Implementing routine use of self-removed ureteric stents on extraction strings: prospective patient-reported outcome measures and complications.

PURPOSE: Ureteric stents placed after ureteroscopy typically require cystoscopy for removal. Stent extraction strings allow the option of patient self-removal. This facilitates shorter stent dwell time, and cost-savings. Concerns regarding safety and limited evidence regarding patient acceptability are speculated reasons for infrequent clinical use of extraction strings. This study investigates our recent experience using routine self-removal of stents on extraction strings to provide evidence to address these concerns. METHODS: In February 2020, our hospital adopted a policy for self-removal of stents on extraction strings to be routine following ureteroscopy. This was influenced by motivation to improve service capacity for diagnostic flexible cystoscopy, hospital avoidance during the pandemic, perceived improvement for the patient experience, and cost-saving. Prospective clinical and patient-reported outcome data were collected and evaluated. RESULTS: There were 168 patients who had stents on extraction strings. Mean stent dwell time was 5.2 ± 1.8 days. Primary ureteroscopy was performed in 40.5%, and 59.5% had procedures using an access sheath. Self-removal at home was successful for 79% of patients. Stent dislodgement rate was 3.0% (5/168) and retained stents due to string detachment occurred in 1.8% (3/168). Almost all indicated they "would remove the stent on string again" (90%, 128/142) and the majority reported stent removal as "very easy" (61%, 87/142). Cost modelling estimates a total saving of AUD $148,869 per annum for routine use of extraction strings at our hospital. CONCLUSION: Our experience reflects that stent extraction strings may be used routinely with acceptable low complication rates, favourable patient experiences and associated cost savings.

Malignant Features in Pretreatment Metastatic Lateral Lymph Nodes in Locally Advanced Low Rectal Cancer Predict Distant Metastases.

INTRODUCTION: Pretreatment enlarged lateral lymph nodes (LLN) in patients with locally advanced low rectal cancer are predictive for local recurrences after neoadjuvant (chemo)radiotherapy (n(C)RT) followed by total mesorectal excision (TME). Not much is known of the impact on oncological outcomes when in addition malignant features are present in enlarged LLN. PATIENTS AND METHODS: A multicenter retrospective cohort study was conducted at five tertiary referral centers in the Netherlands and Australia. All patients were diagnosed with locally advanced low rectal cancer with LLN on pretreatment magnetic resonance imaging (MRI) and underwent n(C)RT followed by TME. LLN were considered enlarged with a short axis of ≥ 5 mm. Malignant features were defined as nodes with internal heterogeneity and/or border irregularity. Outcomes of interest were local recurrence-free survival (LRFS), distant metastatic-free survival (DMFS), and overall survival (OS). RESULTS: Out of 115 patients, the majority was male (75%) and the median age was 64 years (range 26-85 years). Median pretreatment LLN short axis was 7 mm (range 5-28 mm), and 60 patients (52%) had malignant features. After a median follow-up of 47 months, patients with larger LLN (7 + mm) had a worse LRFS (p = 0.01) but no difference in DMFS (p = 0.37) and OS (p = 0.54) compared with patients with smaller LLN (5-6 mm). LLN patients with malignant features had no difference in LRFS (p = 0.20) but worse DMFS (p = 0.004) and OS (p = 0.006) compared with patients without malignant features in the LLN. Cox regression analysis identified LLN short axis as an independent factor for LR. Malignant features in LLN were an independent factor for DMFS. CONCLUSION: The current study suggests that pretreatment enlarged LLN that also harbor malignant features are predictive of a worse DMFS. More studies will be required to further explore the role of malignant features in LLN.

Genome-wide association study and transcriptome of olecranon-type traits in peach (Prunus persica L.) germplasm.

BACKGROUND: The top of the olecranon honey peach (Prunus persica L.) fruit appears similar to an eagle's beak. In this study, a single olecranon honey peach with a round-type fruit was observed in our fruit orchard. To explore the genetic mechanism of olecranon formation, we performed full-length transcriptome sequencing analysis of olecranon and round peaches as well as a genome-wide association study of the association of olecranon-type trait loci. RESULTS: The gene locus was 26,924,482 base pairs in NC_034014.1. Transcriptome sequencing showed that the clean sequencing data of each sample reached 7.10GB, with 14,360 genes and 23,167 transcripts expressed in both the olecranon honey peach and round peach. Among the 11 differentially expressed genes selected as candidate genes, six were highly expressed in olecranon peach and named as LOC18775282, LOC18772209, LOC18773929, LOC18772013, LOC18773401, and ONT.13798.5. Five genes were highly expressed in round peach and named as LOC18773079, LOC18773525, LOC18773067, LOC18775244, and LOC18772236. Notably, ONT.13798.5 was not previously identified. The genes were within 1 Mb up- or down-stream of the main genome-wide association study locus for olecranon-type traits. CONCLUSIONS: This study revealed loci associated with olecranon and provides useful information for analysis and breeding of olecranon honey peach.

Impact of Ageing on Hepatic Malignancy Resection: Is Age Really a Risk Factor for Mortality?

BACKGROUND: With an ageing population, it is paramount for surgeons to comprehend the implications of age on surgical outcomes. This study aims to identify the effects of age on perioperative outcomes post-hepatectomy. METHODS: Between 2001 and 2017, 357 hepatectomies were performed in our centre for malignancy. Data recorded include demographic, histopathology and perioperative outcomes. Patients were divided into three age groups (Group 1 < 65 years, Group 2 65-74 years, Group 3 ≥ 75 years). RESULTS: With increasing age, there was a trend towards patient having: ASA ≥ 3 (from 32.1% to 60.9%, p < 0.0001), clear margins (from 80.4% to 88.3%, p = 0.2256), days of hospitalisation (from 9.5 ± 6.9 to 12 ± 8.0, p = 0.0003), days of ICU admission (from 2.3 ± 2.8 to 2.8 ± 12.9, p = 0.0790) and morbidity (from 39% to 58.5%, p = 0.0073). Cardiovascular complications and postoperative delirium increase with age. There was no significant difference in mortality across the three groups. Univariate and bivariate binary logistic regressions found no association between mortality and age. When adjusted for age, 30- and 90-day mortality was significantly associated with Clavien-Dindo ≥ 3, length of hospital and cardiac complications. Additionally, 90-day mortality was significantly associated with ASA score ≥3, mass of liver resected, length of ICU stay and hepatobiliary, pulmonary and genitourinary complications. CONCLUSION: Increased age is associated with increased post-hepatectomy complications, prolonged hospital stay and ICU admission. However, age itself is not a contraindication for hepatectomy and is not associated with increased mortality. Good histopathology outcomes and low mortality rates are achievable with careful patient selection and appropriate perioperative management.

Quantitative Structure-Activity Relationship Model to Predict Antioxidant Effects of the Peptide Fraction Extracted from a Co-Culture System of Chlorella pyrenoidosa and Yarrowia lipolytica.

In this study, the antioxidant components in co-culture of Chlorella pyrenoidosa and Yarrowia lipolytica (3:1 ratio) were confirmed as trypsin-hydrolyzed peptides (EHPs). The EHPs were composed of 836 different peptides with molecular weights ranging from 639 to 3531 Da and were mainly composed of hydrophobic amino acids (48.1%). These peptides showed remarkable protective effects against oxidative stress in HepG2, which may be attributed to their structures. Furthermore, the mRNA and protein levels of nuclear factor erythroid 2-related factor 2 (Nrf2) were significantly lower in the peptide-treated group than in the control group, suggesting that the antioxidant enzyme-coding genes were not activated. The EC50 value of three peptides in the EHPs were in the order of AGYSPIGFVR (0.04 ± 0.002 mg/mL) > VLDELTLAR (0.09 ± 0.001 mg/mL) > LFDPVYLFDQG (0.41 ± 0.03 mg/mL); these results agreed with the prediction of the model (R2 > 0.9, Q2 > 0.5). Thus, EHPs show potential as potent new antioxidant agents.

Pretreatment of brewery effluent to cultivate Spirulina sp. for nutrients removal and biomass production.

Due to the low concentration of nitrate and high contents of organics, brewery effluent was not suitable for the cultivation of Spirulina sp. This work changed the nutrient profile of brewery effluent effectively by dilution, addition of nitrate, and anaerobic digestion. The result showed that the optimum dilution rate and NaNO3 addition for brewery effluent were 20% and 0.5 g/L, respectively. Spirulina sp. grown in pretreated brewery effluent produced 1.562 mg/L biomass and reduced concentrations of nutrients to reach the permissible dischargeable limits. In addition, Spirulina sp. grown in pretreated brewery effluent had much higher protein content and oil content. So the appropriate treatment converted brewery effluent into a nutrient balanced medium for algae cultivation and alleviated the potential environmental problems. Pretreatment procedure developed in this work is an effective way to realize the sustainable utilization of brewery effluent and produce algal biomass with valuable nutrients.

Association of Electroencephalography (EEG) Power Spectra with Corneal Nerve Fiber Injury in Retinoblastoma Patients.

BACKGROUND In our clinical experience we discovered that EEG band power may be correlated with corneal nerve injury in retinoblastoma patients. This study aimed to investigate biomarkers obtained from electroencephalography (EEG) recordings to reflect corneal nerve injury in retinoblastoma patients. MATERIAL AND METHODS Our study included 20 retinoblastoma patients treated at the Department of Ophthalmology, Affiliated Hospital of Weifang Medical University between 2010 and 2014. Twenty normal individuals were included in the control group. EEG activity was recorded continuously with 32 electrodes using standard EEG electrode placement for detecting EEG power. A cornea confocal microscope was used to examine corneal nerve injury in retinoblastoma patients and normal individuals. Spearman rank correlation analysis was used to analyze the correlation between corneal nerve injury and EEG power changes. The sensitivity and specificity of changed EEG power in diagnosis of corneal nerve injury were also analyzed. RESULTS The predominantly slow EEG oscillations changed gradually into faster waves in retinoblastoma patients. The EEG pattern in retinoblastoma patients was characterized by a distinct increase of delta (P<0.01) and significant decrease of theta power P<0.05). Corneal nerves were damaged in corneas of retinoblastoma patients. Corneal nerve injury was positively correlated with delta EEG spectra power and negatively correlated with theta EEG spectra power. The diagnostic sensitivity and specificity by compounding in the series were 60% and 67%, respectively. CONCLUSIONS Changes in delta and theta of EEG appear to be associated with occurrence of corneal nerve injury. Useful information can be provided for evaluating corneal nerve damage in retinoblastoma patients through analyzing EEG power bands.

Comparative proteomics analysis of Spodoptera frugiperda cells during Autographa californica multiple nucleopolyhedrovirus infection.

BACKGROUND: Increasing evidence sugggest that in addition of balculovirus controling insect host, host cells also responds to balculovirus infection. However, compared to existing knowledge on virus gene, host cell responses are relatively poorly understood. METHODS: In this study, Spodoptera frugiperda (Sf9) cells were infected with Autographa californica multiple nucleopolyhedrovirus (AcMNPV). The protein composition and protein changes of Spodoptera frugiperda (Sf9) cells of different infection stages were analysed by isobaric tag for relative and absolute quantification (iTRAQ) techniques. RESULTS: A total of 4004 Sf9 proteins were identified by iTRAQ and 413 proteins were found as more than 1.5-fold changes in abundance. The 413 proteins were categorised according to GO classification for insects and were categorised into: biological process, molecular function and cellular component. CONCLUSIONS: The determination of the protein changes in infected Sf9 cells would help to better understanding of host cell responses and facilitate better design of this virus-host cell interaction in pest insect control and other related fields.

Tips and Tricks: Evolution of Orchidectomy.

Radical orchidectomy has been the standard surgery for testicular tumours. While a straightforward routine surgery, there are several finer points in the surgical technique and perioperative care that urologists should be familiar with. This mini-review discusses modifications to the conventional surgical approach such as organ-sparing surgery and the subinguinal approach, and practice points regarding prostheses and sperm banking that are pertinent to early management of a patient with a testicular tumour. PATIENT SUMMARY: We reviewed the evidence for surgical removal of a testicle for testicular cancer. There are a number of different techniques to minimise the extent of surgery. Surgeons should also discuss sperm banking and options for a testicular prosthesis with their patients.

Reoperation for post hepatectomy complications.

BACKGROUND: Reoperation for post hepatectomy complications is associated with high rates of morbidity and mortality. We aim to describe the frequency, indications, and risk factors for reoperation after liver resection in a single centre. METHODS: Perioperative data of 464 patients, who underwent elective hepatectomy from 2001 to 2020 at The Queen Elizabeth Hospital in South Australia, were retrospectively analysed. The frequency and indications for reoperation for post hepatectomy complications were recorded. Binary logistic regression analysis was performed to determine variables associated with reoperation. RESULTS: A total of seven patients (1.5%) underwent reoperation post hepatectomy. The most common indications for reoperation were intra-abdominal abscess, post-operative haemorrhage, bile leak, and ischaemic bowel. Three out of the seven patients died. Patients were more likely to require reoperation if an additional major non-hepatic procedure was performed. CONCLUSION: Reoperation post hepatectomy is associated with morbidity and mortality and is more likely to occur in patients who have undergone a non-hepatic procedure at the same time as the primary hepatic resection. Surgeons should ensure these patients are appropriately monitored and be selective about performing complex, multiple procedures. When possible, procedures should be staged.

A Systematic Review on Artificial Intelligence Evaluating Metastatic Prostatic Cancer and Lymph Nodes on PSMA PET Scans.

Early detection of metastatic prostate cancer (mPCa) is crucial. Whilst the prostate-specific membrane antigen (PSMA) PET scan has high diagnostic accuracy, it suffers from inter-reader variability, and the time-consuming reporting process. This systematic review was registered on PROSPERO (ID CRD42023456044) and aims to evaluate AI's ability to enhance reporting, diagnostics, and predictive capabilities for mPCa on PSMA PET scans. Inclusion criteria covered studies using AI to evaluate mPCa on PSMA PET, excluding non-PSMA tracers. A search was conducted on Medline, Embase, and Scopus from inception to July 2023. After screening 249 studies, 11 remained eligible for inclusion. Due to the heterogeneity of studies, meta-analysis was precluded. The prediction model risk of bias assessment tool (PROBAST) indicated a low overall risk of bias in ten studies, though only one incorporated clinical parameters (such as age, and Gleason score). AI demonstrated a high accuracy (98%) in identifying lymph node involvement and metastatic disease, albeit with sensitivity variation (62-97%). Advantages included distinguishing bone lesions, estimating tumour burden, predicting treatment response, and automating tasks accurately. In conclusion, AI showcases promising capabilities in enhancing the diagnostic potential of PSMA PET scans for mPCa, addressing current limitations in efficiency and variability.

The multifaceted mechanisms of Dihydrotanshinone I in the treatment of tumors.

The morbidity and mortality of malignant tumors are progressively rising on an annual basis. Traditional Chinese Medicine (TCM) holds promise as a possible therapeutic agent for the avoidance or therapy of malignant tumors. Salvia miltiorrhiza Bunge (Danshen), a traditional Asian functional food, has therapeutic characteristics in application for the treatment of malignant tumors. Dihydrotanshinone I (DHTS) is the principal lipophilic phenanthraquinone compound found in Salvia miltiorrhiza Bunge, whose anti-tumor effect has attracted widespread attention. The anti-tumor effects include inhibiting cancer cell proliferation, triggering apoptosis of tumor cells, inducing ferroptosis in tumor cells, inhibiting tumor cell invasion and metastasis, and improving drug resistance of tumor cells. In this paper, we summarized and analyzed the mechanisms and targets of anti-tumor effect of DHTS, providing new ideas and establishing a solid theoretical basis for the future advancement and clinical treatment of DHTS.

A Systematic Review on Prostate-Specific Membrane Antigen Positron Emission Tomography (PSMA PET) Evaluating Localized Low- to Intermediate-Risk Prostate Cancer: A Tool to Improve Risk Stratification for Active Surveillance?

Active surveillance remains a treatment option for low- to intermediate-risk prostate cancer (PCa) patients. Prostate-specific membrane antigen positron emission tomography and computed tomography (PSMA PET/CT) has emerged as a useful modality to assess intraprostatic lesions. This systematic review aims to evaluate PSMA PET/CT in localized low- to intermediate-risk PCa to determine its role in active surveillance. Following PRISMA guidelines, a search was performed on Medline, Embase, and Scopus. Only studies evaluating PSMA PET/CT in localized low- to intermediate-risk PCa were included. Studies were excluded if patients received previous treatment, or if they included high-risk PCa. The search yielded 335 articles, of which only four publications were suitable for inclusion. One prospective study demonstrated that PSMA PET/CT-targeted biopsy has superior diagnostic accuracy when compared to mpMRI. One prospective and one retrospective study demonstrated MRI occult lesions in 12.3-29% of patients, of which up to 10% may harbor underlying unfavorable pathology. The last retrospective study demonstrated the ability of PSMA PET/CT to predict the volume of Gleason pattern 4 disease. Early evidence demonstrated the utility of PSMA PET/CT as a tool in making AS safer by detecting MRI occult lesions and patients at risk of upgrading of disease.

Ionic liquids with reversible photo-induced conductivity regulation in aqueous solution.

Stimulus-responsive ionic liquids have gained significant attention for their applications in various areas. Herein, three kinds of azobenzimidazole ionic liquids with reversible photo-induced conductivity regulation were designed and synthesized. The change of electrical conductivity under UV/visible light irradiation in aqueous solution was studied, and the effect of chemical structure and concentration of ionic liquids containing azobenzene to the regulation of photoresponse conductivity were discussed. The results showed that exposing the ionic liquid aqueous solution to ultraviolet light significantly increased its conductivity. Ionic liquids with longer alkyl chains exhibited an even greater increase in conductivity, up to 75.5%. Then under the irradiation of visible light, the electrical conductivity of the solution returned to its initial value. Further exploration of the mechanism of the reversible photo-induced conductivity regulation of azobenzene ionic liquids aqueous solution indicated that this may attributed to the formation/dissociation of ionic liquids aggregates in aqueous solution induced by the isomerization of azobenzene under UV/visible light irradiation and resulted the reversible conductivity regulation. This work provides a way for the molecular designing and performance regulation of photo-responsive ionic liquid and were expected to be applied in devices with photoconductive switching and micro photocontrol properties.

Extended scope of practice needed for Australian rural general surgeons: a review of South Australia's rural general surgical caseload and case mix.

BACKGROUND: There is a shortage of surgeons caring for the 33% of Australians residing in rural and regional areas. In order to help appreciate what rural general surgery entails and optimize training for aspiring rural surgeons, the aim of this study was to analyse the general surgical departments' procedural caseload and casemix in four rural South Australian hospitals. METHODS: This is a retrospective multi-centre study involving four rural surgical centres in South Australia (Mt Gambier, Whyalla, Port Augusta, and Port Lincoln). Surgical procedures performed from 2014-2020 were extracted from departmental audits. To identify trends of surgical procedure over time, the data was divided into three time periods (Period 1: February 2014-December 2015, Period 2: January 2016-December 2017, Period 3: January 2018-March 2020). RESULTS: A total of 44 191 surgical procedures were performed, 70.2% being day procedures. 54% were endoscopic procedures, 46% were operative procedures. 60.6% of the operative procedures were general surgery procedures. 28.5% were general surgery-based subspecialty (colorectal, hepato-pancreato-biliary, upper gastrointestinal, and breast). 10.9% were non-general surgery-based subspecialty (urology, plastics, vascular, orthopaedics, head and neck, and obstetrics and gynaecology). There were no statistically significant fluctuations in procedure caseload in all aspects (endoscopic and operative procedures) over the three time periods. CONCLUSION: The majority of a rural Australian general surgeon's procedures are endoscopic. Operative procedures are mainly general surgery based. It may be beneficial to equip aspiring rural general surgeons to manage basic non-general surgery procedures (urological, vascular, and orthopaedic).

Nitrogen addition increases topsoil carbon stock in an alpine meadow of the Qinghai-Tibet Plateau.

Soil carbon (C) sequestration plays a critical role in mitigating climate change. Nitrogen (N) deposition greatly affects soil C dynamics by altering C input and output. However, how soil C stocks respond to various forms of N input is not well clear. This study aimed to explore the impact of N addition on soil C stock and to elucidate the underlying mechanisms in an alpine meadow on the eastern Qinghai-Tibet Plateau. The field experiment involved three N application rates and three N forms, using a non-N treatment as a control. After six years of N addition, the total C (TC) stocks in the topsoil (0-15 cm) were markedly increased by an average of 12.1 %, with a mean annual rate of 20.1 ‰, and no difference was found between the N forms. Irrespective of rate or form, N addition significantly increased the topsoil microbial biomass C (MBC) content, which was positively correlated with mineral-associated and particulate organic C content and was identified as the most important factor that affecting the topsoil TC. Meanwhile, N addition significantly increased the aboveground biomass in the years with moderate precipitation and relatively high temperature, which leads to higher C input into soils. Owing to decreased pH and/or activities of ß-1,4-glucosidase (ßG) and cellobiohydrolase (CBH) in the topsoil, organic matter decomposition was most likely inhibited by N addition, and this inhibiting effect varied under different N forms. Additionally, TC content in the topsoil and subsoil (15-30 cm) exhibited parabolic and positive linear relationship with the topsoil dissolved organic C (DOC) content, respectively, indicating that DOC leaching might be an important influencing factor for soil C accumulation. These findings improve our understanding of how N enrichment affects C cycles in alpine grassland ecosystems and suggest that soil C sequestration in alpine meadows probably increases with N deposition.

Clinical predictors of rectal cancer response after neo-adjuvant (Chemo)Radiotherapy in Australia and New Zealand: Analysis of the Bi-National Colorectal Cancer Audit (BCCA).

Pathological complete response (pCR) is observed in 11-26% of locally advanced rectal cancers undergoing neoadjuvant chemoradiotherapy (nCRT). This study aims to determine pCR rates and clinicopathological predictors in the Australian and New Zealand (ANZ) cohort. The Bi-National Colorectal Cancer Audit (BCCA) was interrogated for all rectal cancer patients who underwent nCRT prior to surgical resection between 2007 and 2020. Patients were divided in two groups: pCR (AJCC tumour regression grade 0) and partial/no response (pPR, regression grade 1,2 or 3). In total, 3230 patients were included. Rates of pCR and pPR were 704 (21.8%) and 2526 (78.2%), respectively. Long-course nCRT (p < 0.0001), lower clinical tumour stage (cT; p < 0.0001), and nodal stage (cN; p = 0.003) were associated with pCR on univariate analysis. On multivariable analysis, cN0 stage and long-course nCRT remained independent factors for a pCR. Awareness of these predictors provides valuable information when counseling patients regarding prognosis and treatment options.

Understanding unplanned return to theatre in rural South Australia general surgery: review of four major hospitals over a six-year period.

BACKGROUND: Unplanned return to theatre (URTT) is associated with longer hospital stay and higher mortality rates, placing extra burden on hospital resources. There is a lack of literature analysing causes of URTT in a rural general surgery department. This knowledge may be important to help identify patients at risk of URTT. This study aims to identify causes of URTT in rural general surgical patients. METHODS: This is a retrospective multicenter cohort involving four rural South Australian (SA) hospitals: Mount Gambier (MGH), Whyalla (WH), Port Augusta (PAH), and Port Lincoln (PLH). All general surgical inpatients admitted from February 2014 to March 2020 were analysed to identify all-cause of URTT. RESULTS: Of the 44 191 surgical procedures performed, there were 67 (0.15%) URTT. The most common surgical subspecialty cases that resulted in URTT were Colorectal (47.1%), General surgery (33.2%) Plastics (9.8%), and Hepatopancreatico-biliary (3.9%). The three commonest operations during URTT were washouts 22 (32.8%), interventions for haemostasis 11 (16.4%) and bowel resections 9 (13.4%). Sixteen (24%) of URTT followed emergency surgery. When comparing between elective and emergency admissions needing URTT, there were no statistical difference in age, gender, speciality type, types of surgery performed, and median number of days until URTT. CONCLUSION: Rates of URTT are low in South Australian rural hospitals when compared to our overseas counterpart. A wide range of surgery is being performed in rural centres, further supporting the need for rural surgical trainees to have a tailored curriculum encompassing subspecialities and being competent in managing any potential complications.

Treatment outcomes of mucosal melanoma of the head and neck: Analysis of 190 cases from a single institution.

Objectives: To analyze the treatment outcomes and prognostic factors of mucosal melanoma of the head and neck (MMHN) from a single institution. Methods: From December 1989 to November 2018, 190 patients diagnosed with MMHN were included. Survival analysis was performed using the Kaplan-Meier method for univariate analysis with a log-rank test for significance and Cox regression for multivariate analysis. Results: With a median follow-up time of 43.5 months, 126 (68.5%) patients died. The median DSS was 35 months. The 3- and 5-year disease-specific survival (DSS) rates were 48.1% and 33.7%, respectively. The median overall survival (OS) was 34 months. The 3- and 5-year OS rates were 47.0% and 32.9%, respectively. In univariate analysis, the T3 stage, received surgery, R0 resection, and combined therapy (surgery+biotherapy/biochemotherapy) were significantly associated with better survival. Multivariable Cox regression analysis revealed that the T4 stage (HR = 1.692; 95% CI, 1.175-2.438; p = .005) and the N1 stage (HR = 1.600; 95% CI, 1.023-2.504; p = .039) were strong prognostic factors for poor survival, and that combined therapy (surgery+biotherapy/biochemotherapy) was a strong prognostic factor for better survival outcome (HR = 0.563; 95% CI, 0.354-0.896; p = .015). Conclusion: The prognosis of MMHN remains poor. Systemic treatment is warranted to reduce MMHN progression. Surgery combined with biotherapy may improve survival.