multivariate, HR: 7.36, 95% CI: 1.79-30.23, p = 0.006). Transcriptomic results showed non-relapse group had higher cytolytic activity (CYT) score (p = 0.025), and was enriched in the IFN-α pathway (p = 0.036), while those in the relapsed group were enriched in the TNF-α/NF-κB (p = 0.001) and PI3K/Akt pathway (p = 0.014). CONCLUSION: The difference in molecular characteristics between primary lesions and lymph nodes may be the cause of the inconsistent clinical outcomes. Mutations of MUC16 and poor immune infiltration are associated with rapid relapse of nodes-positive ESCC.

20-HETE mediated TRPV1 activation drives allokinesis via MrgprA3+ neurons in chronic dermatitis.

Rationale: Noxious stimuli are often perceived as itchy in patients with chronic dermatitis (CD); however, itch and pain mechanisms of CD are not known. Methods: TRPV1 involvement in CD was analyzed using a SADBE induced CD-like mouse model, and several loss- and gain-of-function mouse models. Trigeminal TRPV1 channel and MrgprA3+ neuron functions were analyzed by calcium imaging and whole-cell patch-clamp recordings. Lesional CD-like skin from mice were analyzed by unbiased metabolomic analysis. 20-HETE availability in human and mouse skin were determined by LC/MS and ELISA. And finally, HET0016, a selective 20-HETE synthase inhibitor, was used to evaluate if blocking skin TRPV1 activation alleviates CD-associated chronic itch or pain. Results: While normally a pain inducing chemical, capsaicin induced both itch and pain in mice with CD condition. DREADD silencing of MrgprA3+ primary sensory neurons in these mice selectively decreased capsaicin induced scratching, but not pain-related wiping behavior. In the mice with CD condition, MrgprA3+ neurons showed elevated ERK phosphorylation. Further experiments showed that MrgprA3+ neurons from MrgprA3;Braf mice, which have constitutively active BRAF in MrgprA3+ neurons, were significantly more excitable and responded more strongly to capsaicin. Importantly, capsaicin induced both itch and pain in MrgprA3;Braf mice in an MrgprA3+ neuron dependent manner. Finally, the arachidonic acid metabolite 20-HETE, which can activate TRPV1, was significantly elevated in the lesional skin of mice and patients with CD. Treatment with the selective 20-HETE synthase inhibitor HET0016 alleviated itch in mice with CD condition. Conclusion: Our results demonstrate that 20-HETE activates TRPV1 channels on sensitized MrgprA3+ neurons, and induces allokinesis in lesional CD skin. Blockade of 20-HETE synthesis or silencing of TRPV1-MrgprA3+ neuron signaling offers promising therapeutic strategies for alleviating CD-associated chronic itch.

Clinical application of molecular residual disease detection by circulation tumor DNA in solid cancers and a comparison of technologies: review article.

Molecular residual disease (MRD), detected by circulating tumor DNA (ctDNA) can be involved in the entire process of solid tumor management, including recurrence prediction, efficacy evaluation, and risk stratification. Currently, the detection technologies are divided into two main categories, as follows: tumor-agnostic and tumor informed. Tumor-informed assay obtains mutation information by sequencing tumor tissue samples before blood MRD monitoring, followed by formulation of a personalized MRD panel. Tumor-agnostic assays are carried out using a fixed panel without the mutation information from primary tumor tissue. The choice of testing strategy may depend on the level of evidence from ongoing randomized clinical trials, investigator preference, cost-effectiveness, patient economics, and availability of tumor tissue. The review describes the difference between tumor informed and tumor agnostic detection. In addition, the clinical application of ctDNA MRD in solid tumors was introduced, with emphasis on lung cancer, colorectal cancer, Urinary system cancer, and breast cancer.

Effects of dietary supplementation of Anabaena sp. PCC7120 expressing VP28 protein on survival and histopathology after WSSV infection in Macrobrachium nipponense.

Shrimp are especially susceptible to the White Spot Syndrome Virus (WSSV). Oral administration of the WSSV envelop protein VP28 is a promising approach to protect shrimp against WSSV. In this study, Macrobrachium nipponense (M. nipponense) were fed for 7 days with food supplemented with Anabaena sp. PCC 7120 (Ana7120) expressing VP28 and then challenged with WSSV. The survival rates of M. nipponense in three groups, including control, WSSV-challenged, and VP28-vaccinated, were subsequently determined. We also determined the WSSV content of different tissues and the tissue morphology in the absence of and after viral challenge. The survival rate of the positive control group (no vaccination and challenge, 10%) and empty vector group (fed with Ana7120 pRL-489 algae and challenged, 13.3%) was much lower than the survival rate of M. nipponense in wild type group (fed with Ana7120 and challenged, 18.9%), immunity group 1 (fed with 3.33% Ana7120 pRL-489-vp28 and challenged, 45.6%) or immunity group 2 (fed with 6.66% Ana7120 pRL-489-vp28 and challenged, 62.2%). RT-qPCR showed that WSSV content of the gill, hepatopancreas and muscle of immunity groups 1 and 2 were substantially lower than the positive control. Microscopic examination revealed that WSSV-challenged positive control exhibited large number of cell rupture, necrosis, nuclear exfoliation in gills and hepatopancreatic tissues. The gill and hepatopancreas of immunity group 1 showed partial symptoms of infection, yet the tissue was visibly healthier than that of the positive control group. No symptoms were visible in the gills and hepatopancreatic tissue of immunity group 2. The results demonstrate that the probability of M. nipponense infected by WSSV can be diminished by oral administration of cyanobacteria-expressed VP28. Such an approach could improve the disease resistance and delay the death of M. nipponense in the commercial production of this shrimp.

Keloid Core Factor CTRP3 Overexpression Significantly Controlled TGF-ß1-Induced Propagation and Migration in Keloid Fibroblasts.

Purpose: Keloid is a type of benign fibrous proliferative tumor characterized by excessive scarring. C1q/TNF-related protein 3 (CTRP3) has been proven to possess antifibrotic effect. Here, we explored the role of CTRP3 in keloid. In the current research, we examined the influence of CTRP3 on keloid fibroblasts (KFs) and investigated the potential molecular mechanism. Methods: KF tissue specimens and adjacent normal fibroblast (NF) tissues were collected cultured from 10 keloid participants. For the TGF-ß1 stimulation group, KFs were processed with human recombinant TGF-ß1. Cell transfection of pcDNA3.1-CTRP3 or pcDNA3.1 was performed. The siRNA of CTRP3 (si-CTRP3) or negative control siRNA (si-scramble) was transfected into KFs. Results: CTRP3 was downregulated in keloid tissues and KFs. CTRP3 overexpression significantly controlled TGF-ß1-induced propagation and migration in KFs. Col I, α-SMA, and fibronectin mRNA and protein levels were enhanced by TGF-ß1 stimulation, whereas they were inhibited by CTRP3 overexpression. In contrast, CTRP3 knockdown exhibited the opposite effect. In addition, CTRP3 attenuated TGF-ß receptors TRI and TRII in TGF-ß1-induced KFs. Furthermore, CTRP3 prevented TGF-ß1-stimulated nuclear translocation of smad2 and smad3 and suppressed the expression levels of p-smad2 and p-smad3 in KFs. Conclusion: CTRP3 exerted an antifibrotic role through inhibiting proliferation, migration, and ECM accumulation of KFs via regulating TGF-ß1/Smad signal path.

Aconitine - A promising candidate for treating cold and mechanical allodynia in cancer induced bone pain.

BACKGROUND AND AIMS: Patients suffering from cancer induced bone pain (CIBP) have a poor quality of life that is exacerbated by the lack of effective therapeutic drugs. Monkshood is a flowering plant that has been used in traditional Chinese medicine where it has been used to relieve cold pain. Aconitine is the active component of monkshood, but the molecular mechanism for how this compound reduces pain is unclear. METHODS AND RESULTS: In this study, we employed molecular and behavioral experiments to explore the analgesic effect of aconitine. We observed aconitine alleviated cold hyperalgesia and AITC (allyl-isothiocyanate, TRPA1 agonist) induced pain. Interestingly, we found aconitine directly inhibits TRPA1 activity in calcium imaging studies. More importantly, we found aconitine alleviated cold and mechanical allodynia in CIBP mice. Both the activity and expression of TRPA1 in L4 and L5 DRG (Dorsal Root Ganglion) neurons were reduced with the treatment of aconitine in the CIBP model. Moreover, we observed aconiti radix (AR) and aconiti kusnezoffii radix (AKR), both components of monkshood that contain aconitine, alleviated cold hyperalgesia and AITC induced pain. Furthermore, both AR and AKR alleviated CIBP induced cold allodynia and mechanical allodynia. CONCLUSIONS: Taken together, aconitine alleviates both cold and mechanical allodynia in cancer induced bone pain via the regulation of TRPA1. This research on the analgesic effect of aconitine in cancer induced bone pain highlights a component of a traditional Chinese medicine may have clinical applications for pain.

Curcumin inhibits the pruritus in mice through mast cell MrgprB2 receptor.

BACKGROUND: Curcumin is a diketone compound extracted from the rhizomes of some plants in the Zingiberaceae and Araceae family. It possesses a variety of biological activities, including antioxidant, anti-inflammatory and anti-cancer properties. However, the cellular and molecular antipruritic mechanisms of curcumin remain to be explored. OBJECTIVE: Our objective was to study the role of curcumin in pruritus and determine whether its antipruritic effect is related to MrgprB2 receptor. METHODS: The effect of curcumin on pruritus in mice was examined by scratching behavior test. The antipruritic mechanism of curcumin was explored by using transgenic mice (MrgprB2-/- mice, MrgprB2CreTd/tomato mice), histological analysis, western blot and immunofluorescence. In addition, the relationship between curcumin and MrgprB2/X2 receptor was studied in vitro by using calcium imaging, plasmid transfection and molecular docking RESULTS: In the current study, we found that curcumin had obvious antipruritic effect. Its antipruritic effect was related to the regulation of MrgprB2 receptor activation and mast cells tryptase release. In vitro, mouse peritoneal mast cells activated by compound 48/80 could be inhibited by curcumin. In addition, curcumin was also found to suppress the calcium flux in MrgprX2 or MrgprB2-overexpression HEK cells induced by compound 48/80, substance P, and PAMP 9-20, displaying the specific relation with the MrgprB2/X2 receptor. Moreover, molecular docking results showed that curcumin had affinity to MrgprX2 protein. CONCLUSIONS: Overall, these results indicated that curcumin has the potential to treat pruritus induced by mast cell MrgprB2 receptor.

Osthole relieves skin damage and inhibits chronic itch through modulation of Akt/ZO-3 pathway in atopic dermatitis.

Atopic dermatitis (AD) is the most prevalent chronic inflammatory skin condition and significantly reduces quality of life. Tight junction (TJ), which is located directly beneath the stratum corneum, maintains skin barrier function and aids in the identification of the cell's "territory". We evaluated seventeen TJ related genes to explore AD related alterations of TJ. Remarkably, we found that the expression of ZO-3, a gene that had not been linked to the development of TJ in AD, was significantly down-regulated in the skin of AD mice and patients. siRNA mediated knock-down of ZO-3 significantly decreased transepithelial electrical resistance in HaCaT cells, demonstrating that ZO-3 is essential to epidermal barrier function. In addition to ZO-3 downregulation, protein kinase B (Akt) phosphorylation was increased in the skin of AD mice. We further confirmed an inverse relationship between Akt phosphorylation and ZO-3 expression in AD using HaCaT cells and mouse model. Finally, we tested the efficacy of osthole as a treatment for AD in mice and HaCaT cells. Osthole inhibits Akt phosphorylation, and thereby enhances ZO-3 expression in mouse models of AD, resulting in greatly lessened AD associated skin damage and chronic itch, and osthole also increased the expression of ZO-3 in HaCaT cells by inhibiting the phosphorylation of Akt. Together, we established that ZO-3 is essential for the development of TJ in AD skin and HaCaT cells, and our findings provide fresh support for osthole's ability to protect ZO-3 expression and the epidermal barrier in AD.

Novel LINC01923 -anaplasticlymphoma kinase rearrangement identified in advanced lung adenocarcinoma with durable response to ensartinib: a case report.

Anaplastic lymphoma kinase ( ALK ) rearrangements are one of the most common mutations in nonsmall cell lung cancer. Majority of the ALK rearrangements were sensitive to crizotinib, yet some rare fusion types may less benefit. The patient with LINC01923-ALK fusion was treated with crizotinib for 1 week and developed an adverse rash reaction. Replaced with second-line treatment with esatinib, the patient had a partial response in the primary site and achieved a complete response in the brain metastases. The patient was treated successfully with ensartinib leading to a progression-free survival of 6 months (and counting). This is the first report on one lung adenocarcinoma patient with a novel LINC01923-ALK fusion beneficial from ensartinib, which provides more knowledge for ALK fusion spectrum.

Rutin ameliorates inflammatory pain by inhibiting P2X7 receptor in mast cells.

Rutin is a natural anti-inflammatory ingredient widely found in medicinal plants. Studies have shown that rutin inhibits mast cell degranulation and the release of inflammatory mediators. Mast cell P2X7 receptor mediates mast cell degranulation and serves as a therapeutic target for inflammatory pain. Herein, the aim of this study was to investigate whether the anti-inflammatory mechanism of rutin is related to the mast cell P2X7 receptor. Our results showed that rutin could inhibit [Ca2+]i elevation induced by 5 mM ATP or 30 µM BZATP in a concentration-dependent manner in mouse peritoneal mast cells. Rutin also suppressed the inward current mediated by P2X7 receptor. In vivo, rutin could significantly inhibit the mechanical hypersensitivity induced by 100 mM ATP that is associated with P2X7 receptor in mast cells. Moreover, molecular docking revealed the high affinity between rutin and the P2X7 receptor crystal structure. Collectively, this study demonstrated that rutin attenuated inflammatory pain by inhibiting the activity of P2X7 receptor in mast cells.

Making "cold" tumors "hot"- radiotherapy remodels the tumor immune microenvironment of pancreatic cancer to benefit from immunotherapy: a case report.

Immune checkpoint inhibitors have limited efficacy in metastatic pancreatic cancer due to the complex tumor immune microenvironment (TIME). Studies have shown that radiotherapy can cause cell lesions to release tumor antigens and then take part in the remodeling of the tumor environment and the induction of ectopic effects via regional and systemic immunoregulation. Here, we reported a case of advanced metastatic pancreatic cancer treated with immunotherapy combined with chemotherapy and radiotherapy and a sharp shift of the TIME from T3 to T2 was also observed. One hepatic metastasis within the planning target volume (PTV) was evaluated complete response (CR), the other one was evaluated partial response (PR) and 2 hepatic metastases outside the PTV were surprisingly considered PR. In the study, we found that immunotherapy combined with chemotherapy and radiotherapy achieved significant therapeutic benefits, which may provide a new strategy for the treatment of advanced pancreatic cancer.

Ligustrazine mitigates chronic venous disease-induced pain hyperalgesia through desensitization of inflammation-associated TRPA1 activity in DRG.

ETHNOPHARMACOLOGICAL RELEVANCE: Ligustrazine, an important active ingredient extracted from Ligusticum chuanxiong hort, has been widely used to cure cardiovascular diseases and exerts an analgesic effect. AIMS OF THIS STUDY: The aim of this study is to investigate whether ligustrazine mitigates chronic venous disease (CVeD)-induced pain and to explore its underlying mechanisms. MATERIALS AND METHODS: A mouse model of CVeD was established by vein ligature. Ligustrazine was administered intraperitoneally to CVeD mice for a single injection (20 mg/kg, 100 mg/kg, and 200 mg/kg) or once a day for three weeks (100 mg/kg and 200 mg/kg), and TRPA1 overexpressed HEK 293 cells were treated with ligustrazine (600 µM) in the presence of mustard oil (100 µM) for 2 min. Patch clamp and calcium imaging were used to measure the inhibitory response of ligustrazine on DRG neurons and TRPA1 transfected HEK293 cells. RESULTS: The present results showed that mice receiving vein ligature surgery exhibited obvious pain hypersensitivity to mechanical, cold and thermal stimuli, whereas ligustrazine significantly reversed the pain hyperalgesia in CVeD mice. Furthermore, ligustrazine desensitized transient receptor potential ankyrin 1 (TRPA1) activity in the dorsal root ganglion (DRG) neurons, resulting in suppressing the DRG neuronal excitability in the CVeD mice. However, ligustrazine could not directly inhibit the response of TRPA1 transfected HEK293 cells to mustard oil. Strikingly, ligustrazine restricted the macrophage infiltration and decreased the mRNA levels of Interleukin-1ß (IL-1ß) and NOD-like receptor protein 3 (NLRP3) in the DRG neurons of the CVeD mice. CONCLUSIONS: The present study provided evidence that ligustrazine alleviated pain hypersensitivity to mechanical, cold and thermal stimuli in CVeD mice. Ligustrazine could weaken the activity of TRPA1 in the DRG to mitigate CVeD-induced pain hyperalgesia mainly through inhibition of inflammation. Our findings identify that ligustrazine may be a new therapeutic agent for the treatment of CVeD-induced pain.

A Mouse Model of Cancer Induced Bone Pain: From Pain to Movement.

Cancer induced bone pain (CIBP) occurs in patients with advanced osteosarcoma or metastasized bone tumors that can negatively affects the patient's quality of life. However, motor impairment in CIBP is still understudied. To improve the quality of life of patients with CIBP, the study of CIBP induced movement impairment is of particular importance. Here, we presented a model of metastatic cancer induced bone pain caused by an allograft of Lewis lung cancer cells. In this method, we injected Lewis lung cancer cells into the femoral medulla cavity and recorded the pain behavior and motor behavior after CIBP surgery. We observed enhanced pain after the initial surgery. Interestingly, we found the latency on rotarod was significantly reduced concomitant with tumor growth and pain. This result indicated that the motor coordination and balance were severely impaired in CIBP. We also found the pain and motor behavioral differences in models that severed the patellar ligament vs. maintaining the patellar ligament. These findings provide a novel clue for further investigating the mechanisms responsible for the generation and development of CIBP.

Circular RNA_0061587 is associated with the tumorigenesis of neurofibromatosis type 1.

Neurofibromatosis type 1 (NF1) is a kind of common neurogenetic disorder associated with various developmental deficits. Circular RNAs (circRNAs) have been frequently verified to be crucial modulators in human diseases. However, the functions of circRNAs on the occurrence of NF1 remain largely obscure. In our study, RT-qPCR was applied to analyze circ_0061,587 expression and we noticed that circ_0061,587 expression was overtly elevated in human NF1-associated malignant peripheral nerve sheath tumor (MPNST) cell lines. Meanwhile, the results of loss-of-function assays revealed that silencing of circ_0061,587 hampered the proliferation, migration, and invasion but stimulated the apoptosis of human NF1-associated MPNST cells. In addition, mechanism assays were implemented to unveil the possible regulatory mechanism behind circ_0061,587. As a result, circ_0061,587 sequestered microRNA-485-5p (miR-485-5p) to modulate the expression of RUNX family transcription factor 1 (RUNX1) and annexin A11 (ANXA11). Finally, rescue experiments confirmed that circ_0061,587 boosted the malignant behaviors of human NF1-associated MPNST cells through up-regulating RUNX1 and ANXA11. In conclusion, circ_0061,587 functioned as an oncogene in NF1-associated MPNST cells and this study might provide novel insights for the diagnosis and treatment of NF1.

Effects of Synechococcus sp. PCC 7942 harboring vp19, vp28, and vp (19 + 28) on the survival and immune response of Litopenaeus vannamei infected WSSV.

This study aimed to assess the effect of oral administration of Synechococcus sp. PCC 7942 harboring vp19, vp28, and vp(19 + 28)against infection by white spot syndrome virus (WSSV) on juveniles of Litopenaeus vannamei. L. vannamei was orally administrated by feeding with different mutants of Synechococcus for 10 days, and then challenged with WSSV. The cumulative mortality of vp19, vp28, vp (19 + 28) groups was lower than that of the positive control group (57.8%, 62.2%, 71.1%, respectively); vp (19 + 28) group had a better protection rate than vp19 and vp28 groups. The analysis of shrimp immunological parameters showed that, after WSSV injection, the activity of superoxide dismutase, phenol oxidase, catalase, and lysozyme in the hepatopancreas of vp19, vp28, and vp (19 + 28) groups was higher than in the positive group; at the same time, growth performances of L. vannamei of experimental groups were better than control groups. Results showed that the Synechococcus mutants harboring vp19, vp28, and vp (19 + 28) could be used both as drug and feed to also enhance the defensive ability of juvenile shrimp against WSSV infection by increasing the activity of immune related enzymes.

Obesity and nonalcoholic fatty liver disease associated with adenocarcinoma in patients with lung cancer.

Lung cancer has become the leading cause of cancer-related deaths around the world. In addition to genetic risk factors and smoking, the metabolic risk factors remain to be elusive.To evaluate the associations between obesity, nonalcoholic fatty liver disease (NAFLD) and pulmonary adenocarcinoma in patients with lung cancer.Consecutive operation-proven lung cancer patients with assessment of metabolic disorders and liver ultrasound in 2009 and 2013 were retrospectively enrolled. T-test and multivariate logistic regression were applied to evaluate the contribution of individual factors to lung adenocarcinoma, as well as the synergistic effects between these factors.Among 3664 lung cancer patients with ultrasound examination, 2844 cases were enrolled for further analysis. Of them, 1053 (37.0%) were females, 1242 (43.7%) were cigarette smokers, 1658 (58.3%) were diagnosed as lung adenocarcinoma, 744 (26.2%) had obesity, and 614 (21.6%) had NAFLD. Proportion of female gender, nonsmoker, obesity, NAFLD, and serum lipid levels in patients with adenocarcinoma were significantly higher than those in other subtypes of lung cancer, and in 2013 than in 2009 (all P < .01). NAFLD and obesity were shown as independent factors and positively associated with pulmonary adenocarcinoma, along with female gender and nonsmoking, higher serum levels of cholesterol. NAFLD and other contributing factors exhibited no synergistic effects on adenocarcinoma.Obesity and NAFLD might increase the risk for pulmonary adenocarcinoma, especially in nonsmoking females, and underscore the need for further study into carcinogenic mechanisms and preventive interventions.