The Efficacy of Low-Kilovoltage X-Rays Intraoperative Radiation as Boost for Breast Cancer: A Systematic Review and Meta-Analysis.

Background: Intraoperative radiotherapy (IORT) is a novel promising technology that may replace external beam radiation therapy (EBRT) as boost for patients receiving breast-conserving surgery. To better evaluate the efficacy of IORT using low-kilovoltage (low-kV) X-rays as boost, we presented this meta-analysis according to the PRISMA checklist. Methods: Studies reported survival outcomes of intraoperative radiation using low-kilovoltage X-rays system (Intrabeam®, Carl Zeiss Meditec, Dublin, CA, USA) as boost were identified through electronic bibliographic database: PUBMED. The meta-analysis module in Stata (16.0) is used to pool the studies. A Poisson regression model is used to predict a 5-year local recurrence rate. Results: Twelve studies including 3006 cases were included in the final analysis, with a median follow-up of 55 months weighted by sample size. The pooled local recurrence rate is 0.39% per person-year (95% CI: 0.15%-0.71%), with a low degree of heterogeneity (I2 = 0%). The predicted 5-year local recurrence rate was 3.45%. No difference in pooled local recurrence rate was found between non-neoadjuvant patients studies and neoadjuvant patients studies (0.41% per person-year vs. 0.58% per person-year, P = 0.580). Conclusions: This study shows that low-kV IORT is an effective method as boost in breast cancer patients, with a low pooled local recurrence rate and low predicted 5-year local recurrence rate. Besides, no difference in the local recurrence rate was found between non-neoadjuvant patients studies and neoadjuvant patients studies. Low-kV IORT boost may be a promising alternative to EBRT boost in the future, which is being tested in the ongoing TARGIT-B trial.

Characterization of heterogeneous metabolism in hepatocellular carcinoma identifies new therapeutic target and treatment strategy.

Background: Metabolic reprogramming is a well-known hallmark of cancer. Systematical identification of clinically relevant metabolic subtypes of Hepatocellular carcinoma (HCC) is critical to understand tumor heterogeneity and develop efficient treatment strategies. Methods: We performed an integrative analysis of genomic, transcriptomic, and clinical data from an HCC patient cohort in The Cancer Genome Atlas (TCGA). Results: Four metabolic subtypes were defined: mHCC1, mHHC2, mHCC3, and mHCC4. These subtypes had distinct differences in mutations profiles, activities of metabolic pathways, prognostic metabolism genes, and immune features. The mHCC1 was associated with poorest outcome and was characterized by extensive metabolic alterations, abundant immune infiltration, and increased expression of immunosuppressive checkpoints. The mHHC2 displayed lowest metabolic alteration level and was associated with most significant improvement in overall survival in response to high CD8+ T cell infiltration. The mHHC3 was a "cold-tumor" with low immune infiltration and few metabolic alterations. The mHCC4 presented a medium degree of metabolic alteration and high CTNNB1 mutation rate. Based on our HCC classification and in vitro study, we identified palmitoyl-protein thioesterase 1 (PPT1) was a specific prognostic gene and therapeutic target for mHCC1. Conclusion: Our study highlighted mechanistic differences among metabolic subtypes and identified potential therapeutic targets for subtype-specific treatment strategies targeting unique metabolic vulnerabilities. The immune heterogeneities across metabolic subtypes may help further clarify the association between metabolism and immune environment and guide the development of novel strategies through targeting both unique metabolic vulnerabilities and immunosuppressive triggers.

Leveraging Tumor Microenvironment Infiltration in Pancreatic Cancer to Identify Gene Signatures Related to Prognosis and Immunotherapy Response.

The hallmark of pancreatic ductal adenocarcinoma (PDAC) is an exuberant tumor microenvironment (TME) comprised of diverse cell types that play key roles in carcinogenesis, chemo-resistance, and immune evasion. Here, we propose a gene signature score through the characterization of cell components in TME for promoting personalized treatments and further identifying effective therapeutic targets. We identified three TME subtypes based on cell components quantified by single sample gene set enrichment analysis. A prognostic risk score model (TMEscore) was established based on TME-associated genes using a random forest algorithm and unsupervised clustering, followed by validation in immunotherapy cohorts from the GEO dataset for its performance in predicting prognosis. Importantly, TMEscore positively correlated with the expression of immunosuppressive checkpoints and negatively with the gene signature of T cells' responses to IL2, IL15, and IL21. Subsequently, we further screened and verified F2R-like Trypsin Receptor1 (F2RL1) among the core genes related to TME, which promoted the malignant progression of PDAC and has been confirmed as a good biomarker with therapeutic potential in vitro and in vivo experiments. Taken together, we proposed a novel TMEscore for risk stratification and selection of PDAC patients in immunotherapy trials and validated effective pharmacological targets.

Development and external validation of a nomogram for predicting the overall survival of patients with stage II nasopharyngeal carcinoma after curative treatment.

Objective: To facilitate decision-making support for individual patients, development and external validation of a nomogram was undertaken to reveal prognostic factors and predict the value of concurrent chemoradiotherapy (CCRT) compared with radiotherapy (RT) for stage-II nasopharyngeal carcinoma (NPC) patients. Methods: Clinical data of 419 and 309 patients with American Joint Committee on Cancer (2017) stage-II NPC in two institutions in China were collected retrospectively. Overall survival (OS) and progression-free survival were compared using Kaplan-Meier estimates. Cox regression analysis was used to identify the prognostic factors for building the nomogram. Predictive accuracy and discriminative ability were measured using the Concordance Index. Results: Finally, there were 24 and 20 deaths in the development and validation group, respectively. Patients with stage T2N1, N1 stage, involvement of retropharyngeal and unilateral cervical lymph nodes, and who had RT alone had worse OS (P=0.019, 0.035, 0.003 and 0.010, respectively; log-rank test) than patients with stage T1N1 and T2N0, N0 stage, involvement of retropharyngeal or unilateral cervical lymph nodes, and CCRT, respectively. After multivariate analysis of the training set, age, neutrophil-to-lymphocyte ratio, therapy type, and pretreatment plasma concentration of Epstein-Barr virus DNA were independent prognostic factors of OS. A nomogram was established externally by involving all the factors stated above. The Concordance Index for the established nomogram to predict the OS of the training set was 0.793 (95% CI 0.689-0.897), and 0.803 (95% CI 0.696-0.910) in the validation set. Conclusion: These data suggest that the nomogram was validated externally, could predict long-term outcome accurately, and enable accurate stratification of risk groups for stage-II NPC. Our model facilitated individualized care of NPC patients.

Expression profiles and prognostic significance of RNA N6-methyladenosine-related genes in patients with hepatocellular carcinoma: evidence from independent datasets.

Background: N6-methyladenosine (m6A) is the most prevalent modification of mammalian RNA. Emerging evidence suggest that m6A has critical roles in multiple biological activities, but little is known about its roles in cancer pathogenesis. Herein, we report the expression profiles and prognostic relevance of twelve m6A-related genes in hepatocellular carcinoma (HCC) by analyzing four independent datasets. Materials and methods: RNA levels of twelve m6A-related genes were detected in samples of 162 HCC patients who underwent curative resection (the Guangdong General Hospital dataset). We additionally analyzed the expression profiles of m6A-related genes in The Cancer Genome Atlas liver HCC dataset and two Gene Expression Omnibus datasets (GSE14520, GSE63898). Prognostic value of genes was evaluated by Kaplan-Meier curves of overall survival (OS) with the log-rank test and multivariate Cox regression analysis. Gene set enrichment analysis (GSEA) was conducted to identify associated KEGG pathways. Results: Five genes (METTL3, YTHDF1, YTHDF2, YTHDF3, and EIF3) showed consistent upregulation in all four datasets. Abnormal expressions of either METTL3 or YTHDF1 but not the other ten genes were associated with OS. Protein expression of METTL3 and YTHDF1 were confirmed in HCC tissues by immunohistochemical staining. Multivariate Cox regression analysis confirmed the independent predictive value of both METTL3 and YTHDF1 on OS. We further divided patients into three groups based on the median expression values of METTL3 and YTHDF1. In all datasets, the low METTL3/low YTHDF1 group showed a consistent better prognosis than other groups. GSEA revealed that both METTL3 and YTHDF1 regulate HCC cell cycle, RNA splicing, DNA replication, base excision repair, and RNA degradation. Conclusion: Both METTL3 and YTHDF1 were upregulated in HCC, and they were independent poor prognostic factors. Combination of METTL3 and YTHDF1 can be regarded as the biological marker that reflect malignant degree and evaluate prognosis in HCC.

Effect of CRP and Kinetics of CRP in Prognosis of Nasopharyngeal Carcinoma.

Baseline C-reactive protein (CRP) has been determined as a prognostic factor in nasopharyngeal carcinoma (NPC). This study was designed to further evaluate the impact of CRP kinetics on NPC patients. Thousand three hundred and seventy eight NPC patients from February 2001 to June 2011 were retrospectively reviewed. CRP were measured at beginning, middle, and the end of the treatment. The endpoints were overall survival (OS) and distant metastasis free survival (DMFS). Patients were divided into three groups according to baseline CRP and CRP kinetics: (1) continuously normal group: patients whose baseline CRP normal and never elevated, (2) ever-elevated group: patients whose CRP ever elevated regardless time points, (3) continuously elevated group: patients whose baseline CRP elevated and never normalized. Baseline CRP, CRP after treatment, and CRP kinetics were correlated with TNM stage, T stage, and N stage. Univariate and multivariate analysis identified that elevated baseline CRP and CRP after treatment had significant association with worse survival than normal CRP. Oppositely, elevated CRP during treatment was not associated with survival. Patients with continuously elevated CRP significantly had poor OS and DMFS (HR:2.610, 95%CI: 1.592-4.279, p < 0.001; HR:2.816, 95%CI: 1.486-5.302, p = 0.001, respectively). In multivariate analysis, CRP kinetics assessment is an independent prognostic factor for OS and DFMS in NPC patients (HR:2.512, 95%CI: 1.452-4.346, p = 0.001; HR:3.389, 95%CI: 1.734-6.625, p = 0.001, respectively). In conclusion, elevated CRP at baseline and after treatment are predictive factors of poor prognosis for NPC. The study of CRP kinetics shows that continuously elevated CRP during treatment might indicate an unfavorable prognosis for NPC.

Prognostic implications of circulating Epstein-Barr virus DNA for extranodal natural killer/T-cell lymphoma, nasal type: a meta-analysis.

INTRODUCTION: To evaluate the prognostic value of circulating Epstein-Barr virus DNA for extra-nodal natural killer/T-Cell lymphoma, nasal type (ENKTL), we performed a meta-analysis of published studies that provided survival information with pre-/post-treatment circulating EBV DNA. METHODS: Eligible studies that discussed prognostic significance of circulating EBV DNA in ENKTL were included. Random effects models were applied to obtain the estimated hazard ratios and 95% confidence intervals to evaluate prognostic significance (OS and DFS/PFS). Eleven studies covering a total of 562 subjects were included in this analysis. RESULTS: The summary HRs and 95% CIs of pre-treatment EBV DNA for OS and PFS/DFS were 4.43 (95% CI 2.66-7.39, P<0.00001) and 3.12 (95% CI 1.42-6.85, P=0.005), respectively. The corresponding HRs and 95% CIs of post-treatment EBV DNA for OS and PFS/DFS were 6.28 (95% CI 2.75-14.35, P<0.0001) and 6.57 (95% CI 2.14-20.16, P=0.001). Subgroup analyses indicated a strong trend of prognostic powers with pre-/post-treatment EBV DNA. CONCLUSION: With the present evidence, circulating EBV DNA consistently correlated with poorer prognosis in patients with ENKTL which need further investigation in large-scale clinical studies.

Impact of diabetes mellitus on the risk and survival of nasopharyngeal carcinoma: a meta-analysis.

BACKGROUND: Diabetes mellitus (DM) has been identified to be both a risk factor and a prognostic factor in a variety of malignancies, but its association with the risk and outcome of nasopharyngeal carcinoma (NPC) is still unclear. To elucidate this issue, we systematically reviewed the evidence concerning the association between DM status and NPC. MATERIALS AND METHODS: We identified studies by a literature search of PubMed, Embase, and ISI Web of Knowledge through May 31, 2017, and by searching the reference lists of pertinent articles. Odds ratios (ORs) and hazard ratios (HRs) with 95% CIs were used to estimate the effect size. Heterogeneity across studies was evaluated by the Cochran's Q and I2 statistics. RESULTS: A total of nine studies were included. Four studies with a total sample size of 221,611 reported the effect of DM on NPC risk, and the other five studies with a sample size of 9,442 reported the impact of DM on survival in NPC patients. All included studies were retrospective, and mostly conducted in Asian populations. Meanwhile, condition of metformin usage was not considered in all studies. A pooled OR of 0.65 (95% CI: 0.43-0.98, P=0.04) revealed an inverse association between DM and NPC. Additionally, pooled analyses of studies investigating the prognosis value of DM revealed that preexisting DM had no effect on overall survival (HR =1.17, 95% CI: 0.94-1.46, P=0.16), local recurrence-free survival (HR =1.16, 95% CI: 0.80-1.67, P=0.44), and distant metastasis-free survival (HR =1.14, 95% CI: 0.92-1.40, P=0.22). CONCLUSION: Our results suggested that DM patients might have decreased NPC risk, and have little impact on prognosis of NPC patients. This conclusion should be limited to Asian population. Our results also suggest that more attention should be paid to metformin medication in further studies in order to clarify whether the effects of DM on NPC risk and prognosis are influenced by the anticancer effect of metformin.

CXCL12 genetic variants as prognostic markers in nasopharyngeal carcinoma.

The chemokine receptor 4/chemokine ligand 12 (CXCR4/CXCL12) axis plays an important role in tumorigenesis, metastasis, and recurrence of tumors. Its single nucleotide polymorphisms (SNPs) are associated with patient survival in several types of cancer. However, the prognostic value of SNPs in nasopharyngeal carcinoma (NPC) has not been fully investigated. This retrospective study assessed the relationships between CXCR4 rs2228014 and CXCL12 rs1801157 polymorphisms and patient outcome in 222 patients newly diagnosed with NPC. The analysis found no significant correlation between the presence of both SNPs and clinicopathological factors. However, univariate analysis showed that N classification, clinical stage, and the CXCL12 rs1801157 polymorphism were significantly associated with distant metastasis-free survival (P=0.018, 0.028, and 0.013, respectively) and progression-free survival (P=0.007, 0.046, and 0.021, respectively). After adjusting clinicopathological factors, multivariate analysis identified CXCL12 rs1801157 as an independent prognostic factor for distant metastasis-free survival and progression-free survival (hazard ratio: 3.332; 95% confidence interval: 1.597-6.949; P=0.001 and hazard ratio: 2.665 95% confidence interval: 1.387-5.119; P=0.003, respectively). Our results suggest that CXCL12 rs1801157 AA genotype might serve as a potential prognostic factor in patients with NPC.

Inhibition of glutamine metabolism counteracts pancreatic cancer stem cell features and sensitizes cells to radiotherapy.

Pancreatic ductal adenocarcinoma (PDAC) cells utilize a novel non-canonical pathway of glutamine metabolism that is essential for tumor growth and redox balance. Inhibition of this metabolic pathway in PDAC can potentially synergize with therapies that increase intracellular reactive oxygen species (ROS) such as radiation. Here, we evaluated the dependence of pancreatic cancer stem cells (PCSCs) on this non-canonical glutamine metabolism pathway and researched whether inhibiting this pathway can enhance radiosensitivity of PCSCs. We showed that glutamine deprivation significantly inhibited self-renewal, decreased expression of stemness-related genes, increased intracellular ROS, and induced apoptosis in PCSCs. These effects were countered by oxaloacetate, but not α-ketoglutarate. Knockdown of glutamic-oxaloacetic transaminase dramatically impaired PCSCs properties, while glutamate dehydrogenase knockdown had a limited effect, suggesting a dependence of PCSCs on non-canonical glutamine metabolism. Additionally, glutamine deprivation significantly increased radiation-induced ROS and sensitized PCSCs to fractionated radiation. Moreover, transaminase inhibitors effectively enhanced ROS generation, promoted radiation sensitivity, and attenuated tumor growth in nude mice following radiation exposure. Our findings reveal that inhibiting the non-canonical pathway of glutamine metabolism enhances the PCSC radiosensitivity and may be an effective adjunct in cancer radiotherapy.

Low RASSF6 expression in pancreatic ductal adenocarcinoma is associated with poor survival.

AIM: To analyze RASSF6 expression in pancreatic ductal adenocarcinoma (PDAC) and to determine whether RASSF6 has an independent prognostic value in PDAC. METHODS: We studied RASSF6 expression in 96 histologically confirmed PDAC samples and 20 chronic pancreatitis specimens using immunohistochemistry and real-time quantitative reverse transcription-PCR. PDAC issues were then classified as RASSF6 strongly positive, weakly positive or negative. RASSF6 mRNA and protein expression in PDAC samples with strong positive staining was further evaluated using real-time PCR and Western blot analysis. Lastly, correlations between RASSF6 staining and patients' clinicopathological variables and outcomes were assessed. RESULTS: RASSF6 was negatively expressed in 51 (53.1%) PDAC samples, weakly positively expressed in 29 (30.2%) and strongly positively expressed in 16 (16.7%), while its expression was much higher in para-tumor tissues and chronic pancreatitis tissues. Positive relationships between RASSF6 expression and T-stage (P = 0.047) and perineural invasion (P = 0.026) were observed. The median survival time of strongly and weakly positive and negative RASSF6 staining groups was 33 mo, 15 mo and 11 mo, respectively. Cox multivariate analysis indicated that RASSF6 was an independent prognostic indicator of overall survival in patients with PDAC. A survival curve analysis revealed that increased RASSF6 expression was correlated with better overall survival (P = 0.009). CONCLUSION: RASSF6 expression is an independent biomarker of an unfavorable prognosis in patients with PDAC.

Macrophage migration inhibitory factor is overexpressed in pancreatic cancer tissues and impairs insulin secretion function of ß-cell.

BACKGROUND: Understanding the pathogenic mechanism of pancreatic cancer associated diabetes (PCDM) might help yield biomarkers for the early diagnosis of pancreatic cancer (PC) from population with new-onset diabetes. In the current study, we sought to determine the role of macrophage migration inhibitory factor (MIF) in PCDM pathogenesis. METHODS: The protein and mRNA levels of MIF in paraffin-embedded human PC samples, chronic pancreatitis specimens, and normal pancreas were measured by immunohistochemistry and quantitative reverse-transcriptase polymerase chain reaction. We measured serum levels of MIF in PC patients and controls. The biologic impacts of MIF overexpression on insulin secretion function of mice islets and ß cells (HIT-T15) were investigated in vitro. RESULTS: MIF expression was significantly increased in pancreatic cancer tissues compared with chronic pancreatitis or normal pancreas specimens. The insulin secretion function of both islets and HIT-T15 cells was impaired by indirect co-cultured with PC cells or treated with conditioned media from them. Stable MIF knock-down significantly decreased the diabetogenic effect of PC cells, while MIF knock-in HPDE6 cells demonstrated a strong inhibitory effect on insulin secretion function of islets and HIT-T15 cells. MIF impaired ßcell function by depressing the Ca⁺ currents, decreasing L-type Ca⁺ channel α1 subunit protein expression level, and enhancing p-Src activity. Mean serum level of MIF was significant higher in new-onset diabetes associated PC patients in comparison with other groups. CONCLUSIONS: MIF is up-regulated in patients with pancreatic cancer and causes dysfunction of insulin secretion in ß-cells.

Evaluation of risk factors for extrahepatic cholangiocarcinoma: ABO blood group, hepatitis B virus and their synergism.

Little is known about the role of association between ABO blood group and development of extrahepatic cholangiocarcinoma (ECC) through effects on hepatitis B viral (HBV) infection. Our aim was to address this question using a matched case-control study in Southern China.We prospectively analyzed 239 ECC patients, and 478 age- and sex-matched controls in Sun Yat-sen Memorial Hospital of Sun Yat-sen University from 1999 to 2011. Information on ABO blood group, HBV infection and other clinicopathologic factors was collected. Adjusted odds ratios (AORs) and the corresponding 95% confidence intervals (CIs) were computed from unconditional logistic regression models, adjusted for major confounding factors. The estimated AORs were as follows: A blood group, 1.784; HBsAg+/HbcAb+, 1.848 and HBsAg-/HbcAb+, 1.501. The A blood type had a significant effect on modifying the risk of ECC among subjects with HBsAg+/HbcAb+ (AOR 3.795, 95% CI 1.427-10.090). ECC patients with A blood group were more common in younger subjects, and a lower proportion of serum CA-125 and CA19-9 elevation in patients with blood type A was found. Our study suggests an association between A blood type, HBV infection and ECC risk, and a synergism between A blood type and HBV infection in the development of ECC.