Advanced Computational Methodologies Used in the Discovery of New Natural Anticancer Compounds

Improved Solubility and Activity of Natural Product in Nanohydrogel

With the development of technology, natural material components are widely used in various fields of science. Natural product components in phytochemical compounds are secondary metabolites produced by plants; they have been shown to have many pharmacological activities. Phytochemical compounds obtained from plants have an important role in herbal medicine. Herbal medicine is safer and cheaper than synthetic medicine. However, herbal medicines have weaknesses, such as low solubility, less stability, low bioavailability, and experiencing physical and chemical degradation, reducing their pharmacological activity. Recent herbal nano-delivery developments are mostly plant-based. A nanotechnology-based system was developed to deliver herbal therapies with better bioavailability, namely the nanohydrogel system. Nanohydrogel is a delivery system that can overcome the disadvantages of using herbal compounds because it can increase solubility, increase pharmacological activity and bioavailability, reduce toxicity, slow delivery, increase stability, improve biodistribution, and prevent physical or chemical degradation. This review article aimed to provide an overview of recent advances in developing nanohydrogel formulations derived from natural ingredients to increase solubility and pharmacological activity, as well as a summary of the challenges faced by delivery systems based on nanohydrogel derived from natural materials. A total of 25 phytochemicals derived from natural products that have been developed into nanohydrogel were proven to increase the activity and solubility of these chemical compounds.

PI3K/Akt signaling in urological cancers: Tumorigenesis function, therapeutic potential, and therapy response regulation

In addition to environmental conditions, lifestyle factors, and chemical exposure, aberrant gene expression and mutations involve in the beginning and development of urological tumors. Even in Western nations, urological malignancies are among the top causes of patient death, and their prevalence appears to be gender dependent. The prognosis for individuals with urological malignancies remains dismal and unfavorable due to the ineffectiveness of conventional treatment methods. PI3K/Akt is a popular biochemical mechanism that is activated in tumor cells as a result of PTEN loss. PI3K/Akt escalates growth and metastasis. Moreover, due to the increase in tumor cell viability caused by PI3K/Akt activation, cancer cells may acquire resistance to treatment. This review article examines the function of PI3K/Akt in major urological tumors including bladder, prostate, and renal tumors. In prostate, bladder, and kidney tumors, the level of PI3K and Akt are notably elevated. In addition, the activation of PI3K/Akt enhances the levels of Bcl-2 and XIAP, hence increasing the tumor cell survival rate. PI3K/Akt ] upregulates EMT pathways and matrix metalloproteinase expression to increase urological cancer metastasis. Furthermore, stimulation of PI3K/Akt results in drug- and radio-resistant cancers, but its suppression by anti-tumor drugs impedes the tumorigenesis.

Anti-Aging Potential of Plants of the Anak Dalam Tribe, Jambi, Indonesia

The process of skin aging is a physiological phenomenon that can not be avoided. According to global population data, the rate of aging increases by approximately 13% every year. The impact of skin aging has become a significant concern and challenge for developed countries. Consequently, there has been a search for potential new anti-aging agents. This review aims to provide an overview of the current research status of plants of the Anak Dalam Tribe (Indonesian: Suku Anak Dalam [SAD]; referred to as SAD henceforth) in Jambi Province, Indonesia, for the development of potential new anti-aging agents. One such discovery is a product derived from natural ingredients with the ability to prevent premature aging. These new anti-aging plants have been used for centuries by the Anak Dalam tribe, for treating skin diseases and maintaining skin health through traditional remedies. Recent research on herbal formulations used by the SAD community in Indonesia for skin beauty treatments, reported by Research on Medicinal Plants and Herbs or RISTOJA, indicates that 64 plant species are used for skin care. Among these plants, Toona sinensis, Curcuma heyneana, Curcuma zedoaria, Curcuma longa, and Kaempferia rotunda are the most commonly used medicinal plants with anti-aging properties. T. sinensis is a tree, while the others are herbs. T. sinensis shows the highest potential for development as an anti-aging agent, with its extracts, active fractions, and bioactive quercetin isolates known to possess strong anti-aging activities both in vitro and in vivo. Furthermore, C. heyneana, C. longa, C. zedoaria, and K. rotunda also show potential for further research, and three of them have demonstrated good potential for in vivo anti-aging activities. Only K. rotunda demonstrates relatively weaker antioxidant activity compared to T. sinensis, C. heyneana, C. longa, and C. zedoaria. Nevertheless, K. rotunda can still be developed to search for potential opportunities as agents with other activities, while T. sinensis, C. heyneana, C. longa, and C. zedoaria in the findings could be an opportunity to explore the potential of new anti-aging agents. In conclusion, of the five medicinal plants traditionally used by the SAD in Jambi, Indonesia, C. longa has received the most extensive research and shows potential for the development of anti-aging solutions. C. zedoaria, C. heyneana and K. rotunda show good potential for in vivo anti-aging activity. T. sinensis is the least-studied medicinal plant. Nevertheless, it has potential for development, as it is widely used by the SAD community for both traditional medicine and skin care.

Isolation and anticancer activity of quercetin from Acalypha indica L. against breast cancer cell lines MCF-7 and MDA-MB-231

In this study, the active components of the plant were carefully extracted and identified using three solvent systems. After extraction, we used solvent systems to further purify the main flavonoid chemical constituent. As a result of our analytical strategy, which included HPLC analysis, MS/MS spectroscopic analysis, and NMR data-based constructions, quercetin was determined to be the main chemical constituent. Our study suggests the potential therapeutic advantages of quercetin, a compound found in the leaves of Acalypha indica, for treating breast cancer cell lines MCF-7 and MDA-MB-231. Our comparison of Quercetin to the regularly prescribed medicine Doxorubicin shows that it has the capacity to inhibit MCF-7 and MDA-MB-231 cells. Measurements of apoptosis and cell cycle phase showed this to be the case. Furthermore, a ladder that formed as a result of cellular damage brought on by ROS provided further proof of the drug's impact on DNA integrity. Notably, pro-apoptotic proteins displayed increased apoptosis activity in cells treated with quercetin. Given that it is extracted from plants and has less adverse effects than other compounds, quercetin is a viable option for further clinical study. The objective is to fight breast cancer, one of the most prevalent diseases in the world and a main cause of death for women. Thus, our research makes a significant addition to the ongoing search for potent, plant-based breast cancer treatments.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13205-023-03705-w.

Artificial Intelligence in Pharmaceutical Technology and Drug Delivery Design

Artificial intelligence (AI) has emerged as a powerful tool that harnesses anthropomorphic knowledge and provides expedited solutions to complex challenges. Remarkable advancements in AI technology and machine learning present a transformative opportunity in the drug discovery, formulation, and testing of pharmaceutical dosage forms. By utilizing AI algorithms that analyze extensive biological data, including genomics and proteomics, researchers can identify disease-associated targets and predict their interactions with potential drug candidates. This enables a more efficient and targeted approach to drug discovery, thereby increasing the likelihood of successful drug approvals. Furthermore, AI can contribute to reducing development costs by optimizing research and development processes. Machine learning algorithms assist in experimental design and can predict the pharmacokinetics and toxicity of drug candidates. This capability enables the prioritization and optimization of lead compounds, reducing the need for extensive and costly animal testing. Personalized medicine approaches can be facilitated through AI algorithms that analyze real-world patient data, leading to more effective treatment outcomes and improved patient adherence. This comprehensive review explores the wide-ranging applications of AI in drug discovery, drug delivery dosage form designs, process optimization, testing, and pharmacokinetics/pharmacodynamics (PK/PD) studies. This review provides an overview of various AI-based approaches utilized in pharmaceutical technology, highlighting their benefits and drawbacks. Nevertheless, the continued investment in and exploration of AI in the pharmaceutical industry offer exciting prospects for enhancing drug development processes and patient care.

Doxorubicin-loaded micelles in tumor cell-specific chemotherapy

Nanomedicine is a field that combines biology and engineering to improve disease treatment, particularly in cancer therapy. One of the promising techniques utilized in this area is the use of micelles, which are nanoscale delivery systems that are known for their simple preparation, high biocompatibility, small particle size, and the ability to be functionalized. A commonly employed chemotherapy drug, Doxorubicin (DOX), is an effective inhibitor of topoisomerase II that prevents DNA replication in cancer cells. However, its efficacy is frequently limited by resistance resulting from various factors, including increased activity of drug efflux transporters, heightened oncogenic factors, and lack of targeted delivery. This review aims to highlight the potential of micelles as new nanocarriers for delivering DOX and to examine the challenges involved with employing chemotherapy to treat cancer. Micelles that respond to changes in pH, redox, and light are known as stimuli-responsive micelles, which can improve the targeted delivery of DOX and its cytotoxicity by facilitating its uptake in tumor cells. Additionally, micelles can be utilized to administer a combination of DOX and other drugs and genes to overcome drug resistance mechanisms and improve tumor suppression. Furthermore, micelles can be used in phototherapy, both photodynamic and photothermal, to promote cell death and increase DOX sensitivity in human cancers. Finally, the alteration of micelle surfaces with ligands can further enhance their targeted delivery for cancer suppression.

Antiproliferative Activity of Krukovine by Regulating Transmembrane Protein 139 (TMEM139) in Oxaliplatin-Resistant Pancreatic Cancer Cells

Krukovine (KV) is an alkaloid isolated from the bark of Abuta grandifolia (Mart.) Sandw. (Menispermaceae) with anticancer potential in some cancers with KRAS mutations. In this study, we explored the anticancer efficacy and mechanism of KV in oxaliplatin-resistant pancreatic cancer cells and patient-derived pancreatic cancer organoids (PDPCOs) with KRAS mutation. After treatment with KV, mRNA and protein levels were determined by RNA-seq and Western blotting, respectively. Cell proliferation, migration, and invasion were measured by MTT, scratch wound healing assay, and transwell analysis, respectively. Patient-derived pancreatic cancer organoids (PDPCOs) with KRAS mutations were treated with KV, oxaliplatin (OXA), and a combination of KV and OXA. KV suppresses tumor progression via the downregulation of the Erk-RPS6K-TMEM139 and PI3K-Akt-mTOR pathways in oxaliplatin-resistant AsPC-1 cells. Furthermore, KV showed an antiproliferative effect in PDPCOs, and the combination of OXA and KV inhibited PDPCO growth more effectively than either drug alone.

Bruceine D and afatinib combination inhibits ovarian cancer cells proliferation and migration through DNA damage repair and EGFR pathway

Owing to the high rates of relapse and migration, ovarian cancer (OC) has been recognized as the most lethal gynecological malignancy worldwide. The activity of the epidermal growth factor receptor (EGFR) signaling pathway is frequently associated with OC cell proliferation and migration. Despite this knowledge, inhibition of EGFR signaling in OC patients failed to achieve satisfactory therapeutic effects. In this study, we identified that bruceine D (BD) and EGFR inhibitor, afatinib, combination resulted in synergistic anti-OC effects. The results indicated that compared with one of both drugs alone, the combination of BD and afatinib slowed the DNA replication rate, inhibition of cell viability, and proliferation and clone formation. This resulted in cell cycle arrest and cell apoptosis. In addition, the combination of BD and afatinib possessed a stronger ability to inhibit the OC cell adhesion and migration than treatment with BD or afatinib alone. Mechanistically, the combined treatment triggered intense DNA damage, suppressed DNA damage repair, and enhanced the inhibition of the EGFR pathway. These results demonstrated that compared with each pathway inhibition, combined blocking of both DNA damage repair and the EGFR pathway appears to more effective against OC treatment. The results support the potential of BD and afatinib combination as a therapeutic strategy for OC patients.

Molecular and Biological Investigation of Isolated Marine Fungal Metabolites as Anticancer Agents: A Multi-Target Approach

Cancer is the leading cause of death globally, with an increasing number of cases being annually reported. Nature-derived metabolites have been widely studied for their potential programmed necrosis, cytotoxicity, and anti-proliferation leading to enrichment for the modern medicine, particularly within the last couple of decades. At a more rapid pace, the concept of multi-target agents has evolved from being an innovative approach into a regular drug development procedure for hampering the multi-fashioned pathophysiology and high-resistance nature of cancer cells. With the advent of the Red Sea Penicillium chrysogenum strain S003-isolated indole-based alkaloids, we thoroughly investigated the molecular aspects for three major metabolites: meleagrin (MEL), roquefortine C (ROC), and isoroquefortine C (ISO) against three cancer-associated biological targets Cdc-25A, PTP-1B, and c-Met kinase. The study presented, for the first time, the detailed molecular insights and near-physiological affinity for these marine indole alkaloids against the assign targets through molecular docking-coupled all-atom dynamic simulation analysis. Findings highlighted the superiority of MEL's binding affinity/stability being quite in concordance with the in vitro anticancer activity profile conducted via sulforhodamine B bioassay on different cancerous cell lines reaching down to low micromolar or even nanomolar potencies. The advent of lengthy structural topologies via the metabolites' extended tetracyclic cores and aromatic imidazole arm permitted multi-pocket accommodation addressing the selectivity concerns. Additionally, the presence decorating polar functionalities on the core hydrophobic tetracyclic ring contributed compound's pharmacodynamic preferentiality. Introducing ionizable functionality with more lipophilic characters was highlighted to improve binding affinities which was also in concordance with the conducted drug-likeness/pharmacokinetic profiling for obtaining a balanced pharmacokinetic/dynamic profile. Our study adds to the knowledge regarding drug development and optimization of marine-isolated indole-based alkaloids for future iterative synthesis and pre-clinical investigations as multi-target anticancer agents.

Interventional nanotheranostics in hepatocellular carcinoma

Interventional nanotheranostics is a system of drug delivery that does a dual function; along with the therapeutic action, it also does have diagnostic features. This method helps in early detection, targeted delivery, and the least chances of damage to surrounding tissue. It ensures the highest efficiency for the management of the disease. Imaging is the near future for the quickest and most accurate detection of disease. After combing both effective measures, it ensures the most meticulous drug delivery system. Nanoparticles such as Gold NPs, Carbon NPs, Silicon NPS, etc. The article emphasizes on effect of this delivery system in the treatment of Hepatocellular Carcinoma. It is one of the widely spreading diseases and theranostics is trying to make the scenario better. The review suggests the pitfall of the current system and how theranostics can help. It describes the mechanism used to generate its effect and believes that interventional nanotheranostics do have a future with rainbow color. The article also describes the current hindrance to the flourishing of this miraculous technology.

mRNA-Based Vaccines and Therapeutics for COVID-19 and Future Pandemics

An unheard mobilization of resources to find SARS-CoV-2 vaccines and therapies has been sparked by the COVID-19 pandemic. Two years ago, COVID-19's launch propelled mRNA-based technologies into the public eye. Knowledge gained from mRNA technology used to combat COVID-19 is assisting in the creation of treatments and vaccines to treat existing illnesses and may avert pandemics in the future. Exploiting the capacity of mRNA to create therapeutic proteins to impede or treat a variety of illnesses, including cancer, is the main goal of the quickly developing, highly multidisciplinary field of biomedicine. In this review, we explore the potential of mRNA as a vaccine and therapeutic using current research findings.

An Impact of COVID-19 on Cancer Care: An Update

The world has been affected socioeconomically for the last two years due to the emergence of different variants of the COVID-19 virus. Vaccination is the major and most efficient way to prevent the widening of this pandemic. Those who are having comorbidities are more vulnerable to serious infections due to their immunocompromised state. Additionally, cancer patients could be at significant risk for COVID-19. In this pandemic era, the diagnosis and treatment of cancer were significantly affected. Clinical trials at the initial stage were performed on healthy or COVID-19 infected patients. This produces a greater level of hesitancy in cancer patients. This review article provide an update regarding the vaccination and treatment for COVID-19 in patients with cancer and future directions.

SARS-CoV-2: Immunopeptidomics and Other Immunological Studies

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has produced a significant continuing epidemic worldwide [...]

Peptide-Drug Conjugates: A New Hope for Cancer Management

Cancer remains the leading cause of death worldwide despite advances in treatment options for patients. As such, safe and effective therapeutics are required. Short peptides provide advantages to be used in cancer management due to their unique properties, amazing versatility, and progress in biotechnology to overcome peptide limitations. Several appealing peptide-based therapeutic strategies have been developed. Here, we provide an overview of peptide conjugates, the better equivalents of antibody-drug conjugates, as the next generation of drugs for required precise targeting, enhanced cellular permeability, improved drug selectivity, and reduced toxicity for the efficient treatment of cancers. We discuss the basic components of drug conjugates and their release action, including the release of cytotoxins from the linker. We also present peptide-drug conjugates under different stages of clinical development as well as regulatory and other challenges.

COVID-19 and vaccination: myths vs science

INTRODUCTION

Several vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been developed since the inception of the coronavirus disease 2019 (COVID-19) in December 2019, at unprecedented speed. However, these rapidly developed vaccines raised many questions related to the efficacy and safety of vaccines in different communities across the globe. Various hypotheses regarding COVID-19 and its vaccines were generated, and many of them have also been answered with scientific evidence. Still, there are many myths/misinformation related to COVID-19 and its vaccines, which create hesitancy for COVID-19 vaccination, and must be addressed critically to achieve success in the battle against the pandemic.

AREA COVERED

The development of anti-SARS-CoV-2 vaccines against COVID-19, their safety and efficacy, and myths/misinformation relating to COVID-19 and vaccines are presented.

EXPERT OPINION

In this pandemic we have seen a global collaborative effort of researchers, governments, and industry, supported by billions of dollars in funding, have allowed the development of vaccines far more quickly than in the past. Vaccines go through rigorous testing, analysis, and evaluations in clinical settings prior to their approval, even if they are approved for emergency use. Despite the myths, vaccination represents an important strategy to get back to normality.

Aged Population and Immunocompromised Patients: Impact on SARS-CoV-2 Variants and Treatment Outcomes

Patients with an immunocompromised state are at risk of developing a long-term infection from the coronavirus 2 that causes severe acute respiratory syndrome (SARS-CoV-2) [...]

SARS-CoV-2 variants and vulnerability at the global level

Numerous variants of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic have evolved. Viral variants may evolve with harmful susceptibility to the immunity established with the existing COVID-19 vaccination. These variants are more transmissible, induce relatively extreme illness, have evasive immunological features, decrease neutralization using antibodies from vaccinated persons, and are more susceptible to re-infection. The Centers for Disease Control and Prevention (CDC) has categorized SARS-CoV-2 mutations as variants of interest (VOI), variants of concern (VOC), and variants of high consequence (VOHC). At the moment, four VOC and many variants of interest have been defined and require constant observation. This review article summarizes various variants of SARS-CoV-2 surfaced with special emphasis on VOCs that are spreading across the world, as well as several viral mutational impacts and how these modifications alter the properties of the virus.

2-Deoxy-D-Glucose and its Derivatives for the COVID-19 Treatment: An Update

Treatment choices for the “severe acute respiratory syndrome‐related coronavirus‐2 (SARS‐CoV‐2)” are inadequate, having no clarity on efficacy and safety profiles. Currently, no established intervention has lowered the mortality rate in the “coronavirus disease 2019 (COVID‐19)” patients. Recently, 2-deoxy-D-glucose (2-DG) has evaluated as a polypharmacological agent for COVID-19 therapy owing to its influence on the glycolytic pathway, interaction with viral proteins, and anti-inflammatory action. In May 2020, the Indian drug regulatory authority approved 2-DG as an emergency adjunct therapy in mild to severe COVID-19 patients. Clinical studies of 2-DG corroborate that it aids in faster recovery of hospitalized patients and decreases supplemental oxygen. Herein, we describe the development process, synthesis, mechanism of viral eradication, and preclinical and clinical development of 2-DG and its derivatives as molecularly targeted therapeutics for COVID-19 treatment.

Nano-Drug Delivery Systems Entrapping Natural Bioactive Compounds for Cancer: Recent Progress and Future Challenges

Cancer is a prominent cause of mortality globally, and it becomes fatal and incurable if it is delayed in diagnosis. Chemotherapy is a type of treatment that is used to eliminate, diminish, or restrict tumor progression. Chemotherapeutic medicines are available in various formulations. Some tumors require just one type of chemotherapy medication, while others may require a combination of surgery and/or radiotherapy. Treatments might last from a few minutes to many hours to several days. Each medication has potential adverse effects associated with it. Researchers have recently become interested in the use of natural bioactive compounds in anticancer therapy. Some phytochemicals have effects on cellular processes and signaling pathways with potential antitumor properties. Beneficial anticancer effects of phytochemicals were observed in both in vivo and in vitro investigations. Encapsulating natural bioactive compounds in different drug delivery methods may improve their anticancer efficacy. Greater in vivo stability and bioavailability, as well as a reduction in undesirable effects and an enhancement in target-specific activity, will increase the effectiveness of bioactive compounds. This review work focuses on a novel drug delivery system that entraps natural bioactive substances. It also provides an idea of the bioavailability of phytochemicals, challenges and limitations of standard cancer therapy. It also encompasses recent patents on nanoparticle formulations containing a natural anti-cancer molecule.

Phytochemical Delivery Through Transferosome (Phytosome): An Advanced Transdermal Drug Delivery for Complementary Medicines

Transdermal drug delivery aims to create a safe and effective method of administering drugs through the skin that attracts a lot of attention and investment due to the constant progress in the field. Transferosomes are flexible or malleable vesicles (having almost the same structure as liposomes but with better skin penetration properties) discovered initially in the early 90s. The name transferosomes, which means "carrying bodies," is coined from the Latin phrase "Transferee," which means "to carry through," and the Greek term "soma," meaning "body." In comparison to typical herbal extracts, phytosomes (Transferosomes) are created by attaching specific herbal extracts to phosphatidylcholine, resulting in a formulation with increased solubility and, hence, better absorption, resulting in improved pharmacokinetic and pharmacodynamic features of the entrapped drugs. We are using the word phytosomes and transferosomes interchangeably as we have consolidated vesicular delivery of herbal drugs through skin. In this mini-review, we have demonstrated the enormous potential of developing nanotechnology to deliver bioactive phytochemicals, with a special emphasis on phytosomes (Transferosomes) as a unique lipid-based nanocarrier for transdermal drug delivery.

Phytochemical-loaded liposomes for anticancer therapy: an updated review

The major obstacles observed in current chemotherapy are severe adverse effects, narrow therapeutic indexes and multidrug resistance. Anticancer phytochemicals are extracted and purified from natural plants, providing alternative therapeutic approaches with recognized biomedical benefits. However, poor bioavailability, high dose requirements and non-specific targeting have made those molecules less effective. To tackle those issues, liposomal nanovesicles for phytochemical delivery are taken into consideration for improving the therapeutic effectiveness by increasing transportation across cell barriers and conferring attractive cancer-specific targeting capabilities. In the present review, the liposomal approaches of anticancer phytochemicals are discussed, and recent advances in these formulations applied to cancer phytotherapy are further reviewed by an informed approach.

A Predictive Model for Nonsentinel Node Status after Sentinel Lymph Node Biopsy in Sentinel Lymph Node-Positive Chinese Women with Early Breast Cancer

BACKGROUND

Axial lymph node dissection (ALND) is needed in patients with positive sentinel lymph node (SLN). ALND is easy to cause upper limb edema. Therefore, accurate prediction of nonsentinel lymph nodes (non-SLN) which may not need ALND can avoid excessive dissection and reduce complications. We constructed a new prognostic model to predict the non-SLN metastasis of Chinese breast cancer patients.

METHODS

We enrolled 736 patients who underwent sentinel lymph node biopsy (SLNB); 228 (30.98%) were diagnosed with SLNB metastasis which was determined by intraoperative pathological detection and further accepted ALND. We constructed a prediction model by univariate analysis, multivariate analysis, "R" language, and binary logistic regression in the abovementioned 228 patients and verified this prediction model in 60 patients.

RESULTS

Based on univariate analysis using α = 0.05 as the significance level for type I error, we found that age (P=0.045), tumor size (P=0.006), multifocality (P=0.011), lymphovascular invasion (P=0.003), positive SLN number (P=0.009), and negative SLN number (P=0.034) were statistically significant. Age was excluded in multivariate analysis, and we constructed a predictive equation to assess the risk of non-SLN metastasis: Logit(P)=Ln(P/1 - P)=0.267∗a+1.443∗b+1.078∗c+0.471∗d - 0.618∗e - 2.541 (where "a" represents tumor size, "b" represents multifocality, "c" represents lymphovascular invasion, "d" represents the number of metastasis of SLN, and "e" represents the number of SLNs without metastasis). AUCs for the training group and validation group were 0.715 and 0.744, respectively. When setting the risk value below 22.3%, as per the prediction equation's low-risk interval, our model predicted that about 4% of patients could avoid ALND.

CONCLUSIONS

This study established a model which demonstrated good prognostic performance in assessing the risk of non-SLN metastasis in Chinese patients with positive SLNs.