Zhejiang Cancer Hospital

Esophageal carcinoma (EC) is a common malignant tumor of the upper digestive tract worldwide. An analysis of the latest data from cancer centers in China showed that the incidence of EC and the number of deaths due to EC in China in 2015 were 266,000 and 188,000, respectively, ranking sixth (6.3%) and fourth (8.0%) among all malignant tumors. The early diagnosis and treatment of EC and standardized diagnosis and treatment are important tasks for EC healthcare professionals in various centers across the country. At present, the 8th edition of the EC staging system jointly released by Union for International Cancer Control (UICC) and American Joint Committee on Cancer (AJCC) is the most recent, authoritative and widely used EC staging standard. The EC professional committee of the Chinese Anti-Cancer Association also organizes the "EC Standardization Campaign in China" every year to promote the development of EC diagnostic and treatment norms throughout the country. Since 2011, the EC Committee of the Chinese Anti-Cancer Association has published the Guidelines for Standardized Diagnosis and Treatment of EC. Considering the increasing number of EC clinical studies and the continuous progress in diagnostic and treatment technologies in recent years, the updated Guidelines will include the latest progress in the diagnosis and treatment of EC, with a goal of promoting the forward development of EC diagnosis and treatment in clinical practice.

We report a multicenter, phase 2 study evaluating the efficacy of pucotenlimab, an anti-PD-1 antibody, in patients with mismatch repair-deficient (dMMR) or microsatellite instability-high (MSI-H) tumors, and potential biomarkers for response. Overall, 100 patients with previously treated, advanced solid tumors centrally confirmed as dMMR or MSI-H received pucotenlimab at 200 mg every 3 weeks. The most common cancer type is colorectal cancer (n = 71). With a median follow-up of 22.5 months, the objective response rate is 49.0% (95% confidence interval 38.86%–59.20%) as assessed by the independent review committee, while the median progression-free survival and overall survival have not been reached. Grade R3 treatmentrelated adverse events were observed in 18 patients. For the biomarker analysis, responders are enriched in patients with mutations in the KMT2D gene. Pucotenlimab is an effective treatment option for previously treated advanced dMMR/MSI-H solid tumors, and the predictive value of KMT2D mutation warrants further research. This study is registered with ClinicalTrials.gov: NCT03704246.

Importance There are currently no therapies approved by the US Food and Drug Administration for nasopharyngeal carcinoma (NPC). Gemcitabine-cisplatin is the current standard of care for the first-line treatment of recurrent or metastatic NPC (RM-NPC). Objective To determine whether toripalimab in combination with gemcitabine-cisplatin will significantly improve progression-free survival and overall survival as first-line treatment for RM-NPC, compared with gemcitabine-cisplatin alone. Design, Setting, and Participants JUPITER-02 is an international, multicenter, randomized, double-blind phase 3 study conducted in NPC-endemic regions, including mainland China, Taiwan, and Singapore. From November 10, 2018, to October 20, 2019, 289 patients with RM-NPC with no prior systemic chemotherapy in the RM setting were enrolled from 35 participating centers. Interventions Patients were randomized (1:1) to receive toripalimab (240 mg [n = 146]) or placebo (n = 143) in combination with gemcitabine-cisplatin for up to 6 cycles, followed by maintenance with toripalimab or placebo until disease progression, intolerable toxicity, or completion of 2 years of treatment. Main Outcome Progression-free survival as assessed by a blinded independent central review. Secondary end points included objective response rate, overall survival, progression-free survival assessed by investigator, duration of response, and safety. Results Among the 289 patients enrolled (median age, 46 [IQR, 38-53 years; 17% female), at the final progression-free survival analysis, toripalimab treatment had a significantly longer progression-free survival than placebo (median, 21.4 vs 8.2 months; HR, 0.52 [95% CI, 0.37-0.73]). With a median survival follow-up of 36.0 months, a significant improvement in overall survival was identified with toripalimab over placebo (hazard ratio [HR], 0.63 [95% CI, 0.45-0.89]; 2-sided P = .008). The median overall survival was not reached in the toripalimab group, while it was 33.7 months in the placebo group. A consistent effect on overall survival, favoring toripalimab, was found in subgroups with high and low PD-L1 (programmed death–ligand 1) expression. The incidence of all adverse events, grade 3 or greater adverse events, and fatal adverse events were similar between the 2 groups. However, adverse events leading to discontinuation of toripalimab or placebo (11.6% vs 4.9%), immune-related adverse events (54.1% vs 21.7%), and grade 3 or greater immune-related adverse events (9.6% vs 1.4%) were more frequent in the toripalimab group. Conclusions and Relevance The addition of toripalimab to chemotherapy as first-line treatment for RM-NPC provided statistically significant and clinically meaningful progression-free survival and overall survival benefits compared with chemotherapy alone, with a manageable safety profile. These findings support the use of toripalimab plus gemcitabine-cisplatin as the new standard of care for this patient population. Trial Registration ClinicalTrials.gov Identifier: NCT03581786

Recent research indicates that OPA-interacting protein 5 antisense RNA 1 (OIP5-AS1) played an essential role in a wide variety of carcinomas. Thus, we sought to evaluate the role of OIP5-AS1 in cancer patients to comprehend the OIP5-AS1 function in cancer better. The studies were collected using network databases, while the odds ratios (ORs) or hazard ratios (HRs) were extracted from included articles. The OIP5-AS1 role in cancer was further analyzed by pooled analysis. A total of 18 studies involved 1181 patients who were diagnosed with 13 different types of cancer. Combined analysis showed that OIP5-AS1 overexpressing patients had a poorer overall survival (OS) rate than those with lower expression (pooled HR = 1.541, 95% confidence interval (CI) = 1.351–1.757, P < 0.001). Interestingly, elevated OIP5-AS1 expression was found to be linked to cancer’s unfavorable clinicopathological aspects, including larger tumor size (pooled OR = 0.274, 95% CI = 0.164–0.455, P < 0.001), advanced TNM stage (pooled OR = 0.301, 95% CI = 0.211–0.427, P < 0.001), and lymph node metastasis (pooled OR = 0.407, 95% CI = 0.234–0.706, P = 0.001). OIP5-AS1 was suggested to be a promising prognostic biomarker and a candidate target for cancer therapeutic strategies.

Tumor heterogeneity and its drivers impair tumor progression and cancer therapy. Single‐cell RNA sequencing is used to investigate the heterogeneity of tumor ecosystems. However, most methods of scRNA‐seq amplify the termini of polyadenylated transcripts, making it challenging to perform total RNA analysis and somatic mutation analysis.Therefore, a high‐throughput and high‐sensitivity method called snHH‐seq is developed, which combines random primers and a preindex strategy in the droplet microfluidic platform. This innovative method allows for the detection of total RNA in single nuclei from clinically frozen samples. A robust pipeline to facilitate the analysis of full‐length RNA‐seq data is also established. snHH‐seq is applied to more than 730 000 single nuclei from 32 patients with various tumor types. The pan‐cancer study enables it to comprehensively profile data on the tumor transcriptome, including expression levels, mutations, splicing patterns, clone dynamics, etc. New malignant cell subclusters and exploring their specific function across cancers are identified. Furthermore, the malignant status of epithelial cells is investigated among different cancer types with respect to mutation and splicing patterns. The ability to detect full‐length RNA at the single‐nucleus level provides a powerful tool for studying complex biological systems and has broad implications for understanding tumor pathology.

Background HOTAIRM1 is revealed to facilitate the malignant progression of glioma. Vasculogenic mimicry (VM) is critically involved in glioma progression. Nevertheless, the molecular mechanism of HOTAIRM1 in regulating glioma VM formation remains elusive. Thus, we attempted to clarify the role and mechanism of HOTAIRM1 in VM formation in glioma. Methods qRT-PCR and western blot assays were used to evaluate the gene and protein expression levels of HOTAIRM1 in glioma patient tissue samples and cell lines. The role of HOTAIRM1 in glioma cell progression and VM formation was explored using a series of function gain-and-loss experiments. RNA-binding protein immunoprecipitation (RIP), RNA pull-down, and mechanism experiments were conducted to assess the interaction between HOTAIRM1/METTL3/IGFBP2 axis. Furthermore, rescue assays were conducted to explore the regulatory function of HOTAIRM1/METTL3/IGFBP2 in glioma cell cellular processes and VM formation. Results We found that HOTAIRM1 presented up-regulation in glioma tissues and cells and overexpression of HOTAIRM1 facilitated glioma cell proliferation, migration, invasion, and VM formation. Furthermore, overexpression of HOTAIRM1 promoted glioma tumor growth and VM formation capacity in tumor xenograft mouse model. Moreover, HOTAIRM1 was demonstrated to interact with IGFBP2 and positively regulated IGFBP2 expression. IGFBP2 was found to promote glioma cell malignancy and VM formation. Mechanistically, METTL3 was highly expressed in glioma tissues and cells and was bound with HOTAIRM1 which stabilized HOTAIRM1 expression. Rescue assays demonstrated that METTL3 silencing counteracted the impact of HOTAIRM1 on glioma cell malignancy and VM formation capacity. Conclusion HOTAIRM1, post-transcriptionally stabilized by METTL3, promotes VM formation in glioma via up-regulating IGFBP2 expression, which provides a new direction for glioma therapy. Graphical Abstract

Background Thymic epithelial tumors (TETs) are rare malignant tumors with limited treatment options. No established second‐line treatment regimen is available following the preferred first‐line chemotherapy, resulting in unsatisfactory efficacy and poor prognosis for patients with advanced TETs. This study aimed to evaluate the efficacy of small molecule multitarget antiangiogenic inhibitors as well as the prognostic factors for advanced TETs. Methods A retrospective study was conducted using data from a real‐world database. Clinical information and survival follow‐up data were collected from 52 patients with advanced TETs who received small molecule multitarget antiangiogenic inhibitors at Zhejiang Cancer Hospital between August 10, 2016 and August 10, 2022. The short‐term efficacy of the treatments, survival time of the patients, and relevant prognostic factors of advanced TETs were analyzed. Results Out of the 52 patients included in this study, 16 had thymoma and 36 had thymic carcinoma. The 52 patients had an overall response rate of 21.1% and a disease control rate of 94.2%. In addition, the median progression‐free survival (PFS) was 8.05 months, and the overall survival (OS) was 25.00 months. Apatinib was given to 33 patients, anlotinib to 15 patients, and sunitinib or lenvatinib to four patients. Only seven patients received antiangiogenic inhibitors as their first‐line therapy, 27 patients as their second‐line therapy, and 18 patients as third‐line or subsequent therapy. Meanwhile, 42 patients received monotherapy with an antiangiogenesis inhibitor, while 10 patients received combination therapy. Univariate analysis indicated that the combined treatment was associated with a superior OS ( p = 0.044); multivariate analysis indicated that the combined treatment was an independent prognostic factor for PFS ( p = 0.014) and OS ( p = 0.012). Conclusion The findings suggest that small molecule multitarget antiangiogenic inhibitors are efficacious as second or post‐line treatments as a viable alternative treatment option for patients with advanced TETs.

Background Breast cancer (BC) is a prevalent malignancy with complex etiology and varied clinical behavior. Long non-coding RNAs (lncRNAs) have emerged as key regulators in cancer progression, including BC. Among these, lncRNA TDRKH-AS1 has been implicated in several cancers, but its role in BC remains unclear. Methods We conducted a comprehensive investigation to elucidate the role of TDRKH-AS1 in BC. Clinical samples were collected from BC patients, and BC cell lines were cultured. Bioinformatics analysis using the starBase database was carried out to assess TDRKH-AS1 expression levels in BC tissue samples. Functional experiments, including knockdown, colony formation, CCK-8, Transwell, and wound-healing assays, were conducted to determine the role of TDRKH-AS1 in BC cell proliferation and invasion. Luciferase reporter and RIP assays were used to examine the interactions between TDRKH-AS1 and miR-134-5p. In addition, the downstream target gene of miR-134-5p, cAMP response element-binding protein 1 (CREB1), was identified and studied using various methods, including RT-qPCR, immunoprecipitation, and rescue experiments. In vivo experiments using mouse tumor xenograft models were conducted to examine the role of TDRKH-AS1 in BC tumorigenesis. Results TDRKH-AS1 was found to be significantly upregulated in BC tissues and cell lines. High TDRKH-AS1 expression correlated with advanced BC stages and worse patient outcomes. Knockdown of TDRKH-AS1 led to decreased BC cell proliferation and invasion. Mechanistically, TDRKH-AS1 acted as a sponge for miR-134-5p, thereby reducing the inhibitory effects of miR-134-5p on CREB1 expression. Overexpression of CREB1 partially rescued the effects of TDRKH-AS1 knockdown in BC cells. In vivo studies further confirmed the tumor-promoting role of TDRKH-AS1 in BC. Conclusions Our study unveiled a novel regulatory axis involving TDRKH-AS1, miR-134-5p, and CREB1 in BC progression. TDRKH-AS1 functioned as an oncogenic lncRNA by promoting BC cell proliferation and invasion through modulation of the miR-134-5p/CREB1 axis. These findings highlighted TDRKH-AS1 as a potential diagnostic biomarker and therapeutic target for BC treatment.

Thyroid carcinoma is one of the most common endocrine malignant tumors and usually occurs in women, and its morbidity has been on the rise in recent years. In 2015, data from the Chinese National Central Cancer Registry (NCCR) showed that the morbidity of thyroid cancer in China in 2011 was 10.32 out of 100,000 and there were 67,800 new cases of thyroid cancer (416,300 males and 189,600 females), accounting for 6.02% of the new cases of malignant tumors. In 2012, the global cancer data showed 229,900 new cases of thyroid cancer in women worldwide, ranking eighth among female cancers. A study in the United States predicted that thyroid cancer will become the third most common cancer in women by 2019. In the past few decades, the overall incidence rate of thyroid cancer in either males or females has been increasing and shows a trend of continuous increase. The trend of increase is seen mainly in papillary thyroid carcinoma but rarely in undifferentiated cancers. In contrast, the overall disease-specific mortality remained unchanged or even decreased, indicating an increase in the proportion of low-invasive subtypes and improved medical care that allows tumors to be detected early.

Salivary glands are exocrine glands that produce and secrete saliva. They include three paired major glands (parotid gland, submandibular gland, and sublingual gland) and minor salivary glands that widely exist in the entire respiratory and digestive tract. Many minor salivary gland tumors are located on the hard palate. The global annual incidence of salivary gland tumors is 0.4/100,000–13.5/100,000, and that of malignant tumors is 0.4/100,000–2.6/100,000, accounting for 0.7%–1.6% of all malignant tumors and 2.3%–10.4% of head and neck malignant tumors. Most of the salivary gland tumors are benign, but about 20% of parotid gland tumors are malignant; the incidence of submandibular gland and minor salivary gland malignant tumors is about 50% and 80%, respectively. Nearly 80% of salivary gland tumors occur in the parotid gland, most commonly in the superficial lobe, less than 1% in the sublingual gland, and 9%–23% in the minor salivary glands. The proportion of malignant tumors is different in different parts: 20%–30%, 45%–60%, and 70%–85% in the parotid gland, submandibular gland, and sublingual gland, respectively; 80%–90% of salivary gland tumors in the tongue, floor of the mouth, and retromolar area are malignant. Salivary gland tumors are slightly more common in women, with the peak age of onset ranging from 50 to 70 years, but the peak age of pleomorphic adenoma, mucoepidermoid carcinoma, and acinus cell carcinoma is 20–40 years. Among all salivary gland tumors, pleomorphic adenoma is the most common, accounting for about 50%, usually occurring in young adults aged 30–50 years without significant gender difference. The second most common is Warthin tumor (adenolymphoma), which is common in men over 50 years old; it is usually multiplex or bilateral, mostly located in the inferior superficial lobe of the parotid gland; almost all of Warthin tumors come from the parotid gland or peripheral lymph nodes. Others such as hemangioma, lymphangioma, and lipoma are rare. The most common malignant tumor is mucoepidermoid carcinoma.

The multiple etiological characteristics of acute kidney injury (AKI) have brought great challenges to its clinical diagnosis and treatment. Renal injury in critically ill patients always indicates hemodynamic injury. The Critical Care UltraSound Guided (CCUSG)-A(KI)BCDE protocol developed by the Chinese Critical Ultrasound Study Group (CCUSG), respectively, includes A(KI) diagnosis and risk assessment and uses B-mode ultrasound, Color doppler ultrasound, spectral Doppler ultrasound, and contrast Enhanced ultrasound to obtain the hemodynamic characteristics of the kidney so that the pathophysiological mechanism of the occurrence and progression of AKI can be captured and the prognosis of AKI can be predicted combined with other clinical information; therefore, the corresponding intervention and treatment strategies can be formulated to achieve targeted, protocolized, and individualized therapy.

Background Calcification is a common phenomenon in both benign and malignant thyroid nodules. However, the clinical significance of calcification remains unclear. Therefore, we explored a more objective method for distinguishing between benign and malignant thyroid calcified nodules. Methods This retrospective study, conducted at two centers, involved a total of 631 thyroid nodules, all of which were pathologically confirmed. Ultrasound image sets were employed for analysis. The primary evaluation index was the area under the receiver-operator characteristic curve (AUROC). We compared the diagnostic performance of deep learning (DL) methods with that of radiologists and determined whether DL could enhance the diagnostic capabilities of radiologists. Results The Xception classification model exhibited the highest performance, achieving an AUROC of up to 0.970, followed by the DenseNet169 model, which attained an AUROC of up to 0.959. Notably, both DL models outperformed radiologists (P < 0.05). The success of the Xception model can be attributed to its incorporation of deep separable convolution, which effectively reduces the model’s parameter count. This feature enables the model to capture features more effectively during the feature extraction process, resulting in superior performance, particularly when dealing with limited data. Conclusions This study conclusively demonstrated that DL outperformed radiologists in differentiating between benign and malignant calcified thyroid nodules. Additionally, the diagnostic capabilities of radiologists could be enhanced with the aid of DL.

Background Sepsis is characterized by a dysregulated immune response to infection. Calcineurin inhibitors (CNIs) is a widely used immunosuppressant and has unique properties that may be associated with beneficial outcomes of patients with sepsis by keeping down of an overactive immune response. Our research is designed to investigate whether the use of CNIs exempt septic patients from adverse prognosis and assess whether it might bring about some adverse reactions. Methods The Medical Information Mart for Intensive Care IV 2.2 (MIMIC-IV 2.2) database was searched to identify septic patients with and without the use of CNIs. Propensity score matching (PSM) was applied to balance the baseline characteristics between the CNIs group and the non-user group. The primary outcome was 28-day mortality, the relationship between CNIs and patient death was analyzed by Kaplan-Meier method and Cox proportional hazard regression models. Results 22517 patients with sepsis were extracted from the MIMIC IV database. In the propensity score-matched sample of 874 individuals, lower 28-day mortality risks were observed in the CNIs group compared to the non-users’ group (HR: 0.26; 95%CI: 0.17, 0.41) by univariate cox hazard analysis. In addition, the Kaplan-Meier survival curves indicated a significant superior 28- and 365-day survival rate for CNI users compared to non-users (the log-rank test p-value was 0.001). There was no significant association between the use of CNIs and an increased risk of new onset of infection (p = 0.144). Conclusion Calcineurin inhibitors was associated with decreased short- and long-term mortality among septic patients without increased incidence of new onset of infection, hyperkalemia, severe hypertension and AKI, but may generate undesirable reaction such as liver injury and mild hypertension.

Aim N6-methyladenosine (m6A) RNA methylation exerts a regulatory effect on endometrioid ovarian cancer (EOC), but the specific m6A regulator genes in EOC remain to be explored. This study investigated that sulforaphene (Sul) is implicated in EOC development by regulating methyltransferase-like 3 (METTL3). Methods The dysregulated m6A RNA methylation genes in EOC were determined by methylated RNA immunoprecipitation (MeRIP-seq) and RNA sequencing. The roles of METTL3 and/or Sul on viability, proliferative ability, cell cycle, and apoptosis of EOC cells were determined by MTT, colony formation, flow cytometry, and TUNEL staining assay, respectively. The expression of METTL3 and apoptosis-related proteins in EOC cells was detected by quantitative real-time polymerase chain reaction (qRT-PCR) and western blot assays. Results Five m6A RNA methylation regulators (METTL3, ELF3, IGF2BP2, FTO, and METTL14) were differentially expressed in EOC, among which METTL3 had the highest expression level. Silencing METTL3 reduced the clonal expansion and viability of EOC cells, and caused the cells to arrest in the G0/G1 phase. This also promoted apoptosis in the EOC cells and activated the FAS/FADD and mitochondrial apoptosis pathways. In contrast, overexpressing METTL3 had the opposite effect. Sul, in a dose-dependent manner, reduced the viability of EOC cells but promoted their apoptosis. Sul also increased the levels of IGF2BP2 and FAS, while decreasing the levels of KRT8 and METTL3. Furthermore, Sul was able to reverse the effects of METTL3 overexpression on EOC cells. Conclusions Sul could suppress cell proliferation and promote apoptosis of EOC cells by inhibiting the METTL3 to activate the FAS/FADD and apoptosis-associated pathways.

Background Involuntary weight loss and increased systemic response are frequently observed in patients with cancer, especially in advanced stages. This study aimed to develop a powerful weight loss and inflammation grading system (WLAIGS) and investigate its prognostic performance in patients with advanced cancer. Methods This multicentre prospective cohort study included 11 423 patients with advanced cancer. A 4 × 4 matrix representing four different per cent weight loss (WL%) categories within each of the four different neutrophil‐to‐lymphocyte ratio (NLR) categories (16 possible combinations of WL% and NLR) was constructed. The WLAIGS consisted of four grades, with hazard ratios (HRs) for overall survival (OS) gradually increasing from grade 1 to grade 4. Survival analyses, including Kaplan–Meier curve, Cox proportional hazards regression, and sensitivity analysis, were performed to investigate the association between WLAIGS and OS. The secondary outcomes were short‐term survival, malnutrition, and quality of life. Two internal validation cohorts with a 7:3 ratio were used to validate the results. Results The median age of patients with advanced cancer in our study was 59.00 (interquartile range, 50.00–66.00) years. There were 6877 (60.2%) and 4546 (39.8%) male and female participants, respectively. We totally recorded 5046 death cases during the median follow‐up of 17.33 months. The Kaplan–Meier curve showed that the survival rate decreased from grade 1 to grade 4 in patients with advanced cancer (log‐rank P < 0.001). The WLAIGS was an independent risk factor associated with OS adjusting for confounders, with HRs increasing from 1.20 (95% confidence interval (CI), 1.11–1.29; P < 0.001) in grade 2, 1.48 (95% CI, 1.38–1.60; P < 0.001) in grade 3 to 1.73 (95% CI, 1.58–1.89; P < 0.001) in grade 4. In each weight loss% group (2.5 ≤ WL% < 6.0; 6.0 ≤ WL% < 11.0, WL% ≥ 11.0), a NLR above 3 was associated with shorter survival and served as an independent prognostic predictor. The risk of short‐term mortality, malnutrition, and poor quality of life increased with WLAIGS grade. Two internal validation cohorts confirmed that the WLAIGS independently identified the survival of patients with advanced cancer. Conclusions The WLAIGS, which reflects malnutrition and systemic inflammation status, is a robust and convenient tool for predicting the prognosis of patients with advanced cancer.

Purpose Drug resistance inevitably occurs despite the encouraging results of immunotherapy. This study attempted to investigate immunotherapy rechallenge treatment regimens and factors associated with outcomes in patients with non-small cell lung cancer (NSCLC) according to resistance status. Methods A retrospective study was conducted on patients with advanced NSCLC who received immune checkpoint inhibitor (ICI) monotherapy and immune rechallenge between March 2016 and December 2022. Primary resistance (RR) was defined by an absence of response after treatment administered for less than 6 months before progression. Acquired resistance (AR) was defined as a response to immunotherapy treatment administered for more than 6 months before progression. Disease progression in as many as three lesions was defined as systemic progression, whereas disease progression in fewer than three lesions was defined as oligo-progression. Results Of 40 patients, 18 (45%) had primary resistance, and 22 (55%) developed AR. Overall survival (OS) was not reached. A significant difference in progression-free survival (PFS) was observed in individuals rechallenged with ICIs after AR and RR (7.0 months vs. 2.1 months, P = 0.003). Patients receiving interval treatment before rechallenge achieved longer PFS than those who did not (6.2 months vs. 4.0 months, P = 0.027). Multivariate analysis demonstrated that systemic progression was a risk factor significantly associated with PFS after ICI rechallenge (P = 0.006). After AR, ICI rechallenge prolonged the duration of PFS if patients developed oligo-progression (5.4 months vs. 1.1 months, P < 0.001). Conclusion ICI rechallenge is likely to be an option for patients with oligo-progression during rechallenge, particularly after AR.