Lung Nodule Segmentation and Uncertain Region Prediction With an Uncertainty-Aware Attention Mechanism.

Radiologists possess diverse training and clinical experiences, leading to variations in the segmentation annotations of lung nodules and resulting in segmentation uncertainty. Conventional methods typically select a single annotation as the learning target or attempt to learn a latent space comprising multiple annotations. However, these approaches fail to leverage the valuable information inherent in the consensus and disagreements among the multiple annotations. In this paper, we propose an Uncertainty-Aware Attention Mechanism (UAAM) that utilizes consensus and disagreements among multiple annotations to facilitate better segmentation. To this end, we introduce the Multi-Confidence Mask (MCM), which combines a Low-Confidence (LC) Mask and a High-Confidence (HC) Mask. The LC mask indicates regions with low segmentation confidence, where radiologists may have different segmentation choices. Following UAAM, we further design an Uncertainty-Guide Multi-Confidence Segmentation Network (UGMCS-Net), which contains three modules: a Feature Extracting Module that captures a general feature of a lung nodule, an Uncertainty-Aware Module that produces three features for the annotations' union, intersection, and annotation set, and an Intersection-Union Constraining Module that uses distances between the three features to balance the predictions of final segmentation and MCM. To comprehensively demonstrate the performance of our method, we propose a Complex-Nodule Validation on LIDC-IDRI, which tests UGMCS-Net's segmentation performance on lung nodules that are difficult to segment using common methods. Experimental results demonstrate that our method can significantly improve the segmentation performance on nodules that are difficult to segment using conventional methods.

Bacillus cereus G2 Facilitates N Cycle in Soil, Further Improves N Uptake and Assimilation, and Accelerates Proline and Glycine Betaine Metabolisms of Glycyrrhiza uralensis Subjected to Salt Stress.

Soil salinity is a severe abiotic stress that reduces crop productivity. Recently, there has been growing interest in the application of microbes, mainly plant-growth-promoting bacteria (PGPB), as inoculants for saline land restoration and plant salinity tolerance. Herein, the effects of the plant endophyte G2 on regulating soil N cycle, plant N uptake and assimilate pathways, proline and glycine betaine biosynthesis, and catabolic pathways were investigated in Glycyrrhiza uralensis exposed to salinity. The results indicated that G2 improved the efficiency of N absorption and assimilation of plants by facilitating soil N cycling. Then, G2 promoted the synthesis substrates of proline and glycine betaine and accelerated its synthesis rate, which increased the relative water content and reduced the electrolyte leakage, eventually protecting the membrane system caused by salt stress in G. uralensis. These findings will provide a new idea from soil to plant systems in a salinity environment.

TME-triggered copper-coordinated engineered programmable nanogenerators for on-demand cascade-amplifying oxidative stress.

Although oxidative stress-based antitumor modality derived from reactive oxygen species (ROS) storm has attracted considerable attention in copper-based nanomaterials, its efficiency is still weakened by the insufficient hydrogen peroxide (H2O2) and overexpressed glutathione (GSH) in a tumor microenvironment (TME). In view of this, we designed an engineered programmable spike-like nanogenerator via the coordination-driven co-assembly of Evans Blue (EB), copper ions (CuII), and 5-hydroxy-p-naphthoquinone (HND). For programmable nanogenerators, the introduction of EB as a stabilizer-like component can not only adjust its morphology but also achieve its visual tracking. Interestingly, such programmable nanogenerators can be efficiently enriched in tumor regions and then internalized into tumor cells due to ECH with spike-like morphology. Notably, once the nanogenerator is disintegrated and burst to release the drug upon acidic lysosome and endogenous GSH triggering, the released HND can not only efficiently amplify endogenous H2O2 by intracellular oxidoreductases but also down-regulate the peptidyl-prolyl cis-trans isomerase NIMA-interacting 1 (Pin 1) activity. In addition, the released CuII ions can efficiently catalyze the degradation of the endogenous H2O2 to amplify hydroxyl radicals (˙OH) and down-regulate the overexpressed GSH to reduce ˙OH elimination for on-demand cascade-amplifying oxidative stress. Importantly, such programmable nanogenerators show an excellent antitumor effect via down-regulating the Pin 1 activity and cascade-amplifying oxidative stress. In this study, we propose a spatiotemporally programmable cascade nanogenerator for oxidative stress-based antitumor therapy.

Platinum-Coordinated Engineered Nanoreactors with O2 Self-Amplificationand On-Demand Cascade Chemo-Drug Synthesis for Self-Reinforcing Hypoxic Oncotherapy.

How to efficiently synthesize toxic chemo-drugs in the hypoxia tumor microenvironment still faces a huge challenge. Herein, we have tailored engineered vehicle-free nanoreactors by coordination-driven co-assembly of photosensitizer indocyanine green (ICG), transition metal platinum (Pt), and nontoxic 1,5-dihydroxynaphthalene (DHN) to self-amplify O2 and cascade chemo-drug synthesis in tumor cells for self-reinforcing hypoxic oncotherapy. Once vehicle-free nanoreactors are internalized into tumor cells, they show a serious instability that results in rapid disassembly and on-demand drug release under the stimuli of acidic lysosome and laser radiation. Notably, the released Pt can efficiently decompose the endogenous hydrogen peroxide (H2O2) into O2 to alleviate tumor hypoxia, which is conducive to enhancing the photodynamic therapy (PDT) efficiency of the released ICG. Complementarily, a large amount of the 1O2 generated by PDT can efficiently oxidize the released nontoxic DHN into the highly toxic chemo-drug juglone. Therefore, such vehicle-free nanoreactors can achieve intracellular on-demand cascade chemo-drug synthesis and self-reinforce photo-chemotherapeutic efficacy on the hypoxic tumor. On the whole, such a simple, flexible, efficient, and nontoxic therapeutic strategy will broaden the study of on-demand chemo-drug synthesis and hypoxic oncotherapy.

Physio-biochemical and transcriptomic analysis reveals that the mechanism of Bacillus cereus G2 alleviated oxidative stress of salt-stressed Glycyrrhiza uralensis Fisch. seedlings.

Salt stress severely affects the growth and productivity of Glycyrrhiza uralensis. Our previous research found that the endophyte Bacillus cereus G2 alleviated the osmotic and oxidative stress in G. uralensis exposed to salinity. However, the mechanism is still unclear. Here, a pot experiment was conducted to analyse the change in parameters related to osmotic adjustment and antioxidant metabolism by G2 in salt-stressed G. uralensis at the physio-biochemistry and transcriptome levels. The results showed that G2 significantly increased proline content by 48 %, glycine betaine content by 75 % due to activated expression of BADH1, and soluble sugar content by 77 % due to upregulated expression of α-glucosidase and SS, which might help to decrease the cell osmotic potential, enable the cell to absorb water, and stabilize the cell's protein and membrane structure, thereby alleviating osmotic stress. Regarding antioxidant metabolism, G2 significantly decreased malondialdehyde (MDA) content by 27 %, which might be ascribed to the increase in superoxide dismutase (SOD) activity that facilitated the decrease in the superoxide radical (O2‾) production rate; it also increased the activities of catalase (CAT), ascorbate peroxidase (APX) and glutathione peroxidase (GPX), which helped stabilize the normal level of hydrogen peroxide (H2O2). G2 also increased glutathione (GSH) content by 65 % due to increased glutathione reductase (GR) activity and GSH/GSSG ratio, but G2 decreased oxidized glutathione (GSSG) content by 13 % due to decreased activity of dehydroascorbate reductase (DHAR), which could provide sufficient substrates for the ascorbate-glutathione (AsA-GSH) cycle to eliminate excess H2O2 that was not cleared in a timely manner by the antioxidant enzyme system. Taken together, G2 alleviated osmotic stress by increasing proline, soluble sugar, and glycine betaine contents and alleviated oxidative stress by the synergistic effect of antioxidant enzymes and the AsA-GSH cycle. Therefore, the results may be useful for explaining the mechanism by which endophyte inoculation regulates the salt tolerance of crops.

Effect of Hypothermia on Serum Myelin Basic Protein and Tumor Necrosis Factor-α in Neonatal Hypoxic-Ischemic Encephalopathy.

OBJECTIVE: Multiple randomized controlled trials have shown that hypothermia is a safe and effective treatment for neonatal moderate or severe hypoxic-ischemic encephalopathy (HIE). The neuroprotective mechanisms of hypothermia need further study. The aim of this study was to investigate the effect of hypothermia on the serum levels of myelin basic protein (MBP) and tumor necrosis factor-α (TNF-α) as well as neurodevelopmental outcomes in neonatal HIE. STUDY DESIGN: Eighty-five neonates with moderate-to-severe HIE were divided into a hypothermia group (n = 49) and a control group (n = 36). Serum levels of MBP and TNF-α within 6 hours after birth and after 3 days of treatment were determined by enzyme-linked immunosorbent assay, and neurodevelopmental outcome at the age of 12 to 15 months was assessed by using the Gesell development scale. RESULTS: After 3 days of treatment, serum levels of MBP and TNF-α in the control group were not significantly different from levels before treatment (p > 0.05), and serum levels of MBP and TNF-α in the hypothermia group were significantly lower than levels before treatment (p < 0.05). Serum levels of MBP and TNF-α were significantly negatively correlated with developmental quotient (DQ; r = - 0.7945, p = 0.0000; r = - 0.7035, p = 0.0000, respectively). Serum levels of MBP and TNF-α in neurodevelopmentally impaired infants were significantly higher than those in infants with suspected neurodevelopmental impairment and those in neurodevelopmentally normal infants (both p < 0.01). The rate of reduction of neurodevelopmental impairment was higher among infants in the hypothermia group than among those in the control group (χ2 = 16.3900, p < 0.05). CONCLUSION: Hypothermia can reduce serum levels of MBP and TNF-α in neonates with HIE. Inhibiting the release of TNF-α may be one of the mechanisms by which hypothermia protects the myelin sheath. KEY POINTS: · Hypothermia can reduce serum levels of MBP and TNF-α in neonatal HIE.. · Hypothermia improves neurodevelopmental outcomes and reduces the rate of neurodevelopmental impairment.. · Hypothermia is a feasible and effective treatment for neonates with moderate or severe HIE..

Hsa_circ_0092276 promotes doxorubicin resistance in breast cancer cells by regulating autophagy via miR-348/ATG7 axis.

Previous study has confirmed that hsa_circ_0092276 is highly expressed in doxorubicin (DOX)-resistant breast cancer cells, indicating that hsa_circ_0092276 may be involved in regulating the chemotherapy resistance of breast cancer. Here we attempted to investigate the biological role of hsa_circ_0092276 in breast cancer. We first constructed DOX-resistant breast cancer cells (MCF-7/DOX and MDA-MB-468/DOX). The 50% inhibiting concentration of MCF-7/DOX and MDA-MB-468/DOX cells was significantly higher than that of their parental breast cancer cells, MCF-7 and MDA-MB-46. MCF-7/DOX and MDA-MB-468/DOX cells also exhibited an up-regulation of drug resistance-related protein MDR1. Compared with MCF-7 and MDA-MB-46 cells, hsa_circ_0092276 was highly expressed in MCF-7/DOX and MDA-MB-468/DOX cells. Hsa_circ_0092276 overexpression enhanced proliferation and the expression of LC3-II/LC3-I and Beclin-1, and repressed apoptosis of breast cancer cells. The effect of hsa_circ_0092276 up-regulation on breast cancer cells was abolished by 3-methyladenine (autophagy inhibitor). Hsa_circ_0092276 modulated autophagy-related gene 7 (ATG7) expression via sponging miR-384. Hsa_circ_0092276 up-regulation promoted autophagy and proliferation, and repressed apoptosis of breast cancer cells, which was abolished by miR-384 overexpression or ATG7 knockdown. In addition, LV-circ_0092276 transfected MCF-7 cell transplantation promoted autophagy and tumor growth of breast cancer in mice. In conclusion, our data demonstrate that hsa_circ_0092276 promotes autophagy and DOX resistance in breast cancer by regulating miR-348/ATG7 axis. Thus, this article highlights a novel competing endogenous RNA circuitry involved in DOX resistance in breast cancer.

Realistic Lung Nodule Synthesis With Multi-Target Co-Guided Adversarial Mechanism.

The important cues for a realistic lung nodule synthesis include the diversity in shape and background, controllability of semantic feature levels, and overall CT image quality. To incorporate these cues as the multiple learning targets, we introduce the Multi-Target Co-Guided Adversarial Mechanism, which utilizes the foreground and background mask to guide nodule shape and lung tissues, takes advantage of the CT lung and mediastinal window as the guidance of spiculation and texture control, respectively. Further, we propose a Multi-Target Co-Guided Synthesizing Network with a joint loss function to realize the co-guidance of image generation and semantic feature learning. The proposed network contains a Mask-Guided Generative Adversarial Sub-Network (MGGAN) and a Window-Guided Semantic Learning Sub-Network (WGSLN). The MGGAN generates the initial synthesis using the mask combined with the foreground and background masks, guiding the generation of nodule shape and background tissues. Meanwhile, the WGSLN controls the semantic features and refines the synthesis quality by transforming the initial synthesis into the CT lung and mediastinal window, and performing the spiculation and texture learning simultaneously. We validated our method using the quantitative analysis of authenticity under the Fréchet Inception Score, and the results show its state-of-the-art performance. We also evaluated our method as a data augmentation method to predict malignancy level on the LIDC-IDRI database, and the results show that the accuracy of VGG-16 is improved by 5.6%. The experimental results confirm the effectiveness of the proposed method.

Supraclavicular Approach of Lobectomy Improves Quality of Life for Patients With Unilateral Papillary Thyroid Microcarcinoma: A Prospective Cohort Study.

Objective: Postoperative neck symptoms, including pain, swelling, uncomfortable feelings during swallowing, and incision adhesion formation, are common in patients after lobectomy through the traditional middle neck approach. A new unilateral supraclavicular approach is proposed to protect the anterior cervical region and reduce related complications. The aim of this study is to investigate the efficacy, safety, and advantages of the supraclavicular approach in lobectomy for unilateral papillary thyroid microcarcinoma (PTMC). Methods: Two hundred sixty-three patients were recruited into either a conventional middle group (CM) or a new supraclavicular (NS) group. Clinicopathological features, surgically related variables, and postoperative symptoms were recorded. Quality of life (QOL) of all patients was assessed by the 12-item short-form health survey (SF-12) and thyroid cancer-specific QOL (THYCA-QoL) questionnaire in 3 and 12 months. Results: There were no statistically significant differences in clinicopathological features (including sex, age, multifocality, extrathyroidal extension, histological variants, largest tumor diameter, Hashimoto's thyroiditis, metastasized central lymph node, removed central lymph node, surgeon, BRAF mutation, and follow-up duration), hospitalization (including hospital cost, surgery time, and blood loss during surgery), and complications between the two groups. Patients who underwent lobectomy through the NS approach had significantly better SF-12 physical, mental, and THYCA-QoL than the CM group patients in both 3 and 12 months (all p < 0.001). Moreover, the NS group had a shorter hospitalization time. Conclusion: In conclusion, the NS approach for lobectomy is a safe and effective method for reducing postoperative symptoms and increasing QOL in patients with unilateral PTMC in both 3 and 12 months' follow-up.

Establishment of cohesion 1 homolog 2 facilitates cell aggressive behaviors and induces poor prognosis in renal cell carcinoma.

BACKGROUND AND AIMS: Establishment of cohesion 1 homolog 2 (ESCO2) has been identified as an essential factor for cohesion in cell cycle in human multiple cancers. Nonetheless, its functional implication on prognosis and cellular behaviors of renal cell carcinoma (RCC) is rarely elucidated. We performed this study to detect the effects of ESCO2 in RCC progression. METHODS: We accessed The Cancer Genome Atlas (TCGA) database to evaluate the ESCO2 expression levels in tumor tissues, including 32 normal tissues and 289 tumor tissues. Quantitative real-time PCR and Western blot were implemented for expression detection. After ESCO2 knockdown using siRNAs interference, functional experiments were conducted to explore the role of ESCO2, such as cell proliferation analysis and colony formation assay. Transwell assays for migration and invasion was also performed. RESULTS: In this study, ESCO2 was significantly increased in RCC tissues and cell lines. The RCC patients with high expression of ESCO2 were susceptible to unfavorable prognosis, and its expression has a marked association with clinical features containing age, gender, pathologic stage, and so on. Furthermore, knockdown of ESCO2 inhibited cell growth, invasion, and migration. Mechanistically, phosphorylation protein kinase B (AKT) and mammalian target of rapamycin (mTOR), proliferating cell nuclear antigen (PCNA), and p53 were all down-regulated due to the ESCO2 inhibition. CONCLUSIONS: Therefore, our results raised the possibility that ESCO2 may act as a promising option for tumor therapeutic interference by exhibiting enhanced selectivity over conventional chemotherapy.

PYCR1 is Associated with Papillary Renal Cell Carcinoma Progression.

OBJECTIVE: We aimed to determine the function of pyrroline-5-carboxylate reductase 1 (PYCR1) on progression of papillary renal cell carcinoma (PRCC) and related mechanism. METHODS: The TCGA database provided us expression profiles of PYCR1 and overall survival rates. Small interfering RNA (siRNA) was used to knockdown PYCR1; quantitative real-time polymerase chain reaction (qRT-PCR) and western blotting were conducted to identify the expression levels of mRNA and protein. The cell counting kit-8 (CCK-8) and colony formation assays were used to explore cell viability in Ketr-3 cells. The migration and invasion of Ketr-3 cells were investigated by transwell assays. RESULTS: We found that PYCR1 was over-expressed in PRCC tissues and cells, causing poor outcomes. Moreover, reduction of PYCR1 played a negative role on cell proliferation, migration and invasion in tumor cells. The important Akt/mTOR pathway proteins, phosphorylated Akt (p-Akt) and phosphorylated mTOR (p-mTOR), also showed lower levels compared with control groups. CONCLUSION: These findings showed that disordered expression of PYCR1 could modulate PRCC progression through the Akt/mTOR pathway, implying a theoretical basis for PYCR1 as a potential therapeutic target in future clinical PRCC treatment.

Silence of lncRNA ANRIL represses cell growth and promotes apoptosis in retinoblastoma cells through regulating miR-99a and c-Myc.

Retinoblastoma is a rare cancer of the immature retina. This study designed to see the function of the lncRNA ANRIL in retinoblastoma Y79 cells. ANRIL, miR-99a and c-Myc expression in Y79 cells was altered by transfection and then trypan blue, transwell assay and flow cytometry were carried out to evaluate the changes of cell phenotype. The connection between ANRIL, miR-99a and c-Myc was measured by luciferase reporter assay and RNA immunoprecipitation analysis. As a result, ANRIL expression was highly expressed in human retinoblastoma tissue as relative to the adjacent noncancerous tissues. ANRIL suppression inhibited Y79 cells viability, migration, invasion, while promoted apoptosis. ANRIL negatively regulated miR-99a by binding to miR-99a. Silence of miR-99a reversed the ANRIL-knockdown effects on Y79 cells. miR-99a overexpression suppressed Y79 cell viability, migration, invasion, and enhanced apoptosis through downregulating c-Myc. Meanwhile, we found that miR-99a inhibited JAK/STAT and PI3K/AKT pathways. To conclude, it seems that ANRIL suppression inhibits cell growth and metastasis in retinoblastoma Y79 cells by regulating miR-99a and c-Myc.

Novel Combination Oncolytic Adenoviral Gene Therapy Armed with Dm-dNK and CD40L for Breast Cancer.

BACKGROUND: Both Drosophila melanogaster deoxyribonucleoside kinase (Dm-dNK) suicide gene therapy and exogenous CD40 ligand (CD40L)-CD40 interaction in cancer via conditionally replicating adenovirus can selectively kill tumors without damaging normal tissues. OBJECTIVE: To further improve the cancer killing effect, we investigated the therapeutic effect of combined cancer gene therapy based on a selective oncolytic adenovirus vector containing Dm-dNK suicide gene and exogenous CD40L on breast carcinoma cells in vitro and in vivo. METHODS: A series of conditionally replicating adenoviruses using adenovirus vector P74 were generated: P74-dNK, P74-CD40L (expressing Dm-dNK or CD40L respectively), and P74-dNK-CD40L (expressing combined Dm-dNK and CD40L). Breast cancer cell lines (MDA-MB-231, MCF-7) and non-tumor cell line (MRC5) were treated with adenovirus and cytotoxicity determined by MTT assay, and apoptosis assessed by flow cytometry after 72h. We also assessed in vivo cell killing efficiency using a mouse xenograft model with MDA-MB-231 cells. RESULTS AND DISCUSSION: Co-expression of Dm-dNK and CD40L reduced cell proliferation of MDAMB- 231 or MCF7 cancer cells, and induced more apoptosis in TERT and CD40 positive cancer cells, but not normal MRC5 cells. Significant reduction in tumor volume was also seen in combined treatment arms as compared to any single treatment. CONCLUSION: Our data suggest enhanced, selective tumor cell killing using combined gene therapy with conditionally replicating adenovirus containing Dm-dNK suicide gene and exogenous CD40 ligation (CD40L-CD40).

Neonatal hypoxic-ischemic encephalopathy: emerging therapeutic strategies based on pathophysiologic phases of the injury.

Neonatal hypoxic ischemic encephalopathy (HIE) is an important cause of neonatal death and disability. At present, there is no unified standard and specialized treatment method for neonatal HIE. In clinical practice, we have found that a gap remains between preclinical medical research and clinical application in the treatment of neonatal HIE. To promote an organic combination of preclinical research and clinical application, we propose the different phases as intervention targets, based on the pathophysiologic changes in phases I, II, and III of neonatal HIE; moreover, we suggest transformative medicine as a principle that may improve the therapeutic effect by blocking the progression of the disease to an irreversible stage. For instance, in phase I, mild hypothermia, free radical scavenger (erythropoietin, hydrogen-rich saline), excitatory amino acid receptor blocker, and neuroprotective agents should be administered to neonates with moderate/severe HIE; in phase II, following phase I treatment, anti-inflammatory agents, neuroprotective or nerve regeneration agents, and stem cell transplantation should be administered to patients; in phase III, anti-inflammatory agents, neuroprotective or nerve regeneration agents, and stem cell transplantation should be administered to patients. As soon as the patient's condition has stabilized, acupuncture, massage, and rehabilitation training should be performed. Following further study of stem cells, stem cell transplantation is expected to become the most promising therapeutic candidate for treatment of severe neonatal HIE with its sequelae.

Neonatal Crohn's disease with Oral ulcer as the first symptom caused by a compound heterozygote mutation in IL-10RA: a case report.

OBJECTIVE: To investigate the clinical and genetic characteristics of neonatal Crohn's disease (CD), improve recognition of neonatal CD, and reduce the number of patients that are missed or misdiagnosed. METHODS: A 10-day-old Chinese girl with oral ulcers was admitted to the Department of Neonatology. She later developed a rash and perianal disease, but without diarrhea and stool abnormalities. The patient and her parents underwent next-generation sequencing. RESULTS: The results showed that the patient carries a compound heterozygous mutation in the interleukin-10 receptor A (IL-10RA) (NM_001558.3) gene. One heterozygous mutation was c.301 c > T, P. (Arg 101 Trp) in exon 3 of IL-10RA (a missense mutation), and the other was c. 537G > A, P. (Thr 179 =) in exon 4 of IL 10RA (a synonymous mutation). The patient's father also carries the c.301 c > T, P. (Arg 101 Trp) heterozygous mutation in exon 3 of IL-10RA, whereas her mother carries the c.537G > A, P. (Thr 179 =) heterozygous mutation in exon 4 of IL-10RA. CONCLUSIONS: The results show that a compound heterozygous mutation in IL-10RA is associated with neonatal CD. Oral ulcers with a rash and perianal disease may be an early symptom of neonatal CD; therefore, such patients should undergo genetic identification as soon as possible.

Expression of vascular endothelial growth factor and caspase-3 in mucinous breast carcinoma and infiltrating ductal carcinoma-not otherwise specified, and the correlation with disease-free survival.

Mucinous breast carcinoma (MBC) is a rare type of breast cancer, but it has been infrequently studied due to its associated good prognosis. Vascular endothelial growth factor (VEGF) and caspase-3 have been identified to be prognostic factors of infiltrating ductal carcinoma-not otherwise specified (IDC-NOS), but their expression in MBC has not been reported. In the present study, the expression of caspase-3 and VEGF in MBC and IDC-NOS were assessed by immunohistochemistry. Scoring was conducted based on staining intensity and percentage of positive cells. Based on the scores of caspase-3 and VEGF expression, all patient samples were divided into two groups: Low expression (score of 0-5) or high expression (score of 6-12). In total, 42.59% of MBC patients exhibited a high VEGF score compared with 61.67% of the IDC-NOS group (P<0.05). Furthermore, 57.41% of MBC patients exhibited high caspase-3 expression compared with only 33.33% of IDC-NOS patients (P<0.05). VEGF expression in MBC was associated with age, nodal status and tumor-node-metastasis (TNM) stage. Cox univariate analysis showed that higher VEGF expression, positive nodal status and higher TNM stage were associated with shorter disease-free survival (DFS). The Kaplan-Meier method showed that higher VEGF expression in MBC was associated with worse DFS times, while Cox multivariate analysis showed that only TNM stage was significantly associated with DFS. VEGF and caspase-3 expression varied in the MBC and IDC-NOS samples, but neither was directly correlated with DFS in the MBC patients.