Prophylactic cranial irradiation (PCI) versus active surveillance in patients with limited-stage small cell lung cancer: a retrospective, multicentre study

Background

The recommendation of PCI for limited-stage small cell lung cancer (LS-SCLC) is primarily based on evidence from the pre-magnetic resonance imaging (MRI) era. However, as MRI accuracy improves and stereotactic radiosurgery advances, the role of PCI for LS-SCLC has become uncertain. This study aims to compare the contemporary survival outcomes of patients with LS-SCLC treated with PCI versus active surveillance.

Methods

We conducted a retrospective cohort study in which 1068 patients with LS-SCLC who achieved a good response to first-line chemoradiotherapy were consecutively enrolled from 5 tertiary medical centres between June 2009 and June 2019. Of these patients, 440 received PCI, while 628 received surveillance without PCI. Propensity score matching with a 1:1 ratio was performed to balance the baseline characteristics of the two cohorts. The endpoints were overall survival (OS) and the incidence of brain metastasis (BM).

Results

In total, 648 patients were matched. The baseline characteristics were generally well balanced. At a median follow-up of 64.5 months (range 2–190), patients who underwent PCI had a significantly lower risk for BM than those who underwent surveillance. The 3-year cumulative incidence rate of BM was 28.2% (95% CI 22.5–33.8%) in the PCI cohort and 38.5% (32.6–44.5%) in the surveillance cohort (Gray’s p = 0.002). However, the lower incidence of BM in the PCI cohort did not translate into a significant extension of OS. The median OS was 35.8 months (95% CI 27.6–44.0 months) in the PCI cohort versus 32 months (26.4–37.6 months) in the surveillance cohort (HR 0.90, 95% CI 0.74–1.10, p = 0.29). Multivariable analysis showed that disease stage, chemoradiotherapy sequence, and response to chemoradiotherapy were independent prognostic factors for BM or OS.

Conclusions

Overall, PCI reduces the risk for BM but does not substantially prolong OS compared with active surveillance. A phase 3, prospective clinical trial (NCT04829708) we initiated is currently underway, which is expected to corroborate our results.

Efficacy of immune checkpoint inhibitor therapy in EGFR mutation-positive patients with NSCLC and brain metastases who have failed EGFR-TKI therapy

Background

Few treatment options are available for brain metastases (BMs) in EGFR-mutant non-small cell lung cancer (NSCLC) that progress with prior EGFR tyrosine kinase inhibitor (EGFR-TKI) therapy. This study aimed to evaluate the efficacy of immune checkpoint inhibitor (ICI) therapy in these patients.

Methods

NSCLC patients with confirmed sensitive EGFR mutations and BMs were retrospectively reviewed. All patients experienced failure of EGFR-TKI therapy and were divided into two cohorts based on subsequent treatment. Cohort 1 included patients who received ICI therapy, while cohort 2 included patients treated with chemotherapy. Overall and intracranial objective response rates (ORRs) were used to evaluate the treatment response. Overall and intacranial progression-free survival (PFS) were calculated by Kaplan−Meier analysis and compared with the log-rank test. Univariate and multivariate Cox analyses were used to identify prognostic factors.

Results

A total of 53 patients treated with ICI therapy and 40 patients treated with chemotherapy were included in cohorts 1 and 2, respectively. In cohort 1, the overall ORR was 20.8%, with a median overall PFS of 4.2 months. The median intracranial PFS was 5.1 months. Of the 38 patients with measurable intracranial lesions, the intracranial ORR was 21.0%. Patients who received ICI combined with chemotherapy had the highest intracranial ORR of 37.5%. Compared to patients treated with chemotherapy in cohort 2, patients receiving ICI combined with chemotherapy had both longer intracranial PFS (6.4 vs. 5.1 months, p = 0.110) and overall PFS (6.2 vs. 4.6 months, p = 0.054), and these differences approached statistical significance. Univariate and multivariate Cox analyses demonstrated that high disease burden (p = 0.019), prior third-generation EGFR-TKI therapy (p = 0.019), and a poor lung immune prognostic index (LIPI) (p = 0.012) were independent negative predicators of overall PFS and that multiple BMs were negatively correlated with intracranial PFS among patients treated with ICI therapy.

Conclusions

Our results suggested that ICI combined with chemotherapy had potent intracranial efficacy and may be a promising treatment candidate in EGFR-mutant NSCLC patients with BMs for whom prior EGFR-TKI therapy failed.

Establishment and validation of a clinicopathological prognosis model of gastroenteropancreatic neuroendocrine carcinomas

Background

Gastroenteropancreatic neuroendocrine carcinomas (GEP-NECs) are a rare, highly malignant subset of gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs). However, how to predict the prognosis of GEP-NECs by clinical features is still under study. This study aims to establish and validate a nomogram model of overall survival (OS) in patients with GEP-NECs for predicting their prognosis.

Methods

We selected patients diagnosed with GEP-NECs from the Surveillance, Epidemiology, and End Results (SEER) database and two Chinese hospitals. After randomization, we divided the data in the SEER database into the train cohort and the test cohort at a ratio of 7:3 and used the Chinese cohort as the validation cohort. The Cox univariate and multivariate analyses were performed to incorporate statistically significant variables into the nomogram model. We then established a nomogram and validated it by concordance index (C-index), calibration curve, receiver operating characteristic (ROC) curve, the area under the curve (AUC), and the decision curve analysis (DCA) curve.

Results

We calculated the nomogram C-index as 0.797 with a 95% confidence interval (95% CI) of 0.783–0.815 in the train cohort, 0.816 (95% CI: 0.794–0.833) in the test cohort and 0.801 (95% CI: 0.784–0.827) in the validation cohort. Then, we plotted the calibration curves and ROC curves, and AUCs were obtained to verify the specificity and sensitivity of the model, with 1-, 3- and 5-year AUCs of 0.776, 0.768, and 0.770, respectively, in the train cohort; 0.794, 0.808, and 0.799 in the test cohort; 0.922, 0.925, and 0.947 in the validation cohort. The calibration curve and DCA curves also indicated that this nomogram model had good clinical benefits.

Conclusions

We established the OS nomogram model of GEP-NEC patients, including variables of age, race, sex, tumor site, tumor grade, and TNM stage. This model has good fitting, high sensitivity and specificity, and good clinical benefits.

Pseudo-progression with osimertinib after definitive chemoradiation in unresectable epidermal growth factor receptor mutation positive of stage III non-small cell lung cancer: A case report

Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR TKIs) have been widely used in the treatment of locally advanced non-small cell lung cancer (NSCLC). The phenomenon of pseudoprogression in targeted therapy in EGFR-mutation NSCLC patients is rare. Here, we reported an EGFR-mutation-positive lung adenocarcinoma patient who was admitted to a hospital for cough and chest distress accompanied by shortness of breath. He underwent four cycles of chemotherapy with pemetrexed combined with carboplatin and concurrent radiotherapy in the third and fourth cycles. Then, he was treated by osimertinib maintenance therapy. After 11.5 months of osimertinib treatment, he was assessed to progressive disease by computed tomography. He underwent fiber bronchoscopy, and the biopsy pathology showed extensive necrosis without tumor cells. Until now, the patient has continued on osimertinib for 7 months without relapse or metastasis. As far as we know, we are the first to report pseudoprogression in osimertinib maintenance after definitive chemoradiation. This study reminds the clinicians to distinguish pseudoprogression from osimertinib-induced progression and avoid abandoning effective treatments.

Transcriptional Memory in Taraxacum mongolicum in Response to Long-Term Different Grazing Intensities

Grazing, as an important land use method in grassland, has a significant impact on the morphological and physiological traits of plants. However, little is known about how the molecular mechanism of plant responds to different grazing intensities. Here, we investigated the response of Taraxacum mongolicum to light grazing and heavy grazing intensities in comparison with a non-grazing control. Using de novo transcriptome assembly, T. mongolicum leaves were compared for the expression of the different genes under different grazing intensities in natural grassland. In total, 194,253 transcripts were de novo assembled and comprised in nine leaf tissues. Among them, 11,134 and 9058 genes were differentially expressed in light grazing and heavy grazing grassland separately, with 5867 genes that were identified as co-expression genes in two grazing treatments. The Nr, SwissProt, String, GO, KEGG, and COG analyses by BLASTx searches were performed to determine and further understand the biological functions of those differentially expressed genes (DEGs). Analysis of the expression patterns of 10 DEGs by quantitative real-time RT-PCR (qRT-PCR) confirmed the accuracy of the RNA-Seq results. Based on a comparative transcriptome analysis, the most significant transcriptomic changes that were observed under grazing intensity were related to plant hormone and signal transduction pathways, carbohydrate and secondary metabolism, and photosynthesis. In addition, heavy grazing resulted in a stronger transcriptomic response compared with light grazing through increasing the of the secondary metabolism- and photosynthesis-related genes. These changes in key pathways and related genes suggest that they may synergistically respond to grazing to increase the resilience and stress tolerance of T. mongolicum. Our findings provide important clues for improving grassland use and protection and understanding the molecular mechanisms of plant response to grazing.

A review of studies on omitting surgery after neoadjuvant chemotherapy in breast cancer

The advancement in systemic neoadjuvant therapy has significantly increased the pathological complete response (pCR) rate in breast cancer. As surgeries inevitably affect patients physically and psychologically and the accuracy of pCR prediction and diagnosis by minimal invasive biopsy is improving, the necessity of surgery in neoadjuvant chemotherapy (NAC) patients who achieve pCR is under debate. Thus, we conducted a literature review of studies on the selective omission of breast surgery after NAC for breast cancer patients. We summarized the existing predictive models and technologies to predict and diagnose pCR after NAC. Our research indicates that, for nearly half a century, the extent of surgery on both breast and axillary lymph nodes is decreasing, while more precise systematic treatments are increasing. NAC has advanced significantly and its pCR rates have improved, so surgery may be omitted in certain patients. However, accurately predicting pCR after NAC is still a challenge. We also described the design for a randomized clinical trial and the potential problems of omitting surgical treatment after NAC. In summary, the decrease in breast cancer surgery is an unavoidable trend, and more high-quality clinical trials need to be conducted.

The Effect of Environmental Policy Uncertainty on Enterprises' Pollution Emissions: Evidence from Chinese Industrial Enterprise

In response to the global call for emission reduction, China has assumed international responsibility for energy conservation and emission reduction by enacting several environmental policies to save energy and reduce consumption. However, it is debatable whether the increased uncertainty in environmental policies negatively affects firms' emission reduction. Few studies have examined this relationship based on micro-level data. Therefore, this study constructs a theoretical framework of environmental policy uncertainty affecting firms' pollution emissions. Based on comprehensive data from the Chinese Industrial Enterprise Database, the Chinese Industrial Enterprise Pollution Emission Database, and the Chinese Patent Database from 2002 to 2014, we empirically analyzed the impact of environmental policy uncertainty on firms' pollution emissions. The results show that (1) environmental policy uncertainty significantly aggravates the pollution emission intensity of industrial enterprises; (2) environmental policy uncertainty inhibits the improvement of enterprises' innovation capacity, reduces their human capital stock and foreign investment, and aggravates their pollution emission; (3) environmental policy uncertainty has significant heterogeneity on enterprise pollution emissions, that is, environmental policy uncertainty has a greater impact on non-export enterprises, large enterprises, young enterprises, capital-intensive enterprises, state-owned enterprises, and enterprises in polluting industries and central regions. This study provides a useful reference for the improvement of environmental policy and the green transformation of enterprises.

The effects of changes in flowering plant composition caused by nitrogen and phosphorus enrichment on plant-pollinator interactions in a Tibetan alpine grassland

Soil eutrophication from atmospheric deposition and fertilization threatens biodiversity and the functioning of terrestrial ecosystems worldwide. Increases in soil nitrogen (N) and phosphorus (P) content can alter the biomass and structure of plant communities in grassland ecosystems; however, the impact of these changes on plant-pollinator interactions is not yet clear. In this study, we tested how changes in flowering plant diversity and composition due to N and P enrichment affected pollinator communities and pollination interactions. Our experiments, conducted in a Tibetan alpine grassland, included four fertilization treatments: N (10 g N m^-2 year^-1), P (5 g P m^-2 year^-1), a combination of N and P (N + P), and control. We found that changes in flowering plant composition and diversity under the N and P treatments did not alter the pollinator richness or abundance. The N and P treatments also had limited effects on the plant-pollinator interactions, including the interaction numbers, visit numbers, plant and pollinator species dissimilarity, plant-pollinator interaction dissimilarity, average number of pollinator species attracted by each plant species (vulnerability), and average number of plant species visited by each pollinator species (generality). However, the N + P treatment increased the species and interaction dissimilarity in flowering plant and pollinator communities and decreased the generality in plant-pollinator interactions. These data highlight that changes in flowering plants caused by N + P enrichment alter pollination interactions between flowering plants and pollinators. Owing to changes in flowering plant communities, the plant-pollinator interactions could be sensitive to the changing environment in alpine regions.

Antibacterial Mechanism of Linalool against Pseudomonas fragi: A Transcriptomic Study

Pseudomonas fragi is the dominant spoilage bacterium that causes the deterioration of chilled meat. Our previous study showed that linalool has potent antibacterial activity against P. fragi, but its antibacterial mechanism is unclear. To explore the antibacterial mechanism of linalool against P. fragi, this study used RNA-seq technology to perform transcriptome analysis of P. fragi samples with or without linalool treatment (1.5 mL/L) for 2 h. The results showed that linalool treatment disrupted the extracellular lipopolysaccharide synthesis pathway in P. fragi and activated fatty acid metabolism and ribosomal function to compensate for cell membrane damage. The energy metabolism of P. fragi was severely disturbed by linalool, and multiple ATP synthases and ATP transportases were overexpressed in the cells but could not guarantee the consumption of ATP. The simultaneous overexpression of multiple ribosomal functional proteins and transporters may also place an additional burden on cells and cause them to collapse.

Comparison of two surgical approaches for acute type A aortic dissection: hybrid debranching versus total arch replacement

Background

The goal of this study was to determine the clinical outcomes of total arch replacement with frozen elephant trunk surgery and hybrid debranching surgery for acute type A aortic dissection patients.

Methods

From January 2017 to December 2019, the clinical data of acute type A aortic dissection patients were retrospectively collected and analyzed. There were 142 patients underwent total arch replacement with frozen elephant trunk surgery and 35 patients underwent hybrid debranching surgery.

Result

The age, the body mass index and the renal insufficiency of patients in the hybrid group were higher than those in the total arch replacement (TAR) group (all P < 0.01). The operation time, the cardiopulmonary bypass time and the aortic occlusion time of patients in the TAR group were significantly longer than those in the hybrid group (all P < 0.01). Patients in the debranching group had shorter ventilator-assisted breathing time, shorter postoperative hospital stay time and shorter intensive care unit (ICU) stay time. The incidence of pulmonary infection and transient neurological dysfunction were lower, and the transfusions of red blood cells and plasma during the perioperative period were smaller. The survival rates at 2 years were 91.9% and 85.9% in the TAR and hybrid groups, respectively.

Conclusion

Hybrid debranching operation is a safe and effective method for acute type A aortic dissection. Compared with TAR surgery, hybrid debranching surgery has the characteristics of less trauma, rapid recovery and lower incidence of complication.

Cross Analysis of Genomic-Pathologic Features on Multiple Primary Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a prevalent malignancy cancer worldwide with a poor prognosis. Hepatic resection is indicated as a potentially curative option for HCC patients in the early stage. However, due to multiple nodules, it leads to clinical challenges for surgical management. Approximately 41%–75% of HCC cases are multifocal at initial diagnosis, which may arise from multicentric occurrence (MO-HCC) or intrahepatic metastasis (IM-HCC) pattern with significantly different clinical outcomes. Effectively differentiating the two mechanisms is crucial to prioritize the allocation of surgery for multifocal HCC. In this study, we collected a multifocal hepatocellular carcinoma cohort of 17 patients with a total of 34 samples. We performed whole-exome sequencing and staining of pathological HE sections for each lesion. Reconstruction of the clonal evolutionary pattern using genome mutations showed that the intrahepatic metastogenesis pattern had a poorer survival performance than independent origins, with variants in the TP53, ARID1A, and higher CNV variants occurring more significantly in the metastatic pattern. Cross-modality analysis with pathology showed that molecular classification results were consistent with pathology results in 70.6% of patients, and we found that pathology results could further complement the classification for undefined patterns of occurrence. Based on these results, we propose a model to differentiate the pattern of multifocal hepatocellular carcinoma based on the pathological results and genome mutations information, which can provide guidelines for diagnosing and treating multifocal hepatocellular carcinoma.

Nuclei-Guided Network for Breast Cancer Grading in HE-Stained Pathological Images

Breast cancer grading methods based on hematoxylin-eosin (HE) stained pathological images can be summarized into two categories. The first category is to directly extract the pathological image features for breast cancer grading. However, unlike the coarse-grained problem of breast cancer classification, breast cancer grading is a fine-grained classification problem, so general methods cannot achieve satisfactory results. The second category is to apply the three evaluation criteria of the Nottingham Grading System (NGS) separately, and then integrate the results of the three criteria to obtain the final grading result. However, NGS is only a semiquantitative evaluation method, and there may be far more image features related to breast cancer grading. In this paper, we proposed a Nuclei-Guided Network (NGNet) for breast invasive ductal carcinoma (IDC) grading in pathological images. The proposed nuclei-guided attention module plays the role of nucleus attention, so as to learn more nuclei-related feature representations for breast IDC grading. In addition, the proposed nuclei-guided fusion module in the fusion process of different branches can further enable the network to focus on learning nuclei-related features. Overall, under the guidance of nuclei-related features, the entire NGNet can learn more fine-grained features for breast IDC grading. The experimental results show that the performance of the proposed method is better than that of state-of-the-art method. In addition, we released a well-labeled dataset with 3644 pathological images for breast IDC grading. This dataset is currently the largest publicly available breast IDC grading dataset and can serve as a benchmark to facilitate a broader study of breast IDC grading.

A Multi-market Comparison of the Intraday Lead-Lag Relations Among Stock Index-Based Spot, Futures and Options

Using 1-min data, we explore the dynamic variation of the intraday lead-lag relations between stock indices and their derivatives through a comprehensive study with broader coverage of research objectives and methodologies. This paper provides explicit evidence that the futures and options exhibit price leadership over the spot market, and the options is ahead of the futures on most trading days in all three markets. This paper also reports a new finding that the relation between the derivative and its underlying index reverses when the index return has a significantly larger mean value, and the reversal phenomenon is also observed in the relations between the futures and the options, which enriches the empirical results of intraday lead-lag relations. Moreover, these conclusions still hold under the impact of extreme events, e.g., the outbreak of the Covid-19. Finally, we construct a pair trading strategy based on the intraday lead-lag relationships, which can get better performance than the corresponding spot index. Our findings can potentially help regulators understand the price discovery process between the index and its derivatives, and also be of great value for timely adjustment of investors intraday trading strategies.

Identification and function analysis of BmPxtA in the immune response regulated by PGE2 of silkworm, Bombyx mori

Prostaglandins (PGs) can mediate the immune response of insects to infection. Mammalian cyclooxygenase (COXs) is a key enzyme in the synthesis of PGs, and Pxt may be its homologous gene in some sequenced insect genomes. As a representative of Lepidoptera, the silkworm also contains PGs, but the biosynthetic source of PGs is still unclear. In this study, Sequence analysis showed that peroxinectin (BmPxtA) gene of silkworm was closely related to human COX gene, and its homologous protein had conserved domains corresponding to human COX. The expression of BmPxtA gene was the highest in the hemocytes and was induced by Nuclear Polyhedrosis Virus (NPV) challenge in the detected tissues. The quantitative polymerase chain reaction (qPCR) results showed that silencing BmPxtA mediated by RNA interference (RNAi) inhibited the expression of immune-related pathway genes, and specifically suppressed hemocyte-spreading and nodule formation in silkworm; Hemocyte-spreading and nodule formation were also inhibited by aspirin, a COX inhibitor. Treatment by PGE₂ but not arachidonic acid (AA) rescued the immunosuppression; PGs concentrations was also inhibited by aspirin. PGE₂, but not AA, treatment rescued the PGs concentrations. These results suggest that BmPxtA gene is associated with PG biosynthesis in silkworm and the immune response of silkworm was affected by regulating the concentrations of PGs.

Evaluation of BPA effects on autophagy in Neuro-2a cells

Bisphenol A (BPA), which is used for the industrial production of polycarbonate plastics and epoxy resins, is found in many commercially available products. Plasticizer BPA produces chemical substances worldwide, and knowledge of its effects on humans and animals is increasing. In the present work, the morphology of cells was observed by optical microscopy and phalloidin staining to evaluate the toxic effect of BPA on Neuro-2a cells. Autophagy has an important role in the regulation of cell metabolism. To study the effect of BPA on the autophagy in Neuro-2a cells, the expression distribution of LC3 was detected by immunofluorescence, and the expression levels of p62 and Beclin1 were determined using western blot and quantitative real-time PCR (qRT-PCR), respectively. Optical microscopy and phalloidin staining revealed that the cells became rounded and small and that the dendritic spine of the cells were reduced at high BPA doses. Immunofluorescence analysis demonstrated that the expression of LC3 fluorescence intensity was weak at increasing BPA concentrations. Western blot results showed that the relative expression of protein p62 increased significantly and that the relative expression levels of the Beclin1 and the LC3 proteins significantly decreased with increasing BPA concentration. qRT-PCR results showed that the relative expression level of autophagy-related p62 mRNA increased significantly and that the relative expression level of Beclin1 mRNA decreased significantly with increasing BPA concentration. The above results indicated that BPA treatment exerted dose-dependent toxic effects on Neuro-2a cells, and BPA inhibited the autophagy level of Neuro-2a cells, thereby providing a new perspective in studying the toxic effect of BPA on Neuro-2a cells.

Global pattern and associated drivers of grassland productivity sensitivity to precipitation change

Precipitation is a primary climatic determinant of grassland productivity, with many global change experiments manipulating precipitation. Here we examine the impacts of precipitation addition and reduction treatment intensity and duration on grassland above- (ANPP) and below- (BNPP) ground net primary productivity in a large-scale meta-analysis. We tested, 1) the double asymmetry model of sensitivity, specifically whether the sensitivity of productivity decreases with treatment intensity under increased precipitation and increases with treatment intensity under decreased precipitation, 2) whether the sensitivity of productivity to precipitation change decreases with treatment length, and 3) how the sensitivity of productivity changes with climate conditions. ANPP showed higher sensitivity than BNPP under increased precipitation but similar sensitivity to BNPP under decreased precipitation. The sensitivity of ANPP and BNPP decreased with increasing treatment intensity (e.g., percentage change in precipitation, ΔPPT) and leveled off in the long-term. With increased precipitation, the sensitivity of productivity decreased with increasing treatment length (e.g., experimental duration) and leveled off in the long-term, whereas the sensitivity increased with increasing treatment length under reduced precipitation. Furthermore, the sensitivity of productivity to precipitation change decreased with increasing mean annual precipitation and temperature. Finally, our meta-analysis shows that above- and belowground net primary productivity have asymmetric responses to precipitation change. Together these results highlight the complex mechanisms underlying the impacts of precipitation change, particularly the intensity and duration of such changes, on grassland productivity.