The Potential Impact and Usability of the Eighth Edition TNM Staging Classification in Oral Cavity Cancer

AIMS

In the current eighth edition head and neck TNM staging, extranodal extension (ENE) is an adverse feature in oral cavity squamous cell cancer (OSCC). The previous seventh edition N1 with ENE is now staged as N2a. Seventh edition N2+ with ENE is staged as N3b in the eighth edition. We evaluated its potential impact on patients treated with surgery and postoperative intensity-modulated radiotherapy (IMRT).

MATERIALS AND METHODS

OSCC patients treated with primary surgery and adjuvant (chemo)radiotherapy between January 2005 and December 2014 were reviewed. Cohorts with pathological node-negative (pN-), pathological node-positive without ENE (pN+_pENE-) and pathological node-positive with ENE (pN+_pENE+) diseases were compared for local control, regional control, distant control and overall survival. The pN+ cohorts were further stratified into seventh edition N-staging subgroups for outcomes comparison.

RESULTS

In total, 478 patients were evaluated: 173 pN-; 159 pN+_pENE-; 146 pN+_pENE+. Outcomes at 5 years were: local control was identical (78%) in all cohorts (P = 0.892), whereas regional control was 91%, 80% and 68%, respectively (P < 0.001). Distant control was 97%, 87%, 68% (P < 0.001) and overall survival was 75%, 53% and 39% (P < 0.001), respectively. Overall survival for N1 and N2a subgroups was not significantly different. In the seventh edition N2b subgroup of pENE- (n = 79) and pENE+ (n = 79) cohorts, overall survival was 67% and 37%, respectively. In the seventh edition N2c subgroups, overall survival for pENE- (n = 17) and pENE+ (n = 38) cohorts was 65% and 35% (P = 0.08), respectively. Overall, an additional 128 patients (42% pN+) were upstaged as N3b.

CONCLUSIONS

When eighth edition staging was applied, stage migration across the N2-3 categories resulted in expected larger separations of overall survival by stage. Patients treated with primary radiation without surgical staging should have outcomes carefully monitored. Strategies to predict ENE preoperatively and trials to improve the outcomes of pENE+ patients should be explored.

Ergosta-7,9(11),22-trien-3β-ol Alleviates Intracerebral Hemorrhage-Induced Brain Injury and BV-2 Microglial Activation

Intracerebral hemorrhage (ICH) is a devastating neurological disorder characterized by an exacerbation of neuroinflammation and neuronal injury, for which few effective therapies are available at present. Inhibition of excessive neuroglial activation has been reported to alleviate ICH-related brain injuries. In the present study, the anti-ICH activity and microglial mechanism of ergosta-7,9(11),22-trien-3β-ol (EK100), a bioactive ingredient from Asian medicinal herb Antrodia camphorate, were evaluated. Post-treatment of EK100 significantly attenuated neurobehavioral deficit and MRI-related brain lesion in the mice model of collagenase-induced ICH. Additionally, EK100 alleviated the inducible expression of cyclooxygenase (COX)-2 and the activity of matrix metalloproteinase (MMP)-9 in the ipsilateral brain regions. Consistently, it was shown that EK100 concentration-dependently inhibited the expression of COX-2 protein in Toll-like receptor (TLR)-4 activator lipopolysaccharide (LPS)-activated microglial BV-2 and primary microglial cells. Furthermore, the production of microglial prostaglandin E₂ and reactive oxygen species were attenuated by EK100. EK100 also attenuated the induction of astrocytic MMP-9 activation. Among several signaling pathways, EK100 significantly and concentration-dependently inhibited activation of c-Jun N-terminal kinase (JNK) MAPK in LPS-activated microglial BV-2 cells. Consistently, ipsilateral JNK activation was markedly inhibited by post-ICH-treated EK100 in vivo. In conclusion, EK100 exerted the inhibitory actions on microglial JNK activation, and attenuated brain COX-2 expression, MMP-9 activation, and brain injuries in the mice ICH model. Thus, EK100 may be proposed and employed as a potential therapeutic agent for ICH.

[Construction of artificial neural network model for predicting the efficacy of first-line FOLFOX chemotherapy for metastatic colorectal cancer]

Objective: To explore and establish an artificial neural network (ANN) model for predicting the efficacy of first-line FOLFOX chemotherapy for metastatic colorectal cancer. Methods: A set of FOLFOX chemotherapy data from a group of patients with metastatic colorectal cancer (mCRC) (GSE104645) was downloaded from the GEO database as a training set. According to the FOLFOX protocol, the efficacy was divided into two groups: the chemo-sensitive group (including complete response and partial response) and the chemo-resistant group (including stable disease and progressive disease), including 31 cases in the sensitive group and 23 in the resistant group. Then, chip data (accessible number: GSE69657) from Fujian Medical University Union Hospital were chosen as a test set. A total of 30 patients were enrolled in the study, including 13 in the sensitive group and 17 in the resistant group. The batch effect correction was performed on the expression values of the two sets of matrices using the R 3.5.1 software Combat package. The gene expression difference of sensitive and resistant group in GSE104645 was analyzed by the GEO2R platform. P<0.05 and the absolute value of log(2)FC>0.33 (FC abbreviation of fold change) were used as the threshold value to screen the drug resistance and sensitive genes of the FOLFOX regimen. An ANN was constructed using the multi-layer perceptron (MLP) to perform the FOLFOX regimen on the GSE104645 dataset. The GSE69657 expression matrix and clinical efficacy parameters were then used for retrospective verification. Receiver operating characteristic(ROC) curves were used to evaluate the test results and predictive power. Results: A total of 2, 076 differentially expressed genes in GSE104645 were selected, of which 822 genes were up-regulated and 1, 254 genes were down-regulated in the chemo-resistance group. The down-regulated genes were sensitive genes. GO analysis of the biological processes in which the differentially expressed genes were involved, revealed that they were mainly involved in the regulation of substance metabolism. A total of 39 genes were included in the final model construction. This was a neural network model with two hidden layers. The accuracy of predicting training samples and test samples was 75.7% and 76.5%, respectively, and the area under the ROC curve was 0.875. The chip data set of our department (GSE69657) was set as the test set, and the area under the ROC curve was 0.778. Conclusions: In this study, an artificial neural network model is successfully constructed to predict the efficacy of first-line FOLFOX regimen for metastatic colorectal cancer based on the microarray, and an independent external verification is also conducted. The model has good stability and well prediction efficiency. Besides, the results of this study suggest that the gene functions related to oxaliplatin resistance are mainly enriched in the regulation process of substance metabolism.

Optimal Performance of Thin-Film Composite Nanofiltration-Like Forward Osmosis Membranes Set Off by Changing the Chemical Structure of Diamine Reacted with Trimesoyl Chloride through Interfacial Polymerization

Thin-film composite (TFC) polyamide membranes formed through interfacial polymerization can function more efficiently by tuning the chemical structure of participating monomers. Accordingly, three kinds of diamine monomers were considered to take part in interfacial polymerization. Each diamine was reacted with trimesoyl chloride (TMC) to manufacture TFC polyamide nanofiltration (NF)-like forward osmosis (FO) membranes. The diamines differed in chemical structure; the functional group present between the terminal amines was classified as follows: aliphatic group of 1,3-diaminopropane (DAPE); cyclohexane in 1,3-cyclohexanediamine (CHDA); and aromatic or benzene ring in m-phenylenediamine (MPD). For FO tests, deionized water and 1 M aqueous sodium sulfate solution were used as feed and draw solution, respectively. Interfacial polymerization conditions were also varied: concentrations of water and oil phases, time of contact between the water-phase solution and the membrane substrate, and polymerization reaction time. The resultant membranes were characterized using attenuated total reflectance-Fourier transform infrared spectroscopy, field emission scanning electron microscopy, atomic force microscopy, and surface contact angle measurement to identify the chemical structure, morphology, roughness, and hydrophilicity of the polyamide layer, respectively. The results of FO experiments revealed that among the three diamine monomers, CHDA turned out to be the most effective, as it led to the production of TFC NF-like FO membrane with optimal performance. Then, the following optimum conditions were established for the CHDA-based membrane: contact between 2.5 wt.% aqueous CHDA solution and polysulfone (PSf) substrate for 2 min, and polymerization reaction between 1 wt.% TMC solution and 2.5 wt.% CHDA solution for 30 s. The composite CHDA-TMC/PSf membrane delivered a water flux (Jw) of 18.24 ± 1.33 LMH and a reverse salt flux (Js) of 5.75 ± 1.12 gMH; therefore, Js/Jw was evaluated to be 0.32 ± 0.07 (g/L).

Modifying Cellulose Acetate Mixed-Matrix Membranes for Improved Oil-Water Separation: Comparison between Sodium and Organo-Montmorillonite as Particle Additives

In this study, cellulose acetate (CA) mixed-matrix membranes were fabricated through the wet-phase inversion method. Two types of montmorillonite (MMT) nanoclay were embedded separately: sodium montmorillonite (Na-MMT) and organo-montmorillonite (O-MMT). Na-MMT was converted to O-MMT through ion exchange reaction using cationic surfactant (dialkyldimethyl ammonium chloride, DDAC). Attenuated total reflectance-Fourier transform infrared (ATR-FTIR) and X-ray photoelectron spectroscopy (XPS) compared the chemical structure and composition of the membranes. Embedding either Na-MMT and O-MMT did not change the crystallinity of the CA membrane, indicating that the nanoclays were dispersed in the CA matrix. Furthermore, nanoclays improved the membrane hydrophilicity. Compared with CA_Na-MMT membrane, CA_O-MMT membrane had a higher separation efficiency and antifouling property. At the optimum concentration of O-MMT in the CA matrix, the pure water flux reaches up to 524.63 ± 48.96 L∙m^-2∙h^-1∙bar^-1 with over 95% rejection for different oil-in-water emulsion (diesel, hexane, dodecane, and food-oil). Furthermore, the modified membrane delivered an excellent antifouling property.

Surface Properties, Free Volume, and Performance for Thin-Film Composite Pervaporation Membranes Fabricated through Interfacial Polymerization Involving Different Organic Solvents

The type of organic solvents used in interfacial polymerization affects the surface property, free volume, and separation performance of the thin-film composite (TFC) polyamide membrane. In this study, TFC polyamide membrane was fabricated through interfacial polymerization between diethylenetriamine (DETA) and trimesoyl chloride (TMC). Four types of organic solvent were explored in the preparation of pervaporation membrane. These are tetralin, toluene, hexane, and isopentane. The solubility parameter distance between organic solvents and DETA follows in increasing order: tetralin (17.07 MPa1/2) < toluene (17.31 MPa1/2) < hexane (19.86 MPa1/2) < isopentane (20.43 MPa1/2). Same trend was also observed between the organic solvents and DETA. The larger the solubility parameter distance, the denser and thicker the polyamide. Consequently, field emission scanning electron microscope (FESEM) and positron annihilation spectroscopy (PAS) analysis revealed that TFCisopentane had the thickest polyamide layer. It also delivered the highest pervaporation efficiency (permeation flux = 860 ± 71 g m-2 h-1; water concentration in permeate = 99.2 ± 0.8 wt%; pervaporation separation index = 959,760) at dehydration of 90 wt% aqueous ethanol solution. Furthermore, TFCisopentane also exhibited a high separation efficiency in isopropanol and tert-butanol. Therefore, a suitable organic solvent in preparation of TFC membrane through interfacial polymerization enables high pervaporation efficiency.

Assessing the Performance of Thin-Film Nanofiltration Membranes with Embedded Montmorillonites

In this study, the basal spacing of montmorillonite (MMT) was modified through ion exchange. Two kinds of MMT were used: sodium-modified MMT (Na-MMT) and organo-modified MMT (O-MMT). These two particles were incorporated separately into the thin-film nanocomposite polyamide membrane through the interfacial polymerization of piperazine and trimesoyl chloride in n-hexane. The membrane with O-MMT (TFNO-MMT) has a more hydrophilic surface compared to that of membrane with Na-MMT (TFNNa-MMT). When various types of MMT were dispersed in the n-hexane solution with trimesoyl chloride (TMC), O-MMT was well-dispersed than Na-MMT. The poor dispersion of Na-MMT in n-hexane led to the aggregation of Na-MMT on the surface of TFNNa-MMT. TFNO-MMT displayed a uniform distribution of O-MMT on the surface, because O-MMT was well-dispersed in n-hexane. In comparison with the pristine and TFNNa-MMT membranes, TFNO-MMT delivered the highest pure water flux of 53.15 ± 3.30 L∙m-2∙h-1 at 6 bar, while its salt rejection for divalent ions remained at 95%-99%. Furthermore, it had stable performance in wide operating condition, and it exhibited a magnificent antifouling property. Therefore, a suitable type of MMT could lead to high separation efficiency.

[Rectum-preserving surgery after consolidation neoadjuvant therapy or totally neoadjuvant therapy for low rectal cancer: a preliminary report]

Objective: To investigate the feasibility and safety of sphincter-preserving surgery after neoadjuvant chemoradiotherapy (nCRT) with consolidation chemotherapy in the interval period or total neoadjuvant therapy (TNT) for low rectal cancer. Methods: A descriptive case series study was carried out. Clinical data of patients with locally advanced low rectal cancer (LALRC) who achieved complete clinical response (cCR) or nearly cCR (near-cCR) after nCRT at the Department of Colorectal Surgery of Fujian Medical University Union Hospital from May 2015 to February 2019 were retrospectively analyzed. Case inclusion criteria: (1) Low rectal adenocarcinoma within 6 cm from the anal verge. (2) After nCRT, tumor presented markedly regression as mucosal nodule or abnormalities, superficial ulcer, scar or a mucosal erythema (< 2 cm); no regional lymph node metastasis or distant metastasis was found in rectal ultrasonography, pelvic MRI and PET-CT; MRI showed obvious fibrosis in the original tumor site; and post-treatment CEA was normal. (3) The patient and the family members adhered to receive the transanal full-thickness local excision with informed consent. (4) When the residual lesions were difficult to detect after nCRT, patients received the watch and wait (W&W) strategy. Exclusion criteria: (1) Before nCRT, pathological results showed poorly differentiated or signet-ring cell carcinoma; lateral lymph node metastasis was suspected. (2) When the residual lesion size was more than 3 cm after nCRT, it was difficult to perform local excision. The consolidation nCRT group received 3-4 cycles of CAPOX regimen (oxaliplatin and capecitabine) or six cycles of mFOLFOX6 (oxaliplatin, leucovorin, and 5-fluorouracil) combined with the long-course radiotherapy (intensity-modulated radiation therapy with a total dose of 50.4Gy). Patients with concurrent chemotherapy more than or equal to five cycles of CAPOX or eight cycles of mFOLFOX6 were defined as total neoadjuvant therapy (TNT) group. Local resection was recommended for patients who were near-cCR according to modified MSKCC criteria 8-33 weeks after the end of radiotherapy. Patients with a near-cCR, who were judged as ycN0 according to PET-CT and MRI and were ypT0 after local excision, could enter the W&W strategy. Patients with pathologic stage more advanced than ypT1, and those with positive resection margin, or lymphovascular invasion were recommended for salvage radical surgery after local excision. The ypT1 patients with a negative resection margin and without lymphovascular invasion might receive the W&W management carefully if they refused radicalsurgery to sacrifice the sphincter for low rectal cancer. Results: Of 32 patients, 14 were males and 18 were females with the average age of 59 years old. Twenty-three patients underwent consolidation nCRT, and 9 received TNT. The first evaluation after treatments showed 19 cases with cCR and 13 with near-cCR. Twenty-nine patients received local excision while 3 patients with undetectable lesions received W&W policy. Four cases (12.5%) underwent salvage radical surgery with abdominoperineal resection. After local excision, 3 cases underwent salvage radical surgery immediately, and the final pathologic result was ypT3N0, ypT2N0, and ypT2N0 respectively, of whom 2 cases were in the group of consolidation CRT and 1 was in the TNT group. Of these 3 cases, 1 case with an initial cT3 stage showed a pathologic stage of ypT1 and a negative circumferential resection margin after consolidation nCRT and local excision, however, the final pathologic stage was ypT3 with fragmented tumor deposits in the mesorectum after the salvage radical surgery. Meanwhile 1 patient in the TNT group receiving W&W suffered from intraluminal regrowth after 7.4 months follow-up and underwent salvage abdominoperineal resection. One patient in the consolidation nCRT group died of stroke 42.5 months after local resection. Another patient in the TNT group had cerebral metastasis 10 months after the W&W policy, but no local recurrence was found in the pelvic cavity, then received resection of the metastatic tumors. The average follow-up for all the patients was 23 (5-51) months. The cumulative local regrowth rate was 5.0%. The overall survival rate was 85.7%, and the sphincter-preservation rate was increased from 25.0% (28/32) in the original plan to 87.5% (28/32) actually. The 3-year disease-free survival rate was 89.7%. The 3-year organ-preserving survival rate was 85.7%, and the 3-year stoma-free survival rate was 82.5%. At present, 31 patients still survived. Conclusions: After nCRT with consolidation chemotherapy or TNT for low rectal cancer, patients with cCR, ycN0 according to PET-CT and MRI, and ypT0 after local excision, can consider the W&W strategy. Strict patient selection with a near-cCR for local resection and sphincter-preserving strategy can reduce the local regrowth of cancer, and the short-term outcomes are satisfactory.

Zwitterion Co-Polymer PEI-SBMA Nanofiltration Membrane Modified by Fast Second Interfacial Polymerization

Nanofiltration membranes have evolved as a promising solution to tackle the clean water scarcity and wastewater treatment processes with their low energy requirement and environment friendly operating conditions. Thin film composite nanofiltration membranes with high permeability, and excellent antifouling and antibacterial properties are important component for wastewater treatment and clean drinking water production units. In the scope of this study, thin film composite nanofiltration membranes were fabricated using polyacrylonitrile (PAN) support and fast second interfacial polymerization modification methods by grafting polyethylene amine and zwitterionic sulfobutane methacrylate moieties. Chemical and physical alteration in structure of the membranes were characterized using methods like ATR-FTIR spectroscopy, XPS analysis, FESEM and AFM imaging. The effects of second interfacial polymerization to incorporate polyamide layer and ‘ion pair’ characteristics, in terms of water contact angle and surface charge analysis was investigated in correlation with nanofiltration performance. Furthermore, the membrane characteristics in terms of antifouling properties were evaluated using model protein foulants like bovine serum albumin and lysozyme. Antibacterial properties of the modified membranes were investigated using E. coli as model biofoulant. Overall, the effect of second interfacial polymerization without affecting the selectivity layer of nanofiltration membrane for their potential large-scale application was investigated in detail.

Development and validation of a clinical prediction-score model for distant metastases in major salivary gland carcinoma

BACKGROUND

The most common pattern of failure in major salivary gland carcinoma (SGC) is development of distant metastases (DMs). The objective of this study was to develop and validate a prediction score for DM in SGC.

PATIENTS AND METHODS

Patients with SGC treated curatively at four tertiary cancer centers were divided into discovery (n = 619) and validation cohorts (n = 416). Multivariable analysis using competing risk regression was used to identify predictors of DM in the discovery cohort and create a prediction score of DM; the optimal score cut-off was determined using a minimal P value approach. The prediction score was subsequently evaluated in the validation cohort. The cumulative incidence and Kaplan-Meier methods were used to analyze DM and overall survival (OS), respectively.

RESULTS

In the discovery cohort, DM predictors (risk coefficient) were: positive margin (0.6), pT3-4 (0.7), pN+ (0.7), lymphovascular invasion (0.8), and high-risk histology (1.2). High DM-risk SGC was defined by sum of coefficients greater than two. In the discovery cohort, the 5-year incidence of DM for high- versus low-risk SGC was 50% versus 8% (P < 0.01); this was similar in the validation cohort (44% versus 4%; P < 0.01). In the pooled cohorts, this model performed similarly in predicting distant-only failure (40% versus 6%, P < 0.01) and late (>2 years post surgery) DM (22% versus 4%; P < 0.01). Patients with high-risk SGC had an increased incidence of DM in the subgroup receiving postoperative radiation therapy (46% versus 8%; P < 0.01). The 5-year OS for high- versus low-risk SGC was 48% versus 92% (P < 0.01).

CONCLUSION

This validated prediction-score model may be used to identify SGC patients at increased risk for DM and select those who may benefit from prospective evaluation of treatment intensification and/or surveillance strategies.

[Identification of gene biomarkers to predict responses to neoadjuvant chemoradiotherapy in patients with rectal cancer and pathways enrichment analysis]

Objective: To screen out the potential gene biomarkers to predict responses to neoadjuvant chemoradiotherapy (CRT) in patients with rectal cancer and to explore the main downstream pathways of resistance. Methods: The gene expression profiles (GSE35452) of locally advanced rectal cancer undergoing neoadjuvant chemoradiotherapy from 46 specimens (24 responders, TRG 0/1, and 22 non-responders, TRG 2/3) were downloaded from the GEO database. The differentially expressed genes were identified to screen out the potential biomarkers by use of the GCBI platform. GO and KEGG pathways enrichment analysis were performed to integrate enrichment results of differentially expressed genes. Signal-signal interaction network was constructed and analyzed to screen out potential main downstream pathways. Results: A total of 1079 differentially expressed genes were screened, including 657 up-regulated and 422 down-regulated ones. Among these genes, REG4 had the maximum fold change value of -6.029 491. In GO term, these differentially expressed genes were mainly enriched in molecule metabolic process, cell cycle, DNA-dependent transcription, signal transduction and apoptotic process. The KEGG pathways enrichment analysis showed that the differentially expressed genes were enriched in 65 KEGG pathways, including metabolic pathways, cell cycle and metabolism pathways. Signal-signal interaction network analysis showed that MAPK signaling pathway and cell cycle pathway might play a determinant role in the development of neoadjuvant chemoradiotherapy resistance. Further analysis showed that CDKN1B, CDKN2A, RBL1, TFDP1, CCND2, CCNE2, CDC6 and CDK6 in cell cycle might induce chemoradiotherapy resistance by blocking G1/S phase cell cycle arrest, decreasing the apoptosis of tumor cells and increasing S phase ratio of chemoradiotherapy resistance. Conclusion: G1/S phase cell cycle arrest blocking plays an important role in the development of chemoradiotherapy resistance in patients with rectal cancer. Moreover, the key genes, such as REG4, may be useful in predicting responses to neoadjuvant chemoradiotherapy.