Clinical feasibility and oncological safety of non-radioactive targeted axillary dissection after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: a prospective diagnostic and prognostic study.

BACKGROUND: Targeted axillary dissection (TAD) includes biopsy of clipped lymph node and sentinel lymph nodes. However, clinical evidence regarding clinical feasibility and oncological safety of non-radioactive TAD in a real-world cohort remains limited. METHODS: In this prospective registry study, patients routinely underwent clip insertion into biopsy-confirmed lymph node. Eligible patients received neoadjuvant chemotherapy followed by axillary surgery. Main endpoints included the false-negative rate (FNR) of TAD and nodal recurrence rate. RESULTS: Data from 353 eligible patients were analyzed. After completion of neoadjuvant chemotherapy, 85 patients directly proceeded to axillary lymph node dissection (ALND), furthermore, TAD with or without ALND was performed in 152 and 85 patients, respectively. Overall detection rate of clipped node was 94.9% (95% CI, 91.3-97.4%) and FNR of TAD was 12.2% (95% CI, 6.0-21.3%) in our study, with FNR decreasing to 6.0% (95% CI, 1.7-14.6%) in initially cN1 patients. During a median follow-up of 36.6 months, 3 nodal recurrences occurred (3/237 with ALND; 0/85 with TAD alone), with a 3-year freedom-from-nodal-recurrence rate of 100.0% among the TAD-only patients and 98.7% among the ALND patients with axillary pathologic complete response ( P =0.29). CONCLUSIONS: TAD is feasible in initially cN1 breast cancer patients with biopsy-confirmed nodal metastases. ALND can safely be foregone in patients with negativity or a low volume of nodal positivity on TAD, with a low nodal failure rate and no compromise of 3-year recurrence-free survival.

GCH1 induces immunosuppression through metabolic reprogramming and IDO1 upregulation in triple-negative breast cancer.

PURPOSE: Regulatory T cells (Tregs) heavily infiltrate triple-negative breast cancer (TNBC), and their accumulation is affected by the metabolic reprogramming in cancer cells. In the present study, we sought to identify cancer cell-intrinsic metabolic modulators correlating with Tregs infiltration in TNBC. EXPERIMENTAL DESIGN: Using the RNA-sequencing data from our institute (n=360) and the Molecular Taxonomy of Breast Cancer International Consortium TNBC cohort (n=320), we calculated the abundance of Tregs in each sample and evaluated the correlation between gene expression levels and Tregs infiltration. Then, in vivo and in vitro experiments were performed to verify the correlation and explore the underlying mechanism. RESULTS: We revealed that GTP cyclohydrolase 1 (GCH1) expression was positively correlated with Tregs infiltration and high GCH1 expression was associated with reduced overall survival in TNBC. In vivo and in vitro experiments showed that GCH1 increased Tregs infiltration, decreased apoptosis, and elevated the programmed cell death-1 (PD-1)-positive fraction. Metabolomics analysis indicated that GCH1 overexpression reprogrammed tryptophan metabolism, resulting in L-5-hydroxytryptophan (5-HTP) accumulation in the cytoplasm accompanied by kynurenine accumulation and tryptophan reduction in the supernatant. Subsequently, aryl hydrocarbon receptor, activated by 5-HTP, bound to the promoter of indoleamine 2,3-dioxygenase 1 (IDO1) and thus enhanced the transcription of IDO1. Furthermore, the inhibition of GCH1 by 2,4-diamino-6-hydroxypyrimidine (DAHP) decreased IDO1 expression, attenuated tumor growth, and enhanced the tumor response to PD-1 blockade immunotherapy. CONCLUSIONS: Tumor-cell-intrinsic GCH1 induced immunosuppression through metabolic reprogramming and IDO1 upregulation in TNBC. Inhibition of GCH1 by DAHP serves as a potential immunometabolic strategy in TNBC.

MYC suppresses STING-dependent innate immunity by transcriptionally upregulating DNMT1 in triple-negative breast cancer.

BACKGROUND: Triple-negative breast cancer (TNBC) is the most aggressive subtype of breast cancer and lacks definite treatment targets. Tumor immune microenvironment (TIME) heterogeneity has a profound impact on the immunotherapy response. Tumors with non-inflamed TIME derive limited benefit from immunotherapy. However, what drives the formation of the non-inflamed TIME in TNBC remains unclear. METHODS: Using our multiomics database of TNBC, we conducted an analysis to explore the key genomic events driving the formation of the non-inflamed TIME in TNBC. In vitro and in vivo studies further revealed potential mechanisms and the efficacy of combination treatment with immunotherapy. RESULTS: With transcriptomic and genomic data, we systematically analyzed the TIME of TNBC and revealed that the classical basal-like subtype of TNBC consisted of two distinct microenvironment phenotypes, defined as the 'inflamed' and 'non-inflamed' subtypes. We performed further screening and demonstrated that MYC amplification and overexpression led to low immune infiltration and cytolytic activity in TIME. Mechanistically, MYC bound to DNMT1 promoter and activated DNMT1 transcription in TNBC cells, thus suppressing the Cyclic GMP-AMP synthase (cGAS)-STING pathway via an epigenetic regulatory way. In MYC-overexpressing TNBC, decitabine, an Food and Drug Administration (FDA)-approved DNA methyltransferase inhibitor, converted tumors from non-inflamed to inflamed tumors by enhancing T cell infiltration. Furthermore, the combination of decitabine with programmed cell death protein 1 (PD-1) inhibitor reversed T cell exhaustion and improved T cell function in mouse models, which elicited potent antitumor activity in MYC-overexpressing TNBC. CONCLUSIONS: Our work elucidates that the classic oncogene MYC induces immune evasion by repressing innate immunity. Furthermore, we provide a rationale for combining DNA methyltransferase inhibition with immunotherapy for the treatment of MYC-overexpressing TNBC.

Prior Local or Systemic Treatment: A Predictive Model Could Guide Clinical Decision-Making for Locoregional Recurrent Breast Cancer.

INTRODUCTION: Locoregional recurrent breast cancer indicates poor prognosis. No solid prediction model is available to predict prognosis and guide clinical management. Prior local treatment or systemic treatment remains controversial. METHODS: Locoregional recurrent breast cancer patients operated in Fudan University Shanghai Cancer Center were enrolled as a training cohort. An external validation cohort included breast cancer patients after locoregional recurrence from Ruijin Hospital, Shanghai Jiaotong University. A nomogram predicting overall survival after locoregional recurrence was established using multivariable Cox regression analysis while internal and external validation were performed to evaluate its calibration and discrimination. RESULTS: Overall, 346 and 96 breast cancer patients were included in the training cohort and the validation cohort separately. A nomogram was developed, including age, neoadjuvant chemotherapy, breast surgery, pathology type, tumor size, lymph node status, hormonal receptor and Her-2 status, disease-free interval, and sites of locoregional recurrence. It had modest calibration and discrimination in the training cohort, internal validation and external validation (concordance index: 0.751, 0.734 and 0.722, respectively). The nomogram classified 266 and 80 patients into low and high-risk subgroups with distinctive prognosis. Local treatment after locoregional recurrence was associated with improved overall survival in low-risk group (P = 0.011), while systemic therapies correlated with better outcomes only in high-risk group (P < 0.001). CONCLUSION: A nomogram based on clinicopathological factors can predict prognosis and identify low and high-risk patients. Local treatment is a prior choice for low-risk patients whereas systemic treatment needs to be considered for high-risk patients, warranting further validation and exploration.

Neoadjuvant systemic therapy does not compromise local control after breast-conserving surgery: a single-center, propensity score matching study in China.

BACKGROUND: To investigate ipsilateral breast tumor recurrence (IBTR) in patients who have undergone breast-conserving surgery (BCS) after neoadjuvant systematic therapy (NST). METHOD: Three hundred and twenty-one patients undergoing BCS after NST and 2,534 patients undergoing initial BCS from June 2008 to June 2017 at Fudan University Shanghai Cancer Center were retrospectively enrolled, and statistical analyses, including propensity score matching, were applied to compare IBTR-free survival. The main factors related to IBTR in the NST group were estimated utilizing univariate and multivariate analyses. RESULTS: After propensity score matching, the 3-year IBTR-free survival rates were 93.7% (95% CI, 90.6-96.8%) in the NST group and 96.9% (95% CI, 94.9-98.9%) in the matched initial BCS group at a median follow-up period of 58 months. IBTR-free survival did not differ statistically between the two groups (P=0.154). According to multivariate analysis in the NST group, tumor-infiltrating lymphocytes (TILs), epidermal growth factor receptor 2 (HER2) status and pathologic ductal carcinoma in situ (DCIS) constituent were the factors related to IBTR after BCS. CONCLUSIONS: BCS after NST and initial BCS have equivalent IBTR-free survival. BCS after NST is a safe and effective therapy in terms of IBTR.

Concurrent neoadjuvant chemotherapy and estrogen deprivation in patients with estrogen receptor-positive, human epidermal growth factor receptor 2-negative breast cancer (CBCSG-036): A randomized, controlled, multicenter trial.

BACKGROUND: The current randomized, controlled, multicenter clinical trial was conducted to investigate the efficacy of concurrent neoadjuvant chemotherapy (NCT) and estrogen deprivation in patients with estrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancer. METHODS: Eligible patients with AJCC stage IIB to stage IIIC, ER-positive, HER2-negative breast cancer were enrolled and randomly assigned to receive NCT with or without estrogen deprivation. The primary endpoint was the objective response rate (ORR). RESULTS: A total of 249 patients were assigned to either neoadjuvant chemoendocrine therapy (NCET) (125 patients) or the NCT group (124 patients). In the intention-to-treat analysis, the ORR was found to be significantly higher in the NCET group compared with the NCT group (84.8% vs 72.6%; odds ratio, 2.11 [95% CI, 1.13-3.95; P = .02). The efficacy of NCET was more prominent in tumors with a higher Ki-67 index (>20%), with an ORR of 91.2% reported in the NCET group versus 68.7% in the NCT group (P = .001). The pathologic complete response and pathological response rates did not differ significantly between the 2 groups. Although there was no significant difference with regard to progression-free survival (PFS) between the 2 groups (P = .188), patients with a higher baseline Ki-67 index appeared to derive a greater PFS benefit from NCET (2-year PFS rate of 91.5% in the NCET group vs 76.5% in the NCT group; P = .058). Adding endocrine agents to NCT did not result in significant differences in adverse events (grade 3 or 4; graded according to National Cancer Institute Common Terminology Criteria for Adverse Events [version 3.0]) between the 2 groups. CONCLUSIONS: The addition of estrogen deprivation to NCT appears to improve the clinical response in patients with ER-positive, HER2-negative breast cancer, especially for those individuals with a higher Ki-67 index. Patients with a higher Ki-67 index might derive more PFS benefit from concurrent neoadjuvant treatment.

Frequent CpG island methylation: a risk factor in the progression of traditional serrated adenoma of the colorectum.

BACKGROUND: Traditional serrated adenoma (TSA) features a unique serrated configuration because it involves two cell types: tall and short columnar cells. The serrated neoplasia pathway is related to the carcinogenesis of colorectal cancer. CpG island methylator phenotype-high (CIMP-high) is a unique genetic alteration in this pathway. MATERIALS AND METHODS: This study investigated the prevalence and level of methylation and CIMP in 30 TSA cases. The tall and short cells in 28 TSAs were separated by microdissection. Methylation-specific PCR was performed to detect the methylation of MGMT, MLH1, P14, P16, MINT1, MINT2 and MINT31. RESULTS: Overall, 30 cases presented CIMP-high, and the prevalence of CIMP-high was 100% (30/30) in tall cells and 93% (28/30) in short cells. CONCLUSIONS: No significant difference was found between tall and short columnar cells. The relationship between methylation and clinicopathological characters remains to be established.

Pulmonary microvascular dysfunction and pathological changes induced by blast injury in a rabbit model.

BACKGROUND: Vascular leakage has been proven to play a critical role in the incidence and development of explosive pulmonary barotrauma. Quantitatively investigated in the present study was the severity of vascular leakage in a gradient blast injury series, as well as ultrastructural evidence relating to pulmonary vascular leakage. METHODS: One hundred adult male New Zealand white rabbits were randomly divided into 5 groups according to distance from the detonator (10 cm, 15 cm, 20 cm, 30 cm, and sham control). Value of pulmonary vascular leakage was monitored by a radioactive 125I-albumin labeling method. Pathological changes caused by the blast wave were examined under light and electron microscopes. RESULTS: Transcapillary escape rate of 125I-albumin and residual radioactivity in both lungs increased significantly at the distances of 10 cm, 15 cm, and 20 cm, suggesting increased severity of vascular leakage in these groups. Ultrastructural observation showed swelling of pulmonary capillary endothelial cells and widened gap between endothelial cells in the 10-cm and 15-cm groups. CONCLUSION: Primary blast wave can result in pulmonary capillary blood leakage. Blast wave can cause swelling of pulmonary capillary endothelial cells and widened gap between endothelial cells, which may be responsible for pulmonary vascular leakage.

Characteristics and mechanisms of extremity injuries caused by mine blasts in shoals.

BACKGROUND: The characteristics of explosion in water are different from those in air and vary in different water depths. It is important to investigate the characteristics and mechanisms of extremity injuries caused by mine blasts in shoals. METHODS: A total of ninety New Zealand rabbits were randomly divided into four groups put in different depths of water (land group, midpoint of the thigh in the shoal 1 group, the xiphoid process in the shoal 2 group, and control group). Electric detonators simulating mines were placed under the rabbits' right hindpaw. After detonation, the animals were subjected to morphological examination. RESULTS: The lower third of the calf was almost completely destroyed by the mine blast on land, and only the rabbits' feet and ankles were destroyed in shoals. The skeleton, artery and sciatic nerve were injured more seriously in shoals than those on land. CONCLUSION: Mine blasts in shoals caused less disruption of the soft tissue than those on land. However, the skeleton was more seriously damaged in shoals since the pressure wave was transmitted with greater intensity and had a stronger shattering effect on the skeleton. Furthermore, the characteristics of extremity injuries varied according to water depths.

Somatic point mutations occurring early in development: a monozygotic twin study.

The identification of somatic driver mutations in cancer has enabled therapeutic advances by identifying drug targets critical to disease causation. However, such genomic discoveries in oncology have not translated into advances for non-cancerous disease since point mutations in a single cell would be unlikely to cause non-malignant disease. An exception to this would occur if the mutation happened early enough in development to be present in a large percentage of a tissue's cellular population. We sought to identify the existence of somatic mutations occurring early in human development by ascertaining base-pair mutations present in one of a pair of monozygotic twins, but absent from the other and assessing evidence for mosaicism. To do so, we genome-wide genotyped 66 apparently healthy monozygotic adult twins at 506 786 high-quality single nucleotide polymorphisms (SNPs) in white blood cells. Discrepant SNPs were verified by Sanger sequencing and a selected subset was tested for mosaicism by targeted high-depth next-generation sequencing (20 000-fold coverage) as a surrogate marker of timing of the mutation. Two de novo somatic mutations were unequivocally confirmed to be present in white blood cells, resulting in a frequency of 1.2×10(-7) mutations per nucleotide. There was little evidence of mosaicism on high-depth next-generation sequencing, suggesting that these mutations occurred early in embryonic development. These findings provide direct evidence that early somatic point mutations do occur and can lead to differences in genomes between otherwise identical twins, suggesting a considerable burden of somatic mutations among the trillions of mitoses that occur over the human lifespan.

BRAF mutation is associated with the unique morphology of traditional serrated adenoma of the colorectum.

Traditional serrated adenoma (TSA) consists of glands with tall cells and short cells. Two kinds of cells alternate to give a unique serrated configuration. The aim of this study was to identify the relationship between the alterations of both Wnt and serrated pathways and the unique morphology of TSAs. The tall and short cells in 28 TSAs were separated by microdissection. Semi-nested polymerase chain reaction was performed to detect the mutations of BRAF, ß-catenin, APC, and KRAS. BRAF mutations were observed in 22 of 28 (78.6%) TSAs, and all mutations occurred at the tall cells. In conclusion, BRAF mutation is associated with the serrated morphology of TSAs. Genetic alterations in both the serrated pathway and the Wnt signaling pathway may both contribute to TSAs.

Bromelain ameliorates the wound microenvironment and improves the healing of firearm wounds.

BACKGROUND: In a previous study, we proposed a new therapy using topical bromelain as a supplement to simple wound-track incision for the debridement of firearm wounds. This enzymatic debridement greatly simplified the management of high-velocity gunshot wounds in a pig model, and bromelain was confirmed to improve wound healing. The purpose of the present study was to investigate the effect of bromelain on the microenvironment of firearm wounds. METHODS: Sixteen Chinese landrace pigs wounded by high-velocity projectiles were divided randomly into four groups: wound incision (group I), incision + bromelain (group IB), wound excision (group E), and control. Blood perfusion, oxygen partial pressure (pO(2)), and the content of tumor necrosis factor (TNF)-α and transforming growth factor (TGF)-ß in wound-track tissue were measured. Wound healing was also noted. RESULTS: The recovery of blood perfusion in tissue and pO(2) in wound tracks was significantly more rapid in group IB and group E than in group I and control. The tissue level of TNF-α was significantly lower in group IB than in group I and control 48 h and 72 h post-wounding, and was lower than in group E 48 h post-wounding. The tissue level of TGF-ß in group IB was sustained at a significantly higher level than in the other three groups. Wound healing time was also shorter in group IB. CONCLUSIONS: Enzymatic debridement using topical bromelain in incised wound tracks accelerates the recovery of blood perfusion, pO(2) in wound tissue, controls the expression of TNF-α and raises the expression of TGF-ß.

[Induction of VEGF in human monocytes by DENV infection and the regulatory mechanism].

To investigate the effects of DENV infection on the expression of Vascular endothelial growth factor (VEGF) in monocytes, and to explore which innate immune signaling pathway is responsible for VEGF induction. Real-time PCR was used to determine the expression levels of VEGF in DENV-infected THP-1. We found that different serotype viruses (DENV1, DENV2, DENV3) induced the VEGF expression. Moreover, VEGF expression was significantly increased in human primary monocytes infected with DENV 2. In addition, VEGF induction by DENV2 was significantly impaired by knockdown of TLR3 and interferon-beta promoter stimulator 1 (IPS-1), or by inhibition of ERK, JNK or NF-kappaB. These results demonstrated that DENV induced VEGF expression in monocytes, and the activation of TLR3, IPS-1 signal pathways were required for DENV2-triggered VEGF induction, suggesting that VEGF might be a promising therapeutic target for DHF.

Repair of acutely injured spinal cord through constructing tissue-engineered neural complex in adult rats.

OBJECTIVE: To construct tissue-engineered neural complex in vitro and study its effect in repairing acutely injured spinal cord in adult rats. METHODS: Neural stem cells were harvested from the spinal cord of embryo rats and propagated in vitro. Then the neural stem cells were seeded into polyglycolic acid scaffolds and co-cultured with extract of embryonic spinal cord in vitro. Immunofluorescence histochemistry and scanning electron microscope were used to observe the microstructure of this complex. Animal model of spine semi-transection was made and tissue-engineered neural complex was implanted by surgical intervention. Six weeks after transplantation, functional evaluation and histochemistry were applied to evaluate the functional recovery and anatomic reconstruction. RESULTS: The tissue-engineered neural complex had a distinct structure, which contained neonatal neurons, oligodendrocytes and astrocytes. After tissue-engineered neural complex was implanted into the injured spinal cord, the cell components such as neurons, astrocytes and oligodendrocytes, could survive and keep on developing. The adult rats suffering from spinal cord injury got an obvious neurological recovery in motor skills. CONCLUSIONS: The tissue-engineered neural complex appears to have therapeutic effects on the functional recovery and anatomic reconstruction of the adult rats with spinal cord injury.