[Surgical treatment and prognosis analysis of hilar cholangiocarcinoma].

Objective: To investigate the surgical treatment effect and prognostic factors of hilar cholangiocarcinoma. Methods: This is an ambispective cohort study. From August 2005 to December 2022,data of 510 patients who diagnosed with hilar cholangiocarcinoma and underwent surgical resection at the Hepatobiliary Center of the First Affiliated Hospital of Nanjing Medical University were retrospectively collected. In the cohort,there were 324 males and 186 females,with an age of (M (IQR)) 63(13)years (range:25 to 85 years). The liver function at admission was Child-Pugh A (343 cases,67.3%) and Child-Pugh B (167 cases,32.7%). Three hundred and seventy-two(72.9%) patients had jaundice symptoms and the median total bilirubin was 126.3(197.6) µmol/L(range: 5.4 to 722.8 µmol/L) at admission. Two hundred and fourty-seven cases (48.4%) were treated with percutaneous transhepatic cholangial drainage or endoscopic nasobiliary drainage before operation. The median bilirubin level in the drainage group decreased from 186.4 µmol/L to 85.5 µmol/L before operation. Multivariate Logistic regression was used to identify the influencing factors for R0 resection,and Cox regression was used to construct multivariate prediction models for overall survival(OS) and disease-free survival(DFS). Results: Among 510 patients who underwent surgical resection,Bismuth-Corlett type Ⅲ-Ⅳ patients accounted for 71.8%,among which 86.1% (315/366) underwent hemi-hepatectomy,while 81.9% (118/144) underwent extrahepatic biliary duct resection alone in Bismuch-Corlett type Ⅰ-Ⅱ patients. The median OS time was 22.8 months, and the OS rates at 1-,3-,5-and 10-year were 72.2%,35.6%,24.8% and 11.0%,respectively. The median DFS time was 15.2 months,and the DFS rates was 66.0%,32.4%,20.9% and 11.0%,respectively. The R0 resection rate was 64.5% (329/510), and the OS rates of patients with R0 resection at 1-,3-,5-and 10-year were 82.5%, 48.6%, 34.4%, 15.2%,respectively. The morbidity of Clavien-Dindo grade Ⅲ-Ⅴ complications was 26.1%(133/510) and the 30-day mortality was 4.3% (22/510). Multivariate Logistic regression indicated that Bismuth-Corlett type Ⅰ-Ⅲ (P=0.009), hemi-hepatectomy and extended resection (P=0.001),T1 and T2 patients without vascular invasion (T2 vs. T1:OR=1.43 (0.61-3.35),P=0.413;T3 vs. T1:OR=2.57 (1.03-6.41), P=0.010;T4 vs. T1, OR=3.77 (1.37-10.38), P<0.01) were more likely to obtain R0 resection. Preoperative bilirubin,Child-Pugh grade,tumor size,surgical margin,T stage,N stage,nerve infiltration and Edmondson grade were independent prognostic factors for OS and DFS of hilar cholangiocarcinoma patients without distant metastasis. Conclusions: Radical surgical resection is necessary to prolong the long-term survival of hilar cholangiocarcinoma patients. Hemi-hepatectomy and extended resection,regional lymph node dissection and combined vascular resection if necessary,can improve R0 resection rate.

Lung cancer screening study from a smoking population in Kunming.

OBJECTIVE: Yunnan, China, is a central tobacco-producing region with a large smoking population and an increasing incidence of lung cancer in recent years. This study aimed to understand the incidence of lung cancer and the characteristics of lung nodules on low-dose computed tomography (LDCT) scans of the chest in a long-term smoking population in Kunming. PATIENTS AND METHODS: Long-term smokers in Kunming who were not at risk of evident lung disease symptoms were recruited through recommendation and publicity by the Kunming University of Science and Technology. RESULTS: Among 375 cases eligible for inclusion,14 cases of lung cancer were detected with a detection rate of 3.73% (95% CI: 2.55%-4.27%), including one case of squamous carcinoma, one case of small cell lung cancer, seven cases of adenocarcinoma of the lung and five cases of early-stage lung cancer (35.71%). In the group of < 6 mm solid nodules and < 5 mm non-solid nodules, no lung cancer was detected in 201 cases; lung cancer was detected in 14 cases in 61 cases, and there was a statistical difference between the two groups (p < 0.05). CONCLUSIONS: The lung cancer detection rate in long-term smokers was high, with the type predominantly adenocarcinoma and a high incidence of lung nodules, and increased when solid nodules≥6 mm or non-solid nodules ≥ 5 mm were present. It is recommended that screening for lung cancer by LDCT of the chest be introduced in the male smoking population who meet the risk factors and that screening for lung cancer in women should be redefined as a high-risk factor.

Impact of sleep status on lung adenocarcinoma risk: a prospective cohort study.

OBJECTIVE: The association between sleep status and lung adenocarcinoma risk was analyzed using long-term follow-up data from 60,443 patients over the period 2016-2022 to provide a reference for exploring the association between sleep status and lung adenocarcinoma development. PATIENTS AND METHODS: Based on long-term follow-up data, a total of 60,443 people were included. Sleep data collected for the study included insomnia symptoms, lunch break habits, and sleep duration. A sleep score (0-3) was constructed based on difficulty falling asleep, premature awakening and sleep duration. Proportional risk regression models were used to analyze the association between each sleep factor, sleep score and lung cancer risk. RESULTS: The study population was followed up for 9.9 ± 4.8 years and a total of 307 cases of lung adenocarcinoma were first recorded during the follow-up period. After controlling for potential confounders, the risk ratios (HR) for lung adenocarcinoma in those with difficulties going asleep or waking up too early were 1.12 (95% CI: 1.02-1.14) and 1.07 (95% CI: 1.01-1.11), respectively, compared to those without symptoms of insomnia. The HR for lung adenocarcinoma in those with less than 7 h of sleep [HR = 1.17 (95% CI: 1.05-1.21)] was compared to those with ≥ 7 h of sleep per day. Compared to those with a sleep score of 3 (highest quality sleep), those with a sleep score of 2, 1 and 0 corresponded to HR of 1.06 (95% CI: 1.01-1.12), 1.11 (95% CI: 1.09-1.18) and 1.15 (95% CI: 1.01-1.32) respectively. CONCLUSIONS: Patients who suffer from insomnia or have a short sleep schedule are at increased risk of developing lung cell cancer. Sleep has an important impact on health and improving sleep conditions can reduce the incidence of lung cancer.

[Efficacy and safety of neoadjuvant immunotherapy for hepatocellular carcinoma].

Objective: To study the surgical safety and efficacy of preoperative neoadjuvant therapy with immune checkpoint inhibitors combined with anti-angiogenic drugs in patients with China liver cancer staging(CNLC)-Ⅱb and Ⅲa resectable hepatocellular carcinoma. Methods: The data of 129 patients with Ⅱb and Ⅲa hepatocellular carcinoma who underwent surgery at the First Affiliated Hospital of Nanjing Medical University from January 2018 to December 2020 were analyzed. All patients were divided into two groups: the neoadjuvant therapy group(n=14,13 males and 1 female,aged (55.4±12.6)years(range:34 to 75 years)) received immune combined targeted therapy before surgery,immune checkpoint inhibitor camrelizumab was administered intravenously at a dose of 200 mg each time,every 2 weeks for 3 cycles,anti-angiogenesis drug apatinib was taken orally and continuously with a dose of 250 mg for 3 weeks and the conventional surgery group(n=115,103 males and 12 females,aged (55.8±12.0)years(range:21 to 83 years)) did not receive antitumor systemic therapy before surgery. There were 3 patients with CNLC-Ⅱb,11 with CNLC-Ⅲa in the neoadjuvant group;28 patients with CNLC-Ⅱb,87 with CNLC-Ⅲa in the conventional group. Student's t test or rank-sum test was used to compare the differences between two groups for quantitative data, Fisher's exact probability method was used to compare the differences of proportions between two groups, and Log-rank test was used to compare survival differences between two groups. Results: The 1-year recurrence rate in the neoadjuvant group was 42.9%,and the 1-year recurrence rate in the conventional group was 64.0%,with a statistically significant difference between the two groups(χ²=3.850,P=0.050);The 1-year survival rate in the neoadjuvant group was 100% and that in the conventional group was 74.2%,with a statistically significant difference between the two groups(χ²=5.170,P=0.023). According to the stratified analysis of the number of tumors,for single tumor,the 1-year recurrence rate in the neoadjuvant group was 25.0%,and that in the conventional surgery group was 71.0%,and the difference between the two groups was statistically significant(χ²=5.280, P=0.022). For multiple tumors, the 1-year recurrence rate in the neoadjuvant group was 66.7%,and the 1-year recurrence rate in the conventional surgery group was 58.9%,with no significant difference between the two groups(χ²=0.110,P=0.736). The operative time,intraoperative blood loss,and postoperative hospital stay in the neoadjuvant group were similar to those in the conventional group,and their differences were not statistically significant. Conclusions: Immune checkpoint inhibitors combined with anti-angiogenic targeted drugs as a neoadjuvant therapy for resectable hepatocellular carcinoma can reduce the 1-year recurrence rate and improve the 1-year survival rate,especially for those with solitary tumor. Limited by the sample size of the neoadjuvant group,the safety of immune combined targeted therapy before surgery cannot be observed more comprehensively,and further studies will be explored.

[Efficacy of radial shock wave guided by soft tissue surgery theory in the treatment of lateral epicondylitis].

Objective: To explore the efficacy of radial shock wave therapy (RSWT) for lateral epicondylitis (LE). Methods: A total of 54 cases suffering from LE from Department of Pain Medicine of Fujian Provincial Hospital between December 2017 to October 2019 were randomly assigned to experimental group (n=27) and control group (n=27). Subjects in the experimental group were applied with RSWT in the lateral elbow area plus scapular back area, while patients in control group were applied with RSWT only in the lateral elbow area. Patients in both groups underwent RSWT one session per week for four weeks. Numeric rating scale (NRS), pain-free grip (PFG) test and patient-rated tennis elbow evaluation (PRTEE) in both groups were evaluated and compared at the pre-treatment, one week, one month and three months after treatment. Results: The NRS scores at pre-treatment, one week, one month and three months after treatment in experimental group were 6.5±1.6, 4.0±1.1, 3.9±1.5, 1.7±1.1, respectively, while those in control group were 6.2±1.4, 3.8±1.3, 4.2±1.2, 2.6±1.2, respectively. Compared with those at pre-treatment, the NRS scores in both groups were significantly decreased at one week, one month and three months after treatment (all P<0.05). The PRTEE and PFG results showed significant improvement after treatment (all P<0.05). The NRS scores and PRTEE at three months after treatment in the experimental group were 18±11, 1.7±1.1, respectively, which were significantly lower than those in the control group (25±11, 2.6±1.2, respectively) (both P<0.05). Conclusions: RSWT exerts a beneficial effect on LE. Guided by the soft tissue surgery theory, RSWT in the lateral elbow area plus scapular back area produces better pain reduction and functional improvement compared with RSWT only in the lateral elbow area.

[Observation on the clinical effect of self-designed modified rhomboid skin flap in facial wound repair].

Objective: To investigate the clinical effect of self-designed modified rhomboid flap in repairing rhomboid, round, and teardrop-shaped wounds on the face. Methods: A retrospective observational study was conducted. From August 2018 to April 2020, 30 patients with facial lesions admitted into Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine and the People's Hospital of Jianchuan County in Yunnan province met the inclusion criteria, including 16 males and 14 females, aged 23 to 88 years. The wound area ranged from 1.0 cm×1.0 cm to 7.0 cm×5.0 cm, with 10 cases of rhomboid wounds, 12 cases of round wounds, and 8 cases of teardrop-shaped wounds. The self-designed modified rhomboid flaps were applied to repair the wounds and after that, the patients were followed up for 1 to 18 months to record the survival of flaps, wound tension, scar formation and complications after surgery. Results: No necrosis or blackening was observed at the tip of the flaps after surgery. All the flaps survived and the wounds healed well with little tension, minimal scars, and no complications. Conclusions: The self-designed modified rhomboid flap is especially suitable for facial wounds with multiple important organs, multiple anatomical subunits, and areas with large changes in soft tissue tension, which can reduce not only the rotation of the flap, but also unnecessary excision of normal skin and soft tissue.

[Application value of machine learning algorithms for predicting recurrence after resection of early-stage hepatocellular carcinoma].

Objective: To compare the performance of multiple machine learning algorithms in predicting recurrence after resection of early-stage hepatocellular carcinoma(HCC). Methods: Clinical data of 882 early-stage HCC patients who were admitted to the First Affiliated Hospital of Nanjing Medical University from May 2009 to December 2019 and treated with curative surgical resection were retrospectively collected. There were 701 males and 181 females,with an age of (57.3±10.5)years(range:21 to 86 years). All patients were randomly assigned in a 2∶1 ratio, the training dataset consisted of 588 patients and the test dataset consisted of 294 patients. The construction of machine learning-based prediction models included random survival forest(RSF),gradient boosting machine,elastic net regression and Cox regression model. The prediction accuracy of the model was measured by the concordance index(C-index). The prediction error of the model was measured by the integrated Brier score. Model fit was assessed by the calibration plot. The performance of machine learning models with that of rival model and HCC staging systems was compared. All models were validated in the independent test dataset. Results: Median recurrence-free survival was 61.7 months in the training dataset while median recurrence-free survival was 61.9 months in the validation dataset, there was no significant difference between two datasets in terms of recurrence-free survival(χ²=0.029,P=0.865). The RSF model consisted of 5 commonly used clinicopathological characteristics, including albumin-bilirubin grade,serum alpha fetoprotein,tumor number,type of hepatectomy and microvascular invasion. In both training and test datasets,the RSF model provided the best prediction accuracy,with respective C-index of 0.758(95%CI:0.725 to 0.791) and 0.749(95%CI:0.700 to 0.797),and the lowest prediction error,with respective integrated Brier score of 0.171 and 0.151. The prediction accuracy of RSF model for recurrence after resection of early-stage HCC was superior to that of other machine learning models,rival model(ERASL model) as well as HCC staging systems(BCLC,CNLC and TNM staging),with statistically significant difference(P<0.01). Calibration curves demonstrated good agreement between RSF model-predicted probabilities and observed outcomes.All patients could be stratified into low-risk,intermediate-risk or high-risk group based on RSF model;statistically significant differences among three risk groups were observed in both training and test datasets(P<0.01). The risk stratification of RSF model was superior to that of TNM staging. Conclusion: The proposed RSF model assembled with 5 commonly used clinicopathological characteristics in this study can predict the recurrence risk with favorable accuracy that may facilitate clinical decision-support for patients with early-stage HCC.

[Surgical treatment of primary liver cancer:a report of 10 966 cases].

Objective: To summarize the experience of surgical treatment of primary liver cancer. Methods: The clinical data of 10 966 surgically managed cases with primary liver cancer, from January 1986 to December 2019 at Hepatobiliary Center, the First Affiliated Hospital of Nanjing Medical University, were retrospectively analyzed. The life table method was used to calculate the survival rate and postoperative recurrence rate. Log-rank test was used to compare the survival process of different groups, and the Cox regression model was used for multivariate analysis. In addition, 2 884 cases of hepatocellular carcinoma(HCC) with more detailed follow-up data from 2009 to 2019 were selected for survival analysis. Among 2 549 patients treated with hepatectomy, there were 2 107 males and 442 females, with an age of (56.6±11.1) years (range: 20 to 86 years). Among 335 patients treated with liver transplantation, there were 292 males and 43 females, with an age of (51.0±9.7) years (range: 21 to 73 years). The outcomes of hepatectomy versus liver transplantation, anatomic versus non-anatomic hepatectomy were compared, respectively. Results: Of the 10 966 patients with primary liver cancer, 10 331 patients underwent hepatectomy and 635 patients underwent liver transplantation. Patients with liver resection were categorized into three groups: 1986－1995(712 cases), 1996－2008(3 988 cases), 2009‒2019(5 631 cases). The 5-year overall survival rate was 32.9% in the first group(1986－1995). The 5-year overall survival rate of resected primary liver cancer was 51.7% in the third group(2009-2019), among which the 5-year overal survival rates of hepatocellular carcinoma, intrahepatic cholangiocarcinoma and mixed liver cancer were 57.4%, 26.6% and 50.6%, respectively. Further analysis was performed on 2 549 HCC patients with primary hepatectomy. The 1-, 3-, 5-, and 10-year overall survival rates were 88.1%, 71.9%, 60.0%, and 41.0%, respectively, and the perioperative mortality rate was 1.0%. Two hundred and forty-seven HCC patients underwent primary liver transplantation, with 1-, 3-, 5-, and 10-year overall survival rates of 84.0%, 64.8%, 61.9%, and 57.6%, respectively. Eighty-eight HCC patients underwent salvage liver transplantation, with the 1-, 3-, 5-, and 10-year overall survival rates of 86.8%, 65.2%, 52.5%, and 52.5%, respectively. There was no significant difference in survival rates between the two groups with liver transplantation (P>0.05). Comparing the overall survival rates and recurrence rates of primary hepatectomy (2 549 cases) with primary liver transplantation (247 cases), the 1-, 3-, 5-, and 10-year overall survival rates in patients within Milan criteria treated with hepatectomy and transplantation were 96.3%, 87.1%, 76.9%, 54.7%, and 95.4%, 79.4%, 77.4%, 71.7%, respectively (P=0.754). The 1-, 3-, 5-year recurrence rates were 16.3%, 35.9%, 47.6% and 8.1%, 11.7%, 13.9%, respectively(P<0.01). The 1-, 3-, 5-, 10-year overall survival rates in patients with no large vessels invasion beyond the Milan criteria treated with liver resection and transplantation were 87.2%, 65.9%, 53.0%, 33.0% and 87.6%, 71.8%, 71.8%, 69.3%, respectively(P=0.003); the 1-, 3-, 5-year recurrence rate were 39.2%, 57.8%, 69.7% and 29.7%, 36.7%, 36.7%, respectively (P<0.01). The 1-, 3-, 5-, and 10-year overall survival rates in patients with large vessels invasion treated with liver resection and transplantation were 62.1%, 36.1%, 22.2%, 15.0% and 62.9%, 31.8%,19.9%, 0, respectively (P=0.387); the 1-, 3-, 5-year recurrence rates were 61.5%, 74.7%, 80.8% and 59.7%, 82.9%, 87.2%, respectively(P=0.909). Independent prognostic factors for both overall survival and recurrence-free survival rates of HCC patients treated with liver resection included gender, neoadjuvant therapy, symptoms, AST, intraoperative or postoperative blood transfusion, tumor number, tumor size, cirrhosis, macrovascular invasion, microvascular invasion, and pathological differentiation. Propensity score matching analysis of 443 pairs further showed that there was no significant difference in overall survival rate between anatomical liver resection and non-anatomical liver resection(P=0.895), but the recurrence rate of non-anatomical liver resection was higher than that of anatomical liver resection(P=0.035). Conclusions: In the past decade, the overall survival rate of HCC undergoing surgical treatment is significantly higher than before. For HCC patients with good liver function reservation, surgical resection can be performed first, and salvage liver transplantation can be performed after recurrence. The effect of salvage liver transplantation is comparable to that of primary liver transplantation. As for the choice of liver resection approaches, non-anatomical resection can reserve more liver tissue and can be selected as long as the negative margin is guaranteed.

[Clinical efficacy and prognostic factors analysis following curative hepatectomy for hepatocellular carcinoma patients with different China Liver Cancer Staging].

Objective: To examine clinical efficacy and prognostic factors of hepatocellular carcinoma(HCC) patients with different China Liver Cancer Staging (CNLC) after hepatectomy. Methods: From January 2010 to December,2019,549 patients underwent surgical resection and pathologically proven HCC were retrospectively reviewed in the First Affiliated Hospital of Nanjing Medical University. There were 462 males(84.2%) and 87 females(15.8%);the median age was 57 years (range: 21-84 years). Preoperative parameters,intraoperative and postoperative conditions,and postoperative pathological examination were observed.Survival analysis was performed by Kaplan-Meier method and the Log-rank test. Factors associated with disease-free survival(DFS) and overall survival(OS) of HCC patients were identified using univariate and multivariate Cox proportional hazards regression models. Results: Among the 549 patients underedwent liver resection,200 patients(36.4%) belonged to CNLC Ⅰa,whiles 148 patients(27.0%) belonged to CNLC Ⅰb. Furthermore,there were 49 patients(8.9%) with CNLC Ⅱa,32 patients(5.8%) with CNLC Ⅱb, 101 patients(18.4%) with CNLC Ⅲa and 19 patients(3.5%) with CNLC Ⅲb.The 1-,3-,5-,10-year OS for the entire cohort was 83.8%,69.0%,54.2%,37.7%,respectively,while 1-,3-, 5-year DFS was 61.0%,44.2%,36.0%, respectively. The 1-,3-, 5-year OS and DFS for CNLC Ⅰa were 97.3%,90.6%,80.5% and 83.9%,65.0%,54.0%,respectively;The 1-, 3-, 5-years OS and DFS for CNLC Ⅰb were 87.9%,71.0%,47.7%,and 58.4%,42.3%,33.4%,respectively.The 5-year OS for CNLC Ⅱa (37.2%) and Ⅱb(44.3%) were similar to CNLC Ⅰb. The 1-, 3-, 5-year OS and DFS for CNLC Ⅲb were 35.3%,13.2%,0 and 23.5%,0 and 0,respectively. Univariate analysis showed that preoperative symptoms,AFP level,total protein level,AST level,total bilirubin level,intraoperative blood loss,intraoperative or postoperative blood transfusion,postoperative complications,tumor number and size,microvascular invasion,macrovascular invasion and tumor differentiation were prognostic factors for long-term survival(≥5 years)(all P<0.05). The multivariate analysis suggested that AST level,intraoperative blood loss,tumor number and size,macrovascular invasion and tumor differentiation were the independent prognostic factors of long-term OS (all P<0.05). Conclusions: HCC patients with different stages of CNLC have different recurrence patterns and prognosis.After strict preoperative evaluation,patients with CNLC Ⅱa-Ⅲb can also benefit from radical resection. AST level,intraoperative blood loss,tumor number,tumor size,macrovascular invasion and tumor differentiation were independent factors that affect long-term survival. This will provide an important basis for the choice of treatment and the evaluation of surgical prognosis for patients with HCC.

[Application and challenge of radiomics technique in the era of precision medicine for hepatobiliary disease].

Radiomics, as an emerging technique of omics, shows the pathophysiological information of images via extracting innumerable quantitative features from digital medical images. In recent years, it has been an exponential increase in the number of radiomics studies. The applications of radiomics in hepatobiliary diseases at present include: assessment of liver fibrosis, discrimination of malignant from benign tumors, prediction of biological behavior, assessment of therapeutic response, and prognosis. Integrating radiomics analysis with machine learning algorithms has emerged as a non-invasive method for predicting liver fibrosis stages, microvascular invasion and post-resection recurrence in liver cancers, lymph node metastasis in biliary tract cancers as well as treatment response in colorectal liver metastasis, with high performance. Although the challenges remain in the clinical transformation of this technique, radiomics will have a broad application prospect in promoting the precision diagnosis and treatment of hepatobiliary diseases, backed by multi-center study with large sample size or multi-omics study.

[A comparative study of total laparoscopic and laparoscopic-assisted simultaneous resection for colorectal cancer liver metastasis].

Objective: To compare the safety and outcome between total laparoscopic and laparoscopy-assisted synchronous resection for colorectal cancer patients with liver metastases. Methods: The data of patients who underwent total laparoscopic or laparoscopy-assisted simultaneous resection of primary colorectal cancer and liver metastases in our hospital between December 2008 and December 2016 were collected and analyzed. The total laparoscopic surgery patients were matched 1∶2 to the laparoscopy-assisted surgery patients based on the propensity score. 22 patients were classified in the total laparoscopic group and 44 patients were classified in the laparoscopy-assisted group. The intraoperative conditions and postoperative outcomes of the two groups were compared. Results: There was no difference in the preoperative baseline data between the two groups (P>0.05). The median operative time were 317.50 and 267.50 minutes in the total laparoscopic group and the laparoscopy-assisted group, respectively, and the median intraoperative blood loss were 100 and 200 ml, both with no statistically significant differences (P>0.05). There were 1 case of intraoperative blood transfusion in the total laparoscopic group and 5 cases in the laparoscopy-assisted group, with no statistically significant difference (P=0.650). The median postoperative hospital stay in the two groups were 11.0 and 10.0 days, the median postoperative defecation time were 4.0 and 4.0 days and postoperative complication rates were 13.6% and 20.5%, and none of these differences were statistically significant (P>0.05). However, no Clavien-DindoⅡ level and above complications occurred in total laparoscopic group. The median disease-free survival (DFS) were 15.0 and 15.7 months in the total laparoscopic group and the laparoscopy-assisted group, the overall survival (OS) were 25.9 and 37.6 months, respectively, with no statistically significant differences (P>0.05). Conclusion: Laparoscopy-assisted approaches are similar, so the appropriate approach should be chosen according to the clinical condition and surgeon's experience.

[Efficacy and safety of low-intensity pulsed ultrasound at different intervals by mechanical force in treating erectile dysfunction: a preliminary study].

Objective: To study the efficacy and safety of low-intensity pulsed ultrasound (LIPUS) at different intervals by mechanical force in treating erectile dysfunction (ED). Method: Forty patients with mild to moderate ED were randomized in a 1∶1 ratio to receive 16-treatment sessions of LIPUS in group A and group B, applied 3 times per week and 2 times per week, respectively. End-point assessments were made at 8th week after treatment. Efficacy were evaluated using International Index of Erectile Function-Erectile Function domain score (IIEF-EF), Erectile Hardness Score (EHS), Self-Esteem and Relationship Questionnaire (SEAR), Sexual Encounter Profile (SEP), Global Assessment Question (GAQ), and pain were assessed by Visual Analogue Score (VAS).Treatment response was confirmed by a minimal clinically importance difference (MCID) at 8th week. Results: Compared with baseline, IIEF-EF score [(17.1±5.48 vs 23.4±3.75, P<0.05) and (18.9±4.34 vs 24.1±4.32, P<0.05)], proportion of EHS 4 [(0 vs 40%, P<0.05) and (16.7% vs 55.6%, P<0.05)], and Overall Relationship score [(50.6 vs 67.5, P<0.05) and (44.4 vs 70.1, P<0.05)] were significantly improved at 8th week in two groups, respectively. Compared with baseline, the positive responses to SEP-3 increased significantly at 8th week in two groups (50.0% vs 80.0%,P<0.05) and (44.4% vs 88.9%, P<0.05), respectively. The positive responses to GAQ-2 were 90.0% and 88.9% at 8th week in two groups, respectively. There were no significant differences in IIEF-EF, EHS, SEAR, SEP and GAQ at 8th week between two groups. There was no significant difference in treatment response using MCID between two groups at end-point (80.5% vs 77.5%). The treatment duration for full sessions were 2.5 weeks less in group A than group B. No adverse effects were reported in all cases. Conclusion: LIPUS at two different intervals is effective and safe for mild to moderate ED, and the regimen at 3 times per week can achieve quite good effect in relatively short duration,while the long-term effects is still be clarified in further study.

Estrogen and estrogen receptor affects MMP2 and MMP9 expression through classical ER pathway and promotes migration of lower venous vascular smooth muscle cells.

OBJECTIVE: To explore the role of estrogen and estrogen receptors in the migration of vascular smooth muscle cells in varicose lower-extremity veins. PATIENTS AND METHODS: Tissue samples of normal lower extremity vein (56 cases) and varicose lower extremity vein (47 cases) were collected. Western blot and real-time fluorescent qPCR were performed to measure the expression of Estrogen receptor α (ERα) in tissues. Two cell co-culture systems were established for human umbilical vein endothelial cells (HUVECs) and human umbilical vein smooth muscle cells (HUVSMCs). One system was incubated under normal oxygen conditions (normal oxygen group), and the other was under oxygen-poor conditions (hypoxia group). The two systems were treated with 10-7 mM Estrogen E2, 10-7 mM BSA-conjugated Estrogen E2-BSA, 10-7 mM Estrogen E2+10-3 mM Tamoxifen (TAM), respectively for 24 h. The treated cells were subjected to cell scratch assay, transwell assay, and Western blot analysis of MMP2 and MMP9 protein expression. RESULTS: The expression of ERα in varicose lower extremity vein was significantly up-regulated compared with that in normal lower extremity vein. The cell migration rate and the number of migrating cells in untreated hypoxia group and E2-treated normal oxygen group were comparable (p>0.05) to those in untreated normal oxygen group. The cell migration rate and the number of migrating cells were significantly increased (p<0.05) in E2-treated hypoxia group, compared with E2-treated normal oxygen group and untreated hypoxia group. The cell migration rate, the number of migrating cells, and expression levels of MMP2 and MMP9 were significantly decreased in E2/TAM-treated hypoxia group, compared with those in E2-treated hypoxia group. CONCLUSIONS: In summary, E2 can promote the migration of vascular smooth muscle cells and induce varicose veins of the lower extremities, which may be related to the promotion of MMP2 and MMP9 expression through the classical pathway of ER.

Genomic and transcriptional heterogeneity of multifocal hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) often presents with multiple nodules within the liver, with limited effective interventions. The high genetic heterogeneity of HCC might be the major cause of treatment failure. We aimed to characterize genomic heterogeneity, infer clonal evolution, investigate RNA expression pattern and explore tumour immune microenvironment profile of multifocal HCC. PATIENTS AND METHODS: Whole-exome sequencing and RNA sequencing were carried out in 34 tumours and 6 adjacent normal liver tissue samples from 6 multifocal HCC patients. Protein expression of Ki67, AFP, P53, Survivin and CD8 was detected by immunohistochemistry. Fluorescence in situ hybridization was carried out to validate the amplification status of sorafenib-targeted genes. RESULTS: We deciphered genomic and transcriptional heterogeneity among tumours in each multifocal HCC patient including mutational profiles, copy number alterations, tumour evolutionary trajectory and tumour immune microenvironment profiles. Of note, sorafenib-targeted alterations were identified in the trunk of phylogenetic tree in only one out of the six patients, which may explain the relative low treatment response rate to sorafenib in clinical practice. Moreover, we demonstrated RNA expression patterns and tumour immune microenvironment profiles of all nodules. We found that RNA expression pattern was associated with Edmondson-Steiner grading. Based on the differential expression of 66 reported immune markers, unsupervised hierarchical clustering analysis of 34 nodules identified immune subsets: one low expression cluster with seven nodules and one high expression cluster with 11 nodules. CD8+ T cells were more enriched in nodules of the high expression cluster. CONCLUSIONS: Our study provided a detailed view of genomic and transcriptional heterogeneity, clonal evolution and immune infiltration of multifocal HCC. The heterogeneity of druggable targets and immune landscape might help interpret the clinical responsiveness to targeted drugs and immunotherapy for multifocal HCC patients.

MiR-218 suppresses metastasis and invasion of endometrial cancer via negatively regulating ADD2.

OBJECTIVE: Endometrial cancer (EC) is one of the three most common gynecological cancers. Due to the lack of effective treatment for EC patients in an advanced stage, the mortality rate of EC is increasing rapidly. Hence, it is essential to seek for novel molecular therapeutic targets and biomarkers for EC. The aim of this study was to explore the role of miR-218 in the occurrence and development of EC and to investigate the possible underlying mechanism. PATIENTS AND METHODS: The expression level of miR-218 in EC tissues and cell lines was detected by quantitative Real Time-Polymerase Chain Reaction (qRT-PCR). Wound healing assay and Matrigel assay were performed to determine the migration and invasion abilities of EC cells. Meanwhile, the potential targets of miR-218 were predicted by bioinformatics analysis and confirmed by Luciferase reporter gene assay. In addition, the protein expression level of Adducin 2 (ADD2) was assessed by Western blotting analysis. RESULTS: QRT-PCR results revealed that miR-218 was significantly downregulated in EC tissues and cell lines. Wound healing assay and Matrigel assay demonstrated that miR-218 suppressed the migration and invasion abilities of EC cells. Online prediction databases predicted that ADD2 was a direct target of miR-218, which was verified by Luciferase reporter gene assay. Rescue experiments further validated that miR-218 could serve as a carcinoma suppressor by negatively regulating ADD2 expression in EC. CONCLUSIONS: In the present study, we elucidated that miR-218 served as a tumor suppressor in EC by negatively regulating ADD2. This might bring a novel insight into new molecular therapeutic targets and biomarkers for EC.

mir-637 inhibits the proliferation of cholangiocarcinoma cell QBC939 through interfering CTSB expression.

OBJECTIVE: To investigate the role of mir-637 on the proliferation, migration and apoptosis in human cholangiocarcinoma (CCA) cell line QBC939, and the impact of mir-637 on Cathepsin B (CTSB) expression. MATERIALS AND METHODS: Expression of mir-637 and CTSB in CCA tissues and adjacent non-tumor tissues were measured by Real-time PCR. CTSB expression in human CCA cell lines was detected with or without mir-637 exogenous overexpression through fluorescent quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) method. The efficiency of lentivirus-mir-637 vector infection, and the effect of mir-637 on the proliferation, migration ability, apoptosis and cell cycle of CCA cell were detected, respectively. The possibility of mir-637 targeting CTSB was also tested by bioinformatics method, correlation analysis and molecular biology method. RESULTS: Decreased mir-637 and increased CTSB expression were observed in CCA tissue compared with adjacent non-tumor tissues. CTSB expression in mir-637 exogenously overexpressed QBC939 cells decreased compared with negative control. Mir-637 overexpression caused significant decrease of proliferation and migration ability of QBC939 cell. In addition, mir-637 overexpression induced that the cell cycle was blocked in G0/G1 phase, and cell apoptosis rate increased significantly. CONCLUSIONS: mir-637 and CTSB play an important role in the proliferation and migration of CCA cells. Mir-637 could inhibit CTSB expression significantly, which in-turn down-regulates the proliferation, migration and invasion ability of QBC939 cell, and promotes apoptosis in QBC939 cell line.

A mutational signature associated with alcohol consumption and prognostically significantly mutated driver genes in esophageal squamous cell carcinoma.

Background: Esophageal squamous cell carcinoma (ESCC) is often diagnosed at an advanced and incurable stage. Information on driver genes and prognosticators in ESCC remains incomplete. The objective was to elucidate significantly mutated genes (SMGs), mutational signatures, and prognosticators in ESCC. Patients and methods: Three MutSig algorithms (i.e. MutSigCV, MutSigCL and MutSigFN) and '20/20+' ratio-metric were employed to identify SMGs. Nonnegative matrix factorization was used to decipher mutational signatures. Kaplan-Meier survival analysis, multivariate Cox and logistic regression models were applied to analyze association between mutational features and clinical parameters. Results: We identified 26 SMGs, including 8 novel (NAV3, TENM3, PTCH1, TGFBR2, RIPK4, PBRM1, USP8 and BAP1) and 18 that have been previously reported. Three mutational signatures were identified to be prevalent in ESCC including clocklike C>T at CpG, APOBEC overactive C>T at TpCp[A/T], and a signature featured by T>C substitution. The T>C mutational signature was significantly correlated with alcohol consumption (OR: 3.59; 95% CI: 2.30-5.67; P < 0.001). This alcohol consumption signature was also observed in liver cancer and head and neck squamous cell carcinoma, and its mutational activity was substantially higher in samples with mutations in TP53. Survival analysis revealed that TENM3 mutations (HR: 5.54; CI: 2.68-11.45; P < 0.001) and TP53 hotspot mutation p.R213* (HR: 3.37; CI: 1.73-8.06; P < 0.001) were significantly associated with shortened survival outcome. The association remained statistically significant after controlling for age, gender, TNM stage and tumor grade. Conclusions: We have uncovered several new SMGs in ESCC and defined an alcohol consumption related mutational signature. TENM3 mutations and the TP53 hotspot mutation p.R213* are independent prognosticators for poor survival in ESCC.

Innate allorecognition by monocytic cells and its role in graft rejection.

Innate recognition of microbial products and danger molecules by monocytes and macrophages has been well established; this is mediated primarily by pattern-recognition receptors and is central to the activation of innate and adaptive immune cells required for productive immunity. Whether monocytes and macrophages are equipped with an allorecognition system that allows them to respond directly to allogeneic grafts is a topic of much debate. Recent studies provide compelling evidence that these cells can recognize allogeneic entities and that they mediate graft rejection via direct cytotoxicity and priming of alloreactive T cells. In addition, these studies have uncovered a mechanism of innate allorecognition based on detection of the polymorphic molecule signal regulatory protein α (SIRPα) on donor cells. Further understanding of innate allorecognition and its consequences would provide essential insight into allograft rejection and lead to better therapies for transplant patients.