[Short-term outcomes of the TRIANGLE operation after neoadjuvant chemotherapy in locally advanced pancreatic cancer]

Objective: To investigate the safety and efficacy of the TRIANGLE operation after neoadjuvant chemotherapy in locally advanced pancreatic cancer(LAPC). Methods: This study is a retrospective case series analysis. Between January 2020 and December 2022, a total of 103 patients were diagnosed as LAPC who underwent neoadjuvant chemotherapy at the Pancreas Center, the First Affiliated Hospital of Nanjing Medical University. Among them, 26 patients (25.2%) underwent the TRIANGLE operation. There were 15 males and 11 females,with a age of (59±7) years (range: 49 to 74 years). The pre-treatment serum CA19-9(M(IQR)) was 248.8(391.6)U/ml (range: 0 to 1 428 U/ml),and the serum carcinoembryonic antigen was 4.1(3.8)μg/L(range: 1.4 to 13.4 μg/L). The neoadjuvant chemotherapy regimens included: mFOLFIRINOX regimen in 6 cases(23.1%), GnP regimen in 14 cases(53.8%), and mFOLFIRINOX+GnP regimen in 6 cases(23.1%). The follow-up duration extended until June 2023 or until the occurrence of the patient's death or loss to follow-up. The Kaplan-Meier method was employed to estimate the 1-year and 3-year overall survival rates. Results: After neoadjuvant chemotherapy,CA19-9 levels decreased by 92.3(40.1)%(range:2.1% to 97.7%). Evaluation of the response to treatment revealed 13 cases(50.0%) of stable disease,11 cases(42.3%) of partial response,and 2 cases(7.7%) of complete response. The surgical operation consisted of 12 cases(46.2%) of pancreaticoduodenectomy,12 cases(46.2%) of distal pancreatectomy,and 2 cases(7.7%) of total pancreatectomy. Margin determination was based on the "standardised pathology protocol" and the "1 mm" principle. No R2 and R1(direct) resections were observed,while the R0 resection rate was 61.5%(16/26), and the R1(1 mm) resection rate was 38.5%(10/26).The R1(1 mm) resection rates for the anterior margin,posterior margin,transected margin,portal vein groove margin,and uncinate margin were 23.1%(6/26),19.2%(5/26),12.5%(3/24),2/14, and 1/12, respectively. The overall postoperative complication rate was 57.8%(15/26),with major complications including grade B/C pancreatic fistula 25.0%(6/24,excluding 2 cases of total pancreatectomy),delayed gastric emptying in 23.1%(6/26),wound complications 11.5%(3/26),postoperative hemorrhage 7.7%(2/26), chylous fistula 7.7%(2/26) and bile fistula 3.8%(1/26). No reoperation was performed during the perioperative period(<90 days). One patient died on the 32nd day postoperatively due to a ruptured pseudoaneurysm. A total of 25 patients were followed up,with a follow-up time of 21(24)months(range: 8 to 42 months). During the follow-up period,8 cases(32.0%) died due to tumor recurrence and metastasis,while 17 patients(68.0%) remained alive,including 11 cases of disease-free survival,5 cases of distant metastasis,and 1 case of local recurrence. The overall survival rates at 1- and 3-year after the initiation of neoadjuvant chemotherapy were 95.8% and 58.9%, respectively. The overall survival rates at 1- and 3-year after surgery were 77.7% and 57.8%, respectively. Conclusion: Performing pancreatoduodenectomy according to the Heidelberg triangle protocol in LAPC patients after neoadjuvant chemotherapy might increase the R0 resection rate without increasing perioperative mortality or the incidence of major postoperative complications.

Effect and safety of anaprazole in the treatment of duodenal ulcers: a randomized, rabeprazole-controlled, phase III non-inferiority study

BACKGROUND

The pharmacokinetic and clinical behaviors of many proton pump inhibitors (PPIs) in peptic ulcer treatment are altered by CYP2C19 genetic polymorphisms. This non-inferiority study evaluated the efficacy and safety of the novel PPI anaprazole compared with rabeprazole. We also explored the influence of Helicobacter pylori ( H. pylori ) infection status and CYP2C19 polymorphism on anaprazole.

METHODS

In this multicenter, randomized, double-blind, double-dummy, positive-drug parallel-controlled, phase III study, Chinese patients with duodenal ulcers were randomized 1:1 to receive rabeprazole 10 mg + anaprazole placebo or rabeprazole placebo + anaprazole 20 mg once daily for 4 weeks. The primary efficacy endpoint was the 4-week ulcer healing rate assessed by blinded independent review. Secondary endpoints were the proportion of patients with improved overall and individual duodenal ulcer symptoms at 4 weeks. Furthermore, exploratory subgroup analysis of the primary endpoint by H. pylori status and CYP2C19 polymorphism was conducted. Adverse events were monitored for safety. Non-inferiority analysis was conducted for the primary endpoint.

RESULTS

The study enrolled 448 patients (anaprazole, n = 225; rabeprazole, n = 223). The 4-week healing rates were 90.9% and 93.7% for anaprazole and rabeprazole, respectively (difference, -2.8% [95% confidence interval, -7.7%, 2.2%]), demonstrating non-inferiority of anaprazole to rabeprazole. Overall duodenal ulcer symptoms improved in 90.9% and 92.5% of patients, respectively. Improvement rates of individual symptoms were similar between the groups. Healing rates did not significantly differ by H. pylori status or CYP2C19 genotype for either treatment group. The incidence of treatment-emergent adverse events was similar for anaprazole (72/220, 32.7%) and rabeprazole (84/219, 38.4%).

CONCLUSIONS

The efficacy of anaprazole is non-inferior to that of rabeprazole in Chinese patients with duodenal ulcers.

REGISTRATION

ClinicalTrials.gov, NCT04215653.

[Evaluation of severity and prognosis of acute pancreatitis by CT severity index and modified CT severity index]

Objectives: To explore the role of computed tomography (CT) severity index (CTSI) and modified CT severity index (MCTSI) in assessing the severity of acute pancreatitis (AP) under the revised Atlanta classification (RAC) and predicting the clinical prognosis. Methods: Based on the prospectively entered AP database, the clinical data of consecutive adult AP inpatients admitted to the Department of Gastroenterology of the First Affiliated Hospital of Nanchang University from January 2012 to December 2020 were retrospectively screened. The imaging data were independently evaluated by two radiologists and entered to the database to calculate the CTSI and MCTSI scores. Their relationship with the difference of RAC severity grade and clinical prognosis was analyzed. Compared with Acute Physiology and Chronic Health Assessment Ⅱ (APACHE Ⅱ) score, the receiver operating characteristic curve was used to evaluate the predictive value of CTSI and MCTSI scores for persistent organ failure and infectious pancreatic necrosis (IPN). Results: A total of 2 612 patients with AP, aged (50±15) years, were included in the study, including 1 547 males (59.2%) and 1 065 females (40.8%). According to RAC standard, AP was divided into 699 cases (26.8%) of mild pancreatitis (MAP), 1 098 cases (42.0%) of moderately severe pancreatitis (MSAP), and 815 cases (31.2%) of severe pancreatitis (SAP). MCTSI judged AP severity similarly to RAC, with 668 cases of MAP (25.6%), 1 207 cases of MSAP (46.2%) and 737 cases of SAP (28.2%), while CTSI judged SAP patients less(400 cases, 15.3%). The severity of AP determined by CTSI and MCTSI scores was significantly correlated with clinical prognosis (r=0.06-0.43, all P<0.05). Compared with APACHE Ⅱ score, CTSI had the highest area under the curve (AUC) for predicting IPN (AUC=0.85, 95%CI: 0.83-0.87), followed by MCTSI (AUC=0.82, 95%CI: 0.80-0.85). APACHE Ⅱ was more accurate in predicting persistent organ failure than CTSI and MCTSI scores,with AUC of 0.73 (95%CI: 0.71-0.75), 0.72 (95%CI: 0.70-0.74) and 0.72 (95%CI: 0.70-0.74), respectively. Conclusions: AP severity judged by MCTSI is consistent with RAC, and SAP patients judged by CTSI are less than RAC. CTSI and MCTSI are significantly correlated with clinical prognosis. CTSI and MCTSI have higher accuracy in predicting IPN, but lower accuracy in predicting persistent organ failure than APACHE Ⅱ.

[Expression comparison and clinical significance of PD-L1 (22C3) and PD-L1 (SP142) in triple negative breast cancer]

Objective: To investigate the expression of programmed death ligand-1 (PD-L1, SP142) and PD-L1 (22C3) in triple-negative breast cancer (TNBC), and analyze their correlation with the clinicopathological factors and prognosis. Methods: The clinicopathologic data of 259 patients with TNBC treated in Cancer Hospital from August 2010 to December 2013 were collected. Whole section of surgical tissue samples were collected to conduct PD-L1 (SP142) and PD-L1 (22C3) immunohistochemical (IHC) staining. The PD-L1 expression in tumor cells and tumor infiltrating immune cells were visually assessed respectively, the relationship between PD-L1 expression and clinicopathologic characterizes were analyzed. Univariable and multivariable Cox proportional hazards regression models were used to test the correlations between PD-L1 expression and disease-free survival (DFS) and overall survival (OS). Results: The positive rates of SP142 (immune cell score, ICs≥1%) and 22C3 (combined positive score, CPS≥1) were 42.1%(109/259) and 41.3%(107/259) in TNBC tissues, respectively, with a total coincidence rate of 82.3%. The Kappa value of positive expression cases was 0.571 and the distribution difference of SP142 and 22C3 positive expression cases was statistically significant (P<0.001). The PD-L1 positive patients were less likely to have vascular invasion (P<0.05), but with higher histological grade and Ki-67 proliferation index (P<0.05). The recurrence/metastasis cases(8) of the patients with positive PD-L1 (SP142) was significantly lower than that of patients with negative PD-L1(SP142, 27, P=0.016). The positive expression of PD-L1 (SP142) patients were longer DFS (P=0.019). The OS of patients with positive PD-L1 (SP142) were longer than those with negative PD-L1 (SP142), but without significance (P=0.116). The positive expression of PD-L1 (22C3) was marginally associated with DFS and OS of patients (P>0.05). Conclusions: The expression of PD-L1 (22C3) is different from that of PD-L1 (SP142) in TNBC, and the two antibodies can't be interchangeable for each other in clinical tests. PD-L1 (SP142) status is an independent prognostic factor of DFS in TNBC. The DFS is significantly prolonged in patients with positive expression of PD-L1 (SP142).

[The expression of p53 protein and its clinicopathological features and prognosis of esophageal spindle cell carcinoma]

Objective: To evaluate the association of p53 protein expression with clinicopathological features and prognosis in esophageal spindle cell carcinoma. Methods: A total of 4 439 esophageal squamous cell carcinoma (ESCC) patients who underwent radical esophagectomy without neoadjuvant therapy between May 2010 and May 2019 were included. The HE slides and clinicopathological parameters were reviewed. Among these, there were 63 cases of esophageal spindle cell carcinoma; p53 protein expression was evaluated by immunohistochemistry (IHC) and its correlation with clinicopathological parameters and patients' outcome was analyzed. Results: The 63 esophageal spindle cell carcinoma accounted for 1.4% (63/4 439) of all ESCC. Of the 63 patients there were 55 males and 8 females, male to female ratio was 7∶1. The p53 protein mutation expression rate was 77.8% (49/63), including 14 cases with wild-type expression, 22 with nonsense mutation expression, and 27 with missense mutation expression. The concordance rate of p53 protein expression between carcinoma components and spindle cell components was 100%. Survival analysis showed that p53 protein mutation expression was significantly correlated with overall survival (OS, P=0.044), patients with p53 protein mutation expression had poorer OS. Conclusion: p53 protein expression is highly concordant in the squamous cell carcinoma components and spindle cell components of esophageal spindle cell carcinoma; its mutation expression is associated with poor outcome of the patients.

Impact of the extent of axillary surgery in patients with N2-3 disease in the de-escalation era: a propensity score-matched study

BACKGROUND

Reduction of surgeries in axillary has been proved feasible in breast cancer with negative and limited involved axillary lymph nodes. However, for women with a heavy axillary burden, the extent of dissection is still arguable.

PATIENTS AND METHODS

From a total of 7042 patients with breast cancer who underwent surgical treatments between 2008 and 2014, 692 (9.85%) patients with the axillary staging of N2-3M0 were classified into Level I-II dissection group and Level I-III dissection group. 203 pairs of patients were matched by the propensity score.

RESULTS

The positive rate of level-III lymph nodes is 62.4% in patients who underwent Level I-III dissection. There are 67 (22.1%) patients who experienced rise in staging from N2 to N3 due to level-III dissection. With a median follow-up of 62.4 months, no significant difference was observed in RFS (P = 0.897), MFS (P = 0.610) and OS (P = 0.755) between level I-II group and level I-III group. The same results were observed in the independent analysis of neoadjuvant and non-neoadjuvant subgroups. The binary regression model showed the positivity of level-III is only associated with involved lymph nodes in level-II.

CONCLUSION

Additional level-III dissection has a limited impact on survival but still valuable in an accurate stage. The reduction of surgeries in axillary should be treated with discretion in breast cancer patients with a heavy axillary burden.

Unique growth paths of heterospecific pollen tubes result in late entry into ovules in the gynoecium of Sagittaria (Alismataceae)

Pollen-pistil interactions are a fundamental process in the reproductive biology of angiosperms and play a particularly important role in maintaining incipient species that exist in sympatry. However, the majority of previous studies have focused on species with syncarpous gynoecia (fused carpels) and not those with apocarpous gynoecia (unfused carpels). In the present study, we investigated the growth of conspecific pollen tubes compared to heterospecific pollen tubes in Sagittaria species, which have apocarpous gynoecia. We conducted controlled pollinations between S. pygmaea and S. trifolia and observed the growth of conspecific and heterospecific pollen tubes under a fluorescence microscope. Heterospecific and conspecific pollen tubes arrived at locules within the ovaries near simultaneously. However, conspecific pollen tubes entered into the ovules directly, whereas heterospecific tubes passed through the carpel base and adjacent receptacle tissue, to ultimately fertilize other unfertilized ovules. This longer route taken by heterospecific pollen tubes therefore caused a delay in the time required to enter into the ovules. Furthermore, heterospecific pollen tubes displayed similar growth patterns at early and peak pollination. The growth pattern of heterospecific pollen tubes at late pollination was similar to that of conspecific pollen tubes at peak pollination. Heterospecific and conspecific pollen tubes took different routes to fertilize ovules. A delayed entry of heterospecific pollen into ovules may be a novel mechanism of conspecific pollen advantage (CPA) for apocarpous species.

[The comparison of the 1992 and 2012 Atlanta classifications for assessing disease severity in patients with acute pancreatitis]

OBJECTIVE

To compare the discrepancy between the new(2012) and the old (1992) Atlanta classification criteria for defining severity, organ failure and local complications in patients with acute pancreatitis (AP).

METHODS

Demographic, clinical and laboratory data of 2,305 consecutive AP patients with onset less than 3 days, were collected between January 2005 to December 2013 in the First Affiliated Hospital of Nanchang University. Severity, organ failure and pancreatic local complications were respectively classified by the old Atlanta classification and the new revised Atlanta classification. Multi-factor scoring system and single serum marker were recorded and calculated using the acute pancreatitis database.

RESULTS

In 2,305 patients with AP, there were 301 cases (13.1%) diagnosed with acute respiratory failure, 136 cases (5.9%) with shock, 105 cases (4.6%) with acute renal failure, 296 cases (12.8%) with gastrointestinal bleeding, based on the old Atlanta classification criteria. According to the severity, 900 cases (39.0%) were classified as mild acute pancreatitis (MAP), 1,405 cases (61.0%) as severe acute pancreatitis (SAP). However, based on the new Atlanta classification criteria, there were 686 cases (29.8%) with acute respiratory failure, 129 cases (5.6%) with acute renal failure, 107 cases (4.6%) with circulatory failure. Consequently, 998 cases (43.3%) were classified as MAP, 937 cases (40.7%) as moderately severe acute pancreatitis (MSAP), 370 cases (16.1%) as SAP. The incidence of respiratory failure was lower than that of the old standard. In SAP patients by new criteria, the discharge rate in critical condition and mortality were not only higher than those in MSAP patients (17.0% vs 4.1%, 4.1% vs 1.5%, respectively, all P < 0.001), but also higher than those in SAP patients by the old classification (17.0% vs 7.2%, 4.1% vs 2.1%, all P < 0.001).

CONCLUSIONS

The diagnostic criteria of organ failure are different between the new and old Atlanta classification. The SAP patients classified by the new standard have worse outcome than those by the old standard. More attention needs to be paid to critical patients stratified by the new standard.

[Kyoto global consensus report for treatment of Helicobacter pylori and its implications for China]

Kyoto global consensus report on Helicobacter pylori gastritis (Gut, July 2015) is another important international consensus since the European Maastricht Ⅳ consensus was published. Kyoto consensus will improve the etiology-based classification, the diagnostic assessment of gastritis, and the treatment of H. pylori-associated dyspepsia and H. pylori gastritis. However, because of high rate of H. pylori infection and antibiotic resistance as well as limited health resources in China, we need to develop our own strategies of H. pylori infection control with the reference of the Kyoto global consensus.

[Impact of Helicobacter pylori infection on autophagy of different cells--a review]

Helicobacter pylori (H. pylori) is a gram-negative pathogen that widely colonizes in the human gastric mucosa, and is associated with various gastric diseases. Recently, much attention has been aroused on the relationship between H. pylori infection and autophagy. Accumulating evidence suggests that H. pylori can induce autophagy in gastric epithelial cells and professional phagocytes. Both the virulent factors of H. pylori and host autophagic proteins have been demonstrated to affect H. pylori-induced autophagy. Besides, the process of autophagy plays an important role in determining the intracellular fate of H. pylori. Here, we review the impact of H. pylori infection on autophagy of different cells.