[The efficacy of radiotherapy based combined therapy for unresectable locally invasive bladder cancer and its associated factors analysis].

Objective: Retrospective analysis of the efficacy and influencing factors of bladder preservation integrated therapy for unresectable invasive bladder cancer confined to the pelvis was done, also including the bladder function preservation and adverse effects analysis. Methods: Sixty-nine patients with unresectable locally invasive bladder cancer who received radiotherapy-based combination therapy from March 1999 to December 2021 at our hospital were selected. Among them, 42 patients received concurrent chemoradiotherapy, 32 underwent neoadjuvant chemotherapyand 43 with transurethral resection of bladder tumors (TURBT) prior to radiotherapy. The late adverse effect of radiotherapy, preservation of bladder function, replase and metastasis and survival were followed-up. Cox proportional hazards models were applied for the multifactorial analysis. Results: The median age was 69 years. There were 63 cases (91.3%) of uroepithelial carcinoma, 64 of stage Ⅲ and 4 of stage Ⅳ. The median duration of follow-up was 76 months. There were 7 grade 2 late genito urinary toxicities, 2 grade 2 gastrointestinal toxicities, no grade 3 or higher adverse events occurred. All patients maintained normal bladder function, except for 8 cases who lost bladder function due to uncontrolled tumor in the bladder. Seventeen cases recurred locally. There were 11 cases in the concurrent chemoradiotherapy group with a local recurrence rate of 26.2% (11/42) and 6 cases in the non-concurrent chemoradiotherapy group with a local recurrence rate of 22.2% (6/27), and the difference in local recurrence rate between the two groups was not statistically significant (P=0.709). There were 23 cases of distant metastasis (including 2 cases of local recurrence with distant metastasis), including 10 cases in the concurrent chemoradiotherapy group with a distant metastasis rate of 23.8% (10/42) and 13 cases in the non-concurrent chemoradiotherapy group with a distant metastasis rate of 48.1% (13/27), and the distant metastasis rate in the non-concurrent chemoradiotherapy group was higher than that in the concurrent chemoradiotherapy group (P=0.036). The median 5-year overall survival (OS) time was 59 months and the OS rate was 47.8%. The 5-year progression-free survival (PFS) time was 20 months and the PFS rate was 34.4%. The 5-year OS rates of concurrent and non-concurrent chemoradiotherapy group were 62.9% and 27.6% (P<0.001), and 5-year PFS rates were 45.4% and 20.0%, respectively (P=0.022). The 5-year OS rates of with or without neoadjuvant chemotherapy were 78.4% and 30.1% (P=0.002), and the 5-year PFS rates were 49.1% and 25.1% (P=0.087), respectively. The 5-year OS rates with or without TURBT before radiotherapy were 45.5% and 51.9% (P=0.233) and the 5-year PFS rates were 30.8% and 39.9% (P=0.198), respectively. Multivariate Cox regression analysis results showed that the clinical stage (HR=0.422, 95% CI: 0.205-0.869) was independent prognostic factor for PFS of invasive bladder cancer. The multivariate analysis showed that clinical stages (HR=0.278, 95% CI: 0.114-0.678), concurrent chemoradiotherapy (HR=0.391, 95% CI: 0.165-0.930), neoadjuvant chemotherapy (HR=0.188, 95% CI: 0.058-0.611), and recurrences (HR=10.855, 95% CI: 3.655-32.638) were independent prognostic factors for OS of invasive bladder cancer. Conclusion: Unresectable localized invasive bladder cancer can achieve satisfactory long-term outcomes with bladder-preserving combination therapy based on radiotherapy, most patients can retain normal bladder function with acceptable late adverse effects and improved survival particularly evident in patients with early, concurrent chemoradiotherapy and neoadjuvant chemotherapy.

[Surgical strategy of intraspinal tumors using minimal invasive channels].

Objective: To compare and analyze the effect of minimally invasive surgery and traditional open surgery in patients with spinal canal tumors, including intraspinal and extraspinal communication tumors. Methods: From 2017 to 2019, 31 patients (minimally invasive channel group) were included in the neurosurgery department of Huashan Hospital Affiliated to Fudan University, and 38 patients (open operation group) were selected as the control group. From the aspects of intraoperative condition, operative effect, postoperative muscle injury, postoperative complications, postoperative spinal stability, the minimally invasive access group and the open operation group were compared and analyzed. Results: The bleeding volume (70.2 ml±4.9 ml), operation time (164.7 min±16.0 min) and hospitalization days (9.5±2.5) in the minimally invasive access group were significantly lower than those in the open operation group (P<0.001). The creatine kinase CK (363.9 U/L±51.6 U/L) in the minimally invasive group was significantly lower than that in the open group (514.2 U/L±68.3 U/L) (P<0.001). According to Panjabi standard, the effect of spinal cord stability in minimally invasive group was significantly lower than that in open operation group (P<0.001), and the symptom improvement rate in minimally invasive group was significantly higher than that in open hand group (P<0.05). Conclusions: Compared with the open surgery, the amount of bleeding, the length of incision, the time of operation and the days of hospitalization were significantly shorter, the degree of muscle damage was also significantly reduced, the incidence of complications was lower, the impact of spinal stability was smaller, and the overall advantage was obvious.

[Clinical analysis of 8 cases of the mixed epithelial and stromal tumour family of kidney].

Objective: To investigate the diagnosis and treatment of the mixed epithelial and stromal tumour family of kidney. Methods: Eight cases of the mixed epithelial and stromal tumour family of kidney were retrospectively analyzed. Before operation, radiologic evaluation was performed in all cases, including CT and MRI scan. Three cases were diagnosed as cystic renal cell carcinoma, 5 cases were diagnosed as renal complex cysts. Radical nephrectomy was performed in 4 cases and partial nephrectomy was performed in 4 cases. Results: The manifestation of the pathological specimens were multilocular cystic or cystic solid tumors grossly. Microscopically, the tumors were composed of two components, epithelial and stromal. Immunohistochemical staining showed that the epithelial components of the tumors were positive for AE1/AE3 (8/8), CK18 (3/3), and CK-7 (1/1). The stromal components were positive for PR (8/8), ER (6/8), Vim (6/6), Desmin (5/5), and SMA (5/5). HB-45 staining were negative (7/7) and Ki-67 staining were negative (7/8). All cases were diagnosed as the mixed epithelial and stromal tumour family of kidney. All patients were followed up for 3-124 months, with a median follow-up of 41 months. No tumour recurrence or metastasis were observed. Conclusion: The mixed epithelial and stromal tumour family of kidney mostly occurs in women, but have no specific clinical manifestations. They were often misdiagnosed as cystic renal cell carcinoma before operation. These following imaging features may be helpful for diagnosis. The definite diagnosis of the disease depends on the pathological examination, and immunohistochemistry plays an important role in differential diagnosis. Surgical treatment is the first choice, and partial nephrectomy is feasible. Most of the tumors are benign, and the patients can be cured after complete excision.

[Effect of 10-Hydroxycamptotbecine on the proliferation of human Fibroblast-like Synoviocyte with Rheumatoid Arthritis].

Objective: To study the effect of 10-Hydroxycamptothecine (10-HCPT) on the proliferation and apoptosis of human Fibroblast-like Synoviocyte (FLS) with Rheumatoid Arthritis (RA). Methods: Different concentrations of 10-HCPT and Methotrexate (MTX) were used to treat FLS cells in RA and Osteoarthritis (OA) for different time (24, 48, and 72 hours), and FLS cells without 10-HCPT and MTX were served as the control group. CCK-8 assay were applied to determine the proliferation of FLS cells, Annexin-V APC/7-AAD staining were used to detect the apoptosis of FLS cells. Results: The survival rate of FLS cells were (66.68±0.48) %, 48 h; (60.09±0.95) %, 72 h and (44.05±1.29) %, 48 h; (30.63±1.79) %, 72 h, when the concentrations were 1.0 µg/ml and 10.0 µg/ml in 10-HCPT group. Compared with the control group, the survival rate of FLS cells in RA and OA both declined in treatment groups with different concentrations of 10-HCPT and MTX. With the extension of time, the survival rate of FLS cells declined significantly. Compared with the MTX group, there were no obvious differences in 10-HCPT group with 1.0 µg/ml. But the concentration of 10.0 µg/ml of 10-HCPT group showed obviously difference in the proliferation of FLS cells. The apoptosis rate of FLS cells were (66.68±0.48) %, 48 h; (60.09±0.95) %, 72 h and (44.05±1.29) %, 48 h; (30.63±1.79) %, 72 h, when the concentrations were 1.0 µg/ml and 10.0 µg/ml in 10-HCPT group. Compared with the control group, two concentrations of 10-HCPT and MTX induced higher apoptosis in FLS cells with RA and OA; with the extension of time (72 h), the rate of apoptosis was significantly enhanced (P<0.05). When FLS cells with RA were treated for 48 h, apoptosis of 10-HCPT group was higher than that of MTX group. The 10.0 µg/ml of 10-HCPT had the highest effect. Conclusion: Compared with MTX, 10-HCPT had the higher efficacy of inhibiting proliferation and promoting apoptosis in FLS cells.

Preparation and biological activity of a paclitaxel-single-walled carbon nanotube complex.

Single-walled carbon nanotubes (SWCNTs) have unique transmembrane abilities. The huge superficial area and abundance of π electrons confer SWCNTs perfect absorptive capability toward proteins, nucleates, and many drugs. These characteristics make SWCNTs a new and efficient drug carrier. The purpose of this study was to disperse SWCNTs in water and have paclitaxel absorbed onto them in order to construct an asparagine-glycine-arginine (NGR)-SWCNT-Paclitaxel complex as a targeting nanoparticle system. The NGR-SWCNT-Paclitaxel complex was systematically studied, and analytical methods, including spectrophotometry for SWCNTs and high-performance liquid chromatography for paclitaxel, were employed. The preparation and the prescription of the NGR-SWCNT-Paclitaxel complex lyophilized powder were investigated. MCF-7 cancer cells, Sprague-Dawley rats, and S180 tumor-bearing mice were used as experimental subjects to evaluate the in vitro and in vivo activity of NGR-SWCNT-Paclitaxel complex dispersion. The complex dispersion showed obvious inhibition activity against MCF-7 cancer cells. Within 1 h, the NGR-SWCNT-Paclitaxel complex could be transferred to cells, and sustained the release of drugs. In addition, the tumor and liver targeting and improved therapeutic effects of the NGR-SWCNT-Paclitaxel complex were confirmed.

[Clinical effect of X-N advancement flap in repairing pressure ulcer on the buttock or back].

Objective: To explore the clinical effect of X-N advancement flap in repairing pressure ulcer on the buttock or back. Methods: From June 2018 to June 2019, 20 patients with grade Ⅳ pressure ulcers on the buttock or back were hospitalized and treated in the Department of Traumatology, Burns and Plastic Surgery of Fourth Affiliated Hospital of Guangxi Medical University, including 15 males and 5 females, aged 48-89 years. The area of the patient's wound was 8 cm×5 cm-15 cm×12 cm after debridement, and all were repaired with the X-N advancement flap designed by the author. The flap was designed according to the direction of skin relaxation on both sides of the wound, and the skin was incised in X-shape and sutured in N-shape. The width and advancement distance of the flap were recorded, and the ratio of the advancement distance to the width of the flap was calculated. The flap survival, complication, and follow-up were observed and recorded. Results: The width of the flap was (5.9±1.2) cm, the advancement distance of the flap was (10.3±2.5) cm, and the ratio of the advancement distance to the width of the flap was 1.8±0.4. All the flaps survived, and none of the flaps had blood flow disorder. Local dehiscence occurred in the flap of one patient 1 week after surgery, which was healed after laying on the floating bed, strengthened care, and wound dressing change. The flap of one patient developed infection 5 days after surgery, which was healed after partial suture removal, smooth drainage, and replacement with sensitive antibiotics. The wounds of the remaining 18 patients were all cured. After 3 months of follow-up, the flaps survived well with good elasticity and texture. Conclusions: The X-N advancement flap can make the skin and soft tissue move forward effectively. It is simple and effective to repair pressure ulcers on the back or buttock of patients with this flap, which is worthy of clinical promotion and application.

Treatment of Strongyloides stercoralis hyperinfection-associated septic shock and acute respiratory distress syndrome with drotrecogin alfa (activated) in a renal transplant recipient.

We report a case of Strongyloides stercoralis hyperinfection syndrome in a renal transplant recipient complicated by septic shock, acute respiratory distress syndrome, and Klebsiella pneumoniae superinfection. The patient was treated successfully with drotrecogin alfa (activated), parenteral ivermectin, albendazole, and piperacillin/tazobactam. This outcome suggests that drotrecogin alfa (activated) may be useful therapy for transplant recipients who develop severe sepsis or septic shock secondary to potentially lethal opportunistic infections.

BMPs inhibit neurogenesis by a mechanism involving degradation of a transcription factor.

Bone morphogenetic proteins (BMPs), negative regulators of neural determination in the early embryo, were found to be potent inhibitors of neurogenesis in olfactory epithelium (OE) cultures. BMPs 2, 4 or 7 decreased the number of proliferating progenitor cells and blocked production of olfactory receptor neurons (ORNs). Experiments suggested that this effect was due to an action of BMPs on an early-stage progenitor in the ORN lineage. Further analysis revealed that progenitors exposed to BMPs rapidly (< 2 h) lost MASH1, a transcription factor known to be required for the production of ORNs. This disappearance was due to proteolysis of existing MASH1 protein, but new gene expression was required to trigger it. The data suggest a novel mechanism of BMP action, whereby the induced degradation of an essential transcription factor results in premature termination of a neuronal lineage.

[Diagnostic values of BRAF(V600E) mutation analysis and Bethesda system for reporting thyroid cytopathology in thyroid nodules with TIRADS 4 and 5].

Objective: To evaluate the diagnostic efficacies of BRAF(V600E) testing and Bethesda system for reporting thyroid cytopathology (BSRTC) in thyroid nodules with thyroid imaging reporting and data system (TIRADS) category 4 and 5. Methods: A total of 187 thyroid nodules in 187 patients underwent the examinations of ultrasound-guided fine needle aspiration cytology (FNAC) and BRAF(V600E) mutation were analyzed retrospectively. Receive operating characteristic (ROC) curve was used to investigate the diagnostic values of both methods and the clinical application of BRAF(V600E) combined with BSRTC was evaluated. SPSS17.0 software was used to analyze the data. Results: Among 187 thyroid nodules, 123 were malignant nodules confirmed with histopathological examination and 64 benign nodules determined by FNAC, histopathological examination, or long-term follow-up. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of BRAF(V600E) test were better than those of BSRTC [69.1%, 98.4%, 98.8%, 62.4%(χ(2)=77.3, P=0.000) vs 62.6%, 93.8%, 95.1%, 56.6%(χ(2)=54.4, P=0.000)]. While the sensitivity, specificity, PPV and NPV of the combined test of BRAF(V600E) and BSRTC for diagnosis of malignant thyroid nodules were 87.8%, 92.2%, 95.6%, 79.7%(χ(2)=112.6, P=0.000), respectively. The area under the ROC curve for the combined test was higher than that for each of tests (0.900 vs 0.858 or 0.838). Conclusions: The combined test of BRAF(V600E) mutation and BSRTC has a higher diagnostic efficacy for malignant thyroid nodules compared with BRAF(V600E) mutation or BSRTC alone.

Dynamics of notch expression during murine prostate development and tumorigenesis.

Notch signaling has been widely demonstrated to be responsible for cell fate determination during normal development and implicated in human T-cell leukemia and mouse mammary carcinomas. Here we show that Notch signaling may be involved in prostatic development and cancer cell growth. In situ hybridization and reverse transcription-PCR analyses revealed that Notch1 was expressed in prostate epithelial cells during normal development and in prostate cancer cells. Characterization of Notch1-green fluorescent protein transgenic mice, in which the expression of reporter green fluorescent protein is under the control of the Notch1 promoter, indicated that Notch1-expressing cells were associated with the basal epithelial cell population in the prostate. Examination of the transgenic adenocarcinoma of the mouse prostate showed that expression of Notch1 was elevated in malignant prostatic epithelial cells of primary and metastatic tumors. Expression of Notch ligands, however, was low or undetectable in cultured prostate cancer cells or in malignant prostatic epithelial cells in transgenic adenocarcinoma of the mouse prostate. Furthermore, overexpression of a constitutively active form of Notch1 inhibited the proliferation of various prostate cancer cells, including DU145, LNCaP, and PC3 cells. Taken together, our data indicate for the first time that Notch signaling may play a role in murine prostatic development and tumorigenesis.

Protein phosphorylation is a regulatory mechanism for O6-alkylguanine-DNA alkyltransferase in human brain tumor cells.

The biochemical regulation of human O6-alkylguanine-DNA alkyltransferase (AGT), which determines the susceptibility of normal tissues to methylating carcinogens and resistance of tumor cells to many alkylating agents, is poorly understood. We investigated the regulation of AGT by protein phosphorylation in a human medulloblastoma cell line. Incubation of cell extracts with [gamma-32P]ATP resulted in Mg(2+)-dependent phosphorylation of the endogenous AGT. Immunoprecipitation after exposure of the cells to 32P-labeled inorganic phosphate showed that AGT exists as a phosphoprotein under physiological conditions. Western analysis and chemical stability studies showed the AGT protein to be phosphorylated at tyrosine, threonine, and serine residues. Purified protein kinase A (PKA), casein kinase II (CK II), and protein kinase C (PKC) phosphorylated the recombinant AGT protein with a stoichiometry of 0.15, 0.28, and 0.44 (mol phosphate incorporated/mol protein), respectively. Residual phosphorylation of the endogenous AGT by the PKs present in cell homogenates and phosphorylation of the recombinant AGT by purified serine/threonine kinases, PKA, PKC, and CK II reduced AGT activity by 30-65%. Conversely, dephosphorylation of cell extracts by alkaline phosphatases stimulated AGT activity. We also identified consensus phosphorylation motifs for many cellular kinases, including PKA and CK II in the AGT protein. These data provide the first and conclusive evidence of AGT phosphorylation and suggest that reversible phosphorylation may control the activity of this therapeutically important DNA repair protein in human normal and cancer cells.

The murine Fhit locus: isolation, characterization, and expression in normal and tumor cells.

The murine Fhit locus maps near the centromere nu proximal Ptprg locus on mouse chromosome 14. The cDNA sequence and structure are similar to those of the human gene, with exons 5-9 encoding the protein. The predominant mRNA in the tissues and cell lines tested was an alternatively spliced form missing exon 3. Most murine cell lines tested, including lines established from normal mouse embryos and tumors, expressed very low or undetectable levels of Fhit mRNA. Most normal mouse tissues expressed wild-type Fhit mRNA, whereas approximately 40% of murine lung carcinomas expressed wild-type and aberrant Fhit RT-PCR products that lacked various exons. Several tumorigenic mouse cell lines exhibited homozygous deletions of Fhit exons. We conclude that the murine Fhit gene, like its human counterpart, is a target of alterations involved in murine carcinogenesis.

Comprehensive proteomic profiling identifies the androgen receptor axis and other signaling pathways as targets of microRNAs suppressed in metastatic prostate cancer.

MicroRNAs are important epigenetic regulators of protein expression by triggering degradation of target mRNAs and/or inhibiting their translation. Dysregulation of microRNA expression has been reported in several cancers, including prostate cancer (PC). We comprehensively characterized the proteomic footprint of a panel of 12 microRNAs that are potently suppressed in metastatic PC (SiM-miRNAs: miR-1, miR-133a, miR-133b, miR-135a, miR-143-3p, miR-145-3p, miR-205, miR-221-3p, miR-221-5p, miR-222-3p, miR-24-1-5p, and miR-31) using reverse-phase proteomic arrays. Re-expression of these SiM-miRNAs in PC cells suppressed cell proliferation and targeted key oncogenic pathways, including cell cycle, apoptosis, Akt/mammalian target of rapamycin signaling, metastasis and the androgen receptor (AR) axis. However, only 12%, at most, of these observed protein expression changes could be explained by predicted direct binding of miRNAs to corresponding mRNAs, suggesting that the majority of these proteomic effects result indirectly. AR and its steroid receptor coactivators (SRCs; SRC-1, -2 and -3) were recurrently affected by these SiM-miRNAs. In agreement, we identified inverse correlations between expression of these SiM-miRNAs and early clinical recurrence, as well as with AR transcriptional activity in human PC tissues. We also identified robust induction of miR-135a by androgen and strong direct binding of AR to the miR-135a locus. As miR-135a potently suppresses AR expression, this results in a negative feedback loop that suppresses AR protein expression in an androgen-dependent manner, while de-repressing AR expression upon androgen deprivation. Our results demonstrate that epigenetic silencing of these SiM-miRNAs can result in increased AR axis activity and cell proliferation, thus contributing to disease progression. We further demonstrate that a negative feedback loop involving miR-135a can restore AR expression under androgen-deprivation conditions, thus contributing to the upregulation of AR protein expression in castration-resistant PC. Finally, our unbiased proteomic profiling demonstrates that the majority of actual protein expression changes induced by SiM-miRNAs cannot be explained based on predicted direct interactions.

Dickkopf-1, an inhibitor of the Wnt signaling pathway, is induced by p53.

Dickkopf-1 (Dkk-1), a secreted glycoprotein, has been found to be necessary and sufficient for inducing amphibian head formation. Interestingly, the mechanism by which Dkk-1 does this is the ability of Dkk-1 to antagonize the Wnt signaling pathway. Wnt, itself a proto-oncoprotein, can promote cell proliferation and transformation when mutated or overexpressed, leading to tumor formation. p53 is a tumor suppressor and loss of p53 function accelerates mammary tumorigenesis by Wnt. In this study, we found that Dkk-1 is induced by wild-type p53 but not mutant p53(R249S). In addition, DNA damage upregulates Dkk-1 in cell lines that harbor an endogenous wild-type p53 gene but not in cell lines that are p53-null or harbor an endogenous mutant p53 gene. We also found a potential p53 responsive element located approximately 2100 nucleotides upstream of the Dkk-1 transcription start site and we show that p53 binds specifically to this element both in vitro and in vivo. Furthermore, we have established several cell lines derived from H1299 lung carcinoma and U118 glioma cells that inducibly express Dkk-1 under a tetracycline-regulated promoter. We found that Dkk-1 has no effect on proliferation of cells that are not transformed by Wnt. Taken together, these results suggest that Dkk-1 may mediate p53 tumor suppression by antagonizing the Wnt signaling pathway.

p53 induces TAP1 and enhances the transport of MHC class I peptides.

The transporter associated with antigen processing (TAP) 1 is required for the major histocompatibility complex (MHC) class I antigen presentation pathway, which plays a key role in host tumor surveillance. Since more than 50% of tumors have a dysfunctional p53, evasion of tumor surveillance by tumor cells may be linked to loss of p53 function. Here we found that TAP1 is strongly induced by p53 and DNA-damaging agents through a p53-responsive element. We also found that p73, which is homologous to p53, is capable of inducing TAP1 and cooperates with p53 to activate TAP1. Furthermore, we found that by inducing TAP1, p53 enhances the transport of MHC class I peptides and expression of surface MHC-peptide complexes, and cooperates with interferon gamma to activate the MHC class I pathway. These results suggest that tumor surveillance may be a mechanism by which p53 and/or p73 function as tumor suppressors.

Growth factor signalling and response to endocrine therapy: the Royal Marsden Experience.

De novo resistance to endocrine therapy is a near-universal feature of oestrogen receptor (ER)- negative breast cancer. Although many ER-positive breast cancers also show no response to tamoxifen or aromatase inhibitors on objective clinical grounds the large majority show reduced proliferation indicating that some oestrogen dependence is present in almost all ER-positive breast cancer. In neoadjuvant studies HER2 positivity is associated with poor response rates to tamoxifen but not aromatase inhibitors, consistent with preclinical models. Acquired resistance to tamoxifen is associated with decreases in ER positivity but most recurrent lesions remain ER-positive. A small proportion of these show increased HER2 expression and in these patients increased phospho-p38 may contribute to the tamoxifen-resistant phenotype. There is an unfortunate paucity of clinical and biological data on acquired resistance to aromatase inhibitors.

Estrogen receptor: current understanding of its activation and modulation.

Breast cancer development and progression are directly related to the effects of the female hormone estrogen. The nuclear receptor for estrogen (ER) functions as a transcription factor controlling estrogen-regulated genes. Receptor conformation on ligand binding, its interaction with various coregulators, and response elements in the promoter region of target genes all contribute to the net estrogenic effects in a cell. ER is an important diagnostic and therapeutic target in breast cancer. Various polypeptide growth factors and their membrane receptors also contribute to breast cancer development and progression. Pathways mediating cell survival, cell proliferation, and response to stress not only generate signals through various protein kinase pathways to enhance cell survival and proliferation, but these pathways also interact with ERs. Kinases in the growth factor cascade can phosphorylate and activate ER, and ER in turn activates and augments signaling through the growth factor pathways. Signaling through the growth factor pathways may contribute to hormonal resistance states by ligand-independent activation of ER. Targeting growth factor pathways, in addition to ER, is a developing strategy that hypothetically may represent optimal therapy by preventing the development of resistance to endocrine therapy.