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Schwantes IR, Patel RK, Kardosh A, Paxton J, Eil R, Chen EY, Rocha FG, Latour E, Pegna G, Lopez CD, Mayo SC. A Modified Floxuridine Reduced-Dose Protocol for Patients with Unresectable Colorectal Liver Metastases Treated with Hepatic Arterial Infusion. Ann Surg Oncol 2024:10.1245/s10434-024-15729-4. [PMID: 38995448 DOI: 10.1245/s10434-024-15729-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 06/19/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Most patients treated with the standard dosing protocol (SDP) of hepatic arterial infusion (HAI) floxuridine require dose holds and reductions, thereby limiting their HAI therapy. We hypothesized that a modified dosing protocol (MDP) with a reduced floxuridine starting dose would decrease dose holds, dose reductions, and have similar potential to convert patients with unresectable colorectal liver metastases (uCRLM) to resection. PATIENTS AND METHODS We reviewed our institutional database of patients with uCRLM treated with HAI between 2016 and 2022. In 2019, we modified the floxuridine starting dose to 50% (0.06 mg/kg) of the SDP (0.12 mg/kg). We compared treatment related outcomes between the SDP and MDP cohorts. RESULTS Of n = 33 patients, 15 (45%) were treated on the SDP and 18 (55%) with our new institutional MDP. The MDP cohort completed more cycles before a dose reduction (mean 4.2 vs. 2), received more overall cycles (median 7.5 vs. 5), and averaged 39 more days of treatment (all P < 0.05). The SDP experienced more dose reductions (1.4 vs. 0.61) and dose holds (1.2 vs. 0.2; both P < 0.01). Of the patients in each group potentially convertible to hepatic resection, three patients (23%) in the SDP and six patients (35%) in the MDP group converted to resection (P = 0.691). Overall, four patients (27%) in the SDP developed treatment ending biliary toxicity compared with one patient (6%) in the MDP. CONCLUSIONS A 50% starting dose of HAI floxuridine provides fewer treatment disruptions, more consecutive floxuridine cycles, and a similar potential to convert patients with initially uCRLM for disease clearance.
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Affiliation(s)
- Issac R Schwantes
- Department of Surgery, Division of Surgical Oncology, Knight Cancer Institute, Oregon Health & Science University (OHSU), Portland, OR, USA
| | - Ranish K Patel
- Department of Surgery, Division of Surgical Oncology, Knight Cancer Institute, Oregon Health & Science University (OHSU), Portland, OR, USA
| | - Adel Kardosh
- Department of Medicine, Division of Hematology and Medical Oncology, Knight Cancer Institute, OHSU, Portland, OR, USA
| | - Jillian Paxton
- Department of Pharmacy Services, OHSU, Portland, OR, USA
| | - Robert Eil
- Department of Surgery, Division of Surgical Oncology, Knight Cancer Institute, Oregon Health & Science University (OHSU), Portland, OR, USA
| | - Emerson Y Chen
- Department of Medicine, Division of Hematology and Medical Oncology, Knight Cancer Institute, OHSU, Portland, OR, USA
| | - Flavio G Rocha
- Department of Surgery, Division of Surgical Oncology, Knight Cancer Institute, Oregon Health & Science University (OHSU), Portland, OR, USA
| | - Emile Latour
- Biostatistics Shared Resource, Knight Cancer Institute, OHSU, Portland, OR, USA
| | - Guillaume Pegna
- Department of Medicine, Division of Hematology and Medical Oncology, Knight Cancer Institute, OHSU, Portland, OR, USA
| | - Charles D Lopez
- Department of Medicine, Division of Hematology and Medical Oncology, Knight Cancer Institute, OHSU, Portland, OR, USA
| | - Skye C Mayo
- Department of Surgery, Division of Surgical Oncology, Knight Cancer Institute, Oregon Health & Science University (OHSU), Portland, OR, USA.
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Ling T, Zhang C, Liu Y, Jiang C, Gu L. Single-cell analysis revealed a potential role of T-cell exhaustion in colorectal cancer with liver metastasis. J Cell Mol Med 2024; 28:e18341. [PMID: 38647235 PMCID: PMC11034372 DOI: 10.1111/jcmm.18341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/19/2024] [Accepted: 04/05/2024] [Indexed: 04/25/2024] Open
Abstract
Liver metastasis (LM) is an important factor leading to colorectal cancer (CRC) mortality. However, the effect of T-cell exhaustion on LM in CRC is unclear. Single-cell sequencing data derived from the Gene Expression Omnibus database. Data were normalized using the Seurat package and subsequently clustered and annotated into different cell clusters. The differentiation trajectories of epithelial cells and T cells were characterized based on pseudo-time analysis. Single-sample gene set enrichment analysis (ssGSEA) was used to calculate enrichment scores for different cell clusters and to identify enriched biological pathways. Finally, cell communication analysis was performed. Nine cell subpopulations were identified from CRC samples with LM. The proportion of T cells increased in LM. T cells can be subdivided into NK/T cells, regulatory T cells (Treg) and exhausted T cells (Tex). In LM, cell adhesion and proliferation activity of Tex were promoted. Epithelial cells can be categorized into six subpopulations. The transformation of primary CRC into LM involved two evolutionary branches of Tex cells. Epithelial cells two were at the beginning of the trajectory in CRC but at the end of the trajectory in CRC with LM. The receptor ligands CEACAM5 and ADGRE5-CD55 played critical roles in the interactions between Tex and Treg cell-epithelial cell, which may promote the epithelial-mesenchymal transition process in CRC. Tex cells are able to promote the process of LM in CRC, which in turn promotes tumour development. This provides a new perspective on the treatment and diagnosis of CRC.
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Affiliation(s)
- Tianlong Ling
- Department of Gastrointestinal Surgery, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Cheng Zhang
- Department of Gastrointestinal Surgery, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Ye Liu
- Department of Gastrointestinal Surgery, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Chunhui Jiang
- Department of Gastrointestinal Surgery, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Lei Gu
- Department of Gastrointestinal Surgery, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
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Pikoulis E, Papaconstantinou D, Pikouli A, Pararas N, Buettner S, Wang J, Stasinos G, Belias M, Dellaportas D, Pozios I, Antoniou E, Beyer K, Kreis ME, Pawlik TM, Margonis GA. Is Precision Surgery Applicable to Colorectal Liver Metastases? A Systematic Review and Meta-analysis of Studies that Investigate the Association of Surgical Technique with Outcomes in the Context of Distinct Tumor Biology. Ann Surg Oncol 2024; 31:1823-1832. [PMID: 38155339 PMCID: PMC11293459 DOI: 10.1245/s10434-023-14774-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/28/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Although some data suggest that patients with mutRAS colorectal liver metastases (CRLM) may benefit from anatomic hepatectomy, this topic remains controversial. We performed a systematic review and meta-analysis to determine whether RAS mutation status was associated with prognosis relative to surgical technique [anatomic resection (AR) vs. nonanatomic resection (NAR)] among patients with CRLM. PATIENTS AND METHODS A systematic review and meta-analysis of studies were performed to investigate the association of AR versus NAR with overall and liver-specific disease-free survival (DFS and liver-specific DFS, respectively) in the context of RAS mutation status. RESULTS Overall, 2018 patients (831 mutRAS vs. 1187 wtRAS) were included from five eligible studies. AR was associated with a 40% improvement in liver-specific DFS [hazard ratio (HR) = 0.6, 95% confidence interval (CI) 0.44-0.81, p = 0.01] and a 28% improvement in overall DFS (HR = 0.72, 95% CI 0.54-0.95, p = 0.02) among patients with mutRAS tumors; in contrast, AR was not associated with any improvement in liver-specific DFS or overall DFS among wtRAS patients. These differences may have been mediated by the 40% decreased incidence in R1 resection among patients with mutRAS tumors who underwent AR versus NAR [relative risk (RR): 0.6, 95% CI 0.40-0.91, p = 0.02]. In contrast, the probability of an R1 resection was not decreased among wtRAS patients who underwent AR versus NAR (RR: 0.93, 95% CI 0.69-1.25, p = 0.62). CONCLUSIONS The data suggest that precision surgery may be relevant to CRLM. Specifically, rather than a parenchymal sparing dogma for all patients, AR may have a role in individuals with mutRAS tumors.
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Affiliation(s)
- Emmanouil Pikoulis
- Third Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Dimitrios Papaconstantinou
- Third Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Anastasia Pikouli
- Third Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Nikolaos Pararas
- Third Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Stefan Buettner
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jane Wang
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | - Michail Belias
- Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dionysios Dellaportas
- Third Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ioannis Pozios
- Department of General and Visceral Surgery, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Efstathios Antoniou
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Katharina Beyer
- Department of General and Visceral Surgery, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Martin E Kreis
- Department of General and Visceral Surgery, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
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Wang J, Luo H, Yi L, Yang P, Zeng X. Downstaging and laparoscopic hepatectomy plus intraoperative radiofrequency ablation for the treatment of initially unresectable multifocal hepatocellular carcinomas. Front Surg 2024; 10:1340657. [PMID: 38283063 PMCID: PMC10811958 DOI: 10.3389/fsurg.2023.1340657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 12/29/2023] [Indexed: 01/30/2024] Open
Abstract
Background Using TKIs plus anti-PD-1 antibodies combined with TACE in the treatment of patients with initially unresectable multiple HCCs has a high tumour response rate, and using laparoscopic hepatectomy (LH) combined with intraoperative RFA for radical treatment of multiple HCCs after successful downstaging treatment has not been reported. Methods Consecutive patients with multiple HCCs (≤4 lesions) who were downstaged with TKIs plus anti-PD-1 antibodies combined with TACE were analysed. Imaging examinations were performed monthly, and RECIST v1.1 criteria were used to evaluate treatment effect and resectability. Results Forty-five consecutive patients with multiple HCCs who met the inclusion criteria received downstaging treatment with TKIs plus anti-PD-1 antibodies combined with TACE. Nine patients were successfully downstaged and met the R0 resection criteria, and 8 patients underwent surgery. Among the patients, 5 patients had BCLC stage C, and 3 patients had BCLC stage B. There were 2 lesions in 5 patients, 3 lesions in 2 patients, and 4 lesions in 1 patient. The average size of the main HCC was 8.5 cm (range: 5.4-9.1 cm), and the diameter of the remaining HCCs was 1.6 cm (range: 0.8-2.9 cm). The average time from the start of downstaging therapy to surgery was 81 days (range: 60-210 days). All 8 patients underwent LH of the main HCC, and the remaining HCCs were targeted with RFA. The mean operation time was 220 min (range 150-370 min), the average intraoperative blood loss was 260 ml (range 100-750 ml), there was no case conversion to laparotomy, and the average postoperative hospital stay was 9 days (range 7-25 days). The incidence of postoperative complications was 37.5% and there were no deaths. The average follow-up time was 18.2 months (range 6.1-22.4 months), 5 patients survived tumour-free, 2 patients had tumour recurrence, and 1 patient died. Conclusions After successful downstaging of multiple HCCs by treatment with TKIs plus anti-PD-1 antibodies and TACE, LH combined with RFA for radical surgery is safe and feasible, and the treatment effect is satisfactory. It is worthy of clinical reference, and its long-term effects require further research for confirmation.
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Affiliation(s)
| | | | | | | | - Xintao Zeng
- Department of Hepatobiliary Surgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
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Wu N, Chen J, Lin T, Zhong Z, Li M, Yu Y, Guo J, Yu W. Identification of AP002498.1 and LINC01871 as prognostic biomarkers and therapeutic targets for distant metastasis of colorectal adenocarcinoma. Cancer Med 2024; 13:e6823. [PMID: 38083905 PMCID: PMC10807603 DOI: 10.1002/cam4.6823] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Increasing evidence suggests that lncRNA (Long non-coding RNA, lncRNA)-mediated ceRNA (competing endogenous RNA, ceRNA) networks are involved in the occurrence and progression of colorectal cancer (CRC). However, the roles of the lncRNA-miRNA-mRNA ceRNA network in distant metastasis of CRC are still unclear. METHODS In this study, we constructed a specific ceRNA network to identify potential biomarkers and therapeutic targets for distant metastasis of CRC. Specifically, RNA-Seq data from The Cancer Genome Atlas (TCGA) were used to screen for differentially expressed lncRNAs (DElncRNAs) and mRNAs (DEmRNAs) related to metastasis. After validation and selection by qRT-PCR and univariate and multivariate analysis of the metastasis- and prognosis-related lncRNAs, the regulated microRNAs (miRNAs) and coexpressed mRNAs were used to construct a ceRNA network for distant metastasis of CRC. RESULTS Two key distant metastasis-related DElncRNAs, AP002498.1 and LINC01871, were identified by univariate and multivariate analysis in combination with analyses of clinical data and expression levels. Furthermore, lncRNA-associated ceRNA subnetworks were constructed from the predicted miRNAs and 13 coexpressed DEmRNAs (SERPINA1, ITLN1, REG4, L1TD1, IGFALS, MUC5B, CIITA, CXCL9, CXCL10, GBP4, GNLY, IDO1, and NOS2). The AP002498.1- and LINC01871-associated ceRNA subnetworks regulated the expression of the target genes SERPINA1 and MUC5B and GNLY, respectively, through the associated miRNAs. CONCLUSION The DElncRNA AP002498.1 and the LINC01871/miR-4644 and miR-185-5p/GNLY axes were identified as being closely associated with distant metastasis and could represent independent prognostic biomarkers or therapeutic targets in colorectal adenocarcinoma.
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Affiliation(s)
- Na Wu
- Department of Central Laboratory and Institute of Clinical Molecular BiologyPeking University People's HospitalBeijingChina
| | - Jingyi Chen
- Department of Central Laboratory and Institute of Clinical Molecular BiologyPeking University People's HospitalBeijingChina
- Department of GastroenterologyPeking University People's HospitalBeijingChina
| | - Tingru Lin
- Department of Central Laboratory and Institute of Clinical Molecular BiologyPeking University People's HospitalBeijingChina
- Department of GastroenterologyPeking University People's HospitalBeijingChina
| | - Zhaohui Zhong
- Department of General SurgeryPeking University People's HospitalBeijingChina
| | - Mei Li
- Department of Central Laboratory and Institute of Clinical Molecular BiologyPeking University People's HospitalBeijingChina
| | - Yimeng Yu
- Department of Central Laboratory and Institute of Clinical Molecular BiologyPeking University People's HospitalBeijingChina
| | - Jingzhu Guo
- Department of PediatricPeking University People's HospitalBeijingChina
| | - Weidong Yu
- Department of Central Laboratory and Institute of Clinical Molecular BiologyPeking University People's HospitalBeijingChina
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6
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Pan Q, Li K, Kang X, Li K, Cheng Z, Wang Y, Xu Y, Li L, Li N, Wu G, Yang S, Qi S, Chen G, Tan X, Zhan Y, Tang L, Zhan W, Yang Q. Rational design of NIR-II molecule-engineered nanoplatform for preoperative downstaging and imaging-guided surgery of orthotopic hepatic tumor. J Nanobiotechnology 2023; 21:489. [PMID: 38111035 PMCID: PMC10726515 DOI: 10.1186/s12951-023-02263-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 12/12/2023] [Indexed: 12/20/2023] Open
Abstract
Orthotopic advanced hepatic tumor resection without precise location and preoperative downstaging may cause clinical postoperative recurrence and metastasis. Early accurate monitoring and tumor size reduction based on the multifunctional diagnostic-therapeutic integration platform could improve real-time imaging-guided resection efficacy. Here, a Near-Infrared II/Photoacoustic Imaging/Magnetic Resonance Imaging (NIR-II/PAI/MRI) organic nanoplatform IRFEP-FA-DOTA-Gd (IFDG) is developed for integrated diagnosis and treatment of orthotopic hepatic tumor. The IFDG is designed rationally based on the core "S-D-A-D-S" NIR-II probe IRFEP modified with folic acid (FA) for active tumor targeting and Gd-DOTA agent for MR imaging. The IFDG exhibits several advantages, including efficient tumor tissue accumulation, good tumor margin imaging effect, and excellent photothermal conversion effect. Therefore, the IFDG could realize accurate long-term monitoring and photothermal therapy non-invasively of the hepatic tumor to reduce its size. Next, the complete resection of the hepatic tumor in situ lesions could be realized by the intraoperative real-time NIR-II imaging guidance. Notably, the preoperative downstaging strategy is confirmed to lower the postoperative recurrence rate of the liver cancer patients under middle and advanced stage effectively with fewer side effects. Overall, the designed nanoplatform demonstrates great potential as a diagnostic-therapeutic integration platform for precise imaging-guided surgical navigation of orthotopic hepatic tumors with a low recurrence rate after surgery, providing a paradigm for diagnosing and treating the advanced tumors in the future clinical translation application.
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Affiliation(s)
- Qi Pan
- Center for Molecular lmaging Probe, Hunan Province Key Laboratory of Cancer Cellular and Molecular Pathology, Hengyang Medical School, Cancer Research lnstitute, University of South China, Hengyang, 421001, China
- Medical Imaging Department, The Second Affiliated Hospital of Xi'an Medical University, Xi'an, 710038, China
| | - Ke Li
- Xi'an Key Laboratory for Prevention and Treatment of Common Aging Diseases, Translational and Research Centre for Prevention and Therapy of Chronic Disease, Institute of Basic and Translational Medicine, Xi'an Medical University, Xi'an, 710021, China
| | - Xueqin Kang
- School of Life Science and Technology, Engineering Research Center of Molecular & Neuro Imaging of the Ministry of Education, Xidian University, Xi'an, 710126, China
| | - Kaixuan Li
- Medical Imaging Department, The Second Affiliated Hospital of Xi'an Medical University, Xi'an, 710038, China
| | - Zihe Cheng
- Xi'an Key Laboratory for Prevention and Treatment of Common Aging Diseases, Translational and Research Centre for Prevention and Therapy of Chronic Disease, Institute of Basic and Translational Medicine, Xi'an Medical University, Xi'an, 710021, China
| | - Yafei Wang
- Xi'an Key Laboratory for Prevention and Treatment of Common Aging Diseases, Translational and Research Centre for Prevention and Therapy of Chronic Disease, Institute of Basic and Translational Medicine, Xi'an Medical University, Xi'an, 710021, China
| | - Yuye Xu
- Xi'an Key Laboratory for Prevention and Treatment of Common Aging Diseases, Translational and Research Centre for Prevention and Therapy of Chronic Disease, Institute of Basic and Translational Medicine, Xi'an Medical University, Xi'an, 710021, China
| | - Lei Li
- Radiology Department, Ninth Affiliated Hospital of Medical College of Xi'an Jiaotong University, Xi'an, 710054, China
| | - Na Li
- Center for Molecular lmaging Probe, Hunan Province Key Laboratory of Cancer Cellular and Molecular Pathology, Hengyang Medical School, Cancer Research lnstitute, University of South China, Hengyang, 421001, China
| | - Guilong Wu
- Center for Molecular lmaging Probe, Hunan Province Key Laboratory of Cancer Cellular and Molecular Pathology, Hengyang Medical School, Cancer Research lnstitute, University of South China, Hengyang, 421001, China
| | - Sha Yang
- Center for Molecular lmaging Probe, Hunan Province Key Laboratory of Cancer Cellular and Molecular Pathology, Hengyang Medical School, Cancer Research lnstitute, University of South China, Hengyang, 421001, China
| | - Shuo Qi
- Department of Hepatopancreatobiliary Surgery, Hengyang Medical School, The First Affiliated Hospital, University of South China, Hengyang, 421001, Hunan, China
| | - Guodong Chen
- Department of Hepatopancreatobiliary Surgery, Hengyang Medical School, The First Affiliated Hospital, University of South China, Hengyang, 421001, Hunan, China
| | - Xiaofeng Tan
- Center for Molecular lmaging Probe, Hunan Province Key Laboratory of Cancer Cellular and Molecular Pathology, Hengyang Medical School, Cancer Research lnstitute, University of South China, Hengyang, 421001, China.
| | - Yonghua Zhan
- School of Life Science and Technology, Engineering Research Center of Molecular & Neuro Imaging of the Ministry of Education, Xidian University, Xi'an, 710126, China.
| | - Li Tang
- Center for Molecular lmaging Probe, Hunan Province Key Laboratory of Cancer Cellular and Molecular Pathology, Hengyang Medical School, Cancer Research lnstitute, University of South China, Hengyang, 421001, China.
- Key Laboratory of Tropical Medicinal Plant Chemistry of Ministry of Education, College of Chemistry and Chemical Engineering, Hainan Normal University, Haikou, 571158, China.
| | - Wenhua Zhan
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, 750004, China.
| | - Qinglai Yang
- Center for Molecular lmaging Probe, Hunan Province Key Laboratory of Cancer Cellular and Molecular Pathology, Hengyang Medical School, Cancer Research lnstitute, University of South China, Hengyang, 421001, China.
- Department of Hepatopancreatobiliary Surgery, Hengyang Medical School, The First Affiliated Hospital, University of South China, Hengyang, 421001, Hunan, China.
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Li H, Zhang X, Zhao W, Cai F, Qin J, Tian J. Efficacy of CalliSpheres® microspheres versus conventional transarterial chemoembolization in the treatment of refractory colorectal cancer liver metastasis. BMC Cancer 2023; 23:970. [PMID: 37828491 PMCID: PMC10568812 DOI: 10.1186/s12885-023-11350-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 08/29/2023] [Indexed: 10/14/2023] Open
Abstract
OBJECTIVE CalliSpheres® is a microsphere that is already widely used for primary liver cancer treatment; however, its application in colorectal cancer liver metastasis (CRLM) is limited. The current study aimed to investigate the efficacy of CalliSpheres® drug-eluting bead (DEB) transarterial chemoembolization (TACE) therapy versus (vs.) conventional cTACE therapy in treating refractory CRLM (RCRLM) patients. METHODS Twenty-two RCRLM patients who underwent CalliSpheres® DEB-TACE therapy (n = 11) or cTACE therapy (n = 11) were retrospectively analyzed. Data on clinical response, progression-free survival (PFS) and overall survival (OS) were retrieved. RESULTS The objective response rate (36.4% vs. 18.2%, P = 0.338) and disease control rate (81.8% vs. 54.4%, P = 0.170) were both numerically (but not statistically) higher in the DEB-TACE group than in the cTACE group. Meanwhile, PFS was prolonged in the DEB-TACE group compared with the cTACE group [median: 12.0 (95% CI: 5.6-18.4) vs. 4.0 (95% CI: 0.9-7.1) months, P = 0.018]; OS was also longer in the DEB-TACE group compared with the cTACE group [median: 24.0 (95% CI: 18.3-29.7) vs. 14.0 (95% CI: 7.1-20.9) months, P = 0.040]. In addition, after adjustment by multivariate Cox analyses, DEB-TACE was superior to cTACE independently regarding PFS (HR: 0.110, 95% CI: 0.026-0.463, P = 0.003) and OS (HR: 0.126, 95% CI: 0.028-0.559, P = 0.006). CONCLUSION CalliSpheres® DEB-TACE therapy may prolong survival profile than cTACE therapy in RCRLM patients, while further validation is still needed.
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Affiliation(s)
- Haitao Li
- Department of Interventional Radiology, Yichang Central People's Hospital, First College of Clinical Medical Science, China Three Gorges University, 183 Yiling Avenue, Yichang, 443003, China
| | - Xiaolin Zhang
- Department of Interventional Radiology, Yichang Central People's Hospital, First College of Clinical Medical Science, China Three Gorges University, 183 Yiling Avenue, Yichang, 443003, China
| | - Wenjiang Zhao
- Department of Interventional Radiology, Yichang Central People's Hospital, First College of Clinical Medical Science, China Three Gorges University, 183 Yiling Avenue, Yichang, 443003, China
| | - Fei Cai
- Department of Interventional Radiology, Yichang Central People's Hospital, First College of Clinical Medical Science, China Three Gorges University, 183 Yiling Avenue, Yichang, 443003, China
| | - Jia Qin
- Department of Interventional Radiology, Yichang Central People's Hospital, First College of Clinical Medical Science, China Three Gorges University, 183 Yiling Avenue, Yichang, 443003, China
| | - Jie Tian
- Department of Interventional Radiology, Yichang Central People's Hospital, First College of Clinical Medical Science, China Three Gorges University, 183 Yiling Avenue, Yichang, 443003, China.
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Moorman AR, Cambuli F, Benitez EK, Jiang Q, Xie Y, Mahmoud A, Lumish M, Hartner S, Balkaran S, Bermeo J, Asawa S, Firat C, Saxena A, Luthra A, Sgambati V, Luckett K, Wu F, Li Y, Yi Z, Masilionis I, Soares K, Pappou E, Yaeger R, Kingham P, Jarnagin W, Paty P, Weiser MR, Mazutis L, D'Angelica M, Shia J, Garcia-Aguilar J, Nawy T, Hollmann TJ, Chaligné R, Sanchez-Vega F, Sharma R, Pe'er D, Ganesh K. Progressive plasticity during colorectal cancer metastasis. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.08.18.553925. [PMID: 37662289 PMCID: PMC10473595 DOI: 10.1101/2023.08.18.553925] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Metastasis is the principal cause of cancer death, yet we lack an understanding of metastatic cell states, their relationship to primary tumor states, and the mechanisms by which they transition. In a cohort of biospecimen trios from same-patient normal colon, primary and metastatic colorectal cancer, we show that while primary tumors largely adopt LGR5 + intestinal stem-like states, metastases display progressive plasticity. Loss of intestinal cell states is accompanied by reprogramming into a highly conserved fetal progenitor state, followed by non-canonical differentiation into divergent squamous and neuroendocrine-like states, which is exacerbated by chemotherapy and associated with poor patient survival. Using matched patient-derived organoids, we demonstrate that metastatic cancer cells exhibit greater cell-autonomous multilineage differentiation potential in response to microenvironment cues than their intestinal lineage-restricted primary tumor counterparts. We identify PROX1 as a stabilizer of intestinal lineage in the fetal progenitor state, whose downregulation licenses non-canonical reprogramming.
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Vonderhaar EP, Dwinell MB, Craig BT. Targeted immune activation in pediatric solid tumors: opportunities to complement local control approaches. Front Immunol 2023; 14:1202169. [PMID: 37426669 PMCID: PMC10325564 DOI: 10.3389/fimmu.2023.1202169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/31/2023] [Indexed: 07/11/2023] Open
Abstract
Surgery or radiation therapy is nearly universally applied for pediatric solid tumors. In many cases, in diverse tumor types, distant metastatic disease is present and evades surgery or radiation. The systemic host response to these local control modalities may lead to a suppression of antitumor immunity, with potential negative impact on the clinical outcomes for patients in this scenario. Emerging evidence suggests that the perioperative immune responses to surgery or radiation can be modulated therapeutically to preserve anti-tumor immunity, with the added benefit of preventing these local control approaches from serving as pro-tumorigenic stimuli. To realize the potential benefit of therapeutic modulation of the systemic response to surgery or radiation on distant disease that evades these modalities, a detailed knowledge of the tumor-specific immunology as well as the immune responses to surgery and radiation is imperative. In this Review we highlight the current understanding of the tumor immune microenvironment for the most common peripheral pediatric solid tumors, the immune responses to surgery and radiation, and current evidence that supports the potential use of immune activating agents in the perioperative window. Finally, we define existing knowledge gaps that limit the current translational potential of modulating perioperative immunity to achieve effective anti-tumor outcomes.
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Affiliation(s)
- Emily P. Vonderhaar
- Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, WI, United States
- Center for Immunology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Michael B. Dwinell
- Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, WI, United States
- Center for Immunology, Medical College of Wisconsin, Milwaukee, WI, United States
- Cancer Center, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Brian T. Craig
- Center for Immunology, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
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Qiao Y, Li X, Hu Y, Guo P, Liu H, Sun H. Relationship between SUVmax on 18F-FDG PET and PD-L1 expression in liver metastasis lesions after colon radical operation. BMC Cancer 2023; 23:535. [PMID: 37308878 DOI: 10.1186/s12885-023-11014-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/25/2023] [Indexed: 06/14/2023] Open
Abstract
PURPOSE Our study was to investigate the correlation correlation between FDG uptake and PD-L1 expression of liver metastasis in patients with colon cancer, and to determine the value of FDG-PET in predicting PD-L1 expression in liver metastasis of colon cancer. METHODS A total of 72 patients with confirmed liver metastasis of colon cancer were included in this retrospective study. The PD-L1 expression and immune cell infiltrating of tumors were determined through immunohistochemistry staining. The SUVmax of liver metastasis lesions were assessed using 18 F-FDG PET/CT. The correlation between PD-L1 expression and the clinicopathological were evaluated by the Cox proportional hazards model and the Kaplan-Meier survival analysis. RESULTS PD-L1 expression was significantly correlated with FDG uptake (SUVmax), tumor size, differentiation, survival and cytotoxic T cells infiltration in liver metastasis of colon cancer (P < 0.05). And liver metastases with high counts of infiltrating cytotoxic T cells showed greater FDG uptake than those with low counts of infiltrating cytotoxic T cells. The SUVmax of liver metastases and the degree of differentiation of metastases were closely related to PD-L1 expression, and were independent risk factors.The combined assessment of SUVmax values and tthe degree of differentiation of metastase can help determine PD-L1 expression in liver metastasis of colon cancer. CONCLUSIONS FDG uptake in liver metastasis of colon cancer was positively correlated with the PD-L1 expression and the number of cytotoxic T cells infiltration. The joint evaluation of two parameters, SUVmax and degree of differentiation, can predict PD-L1 expression in liver metastases.
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Affiliation(s)
- Yan Qiao
- Department of infectious disease, The First Affiliated Hospital of Bengbu Medical College, Anhui, Bengbu, 233004, China
| | - Xiaomeng Li
- Department of Clinical Laboratory Science, The First Affiliated Hospital of Bengbu Medical College, 287 Zhihuai Rd, Bengbu233004, Bengbu, 233004, China
| | - Yongquan Hu
- Department of nuclear medicine, The First Affiliated Hospital of Bengbu Medical College, Anhui, Bengbu, 233004, China
| | - Pu Guo
- Department of Clinical Laboratory Science, The First Affiliated Hospital of Bengbu Medical College, 287 Zhihuai Rd, Bengbu233004, Bengbu, 233004, China
| | - Hengchao Liu
- Department of nuclear medicine, The First Affiliated Hospital of Bengbu Medical College, Anhui, Bengbu, 233004, China
| | - Hong Sun
- Department of Clinical Laboratory Science, The First Affiliated Hospital of Bengbu Medical College, 287 Zhihuai Rd, Bengbu233004, Bengbu, 233004, China.
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11
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Ershov P, Poyarkov S, Konstantinova Y, Veselovsky E, Makarova A. Transcriptomic Signatures in Colorectal Cancer Progression. Curr Mol Med 2023; 23:239-249. [PMID: 35490318 DOI: 10.2174/1566524022666220427102048] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/05/2021] [Accepted: 03/09/2022] [Indexed: 02/08/2023]
Abstract
AIMS Due to a large number of identified hub-genes encoding key molecular regulators, which are involved in signal transduction and metabolic pathways in cancers, it is relevant to systemize and update these findings. BACKGROUND Colorectal cancer (CRC) is the third leading cause of cancer death in the world, with high metastatic potential. Elucidating the pathogenic mechanisms and selection of novel biomarkers in CRC is of great clinical significance. OBJECTIVE This analytical review aims at the systematization of bioinformatics and experimental identification of hub-genes associated with CRC for a more consolidated understanding of common features in networks and pathways in CRC progression as well as hub-genes selection. RESULTS In total, 301 hub-genes were derived from 40 articles. The "core" consisted of 28 hub-genes (CCNB1, LPAR1, BGN, CXCL3, COL1A2, UBE2C, NMU, COL1A1, CXCL2, CXCL11, CDK1, TOP2A, AURKA, SST, CXCL5, MMP3, CCND1, TIMP1, CXCL8, CXCL1, CXCL12, MYC, CCNA2, GCG, GUCA2A, PAICS, PYY and THBS2) mentioned in not less than three articles and having clinical significance in cancerassociated pathways. Of them, there were two discrete clusters enriched in chemokine signaling and cell cycle regulatory genes. High expression levels of BGN and TIMP1 and low expression levels of CCNB1, CXCL3, CXCL2, CXCL2 and PAICS were associated with unfavorable overall survival of patients with CRC. Differently expressed genes such as LPAR1, SST, CXCL12, GUCA2A, and PYY were shown as down regulated, whereas BGN, CXCL3, UBE2C, NMU, CXCL11, CDK1, TOP2A, AURKA, MMP3, CCND1, CXCL1, MYC, CCNA2, PAICS were up regulated genes in CRC. It was also found that MMP3, THBS2, TIMP1 and CXCL12 genes were associated with metastatic CRC. Network analysis in ONCO.IO showed that upstream master regulators RELA, STAT3, SOX2, FOXM1, SMAD3 and NF-kB were connected with "core" hub-genes. Conclusión: Results obtained are of useful fundamental information on revealing the mechanism of pathogenicity, cellular target selection for optimization of therapeutic interventions, as well as transcriptomics prognostic and predictive biomarkers development.
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Affiliation(s)
- Pavel Ershov
- Department of Analysis and Forecasting of Medical and Biological Health Risks, Federal State Budgetary Institution "Centre for Strategic Planning and Management of Biomedical Health Risks" of the Federal Medical Biological Agency, Moscow, Russia
| | - Stanislav Poyarkov
- Department of Analysis and Forecasting of Medical and Biological Health Risks, Federal State Budgetary Institution "Centre for Strategic Planning and Management of Biomedical Health Risks" of the Federal Medical Biological Agency, Moscow, Russia
| | - Yulia Konstantinova
- Oncology Department, Federal Research and Clinical Center of Specialized Kinds of Medical Care and Medical Technology of the Federal Medical Biological Agency, Moscow, Russia
| | - Egor Veselovsky
- Department of Analysis and Forecasting of Medical and Biological Health Risks, Federal State Budgetary Institution "Centre for Strategic Planning and Management of Biomedical Health Risks" of the Federal Medical Biological Agency, Moscow, Russia
| | - Anna Makarova
- Department of Analysis and Forecasting of Medical and Biological Health Risks, Federal State Budgetary Institution "Centre for Strategic Planning and Management of Biomedical Health Risks" of the Federal Medical Biological Agency, Moscow, Russia
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12
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Qiu B, Su XH, Qin X, Wang Q. Application of machine learning techniques in real-world research to predict the risk of liver metastasis in rectal cancer. Front Oncol 2022; 12:1065468. [PMID: 36605425 PMCID: PMC9807609 DOI: 10.3389/fonc.2022.1065468] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Background The liver is the most common site of distant metastasis in rectal cancer, and liver metastasis dramatically affects the treatment strategy of patients. This study aimed to develop and validate a clinical prediction model based on machine learning algorithms to predict the risk of liver metastasis in patients with rectal cancer. Methods We integrated two rectal cancer cohorts from Surveillance, Epidemiology, and End Results (SEER) and Chinese multicenter hospitals from 2010-2017. We also built and validated liver metastasis prediction models for rectal cancer using six machine learning algorithms, including random forest (RF), light gradient boosting (LGBM), extreme gradient boosting (XGB), multilayer perceptron (MLP), logistic regression (LR), and K-nearest neighbor (KNN). The models were evaluated by combining several metrics, such as the area under the curve (AUC), accuracy score, sensitivity, specificity and F1 score. Finally, we created a network calculator using the best model. Results The study cohort consisted of 19,958 patients from the SEER database and 924 patients from two hospitals in China. The AUC values of the six prediction models ranged from 0.70 to 0.95. The XGB model showed the best predictive power, with the following metrics assessed in the internal test set: AUC (0.918), accuracy (0.884), sensitivity (0.721), and specificity (0.787). The XGB model was assessed in the outer test set with the following metrics: AUC (0.926), accuracy (0.919), sensitivity (0.740), and specificity (0.765). The XGB algorithm also shows a good fit on the calibration decision curves for both the internal test set and the external validation set. Finally, we constructed an online web calculator using the XGB model to help generalize the model and to assist physicians in their decision-making better. Conclusion We successfully developed an XGB-based machine learning model to predict liver metastasis from rectal cancer, which was also validated with a real-world dataset. Finally, we developed a web-based predictor to guide clinical diagnosis and treatment strategies better.
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Affiliation(s)
- Binxu Qiu
- Department of Gastric and Colorectal Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, China
| | - Xiao hu Su
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Xinxin Qin
- Department of Gastric and Colorectal Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, China
| | - Quan Wang
- Department of Gastric and Colorectal Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, China,*Correspondence: Quan Wang,
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Uludag SS, Kurt SA, Sanli DET, Sanli AN, Tutar O, Zengin AK, Ozcelik MF. Evaluating Portal Vein and Right Colon Venous Vascular Anatomy and Its Variations via Multidetector CT in Healthy Individuals. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03583-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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14
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Chan AKC, Mason JM, Baltatzis M, Siriwardena AK. Management of Colorectal Cancer with Synchronous Liver Metastases: An Inception Cohort Study (CoSMIC). Ann Surg Oncol 2021; 29:1939-1951. [PMID: 34716838 DOI: 10.1245/s10434-021-11017-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/12/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Approximately one-fifth of patients with colorectal cancer present with hepatic metastases. There are limited prospective data on the outcomes of synchronous combined liver and bowel surgery and liver-first or bowel-first routes where contemporary chemo(radio)therapy is integrated into management. METHODS Between 1 April 2014 and 31 March 2017, 125 patients with colorectal cancer and synchronous liver metastases were recruited. Data are reported on pathway-specific outcomes, including perioperative complications, treatment completion, and overall and disease-free survival. The study was registered with ClinicalTrials.gov (NCT02456285). RESULTS There was no difference in age, body mass index, or Charlson score between surgical groups. Neoadjuvant chemotherapy was used in 50 (40%) patients for a mean duration of 4.6 months (standard deviation [SD] 5.4), and mean time from completion of chemotherapy to surgery was 2.6 months (SD 1.9). Complications were similar between patients completing the synchronous and staged pathways (p = 0.66). Mean total inpatient stay was 16.5 days (SD 8.1) for staged surgery compared with 16.8 days (SD 10.3) for the synchronous group (t-test; p = 0.91). There was no difference in time to treatment completion between pathways. Thirty six (35%) patients were disease-free at 12 months, with no significant difference between groups (Chi-square, p = 0.448). Quality of life was similar in all surgical groups. CONCLUSIONS Perioperative complications and oncological and healthcare occupancy outcomes are equivalent between patients completing staged and synchronous pathways for the management of patients with colorectal cancer and synchronous liver metastases. Future studies should focus on optimizing the criteria for pathway selection, incorporation of cancer genomics data, and patient (user) preferences.
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Affiliation(s)
- Anthony K C Chan
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, UK
| | - James M Mason
- Warwick Medical School, The University of Warwick, Coventry, UK
| | - Minas Baltatzis
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, UK
| | - Ajith K Siriwardena
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, UK. .,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
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Cai Z, Mei Y, Jiang X, Shi X. WDR74 promotes proliferation and metastasis in colorectal cancer cells through regulating the Wnt/β-catenin signaling pathway. Open Life Sci 2021; 16:920-929. [PMID: 34553072 PMCID: PMC8422980 DOI: 10.1515/biol-2021-0096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/22/2021] [Accepted: 07/23/2021] [Indexed: 12/13/2022] Open
Abstract
Colon cancer (CRC) is a common type of cancer and has a high incidence worldwide. Protein 74 (WDR74), which consists of the WD repetition sequence, has been previously associated with tumor tumorigenesis. However, its mechanism of action in CRC remains unclear. Here, we found that WDR74 expression was upregulated in CRC tissues and cells. Downregulation of WDR74 repressed the proliferation and cell cycles in CRC cells. In addition, WDR74 knockdown induced cell apoptosis and suppressed both cell metastasis and invasion. Mechanistically, WDR74 decreased the phosphorylation of β-catenin and induced nuclear β-catenin accumulation, activating the Wnt/β-catenin signaling pathway in CRC cells. Further investigation showed that blocking the Wnt/β-catenin signaling pathway by XAV-939 reversed the effects of WDR74 on cell proliferation, migration, and invasion in HCT116 cells. Overall, WDR74 induced β-catenin translocation to the nucleus and activated the Wnt/β-Catenin, thus facilitated CRC cell proliferation and metastasis. In summary, WDR74 could be a potential target for the intervention of CRC.
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Affiliation(s)
- Zhou Cai
- Department of Medical, Wuhan City College, Wuhan City, Hubei Province, 430083, China
| | - Yan Mei
- Department of Medical, Wuhan City College, Wuhan City, Hubei Province, 430083, China
| | - Xiaoye Jiang
- Department of Medical, Wuhan City College, Wuhan City, Hubei Province, 430083, China
| | - Xingfeng Shi
- Department of Colorectal Surgery, The Ninth People's Hospital of Chongqing, No. 69, Jialing Village, Beibei District, Chongqing City, 400700, China
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Khan TM, Verbus EA, Rehman SU, Chun YS, Hernandez JM. The Role of Liver Resection for Patients with Liver and Unresectable Lung Colorectal Metastases (LUNA). Ann Surg Oncol 2021; 28:4102-4103. [PMID: 33987761 DOI: 10.1245/s10434-021-10109-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/17/2021] [Indexed: 12/18/2022]
Affiliation(s)
- Tahsin M Khan
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Emily A Verbus
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Shahyan U Rehman
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Yun Shin Chun
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Jonathan M Hernandez
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
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