Targeting tumor‑associated macrophages: Critical players in tumor progression and therapeutic strategies (Review)

Tumor‑associated macrophages (TAMs) are essential components of the tumor microenvironment (TME) and display phenotypic heterogeneity and plasticity associated with the stimulation of bioactive molecules within the TME. TAMs predominantly exhibit tumor‑promoting phenotypes involved in tumor progression, such as tumor angiogenesis, metastasis, immunosuppression and resistance to therapies. In addition, TAMs have the potential to regulate the cytotoxic elimination and phagocytosis of cancer cells and interact with other immune cells to engage in the innate and adaptive immune systems. In this context, targeting TAMs has been a popular area of research in cancer therapy, and a comprehensive understanding of the complex role of TAMs in tumor progression and exploration of macrophage‑based therapeutic approaches are essential for future therapeutics against cancers. The present review provided a comprehensive and updated overview of the function of TAMs in tumor progression, summarized recent advances in TAM‑targeting therapeutic strategies and discussed the obstacles and perspectives of TAM‑targeting therapies for cancers.

Comparison of manual sutures and laparoscopic stapler for pancreatic stump closure techniques in robotic distal pancreatectomy: a single-center experience

BACKGROUND

Postoperative pancreatic fistulas (POPFs) are prevalent and major postoperative complications of distal pancreatectomy (DP). There are numerous ways to manage the pancreatic stump. However, no single approach has been shown to be consistently superior. Moreover, the potential role of robotic systems in reducing POPFs has received little attention.

METHODS

The clinical data of 119 patients who had consecutively received robotic distal pancreatectomy between January 2019 and December 2022 were retrospectively analyzed. Patients were divided into two groups according to the method of handling the pancreatic stump. The attributes of the patients and the variables during the perioperative period were compared.

RESULTS

The analysis included 72 manual sutures and 47 stapler procedures. The manual suture group had a shorter operative time (removing installation time) than the stapler group (125.25 ± 63.04 min vs 153.30 ± 62.03 min, p = 0.019). Additionally, the manual suture group had lower estimated blood loss (50 mL vs 100 mL, p = 0.009) and a shorter postoperative hospital stay. There were no significant differences in the incidence of clinically relevant POPFs between the two groups (18.1% vs 23.4%, P > 0.05). No perioperative death occurred in either group.

CONCLUSION

The manual suturing technique was shown to have an incidence of POPFs similar to the stapler technique in robotic distal pancreatectomy and to be safe and feasible.

Electrostatic Nanocage-Confined Probe for Electrochemical Detection of CA19-9 in Human Serum

Prompt and accurate detection of CA19-9 in human serum has great clinical significance for the early diagnosis and disease monitoring of cancer. Herein, we develop a convenient and antifouling electrochemical sensor for CA19-9 determination by immobilization of both an electrochemical redox probe [methylene blue (MB)] and immunorecognition element (CA19-9 antibody) on an electrostatic nanocage consisting of bipolar silica nanochannel array (bp-SNA). bp-SNA is composed of a negatively charged inner layer (n-SNA) and positively charged outer layer (p-SNA), which could be stably prepared on indium tin oxide (ITO) in several seconds using a two-step electrochemically assisted self-assembly approach and display asymmetric surface charges for confinement and enrichment of cationic MB into the inner n-SNA layer through electrostatic interaction. Modification of the CA19-9 antibody on the top surface of bp-SNA confers the sensing interface with specific recognition capacity. An antibody-antigen complex formed at the as-prepared immunosensor causes the decreased electrochemical signals of MB, achieving sensitive determination of CA19-9 with a wider linear dynamic range from 10 μU/mL to 50 U/mL and a low detection limit (3 μU/mL). Furthermore, accurate and feasible analysis of the CA19-9 amount in human serum samples by our proposed probe-integrated electrochemical immunosensor is realized.

Protocadherin-1 serves as a prognostic biomarker and promotes pancreatic cancer progression by suppressing CD8+ T cell infiltration through CCL5-CCR5 axis

Previous studies have shown that Protocadherins (PCDHs) enhance tumor proliferation, invasion, and metastasis; yet their role in pancreatic cancer (PC) progression and the tumor immune microenvironment remains unclear. This study aims to elucidate the role of PCDH1 in different cancer types, with a particular focus on its impact on immune suppression in PC. Utilizing data from TCGA, GTEx, and Gent2 databases, we assessed the expression of PCDH1 across various cancer types. The prognostic value of PCDH1 was demonstrated through Cox regression, Kaplan-Meier analysis, and ROC curve, while its relationship with gene mutations, tumor mutational burden (TMB), immune cell infiltration, and other clinical factors was investigated using Spearman correlation. Furthermore, the effect of PCDH1 on PC malignancy was experimentally validated by a series of in vitro and in vivo assays. Our results show a significant upregulation of PCDH1 in various tumor types, which is associated with poor prognosis, suggesting its potential application as an independent prognostic biomarker. Notably, in PC, PCDH1 exhibited significant associations with gene mutations, TMB, and immune cell infiltration. Clinical validations revealed a correlation between high PCDH1 expression and poor prognosis, coupled with a low level of CD8+ T cell infiltration. Furthermore, both in vitro and in vivo experiments confirmed the role of PCDH1 in promoting PC cell proliferation and migration while inhibiting CD8+ T cell recruitment through its modulation of CCL5-CCR5 axis. In conclusion, PCDH1 regulates the proliferation and migration of PC cells as well as CD8+ T cell infiltration in PC. PCDH1 may serve as a prognostic biomarker in multiple tumor types.

Causal effect between gut microbiota and pancreatic cancer: a two-sample Mendelian randomization study

BACKGROUND

Gut microbiota (GM) comprises a vast and diverse community of microorganisms, and recent studies have highlighted the crucial regulatory roles of various GM and their secreted metabolites in pancreatic cancer (PC). However, the causal relationship between GM and PC has yet to be confirmed.

METHODS

In the present study, we used two-sample Mendelian randomization (MR) analysis to investigate the causal effect between GM and PC, with genome-wide association study (GWAS) from MiBioGen consortium as an exposure factor and PC GWAS data from FinnGen as an outcome factor. Inverse variance weighted (IVW) was used as the primary method for this study.

RESULTS

At the genus level, we observed that Senegalimassilia (OR: 0.635, 95% CI: 0.403-0.998, P = 0.049) exhibited a protective effect against PC, while Odoribacter (OR:1.899, 95%CI:1.157-3.116, P = 0.011), Ruminiclostridium 9(OR:1.976,95%CI:1.128-3.461, P = 0.017), Ruminococcaceae (UCG011)(OR:1.433, 95%CI:1.072-1.916, P = 0.015), and Streptococcus(OR:1.712, 95%CI:1.071-1.736, P = 0.025) were identified as causative factors for PC. Additionally, sensitivity analysis, Cochran's Q test, the Mendelian randomization pleiotropy residual sum and outlier (MR-PRESSO), and MR-Egger regression indicated no heterogeneity, horizontal pleiotropy, or reverse causality between GM and PC.

CONCLUSIONS

Our analysis establishes a causal effect between specific GM and PC, which may provide new insights into the potential pathogenic mechanisms of GM in PC and the assignment of effective therapeutic strategies.

Biological characteristics of pancreatic ductal adenocarcinoma: Initiation to malignancy, intracellular to extracellular

Pancreatic ductal adenocarcinoma (PDAC) is a highly life-threatening tumour with a low early-detection rate, rapid progression and a tendency to develop resistance to chemotherapy. Therefore, understanding the regulatory mechanisms underlying the initiation, development and metastasis of pancreatic cancer is necessary for enhancing therapeutic effectiveness. In this review, we summarised single-gene mutations (including KRAS, CDKN2A, TP53, SMAD4 and some other less prevalent mutations), epigenetic changes (including DNA methylation, histone modifications and RNA interference) and large chromosome alterations (such as copy number variations, chromosome rearrangements and chromothripsis) associated with PDAC. In addition, we discussed variations in signalling pathways that act as intermediate oncogenic factors in PDAC, including PI3K/AKT, MAPK/ERK, Hippo and TGF-β signalling pathways. The focus of this review was to investigate alterations in the microenvironment of PDAC, particularly the role of immunosuppressive cells, cancer-associated fibroblasts, lymphocytes, other para-cancerous cells and tumour extracellular matrix in tumour progression. Peripheral axons innervating the pancreas have been reported to play a crucial role in the development of cancer. In addition, tumour cells can influence the behaviour of neighbouring non-tumour cells by secreting certain factors, both locally and at a distance. In this review, we elucidated the alterations in intracellular molecules and the extracellular environment that occur during the progression of PDAC. Altogether, this review may enhance the understanding of the biological characteristics of PDAC and guide the development of more precise treatment strategies.

Digestive tract reconstruction after laparoscopic proximal gastrectomy for Gastric cancer: A systematic review

The incidence of gastroesophageal junction adenocarcinoma has gradually increased. Proximal gastrectomy or total gastrectomy is recommended for early gastric cancer of the upper third of the stomach. Because total gastrectomy is often accompanied by body mass loss and nutrient absorption disorders, such as severe hypoproteinemia and anemia, Proximal gastrectomy is more frequently recommended by researchers for early upper gastric cancer (T1N0M0) and Siewert II gastroesophageal junction cancer less than 4 cm in length. Although some functions of the stomach are retained after proximal gastrectomy, the anatomical structure of the gastroesophageal junction can be destroyed, and the anti-reflux effect of the cardia is lost. In recent years, as various reconstruction methods for anti-reflux function have been developed, some functions of the stomach are retained, and serious reflux esophagitis is avoided after proximal gastrectomy. In this article, we summarized the indications, advantages, and disadvantages of various classic reconstruction methods and latest improved reconstruction method including esophageal and residual stomach anastomosis, tubular gastroesophageal anastomosis, muscle flap anastomosis, jejunal interposition, and double-tract reconstruction.

Factors predicting recurrence after left‑sided pancreatectomy for pancreatic ductal adenocarcinoma

BACKGROUND

Recurrence after resection is the main factor for poor survival. The relationship between clinicopathological factors and recurrence after curative distal pancreatectomy for PDAC has rarely been reported separately.

METHODS

Patients with PDAC after left‑sided pancreatectomy between May 2015 and August 2021 were retrospectively identified.

RESULTS

One hundred forty-one patients were included. Recurrence was observed in 97 patients (68.8%), while 44 (31.2%) patients had no recurrence. The median RFS was 8.8 months. The median OS was 24.9 months. Local recurrence was the predominant first detected recurrence site (n = 36, 37.1%), closely followed by liver recurrence (n = 35, 36.1%). Multiple recurrences occurred in 16 (16.5%) patients, peritoneal recurrence in 6 (6.2%) patients, and lung recurrence in 4 (4.1%) patients. High CA19-9 value after surgery, poor differentiation grade, and positive lymph nodes were found to be independently associated with recurrence. The patients receiving adjuvant chemotherapy had a decreased likelihood of recurrence. In the high CA19-9 value cohort, the median PFS and OS of the patients with or without chemotherapy were 8.0 VS. 5.7 months and 15.6 VS. 13.8 months, respectively. In the normal CA19-9 value cohort, there was no significant difference in PFS with or without chemotherapy (11.7 VS. 10.0 months, P = 0.147). However, OS was significantly longer in the patients with chemotherapy (26.4 VS. 13.8 months, P = 0.019).

CONCLUSIONS

Tumor biologic characteristics, such as T stage, tumor differentiation and positive lymph nodes, affecting CA19-9 value after surgery are associated with patterns and timing of recurrence. Adjuvant chemotherapy significantly reduced recurrence and improved survival. Chemotherapy is strongly recommended in patients with high CA199 after surgery.

Functions and clinical applications of exosomes in pancreatic cancer

Pancreatic cancer (PC) is one of the most malignant tumors and has an abysmal prognosis, with a 5-year survival rate of only 11%. At present, the main clinical dilemmas in PC are the lack of biomarkers and the unsatisfactory therapeutic effects. The treatments for and outcomes of PC have improved, but remain unsatisfactory. Exosomes are nanosized extracellular vesicles, and an increasing number of studies have found that exosomes play an essential role in tumor pathology. In this review, we describe the process of exosome biogenesis, as well as exosome extraction methods and identification strategies, and we then explain in detail the roles and mechanisms of exosomes in invasion, metastasis, chemoresistance and immunosuppression in PC. Finally, we summarize the clinical applications of exosomes. Our observations indicate that exosomes represent a novel direction in the clinical treatment of PC.

PBRM1 presents a potential prognostic marker and therapeutic target in duodenal papillary carcinoma

BACKGROUND

Due to its rarity, duodenal papillary carcinoma (DPC) is seldom studied as a unique disease and no specific molecular features or treatment guidelines are provided.

METHODS

Whole-exome sequencing was performed to gain new insights into the DPC mutation landscape and to identify potential signalling pathways and therapeutic targets. Mechanistically, immunohistochemistry (IHC), immunofluorescence, RNA-seq, ATAC-seq and in vitro cell function experiments were performed to confirm the underlying mechanisms.

RESULTS

We described the mutational landscape of DPC for the first time as a group of rare tumours with a high frequency of dysregulation in the chromatin remodelling pathway, particularly PBRM1-inactivating mutations that are significantly higher than duodenal adenocarcinomas and ampullary adenocarcinoma (27% vs. 0% vs. 7%, p < .01). In vitro cell experiments showed that downregulation of PBRM1 expression could significantly promote the cancer progression and epithelial-to-mesenchymal transition via the PBRM1-c-JUN-VIM axis. The IHC data indicated that PBRM1 deficiency (p = .047) and c-JUN expression (p < .001) were significantly associated with poor prognosis. Meanwhile, the downregulation of PBRM1 expression in HUTU-80 cells was sensitive to radiation, which may be due to the suppression of c-JUN by irradiation.

CONCLUSIONS

Our findings define a novel molecular subgroup of PBRM1-inactivating mutations in DPC. PBRM1 play an important role in DPC progression and may serve as a potential therapeutic target and prognostic indicator.

Clinical outcome comparison of laparoscopic radical antegrade modular pancreatosplenectomy vs. laparoscopic distal pancreatosplenectomy for left-sided pancreatic ductal adenocarcinoma surgical resection

Background

Laparoscopic radical antegrade modular pancreatosplenectomy (LRAMPS) is a validated surgical treatment for patients with left-sided pancreatic ductal adenocarcinoma (PDAC). In addition, laparoscopic distal pancreatectomy (LDPS) has purported benefits. However, there is a limited analysis comparing the results between LRAMPS and LDPS. Thus, this study aims to compare the short-term and long-term outcomes of patients who underwent LRAMPS and LDPS for PDAC treatment.

Methods

Patients with left-sided PDAC that underwent LRAMPS or LDPS from 2015 to 2021 were retrospectively identified. Demographic and clinic pathologic data were collected. Disease-free survival (DFS) and overall survival (OS) probabilities were obtained.

Results

The number of lymph nodes retrieved was significantly greater in the LRAMPS group than in the LDPS group. Several clinicopathological factors, including CA19-9 levels greater than 37 U/ml, positive lymph nodes, moderate to poor tumor differentiation, and peripancreas fat invasion, were associated with DFS. Moderate with poor tumor differentiation was associated with poor DFS (HR 0.568; 95% CI 0.373–0.921; P = 0.021). Levels of CA19-9 greater than 37 U/ml, CEA levels greater than 5 μg/ml, larger tumor size, positive lymph nodes, moderate with poor tumor differentiation, peripancreas fat invasion, and adjuvant chemotherapy were all associated with OS. LRAMPS nearly improved OS but did not reach statistical significance. Serum carcinoembryonic antigen (CEA) levels greater than 5 ug/ml (HR 1.693; 95% CI 1.200–1.132; P = 0.001), and positive lymph nodes (HR 2.410; 95% CI 1.453–3.995; P = 0.001) were independently associated with poor OS. Treatment with adjuvant chemotherapy was associated with improved OS (HR 0.491; 95% CI 0.248–0.708; P = 0.001).

Conclusions

The LRAMPS procedure achieved comparable results to standard LDPS in terms of postoperative outcomes. Treatment with chemotherapy is important for the prognosis of patients with left-sided pancreatic cancer.

The Role and Therapeutic Potential of Macropinocytosis in Cancer

Macropinocytosis, a unique endocytosis pathway characterized by nonspecific internalization, has a vital role in the uptake of extracellular substances and antigen presentation. It is known to have dual effects on cancer cells, depending on cancer type and certain microenvironmental conditions. It helps cancer cells survive in nutrient-deficient environments, enhances resistance to anticancer drugs, and promotes invasion and metastasis. Conversely, overexpression of the RAS gene alongside drug treatment can lead to methuosis, a novel mode of cell death. The survival and proliferation of cancer cells is closely related to macropinocytosis in the tumor microenvironment (TME), but identifying how these cells interface with the TME is crucial for creating drugs that can limit cancer progression and metastasis. Substantial progress has been made in recent years on designing anticancer therapies that utilize the effects of macropinocytosis. Both the induction and inhibition of macropinocytosis are useful strategies for combating cancer cells. This article systematically reviews the general mechanisms of macropinocytosis, its specific functions in tumor cells, its occurrence in nontumor cells in the TME, and its application in tumor therapies. The aim is to elucidate the role and therapeutic potential of macropinocytosis in cancer treatment.

The crosstalk effect between ferrous and other ions metabolism in ferroptosis for therapy of cancer

Ferroptosis is an iron-dependent cell death process characterized by excessive accumulation of reactive oxygen species and lipid peroxidation. The elucidation of ferroptosis pathways may lead to novel cancer therapies. Current evidence suggests that the mechanism of ferroptosis can be summarized as oxidative stress and antioxidant defense mechanisms. During this process, ferrous ions play a crucial role in cellular oxidation, plasma membrane damage, reactive oxygen species removal imbalance and lipid peroxidation. Although, disregulation of intracellular cations (Fe²⁺, Ca²⁺, Zn²⁺, etc.) and anions (Cl^-, etc.) have been widely reported to be involved in ferroptosis, their specific regulatory mechanisms have not been established. To further understand the crosstalk effect between ferrous and other ions in ferroptosis, we reviewed the ferroptosis process from the perspective of ions metabolism. In addition, the role of ferrous and other ions in tumor therapy is briefly summarized.

Laparoscopic duodenum-preserving pancreatic head resection with real-time indocyanine green guidance of different dosage and timing: enhanced safety with visualized biliary duct and its long-term metabolic morbidity

PURPOSE

Laparoscopic duodenum-preserving pancreatic head resection (L-DPPHR) is technically demanding with extreme difficulty in biliary preservation. Only a few reports of L-DPPHR are available with alarming bile leakage, and none of them revealed the long-term metabolic outcomes. For the first time, our study explored the different dosage and timing of indocyanine green (ICG) for guiding L-DPPHR and described the long-term metabolic results.

METHODS

Between October 2015 and January 2021, different dosage and timing of ICG were administrated preoperatively and evaluated intra-operatively using Image J software to calculate the relative fluorescence intensity ratio of signal-to-noise contrast between bile duct and pancreas. Short-term complications and long-term metabolic disorder were collected in a prospectively maintained database and analyzed retrospectively.

RESULTS

Twenty-five patients were enrolled without conversion to laparotomy or pancreaticoduodenectomy. Administrating a dosage of 0.5 mg/kg 24 h before the operation had the highest relative fluorescence intensity ratio of 19.3, and it proved to guide the biliary tract the best. Fifty-six percent of patients suffered from postoperative complications with 48% experiencing pancreatic fistula and 4% having bile leakage. No one suffered from the duodenal necrosis, and there was no mortality. When compared with the non-ICG group, the ICG group had a comparable diameter of tumor and similar safety distance from lesions to common bile duct; however, it decreased the incidence of bile leakage from 10% to none. The median length of hospital stay was 16 days. After a median follow-up of 26.6 months, no one had tumor recurrence or refractory cholangitis. No postoperative new onset of diabetes mellitus (pNODM) was observed, while pancreatic exocrine insufficiency (pPEI) and non-alcoholic fatty liver disease (NAFLD) were seen in 4% of patients 12 months after the L-DPPHR.

CONCLUSION

L-DPPHR is feasible and safe in selected patients, and real-time ICG imaging with proper dosage and timing may greatly facilitate the identification and the prevention of biliary injury. And it seemed to be oncological equivalent to PD with preservation of metabolic function without refractory cholangitis.

[Clinical application of complete laparoscopic gastrectomy with function preservation of cardia in gastric carcinoma]

To investigate the feasibility and safety of total laparoscopic cardia function preserving gastrectomy for gastric carcinoma. Clinical data of 10 patients undergoing total laparoscopic cardia function preserving gastrectomy for gastric carcinoma from November 2020 to December 2021 were retrospectively collected. There were 7 males and 3 females. The mean age was (66.1±12.9) years (ranged from 38 to 86 years). All of the 10 patients were successfully performed total laparoscopic cardia function preserving gastrectomy without conversion to laparotomy. The time of digestive tract reconstruction was (24.8±3.3) min (20-30 min), and the intraoperative blood loss was (35±24) ml(20-100 ml). The time of postoperative exhaust was (2.5±0.9) days(2-3 d), the time of postoperative liquid diet was (2.25±0.87) days(2-3 d), postoperative hospital stay was (9.5±2.1) days(6-13 d). No surgical complications such as bleeding, anastomotic fistula or anastomotic stenosis occurred. Postoperative pathology showed that the proximal and distal margins of resected specimens were negative. Patients were followed up for 2 to 15 months, respectively. No death or tumor recurrence and metastasis occurred during the follow-up period. There were no symptoms of reflux after operation. Compared with total gastrectomy and proximal gastrectomy, total laparoscopic cardia function preserving gastrectomy can theoretically reduce the incidence of reflux esophagitis. We used manual suture method for digestive tract reconstruction, which can reduce the application of 2-3 stapling studs and reduce the cost of surgical materials. Compared with subtotal gastrectomy, total laparoscopic cardia function preserving gastrectomy has the advantages of more thorough lymph node dissection, with little residual gastric tissue; therefore, the blood supply is relatively better. The incidence of reflux esophagitis of total laparoscopic cardia function preserving gastrectomy for gastric cancer may was lower than total gastrectomy.

Identification of Genes Related to 5-Fluorouracil Based Chemotherapy for Colorectal Cancer

Background

Colorectal cancer (CRC) is one of the most common malignancies and its incidence and mortality are increasing yearly. 5-Fluorouracil (5-FU) has long been used as a standard first-line treatment for CRC patients. Although 5-FU-based chemotherapy is effective for advanced CRC, the consequent resistance remains a key problem and causes the poor prognosis of CRC patients. Thus, there is an urgent need to identify new biomarkers to predict the response to 5-FU-based chemotherapy.

Methods

CRC samples were retrieved from Gene Expression Omnibus (GEO) and The Cancer Genome Atlas (TCGA). The immune-related genes were retrieved from the ImmPort database. Single-cell sequencing results from colorectal cancer were obtained by the ArrayExpress database. 5-FU resistance-related genes were filtered and validated by R packages. ESTIMATE algorithms were used to assess the tumor microenvironment (TME). KEGG and GO analysis were performed to explore the biological signaling pathway for resistant-response patients and sensitive-response patients in the tumor microenvironment. pRRophetic algorithms were used to predict 5-FU sensitivity. GSEA and GSVA analysis was performed to excavate the biological signaling pathway of the RBP7 gene.

Results

Nine immune-related genes were identified to be associated with 5-FU resistance and poor disease-free survival (DFS) of CRC patients and the signature of these genes was developed in a DFS-prognostic model. Four immune-related genes were determined to be associated with 5-FU resistance and overall survival (OS) of CRC patients. The signature of these genes was developed an OS-prognostic model. ESTIMATE scores showed a significant difference between 5-FU resistant and 5-FU sensitive CRC patients. Resistant-response patients and sensitive-response patients to 5-FU based chemotherapy showed different GO and KEGG enrichment on the tumor microenvironment. RBP7, as a tumor immune microenvironment (TIME) related gene, was found to have the potential of predicting chemotherapy resistance and poor prognosis of CRC patients. GSEA analysis showed multiple signaling differences between the high and low expression of RBP7 in CRC patients. Hypoxia and TNFα signaling via NFκB gene sets were significantly different between chemotherapy resistant (RBP7^High) and chemotherapy sensitive (RBP7^Low) patients. Single-cell RNA-seq suggested RBP7 was centrally distributed in endothelial stalk cells, endothelial tip cells, and myeloid cells.

Conclusions

Immune-related genes will hopefully be potential prognostic biomarkers to predict chemotherapy resistance for CRC. RBP7 may function as a tumor microenvironment regulator to induce 5-FU resistance, thereby affecting the prognosis of CRC patients.

Immune cell atlas of cholangiocarcinomas reveals distinct tumor microenvironments and associated prognoses

BACKGROUND

Immunotherapy has demonstrated a limited clinical efficacy in approximately 5% of cholangiocarcinoma. The main challenges for an effective immunotherapy response in cholangiocarcinoma arise from the tumor microenvironment, which is poorly understood.

METHODS

For a comprehensive analysis of the tumor microenvironment in cholangiocarcinoma, we performed multiplex immunohistochemistry with two 15-marker immune panels and Nanostring assays for a comprehensive analysis of 104 surgically resected cholangiocarcinomas including intrahepatic, hilar, and distal cholangiocarcinoma. We also validated some key findings with a batch integration analysis of published single cell RNA sequencing data.

RESULTS

This study found that natural killer cells occupy the largest immune cell compartment in cholangiocarcinoma. Granzyme-B+CD8+ effector T cells are significantly associated with better overall survival in both intrahepatic and distal cholangiocarcinoma. Above 85% of intrahepatic cholangiocarcinomas with higher density of PD-1-EOMES-CD8+ effector T cells are associated with long-term survival. However, only the density of PD-1-EOMES-CD8+ T cells in the tumor areas, but not in the peripheries of the tumors, is prognostic. In all three cholangiocarcinoma subtypes, T regulator cells are significantly associated with a poor prognosis; however, M1 and M2 tumor-associated macrophages or PD-L1+ tumor-associated macrophage demonstrate different prognostic values. Combining PD-L1+ M1 or M2, PD-L1- M1 or M2 tumor-associated macrophages, and T regulator cells to subgroup intrahepatic and distal cholangiocarcinoma, the prognosis is significantly better distinguished. Moreover, PD-L1- M2 tumor-associated macrophages is associated with a good prognosis in intrahepatic and distal cholangiocarcinoma, suggesting this subtype of M2 tumor-associated macrophages may be antitumoral. Interestingly, lower densities of various types of immunosuppressive cells are associated with decreased infiltration of effector T cells in distal and hilar cholangiocarcinoma, but not in intrahepatic cholangiocarcinoma. In intrahepatic cholangiocarcinoma, PD-L1+ tumor-associated macrophages exert their immunosuppressive function likely through promoting T cell exhaustion.

CONCLUSIONS

This study suggests that the densities of Granzyme-B+CD8+ effector T cells and non-exhausted PD-1-EOMES-CD8+ T cells and the PD-L1 status in the tumor-associated macrophages are prognostic makers in cholangiocarcinomas. The study also supports targeting PD-L1+ tumor-associated macrophages as the immunotherapy for cholangiocarcinoma.

[Clinical effect of minimally invasive duodenum preserving pancreatic head resection for benign and pre-malignant lesions of pancreatic head]

Objective: To examine the clinical effect of minimally invasive duodenum preserving pancreatic head resection(DPPHR) for benign and pre-malignant lesions of pancreatic head. Methods: The clinical data of patients with diagnosis of benign or pre-malignant pancreatic head tumor were retrospectively collected and analyzed,all of them underwent laparoscopic or robotic DPPHR between October 2015 and September 2021 at Division of Gastrointestinal and Pancreatic surgery,Zhejiang Provincial People's Hospital. Thirty-three patients were enrolled with 10 males and 23 females. The age(M(IQR)) was 54(32) years old(range: 11 to 77 years old) with body mass index of 21.9(2.9)kg/m²(range: 18.1 to 30.1 kg/m²). The presenting symptoms included abdominal pain(n=12), Whipple triad(n=2), and asymptomatic(n=19), among them there were 7 patients with hypertension and 1 patient with diabetes mellitus. There were 19 patients diagnosed as American Society of Anesthesiologists class Ⅰ and 14 patient as class Ⅱ. The student t test,U test, χ² test or Fisher exact test was used to compare continuous data or categorized data,respectively. All the perioperative data and metabolic morbidity were analyzed and experiences on minimally invasive DPPHR was concluded. Results: Fourteen patients underwent laparoscopic DPPHR,while the rest of 19 patients received robotic DPPHR. Indocyanine green fluorescence imaging was used in 19 patients to guide operation. Five patients were performed pancreatico-gastrostomy and the rest 28 patients underwent pancreaticojejunostomy. Pathological outcomes confirmed 9 solid pseudo-papillary neoplasms, 9 intraductal papillary mucinous neoplasms, 7 serous cystic neoplasms, 6 pancreatic neuroendocrine tumors, 1 mucous cystic neoplasm, 1 chronic pancreatitis. The operative time was (309.4±50.3) minutes(range:180 to 420 minutes),and the blood loss was (97.9±48.3)ml(range:20 to 200 ml). Eighteen patients suffered from postoperative complications,including 3 patients experienced severe complications(Clavien-Dindo Grade ≥Ⅲ). Pancreatic fistula occurred in 16 patients,including 8 patients with biochemical leak,7 patients with grade B pancreatic fistula and 1 patient with grade C pancreatic fistula. No one suffered from the duodenal necrosis and none perioperative death was occurred. The length of hospital stay was 14(7) days (range:6 to 87 days). The follow-up was 22.6(24.5)months(range:2 to 74 months). None suffered from recurrence or metastasis. During the follow-up,all the patients were free of refractory cholangitis. Moreover,in the term of endocrine dysfunction,no postoperative new onset of diabetes mellitus were observed in the long-term follow-up. However,in the view of exocrine insufficiency,pancreatic exocrine insufficiency and non-alcoholic fatty liver disease (NAFLD) was complicated in 2 and 1 patient,respectively,with the supplement of pancreatic enzyme,steatorrhea and weight loss relieved,but NAFLD was awaited to be seen. Conclusions: Minimally invasive DPPHR is feasible and safe for benign or pre-malignant lesions of pancreatic head. Moreover,it is oncological equivalent to pancreaticoduodenectomy with preservation of metabolic function without refractory cholangitis.

Robotic versus Open Pancreatoduodenectomy for Pancreatic and Periampullary Tumors (PORTAL): a study protocol for a multicenter phase III non-inferiority randomized controlled trial

BACKGROUND

Pancreatoduodenectomy is a complex and challenging procedure that requires meticulous tissue dissection and proficient suturing skills. Minimally invasive surgery with the utilization of robotic platforms has demonstrated advantages in perioperative patient outcomes in retrospective studies. The development of robotic pancreatoduodenectomy (RPD) in specific has progressed significantly, since first reported in 2003, and high-volume centers in pancreatic surgery are reporting large patient series with improved pain management and reduced length of stay. However, prospective studies to assess objectively the feasibility and safety of RPD compared to open pancreatoduodenectomy (OPD) are currently lacking.

METHODS/DESIGN

The PORTAL trial is a multicenter randomized controlled, patient-blinded, parallel-group, phase III non-inferiority trial performed in seven high-volume centers for pancreatic and robotic surgery in China (> 20 RPD and > 100 OPD annually in each participating center). The trial is designed to enroll and randomly assign 244 patients with an indication for elective pancreatoduodenectomy for malignant periampullary and pancreatic lesions, as well as premalignant and symptomatic benign periampullary and pancreatic disease. The primary outcome is time to functional recovery postoperatively, measured in days. Secondary outcomes include postoperative morbidity and mortality, as well as perioperative costs. A sub-cohort of 128 patients with pancreatic adenocarcinoma (PDAC) will also be compared to assess the percentage of patients who undergo postoperative adjuvant chemotherapy within 8 weeks, in each arm. Secondary outcomes in this cohort will include patterns of disease recurrence, recurrence-free survival, and overall survival.

DISCUSSION

The PORTAL trial is designed to assess the feasibility and safety of RPD compared to OPD, in terms of functional recovery as described previously. Additionally, this trial will explore whether RPD allows increased access to postoperative adjuvant chemotherapy, in a sub-cohort of patients with PDAC.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04400357 . Registered on May 22, 2020.

Hepatic Arterial Infusion Chemotherapy Is a Feasible Treatment Option for Hepatocellular Carcinoma: A New Update

Background

Hepatic arterial infusion chemotherapy (HAIC) is one option for treating massive tumors and unresectable hepatocellular carcinoma (HCC). However, there is a lack of remedial treatment after these treatments are ineffective or failed.

Summary

Some studies have discovered that HAIC has greater survival in patients with advanced HCC. A previous study has shown that HAIC is effective in the treatment of advanced HCC, and the data on randomized clinical trials are limited and unclear.

Key Message

More clinical trials and research are needed in order to make HAIC a standard and recommended therapy for advanced HCC. Our review focuses on the clinical applications of hepatic artery infusion treatment.

Clinicopathological Prognostic Factors and Chemotherapeutic Outcome for Two Histopathological Types of Ampulla of Vater Adenocarcinoma

Background

Adenocarcinoma of the ampulla of Vater (AAV) is standardly treated using a complex operation, a pancreatoduodenectomy (PD), to remove the tumor. However, dicision-making in AAV clinical treatment remains difficult due to the broad range of AAV types, outcomes, and responses to special chemotherapeutics. Thus, this study aimed to explore clinicopathological prognostic factors associated with overall survival, as well as post-chemotherapeutic effects related to curative resection of AAV.

Methods

We retrospectively reviewed data for clinicopathological outcome of 47 patients diagnosed with AAV that had underwent a PD. Overall survival probabilities were obtained using the Kaplan–Meier estimate method and a Cox proportional hazards model.

Results

Forty-five patients underwent LPD (laparoscopic pancreatoduodenectomy) and two patients underwent PD. The patient group was composed of 31 males (66%) and 16 females (34%) with a mean age of 65(34–91)years. We selected 45 patients for long-term survival analysis. One- and three-year overall survival rates after resection were 97.6% and 58.9% respectively. The median survival was 37.7 months for the intestinal-type and 26.9 months in pancreatobiliary-type ampullary tumors. Serum carbohydrate antigen (CA) 19-9 greater than 37 U/ml (HR 0.140, P = 0.007), perineural invasion (HR 0.141, P = 0.003), and classification as pancreatobiliary-type (HR 6.633, P = 0.006) were independently associated with poor survival. Serum carcinoembryonic antigen (CEA) greater than 5 µg/ml (P = 0.031), serum CA 19-9 greater than 37 U/ml (P = 0.002), tumor sizes greater than 2.5cm (P=0.002), and positive perineural invasion (P=0.003) were all associated with a poor prognosis in the histopathological subgroup. Serum CA 19-9 greater than 37 U/ml (P=0.002) and positive perineural invasion (P=0.001) were significantly associated with poor survival in of patients with intestinal-type ampullary tumors. Serum CEA greater than 5 µg/ml (P=0.013) and tumor sizes greater than 2.5cm (P=0.002) were significantly associated with poor survival in patients with pancreatobiliary-type ampullary tumors.

Conclusions

Pancreatobiliary-type ampullary tumors were associated with poor survival. Serum CA 19-9 in the intestinal-type and CEA in the pancreatobiliary-type were significantly associated with poor survival. Ajuvant chemotherapy could not predict the survival of AAV patients.

Accurate Cancer Diagnosis and Stage Monitoring Enabled by Comprehensive Profiling of Different Types of Exosomal Biomarkers: Surface Proteins and miRNAs

Exosomes are recognized as promising biomarkers for early cancer diagnosis and prognosis owing to a large amount of biological information they carried. But the key is that single type of exosomal biomarker analysis is not sufficient enough for accurate cancer diagnosis and stage monitoring due to the insufficient information and high false positive signal. To address the challenge, here simultaneous in situ detection of different types of exosomal biomarkers (surface proteins: CD81, ephrin type-A receptor 2, and carbohydrate antigen 19-9; miRNAs: miR-451a, miR-21, and miR-10b) is conducted with a 3D microfluidic chip, which works in conjunction with quantum dot (QD) labeling and vesicle fusion technology. After exosomes are efficiently captured by the microfluidic chip, the quantification of multiple exosomal proteins is achieved by using three kinds of QDs with the same excitation and different emission wavelengths, and virus-mimicking fusogenic vesicles encapsulating three exquisitely engineered molecular beacons are introduced for ultrasensitive detection of multiple exosomal miRNAs without requiring RNA extraction. Through comprehensive profiling different types of exosomal biomarkers, the false positive rate is substantially avoided and the accuracy of cancer diagnosis and stage monitoring is improved to ≈100%, which are critical to cancer effective treatment and favorable prognosis.

IL35 predicts prognosis in gastric cancer and is associated with angiogenesis by altering TIMP1, PAI1 and IGFBP1

Tumor angiogenesis is required for tumor growth and metastasis. Interleukin‐35 (IL35), a member of the IL12 family, is a dimer composed of IL12A and EBV‐induced gene 3（EBI3）. Elevated plasma IL35 levels have been reported to be associated with the occurrence and development of tumors. However, the role of IL35 in the angiogenesis of gastric cancer (GC) is still unclear. Here, we report that expression of IL35 is correlated with higher microvessel density, distant metastasis and poor prognosis in GC. Moreover, in vitro tube formation assays were performed to show that IL35 may contribute to the tube formation abilities of human umbilical vein endothelial cells. IL12A was observed to be the dominant subunit in promotion of tube formation. IL12A also inhibited expression of tissue inhibitor of metalloproteinase 1 and enhanced expression of plasminogen activator inhibitor 1 and insulin‐like growth factor‐binding protein 1 in a GC cell line. In conclusion, our data suggest that IL35 is involved in angiogenesis and is associated with poor prognosis for GC.

[Clinical analysis of minimal invasive surgical treatment for pancreatic neuroendocrine tumors]

Objective: To analyze the safety and effectiveness of minimal invasive surgery treating pancreatic neuroendocrine tumors (pNETs), and to summarize surgical characteristics and share experience. Methods: The clinical data of 80 pNETs treated by a single hospital from January 2015 to December 2019 were retrospectively analyzed. The patients were divided into laparoscopic group and robot group. And surgical procedures included pancreaticoduodenectomy (PD), distal pancreatectomy (DP), central pancreatectomy (CP), and tumor enucleation. Results: Of 80 patients, 76 cases (95%) underwent minimal invasive surgery and 4 cases (5%) changed to open surgery. There were 38 females, with median age of 54.4 (20-80) years and median BMI (17.0-38.0) kg/m(2). Among them, 24 patients (31.6%) underwent PD, 36 patients (47.4%) underwent DP, 8 patients (10.5%) underwent CP and 8 patients (10.5%) received tumor enucleation. The postoperative incidence of grade B/C pancreatic fistula was 35.5%, the incidence of abdominal infection was 10.5%, the postoperative bleeding was 7.9%, and the reoperation rate was 6.6%, without perioperative deaths. There was no significant difference in postoperative complications among different surgical methods, including postoperative pancreatic fistula (P=0.396), postoperative bleeding (P=0.297), postoperative abdominal infection (P=0.339) and reoperation (P=0.396). Conclusions: Surgical resection is an effective treatment for pNETs. pNETs are suitable for minimally invasive surgery with earlier stage and smaller tumor diameter. Minimally invasive surgery for pNETs is safe and feasible, and functional preserving surgery could take into consideration.

Laparoscopic pancreaticodoudenectomy: An excellent approach in elderly patients, a multicenter, comparative study

BACKGROUND

Management of malignant diseases in elderly patients has become a global clinical issue because of increased life expectancy worldwide. Advancements in surgical techniques and perioperative management have reduced age-related contraindications for LPD. Past articles have reported that elderly patients undergoing laproscopic pancreatoduodenectomy (LPD) are at an increased risk compared to younger patients. The aim of this article is to compare a multicenter center risk of LPD in elderly and nonelderly patients.

METHODS

Retrospective review (n = 237) of perisurgical outcomes in patients undergoing LPD during the months of September 2012 to December 2017. Outcomes in elderly patients (aged ≥75 years) were compared with those in nonelderly patients.

RESULTS

Transfer to ICU was more frequent in elderly patients (odds ratio [OR] 6.49, P = .001) and the mean hospital stay was longer (21.4 days compared with 16.6 days), (P = .0033) than for nonelderly patients. There was no statistically significant difference in operation time (P = .494), estimated blood loss (P = .0519), blood transfusion (P = .863), decreased gastric emptying (P = .397), abdominal pain (P = .454), food intake (P = .241), time to self-ambulation (P = 1), reoperation (P = .543), postoperative pancreatic fistula (POPF) grade A (P = .454), POPF grade B (P = .736), POPF grade C (P = .164), hemorrhage (P = .319), bile leakage (P = .428), infection (P = .259), GI bleeding (P = .286), morbidity (P = .272) or mortality (P = .449) between the 2 groups.

CONCLUSIONS

Elderly patients who underwent LPD in this study had good overall outcomes after LPD that were similar to young patients. The perioperative and long-term outcomes of LPD are not worse. Rates of ICU admission and hospital stays increased in elderly patients undergoing LPD when compared with nonelderly ones. LPD can be performed on elderly patients with similar outcomes as younger patients; therefore, age itself should not be a contraindication for LPD for pancreatic cancer, but it suggests that elderly patients with comorbidities should be more stringently selected for surgery.

[Early experience of minimal invasive surgery for adolescent with pancreatic head tumor: a report of 15 cases]

Objective: To summarize the characteristics and difficulties of minimal invasive surgery for adolescent with pancreatic head tumor. Methods: The data of adolescent younger than 28 years old with pancreatic head tumor treated at Department of Gastroenterology and Pancreatic Surgery, Zhejiang Province People's Hospital from January 2014 to December 2019 were analyzed retrospectively. Fifteen cases were enrolled, included 5 males and 10 females. The median age was 20 years(range: 11 to 27 years) and the body mass index was (19.8±2.3)kg/m(2)(range: 17.3 to 21.6 kg/m(2)). Results: Standard pancreaticoduodenectomy was performed in 12 cases, including 9 cases of laparoscopic surgery and 3 cases of robotic-assisted surgery, and laparoscopic pancreaticoduodenectomy with resection of hepatic flexure of colon was performed on 1 case, and robotic-assisted duodenum-preserving pancreatic head resection with pancreatogastrostomy was performed on other 2 cases. The operative time was (269.0±65.1)minutes(range: 150 to 410 minutes), and the blood loss was (135.6±52.7)ml(range: 50 to 400 ml). Six patients got postoperative complications with gastrointestinal bleeding biochemical leakage and intestinal obstruction(n=1), pancreatic biochemical leakage(n=1), bile leakage(n=1), chylous leakage(n=1), wound infection(n=1), hepatic injury(n=1). The median postoperative hospital stay was 13 days(range: 9 to 22 days).The pathologic findings were solid pseudopapillary neoplasms(n=8), neuroendocrine neoplasms(n=3), introductal papillary mucinous neoplasm(n=1), cystic fibroma(n=1), serous cystadenoma(n=1), Ewing sarcoma(n=1).The median follow-up was 37 months(range: 2 to 75 months).The patient with Ewing sarcoma was diagnosed as liver metastasis at 41 months after surgery and died at 63 months after surgery.All the other patients survived without tumor.Three patients got the long-term complication of bile duct. Conclusions: Most of pancreatic head tumors for adolescent are benign or low malignant. Minimally invasive surgery be the first choice, and function-preserving surgery should be taken into account as much as possible.Perioperative management and communication is essential as the parents pay much attention to the quality of life after surgery.

International expert consensus on laparoscopic pancreaticoduodenectomy

IMPORTANCE

While laparoscopic pancreaticoduodenectomy (LPD) is being adopted with increasing enthusiasm worldwide, it is still challenging for both technical and anatomical reasons. Currently, there is no consensus on the technical standards for LPD.

OBJECTIVE

The aim of this consensus statement is to guide the continued safe progression and adoption of LPD.

EVIDENCE REVIEW

An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreaticoduodenectomy. Statements were produced upon reviewing the literature and assessed by the members of the expert panel. The literature search and its critical appraisal were limited to articles published in English during the period from 1994 to 2019. The Web of Science, Medline, and Cochrane Library and Clinical Trials databases were searched, The search strategy included, but was not limited to, the terms 'laparoscopic', 'pancreaticoduodenectomy, 'pancreatoduodenectomy', 'Whipple's operation', and 'minimally invasive surgery'. Reference lists from the included articles were manually checked for any additional studies, which were included when appropriate. Delphi method was used to establish expert consensus and the AGREE II-GRS Instrument was applied to assess the methodological quality and externally validate the final statements. The statements were further discussed during a one-day face-to-face meeting at the 1st Summit on Minimally Invasive Pancreatico-Biliary Surgery in Wuhan, China.

FINDINGS

Twenty-eight international experts from 8 countries constructed the expert panel. Sixteen statements were produced by the members of the expert panel. At least 80% of responders agreed with the majority (80%) of statements. Other than three randomized controlled trials published to date, most evidences were based on level 3 or 4 studies according to the AGREE II-GRS Instrument.

CONCLUSIONS AND RELEVANCE

The Wuhan international expert consensus meeting on LPD has produced a set of clinical practice statements for the safe development and progression of LPD. LPD is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. More robust randomized controlled trial and registry study are essential to proceed with the assessment of LPD.

Circular RNA expression profile and m6A modification analysis in poorly differentiated adenocarcinoma of the stomach

Aims: To profile and characterize the circular RNA (circRNA) expression pattern in poorly differentiated gastric adenocarcinoma (PDGA). Methods & materials: CircRNA expression profiles in PDGA and adjacent nontumor tissues were analyzed by microarray. Five randomly selected differentiated expressed circRNAs (DECs) were validated by real-time quantitative PCR. m6A qualification of the top 20 DECs was conducted by m6A-immunoprecipitation and real-time quantitative PCR. Results: A total of 65 DECs were found in PDGA compared with the control. Hsa_circRNA_0077837 had the largest area under the curve. Most DECs had m6A modifications, the trend of m6A modification alteration was mainly consistent with the circRNA expression level. Conclusion: Our study revealed a set of DECs and their m6A modification alterations, which may provide new insight for their potential function in PDGA.

Optimal Laparoscopic Management and Oncological Outcomes of Gastrointestinal Stromal Tumors in Duodenum: Pancreaticoduodenectomy or Pancreas-Sparing Duodenectomy?

Background

Gastrointestinal stromal tumors (GIST) of the duodenum are rarely reported and optimal minimally invasive management has not been well proposed. Pancreaticoduodenectomy and different types of pancreas-sparing duodenectomy can be chosen; however, which to choose and its corresponding clinical outcomes and oncological concerns remain controversial.

Patients and Methods

Patients diagnosed with GIST of duodenum underwent laparoscopic pancreaticoduodenectomy (L-PD) or pancreas-sparing duodenectomy (L-PSD) in Zhejiang Provincial People's Hospital were enrolled. All prospectively maintained data were analyzed retrospectively. Patients were grouped into the L-PD group or the L-PSD group, and the clinical outcomes and oncological outcomes were analyzed.

Results

Between June 2013 and March 2019, a total of 22 patients (11 males/11 females) underwent surgical management, including 13 L-PDs and 9 L-PSDs. The average age was 58.2±9.5 year-old (median 60.5 year-old). The most common presentations were GI bleeding (54.5%) and abdominal discomfort (27.2%), and the dominant lesion located in the second portion of duodenum (59.1%). Compared with L-PD group, L-PSD group showed much shorter operation time (364.2±58.7min vs. 230.0±12.3min, P<0.001), less blood loss (176.9±85.7mL vs. 61.1±18.2min, P<0.001), faster recovery to off-bed (2.6±1.3d vs. 1.1±0.3d, P=0.003), anus flatus (4.5±1.0d vs. 2.4±0.5d, P<0.001) and liquid intake (4.9±1.3d vs. 2.3±0.5d, P<0.001). Lymph node retrieval was much less in L-PSD, but no lymph node metastasis was observed in any patients. L-PSD had much Lower morbidity of both minor (Grade I/II) and major (III/IV/V) complications than that of L-PD (11.1% vs. 61.6%, P=0.02), resulting in shorter hospital stays (10.9±3.8d vs. 20.6±11.1d, P=0.021) and less total cost (76,972.4±11,614.8yuan vs 125,628.7±46,356.8yuan, P=0.006). The median follow-up was 42 months (range from 12 to 82months) without loss. Only 1 L-PD patient suffered hepatic metastasis 36months after surgery, and given sunitinib to stabilize the disease, none of the rest observed recurrence or metastasis.

Conclusion

For GIST located opposite the major papilla, L-PSD showed comparable safety and oncological benefits when compared to L-PD, with shorter operation time, less blood loss and much faster recovery time, resulting in much less total cost. L-PSD should be applied in selected patients with experienced hands.

[Laparoscopic gastroduodenostomy with manual suture for Billroth Ⅰ anastomosis: a report of 36 cases]

Objective: To examine the clinical efficiency of laparoscopic gastroduodenostomy with BillrothⅠanastomosis with manual suture. Methods: The clinic data of 36 patients with gastric cancer who underwent laparoscopic gastroduodenostomy with Billroth Ⅰ anastomosis from November 2017 to September 2019 in Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital were analyzed retrospectively.There were 22 males and 14 females, aged (64.3±9.3) years(range: 43 to 80 years), underwent complete laparoscopic gastroduodenostomy. The laparoscopic manual suture was used for Billroth Ⅰ anastomosis. Results: All the laparoscopic radical gastrectomy and manual suturing gastroduodenostomy were successfully performed. The operation time was (226.7±40.4) minutes (range: 180 to 320 minutes), including (24.8±7.1) minutes (range: 15 to 48 minutes) for gastroduodenostomy.There was (3.8±0.9) days (range: 2 to 6 days) for anal exhaust, (5.7±2.0) days (range: 3 to 13 days) for extubation of gastric tube, and (10.3±3.1) days (range: 7 to 19 days) for hospitalization. There was no death in perioperative period. Postoperative pathological report showed 3 cases of highly differentiated adenocarcinoma, 5 cases of moderately differentiated adenocarcinoma, 22 cases of poorly differentiated adenocarcinoma and 6 cases of signet ring cell carcinoma, including 27 cases in T1 stage and 9 cases in T2 stage. The number of lymph nodes harvested was 36.4±8.9 (range: 23 to 60). Lymph node metastasis was positive in 7 cases and negative in 29 cases. TNM stage included 24 cases in ⅠA stage, 8 cases in ⅠB stage and 4 cases in Ⅱ stage. After the operation, the upper digestive tract radiography showed that the anastomosis opening was unobstructed without complications such as anastomotic stenosis. Conclusion: Laparoscopic gastroduodenostomy with Billroth Ⅰ anastomosis with manual suture is safe and feasible, has a good short-term effect.

Laparoscopic versus open pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a propensity score matching analysis

BACKGROUND

A growing body of evidence supports the use of laparoscopic pancreaticoduodenectomy (LPD) as an efficient and feasible surgical technique. However, few studies have investigated its applicability in pancreatic ductal adenocarcinoma (PDAC), and the long-term efficacy of LPD on PDAC remains unclear. This study aimed to compare the short- and long-term outcomes between LPD and open pancreaticoduodenectomy (OPD) for PDAC.

METHODS

The data of patients who had OPD or LPD for PDAC between January 2013 and September 2017 were retrieved. Their postoperative outcomes and survival were compared after propensity score matching.

RESULTS

A total of 309 patients were included. After a 2:1 matching, 93 cases in the OPD group and 55 in the LPD group were identified. Delayed gastric emptying (DGE), particularly grade B/C DGE, occurred less frequently in the LPD group than in the OPD group (1.8% vs. 36.6%, P < 0.001; 1.8% vs. 22.6%, P = 0.001). The overall complication rates were significantly lower in the LPD group than in the OPD group (49.1% vs. 71.0%, P = 0.008), whereas the rates of major complications were similar (10.9% vs. 14.0%, P = 0.590). In addition, the median overall survival was comparable between the two groups (20.0 vs. 18.7 months, P = 0.293).

CONCLUSION

LPD was found to be technically feasible with efficacy similar to OPD for patients with PDAC.

[Preliminary application of endoscopic titanium clip localization combined with three-dimensional CT reconstruction in the determination of resection margin of gastric central cancer under laparoscopy]

Objective: To evaluate the accuracy of endoscopic titanium clip localization combined with CT three-dimensional reconstruction for the control of incision margin in early gastric cancer under laparoscopy. Methods: A prospective analysis was made for gastric cancer whose lesions were located in the middle of the stomach and T stage was 1 to 2 from October 2017 to January 2019 at Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital. Totally 25 patients were eventually enrolled in the study. There were 17 males and 8 females aging of (63.6± 7.2) years (range: 48 to 77 years). All cases were treated with titanium clip localization under endoscope combined with CT three-dimensional (3D) reconstruction to construct a virtual panorama of gastric cavity and lesions, and to design surgical margins. Laparoscopic surgical resection was performed according to the surgical margins designed before operation. The distance from the gastric angle to the origin of the minor curvature of the incisional margin, the distance from the gastric angle to the the center of lesion and the distance of the upper incision margin were measured under three-dimensional CT reconstruction and under actual specimen. Paired t test was used to compare the three distances measured by two methods. Results: The measured distances from the gastric angle to the center of the lesion and the proximal incisional margin under 3D reconstruction CT were according to the measured values of actual specimens ((2.67±1.38) cm vs. (2.83±1.56) cm, t=1.51, P=0.14; (5.23±0.60) cm vs. 5 cm, t=1.93, P=0.07); the measured distances from the gastric angle to the origin of the minor curvature of the incisional margin under CT 3D reconstruction were different with the measured values of solid specimens ((5.94±0.94) cm vs. (6.37±0.90) cm, t=3.52, P=0.00). Conclusion: The method of titanium clip localization combined with CT 3D reconstruction can provide a feasible laparoscopic localization method and incision edge solution for T1 to 2 gastric central cancer.

MicroRNA‑203a‑3p is a candidate tumor suppressor that targets thrombospondin 2 in colorectal carcinoma

The aim of the present study was to investigate the role of miR-203a-3p in colorectal cancer (CRC) and identify the target gene of microRNA (miR)-203a-3p. A total of 59 sets of cancer tissues and corresponding adjacent non-tumor tissues were collected from CRC patients (aged 31–78 years) between October 2016 and May 2017. Total RNA extraction and reverse transcription-quantitative polymerase chain reaction analysis, transfection assay, and Transwell and apoptosis assays, western blot analysis, a luciferase reporter assay and immunohistochemistry were performed. miR-203a-3p was found to be significantly downregulated in CRC tissues compared with adjacent normal tissues. The overexpression of miR-203a-3p was shown to inhibit the invasion and migration of human CRC SW480 and HT29 cells, and increase their apoptosis rates. Furthermore, miR-203a-3p downregulated the expression of thrombospondin 2 (THBS2) in SW480 and HT29 cells. It was also experimentally demonstrated that miR-203a-3p binds to the 3′-untranslated region of THBS2, downregulating THBS2 expression and thereby inhibiting CRC progression and metastasis. The expression of miR-203a-3p, which serves a tumor-suppressive role, in CRC tissues was significantly downregulated. As miR-203a-3p was determined to target THBS2 to inhibit CRC progression and metastasis; thus, miR-203a-3p may be considered as a potential novel approach to treating CRC.

[Surgical treatment of port-site metastases after laparoscopic radical resection of gastric cancer]

Objective: To investigate the feasibility of surgical treatment of port-site metastasis after laparoscopic radical resection of gastric cancer. Methods: The clinical and follow-up data of five patients with port-site metastases after laparoscopic radical resection of gastric cancer at Zhejiang Provincial People's Hospital between January 2014 and January 2018 were retrospectively analyzed. Results: Port-site metastases occurred within 6 months after gastrointestinal tumor resection in three patients, 10 months after the operation in one patient, and 30 months after the operation in one patient, respectively. Metastasis to the abdominal cavity or distant metastasis was excluded before the surgical treatment of the port-site metastases, and all patients recovered well after the operation. No incisional infection or hernia occurred. By December 2018, two patients died (they survived for 13 and 24 months, respectively) and three patients survived. The follow-up duration ranged from 7 to 19 months. Conclusions: Surgical resection of port-site metastases is not difficult due to their superficial location. Surgical treatment can improve the prognosis of patients without abdominal or distant metastasis/recurrence.

Laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: oncologic outcomes and long-term survival

OBJECTIVE

The study aimed to compare the oncologic outcomes and long-term survival of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) for patients diagnosed with pancreatic ductal adenocarcinoma (PDAC).

BACKGROUND

Substantial evidence demonstrated that LPD is technically safe and feasible with perioperative outcomes equivalent to that of OPD. However, for patients with malignancy, especially PDAC, the oncologic outcomes and long-term survival of patients who underwent LPD remains to be elucidated.

METHODS

Studies on LPD for the treatment of PDAC published before December 25, 2018 were searched online. The oncologic outcomes (e.g., numbers of lymph nodes retrieved, negative margin (R0) resection), and long-term survival (postoperative survival from 1 to 5 year) of LPD were compared to that of ODP.

RESULTS

After screening 1507 studies, six comparative cohort studies, which reported the oncologic outcomes and long-term survival of patients with PDAC were included. No significant difference was found between LPD and OPD regarding lymph nodes harvested (OR 1.96, 95% CI - 1.17 to 5.09, p = 0.22), R0 rate (OR 1.44, 95% CI 1.00 to 2.06, p = 0.05), number of positive lymph nodes (OR - 0.44, 95% CI - 1.06 to 0.17, p = 0.16), rate of adjuvant treatment (OR 1.04, 95% CI 0.68 to 1.59, p = 0.86) and time to adjuvant treatment (OR - 6.21, 95% CI - 16.00 to 3.59, p = 0.21). LPD showed similar 1-year (OR 1.20, 95% CI 0.87 to 1.65, p = 0.28), and 2-year survival (OR 1.25, 95% CI 0.94 to 1.66, p = 0.13) to that of OPD. The 3-year (OR 1.50, 95% CI 1.12 to 2.02, p = 0.007), 4-year (OR 1.73, 95% CI 1.02 to 2.93, p = 0.04), and 5-year survival (OR 2.11, 95% CI 1.35 to 3.31, p = 0.001) were significantly longer in LPD group.

CONCLUSION

For the treatment of PDAC, the oncologic outcomes of LPD were equivalent to that of OPD; LPD seemed promising regarding the postoperative long-term survival.

[Laparoscopic radical antegrade modular pancreatosplenectomy for left-sided pancreatic adenocarcinoma: analysis of 12 cases]

Objective: To evaluate the safety and feasibility of laparoscopic radical antegrade modular pancreatosplenectomy(Lap-RAMPS) for left-sided pancreatic adenocarcinoma. Methods: Clinical data of total 12 patients underwent Lap-RAMPS for left-sided pancreatic adenocarcinoma at Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital from March 2016 to August 2017 were reviewed retrospectively.There were 7 male patients and 5 female patients, with median age of 60.5 years old(47-68 years old). Abdominal enhanced CT, pancreatic MRI, PET-CT were performed on all patients to evaluate the lesion and exclude metastasis.Follow-up were done with out-patient clinic or telephone consultancy until October 2017. Results: All patients underwent pure Lap-RAMPS.The medium operative time was 250 minutes(180-445 minutes), and the blood loss was 150 ml(50-500 ml). The medium first flatus time and diet resumption time were 3.0 days(1-5 days) and 3.5 days(1-7 days) respectively.The medium postoperative hospital stay was 9 days(4-18 days). Morbidity occurred in 8 patients with gastric empty delay(n=1), bleeding(n=1), fluid collection(n=3). There was no mortality.The medium overall number of retrived lymph nodes was 15.6 and the positive rate was 41.7%. The R0 rate was 100%.The medium follow-up was 10 months.One patient was diagnosed as liver metastasis after 8 months and accepted chemotherapy.One patient died after 14 months for tumor recurrence and metastasis.Others survived without tumor recurrence or metasitasis. Conclusion: Lap-RAMPS is safe and feasible with accepted oncological outcomes for selected left side pancreatic adenocarcinoma under skilled hands.

[Minimal invasive surgery in the treatment of neuroendocrine tumors of the pancreas]

Neuroendocrine tumor of the pancreas (pNET) is a rare group of neoplasms with widely heterogeneity. Complete surgical resection remains the only potentially curative treatment for pNET. Compared to open surgery, minimal invasive approach treating pNET could decrease bleeding and shorten postoperative hospital stay, while didn't show difference in operation time, postoperative complication rate and overall mortality. Therapeutic strategy was formulated by synthesizing clinical symptoms, tumor size and tumor stage. Minimal invasive approach can achieve radical curve of oncology and provide refine manipulation condition to improve surgical safety and efficacy, meanwhile realize function preservation. Minimal invasive approach is a safe and efficient method in treating pNET, but further prospective, randomized control trials are required.

[Experience on postoperative complications of laparoscopic pancreaticoduodenectomy]

Objective: To summarize the incidence and characteristics of postoperative complications after laparoscopic pancreaticoduodenectomy(LPD), and to share our experience on management of complications. Methods: The clinical data of 320 LPD performed by a single team in Sir Run Run Shaw Hospital and Zhejiang Provincial People's Hospital between September 2012 and September 2017 were retrospectively analyzed, among which there were 196 males and 124 females with age of (60.2±11.6) years old.There were 306 patients who underwent standard LPD, and 14 patients who underwent extended LPD. The patients were divided into 2 groups of former 160 LPD and later 160 LPD according to the time order. By analyzing the differences of clinical outcomes between the two groups, especially focusing on the incidence of postoperative complications.The experience on management of complications was concluded. The prior surgical history of latter group was significantly higher than the former group(30.0%(48/160)vs. 18.8%(30/160), χ(2)=5.49, P=0.019), and the rest of baseline characteristics remained the comparable (P>0.05). For resectable lesions, LPD was performed by "No back" approach, following the principle of "From distal to cephalad, from ventral to dorsal, and from left to right" . As for the borderline resectable patients, LPD was performed by "Easy first" strategy. Student t test, χ(2) test or Fisher test was used to analyzed the data between the two groups respectively. Results: Of 320 LPD patients, 306 cases underwent standard LPD, 14 cases underwent LPD with resection of other organs.There were 278 LPD cases who followed "No back" approach, and 42 cases who followed "Easy first" strategy because of difficulty in creating the retro-pancreatic tunnel. And the overall morbidity was 32.2%(103/320) with reoperation rate of 5.3%(17/320). The perioperative mortality was 0.6%(2/320). The operation time of latter group was ((346.6±48.8)minutes), which was shorter than that of former group((358.0±54.4)minutes)(t=1.97, P=0.048). The blood loss of former and latter group remained comparable((207.9±135.8)ml vs.(189.6±121.4)ml, P=0.205). However, in subgroup analysis, the patients with blood loss less <200 ml of latter group decreased significantly from 59.4%(95/160) to 47.5%(76/160)(χ(2)=4.53, P=0.033). The overall morbidity of latter group was 28.8%(46/160), indicated a decrease from 35.6%(57/160) of former group without significant difference(P=0.188). Moreover, Grade A/B/C pancreatic fistula rate, Grade A/C bile leakage rate, Grade B/C postoperative hemorrhage rate of the later group tended to decrease, although they also didn't reach a significant difference. However, the abdominal infection rate decreased significantly(χ(2)=3.93, P=0.047). The length of hospital stay remained comparable(P=0.156). Conclusions: The most common complications after LPD were postoperative hemorrhage and pancreatic fistula. With specialized team and accumulated experience, the morbidity can decrease progressively by analyzing the leading cause and improving the technical skills.

Identification of long noncoding RNAs biomarkers in patients with hepatitis B virus-associated hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common and aggressive cancer worldwide and chronic infection of hepatitis B virus (HBV) serve as one of leading causes of HCC.

OBJECTIVE

This study aimed to identify the novel long noncoding RNAs (lncRNAs) biomarkers for HBV-associated HCC.

METHODS

The lncRNA and mRNA expression profiles of HCC patients with HBV infection were downloaded from The Cancer Genome Atlas. The differentially expressed lncRNAs (DElncRNAs) and mRNAs (DEmRNAs) between HCC and adjacent tissues were identified. The optimal diagnostic and prognostic lncRNA biomarkers for HCC were identified by using feature selection procedure and classification model. Functional annotation of DEmRNAs co-expressed with these lncRNAs biomarkers were performed. Receiver operating characteristic (ROC) curve and survival analysis of these lncRNAs biomarkers were performed. qRT-PCR validation was performed.

RESULTS

A total of 82 DElncRNAs and 805 DEmRNAs between HBV-associated HCC and normal tissues were identified. CAPN10-AS1, LINC01093, RP5-890E16.2, FENDRR and C17orf82 were selected as optimal diagnostic and prognostic lncRNA biomarkers for HBV-associated HCC that were co-expressed with 105, 86, 70, 30 and 1 DEmRNAs, respectively. Based on the DEmRNAs co-expressed with these five lncRNAs biomarkers, Jak-STAT signaling pathway and retinol metabolism were two significantly enriched pathways. The result in qRT-PCR validation were consistent with our analysis based on TCGA, generally.

CONCLUSIONS

This study identified five potential lncRNAs biomarkers for HBV-associated HCC with great diagnostic and prognostic value and provided clues for their functions in HBV-associated HCC.

Difficulty scoring system in laparoscopic distal pancreatectomy

BACKGROUND

Several factors affect the level of difficulty of laparoscopic distal pancreatectomy (LDP). The purpose of this study was to develop a difficulty scoring (DS) system to quantify the degree of difficulty in LDP.

METHODS

We collected clinical data for 80 patients who underwent LDP. A 10-level difficulty index was developed and subcategorized into a three-level difficulty index; 1-3 as low, 4-6 as intermediate, and 7-10 as high index. The automatic linear modeling (LINEAR) statistical tool was used to identify factors that significantly increase level of difficulty in LDP.

RESULTS

The operator's 10-level DS concordance between the 10-level DS by the reviewers, LINEAR index DS, and clinical index DS systems were analyzed, and the weighted Cohen's kappa statistic were at 0.869, 0.729, and 0.648, respectively, showing good to excellent inter-rater agreement. We identified five factors significantly affecting level of difficulty in LDP; type of operation, resection line, proximity of tumor to major vessel, tumor extension to peripancreatic tissue, and left-sided portal hypertension/splenomegaly.

CONCLUSIONS

This novel DS for LDP adequately quantified the degree of difficulty, and can be useful for selecting patients for LDP, in conjunction with fitness for surgery and prognosis.

[Strategy in management of adjacent organ lesion during laparoscopic pancreaticoduodenectomy]

Objective: To evaluate the safety and feasible of adjacent organ resection during laparoscopic pancreaticoduodenectomy(LPD), and summary the surgical strategies. Methods: Clinical data of 15 adjacent organ resections combined with LPD from March 2013 to September 2017 were reviewed.There were 10 male and 5 female patients aging from 20 to 86 years, and the body mass index ranged from 19.6 to 34.5 kg/m(2).Two patients had previous abdominal surgical history.Two patients underwent preoperative chemotherapy. Results: The resected adjacent organs included liver(n=4), stomach(n=3), colon(n=6), right kidney with embolectomy and vasoplastic of inferior vena cava(n=1), and spleen artery aneurysms(n=1). The operative time ranged from 280 to 450 minutes, and the blood loss ranged from 100 to 450 ml.The total complication rate was 5/15 and no one died in 90 days after surgery.The postoperative hospital stay ranged from 10 to 42 days with medium 18 days.The pathology included adenocarcinoma of stomach and duodenum(n=1), gastric cancer invading pancreas or duodenum(n=2), ampullary adenocarcinoma with left hepatolithiasis(n=1), ampullary adenocarcinoma with a benign lesion in left liver(n=1), ampullary adenocarcinoma with single liver metastasis(n=1), ampullary adenocarcinoma(n=1), pancreatic intraductal papillary mucinous neoplasm with splenic artery aneurysms(n=1), pancreatic neuroendocrine neoplasm with colon cancer(n=1), distal common bile duct adenocarcinoma involving righ hepatic duct(n=1), pancreatic neuroendocrine neoplasm invading inferior vena cava and right renal vein(n=1), duodenal adnocarcinoma(n=1), duodenal ewing's sarcoma(n=1), duodenal intesititialoma(n=2). The follow-up was from 3 to 40 months with the medium survival of 17.5 months. Conclusions: The oncological outcomes of PD combined with adjacent organ resection is acceptable.Surgical treatment for those patients with periampullary neoplasma and adjacent organ lesions should be aggressive.

Cancer-Associated Fibroblasts Promote the Chemo-resistance in Gastric Cancer through Secreting IL-11 Targeting JAK/STAT3/Bcl2 Pathway

Purpose

Our aim was to detect the potential role of interleukin 11 (IL-11) in the development of chemo-resistance in gastric cancer and to reveal the mechanism involved in the process.

Materials and Methods

Here, we used flow cytometry to examine the percentage of cancer-associated-fibroblasts in tumor samples from chemo-resistant and -sensitive gastric cancer patients. Using MTT assay, we detected the cell viability under different conditions. Using quantitative real-time polymerase chain reaction and Western blotting, we determined the target expressions in mRNA and protein levels. We also performed immunohistochemistry and immunofluorescence to detect the target proteins under different conditions. Animal models were constructed to verify the potential role of IL-11 in chemo-resistant develop in vivo.

Results

Herein, we observed enriched cancer associated fibroblasts in drug resistant tumor tissues from gastric patients. Those fibroblasts facilitate the chemotherapeutic drugs resistance development through the secretion of IL-11, which activates the IL-11/IL-11R/gp130/JAK/STAT3 anti-apoptosis signaling pathway in gastric cancer cells. We found that the combination of chemotherapeutic drugs and JAK inhibitor overcomes the resistance and increases the survival of mice with gastric cancer xenografts.

Conclusion

Ourresults demonstrated that IL-11 contributed to the obtain ofresistance to chemotherapy drugs through gp130/JAK/STAT3/Bcl2 pathway, and targeting the IL-11 signaling pathway induced by fibroblasts might be a promising strategy to overcome the multi-drugs resistant cancer in clinic.

HOXB7 overexpression promotes cell proliferation and correlates with poor prognosis in gastric cancer patients by inducing expression of both AKT and MARKs

Increased expression of HOXB7 has been reported to correlate with the progression in many cancers. However, the specific mechanism by which it promotes the evolution of gastric cancer (GC) is poorly understood.In this study, we sought to investigate the role of HOXB7 in GC by assessing HOXB7 expression in patient tissue and its correlation to clinical characteristics. We found that GC tissues showed increased expression of HOXB7 and that the HOXB7 expression was significantly associated with Lauren classification, invasion depth, lymphatic metastasis and poor prognosis, and could serve as an independent prognostic factor. To further investigate the role of HOXB7 in GC, we generated stable GC cell lines and both over-expressed and knocked down HOXB7 expression. Over-expression of HOXB7 in GC cell lines enhanced cell proliferation, colony formation, migration and invasion ability, whereas the opposite trends were observed upon reduction of HOXB7 expression by knockdown. These findings were further supported by our in vivo studies which show that HOXB7 expression can affect the GC cells' subcutaneous growth and lung metastases. A Phospho-MAPK Array Kit was used to explore the possible mechanism of HOXB7-induced cell proliferation and invasion. We found that the AKT signaling pathway and the two members of the MAPK pathway, were involved in those promoting effects. In conclusion, our results showed that increased expression of HOXB7 might play an important role in promoting GC proliferation, migration and invasion by inducing both AKT and MAPK pathways, thus resulting in progression of, and poor prognosis in GC patients.