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Ciobica ML, Sandulescu BA, Chicea LM, Iordache M, Groseanu ML, Carsote M, Nistor C, Radu AM. The Constellation of Risk Factors and Paraneoplastic Syndromes in Cholangiocarcinoma: Integrating the Endocrine Panel Amid Tumour-Related Biology (A Narrative Review). BIOLOGY 2024; 13:662. [PMID: 39336089 PMCID: PMC11429066 DOI: 10.3390/biology13090662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 08/07/2024] [Accepted: 08/24/2024] [Indexed: 09/30/2024]
Abstract
Cholangiocarcinomas (CCAs), a heterogeneous group of challenging malignant tumours which originate from the biliary epithelium, are associated with an alarming increasing incidence during recent decades that varies between different regions of the globe. Thus, awareness represents the key operating factor. Our purpose was to overview the field of CCAs following a double perspective: the constellation of the risk factors, and the presence of the paraneoplastic syndromes, emphasizing the endocrine features amid the entire multidisciplinary panel. This is a narrative review. A PubMed-based search of English-language original articles offered the basis of this comprehensive approach. Multiple risk factors underlying different levels of statistical evidence have been listed such as chronic biliary diseases and liver conditions, inflammatory bowel disease, parasitic infections (e.g., Opisthorchis viverrini, Clonorchis sinensis), lifestyle influence (e.g., alcohol, smoking), environmental exposure (e.g., thorotrast, asbestos), and certain genetic and epigenetic interplays. With regard to the endocrine panel, a heterogeneous spectrum should be taken into consideration: non-alcoholic fatty liver disease, obesity, type 2 diabetes mellitus, and potential connections with vitamin D status, glucagon-like peptide 1 receptor, or the galanin system, respectively, with exposure to sex hormone therapy. Amid the numerous dermatologic, hematologic, renal, and neurologic paraneoplastic manifestations in CCAs, the endocrine panel is less described. Humoral hypercalcaemia of malignancy stands as the most frequent humoral paraneoplastic syndrome in CCAs, despite being exceptional when compared to other paraneoplastic (non-endocrine) manifestations and to its reported frequency in other (non-CCAs) cancers (it accompanies 20-30% of all cancers). It represents a poor prognosis marker in CCA; it may be episodic once the tumour relapses. In addition to the therapy that targets the originating malignancy, hypercalcaemia requires the administration of bisphosphonates (e.g., intravenous zoledronic acid) or denosumab. Early detection firstly helps the general wellbeing of a patient due to a prompt medical control of high serum calcium and it also provides a fine biomarker of disease status in selected cases that harbour the capacity of PTHrP secretion. The exact molecular biology and genetic configuration of CCAs that display such endocrine traits is still an open matter, but humoral hypercalcaemia adds to the overall disease burden.
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Affiliation(s)
- Mihai-Lucian Ciobica
- Department of Internal Medicine and Gastroenterology, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Internal Medicine I and Rheumatology, "Dr. Carol Davila" Central Military University Emergency Hospital, 010825 Bucharest, Romania
| | - Bianca-Andreea Sandulescu
- Department of Internal Medicine and Gastroenterology, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Internal Medicine I and Rheumatology, "Dr. Carol Davila" Central Military University Emergency Hospital, 010825 Bucharest, Romania
- PhD Doctoral School of "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Liana-Maria Chicea
- Clinical Medical Department, University "Lucian Blaga" Sibiu, 550024 Sibiu, Romania
| | - Mihaela Iordache
- 1st Internal Medicine Department, "Dr. Carol Davila" Central Military University Emergency Hospital, 010825 Bucharest, Romania
| | - Maria-Laura Groseanu
- Internal Medicine and Rheumatology Department, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Mara Carsote
- Department of Endocrinology, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Clinical Endocrinology V, C.I. Parhon National Institute of Endocrinology, 011863 Bucharest, Romania
| | - Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Thoracic Surgery Department, "Dr. Carol Davila" Central Emergency University Military Hospital, 010825 Bucharest, Romania
| | - Ana-Maria Radu
- Department of Internal Medicine and Gastroenterology, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Internal Medicine I and Rheumatology, "Dr. Carol Davila" Central Military University Emergency Hospital, 010825 Bucharest, Romania
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Hong Q, Hu H, Liu D, Hu X, Wang Z, Zhou D. Bioinformatic analysis of differentially expressed genes in lung cancer bone metastasis and their implications for disease progression in lung cancer patients. J Thorac Dis 2024; 16:4666-4677. [PMID: 39144363 PMCID: PMC11320291 DOI: 10.21037/jtd-24-1081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 07/19/2024] [Indexed: 08/16/2024]
Abstract
Background Lung cancer is the most commonly diagnosed cancer and the leading cause of cancer-related death worldwide. Moreover, it is highly susceptible to distant metastasis, which is the main cause of pain in advanced lung cancer, and frequently occurs in the bone. This study aimed to identify the differentially expressed genes (DEGs) related to metastatic bone disease in lung cancer using bioinformatics methods and to analyze the risk factors influencing the incidence of secondary bone metastasis in lung cancer. Methods Gene expression profiles from the GSE175601 and GSE10799 datasets in the Gene Expression Omnibus (GEO) database were analyzed to screen for the DEGs associated with lung cancer bone metastasis. The STRING database was used to construct a protein-protein interaction (PPI) network, and the MCODE plugin was used to identify the key genes. The expression of these important genes in lung tumor tissues and their correlation with prognosis were validated in The Cancer Genome Atlas (TCGA) database. An examination of clinical data from patients diagnosed with stage IV lung adenocarcinoma treated at the Anhui No. 2 Provincial People's Hospital was conducted. Immunohistochemistry was used to examine the expression of key genes in lung cancer tumor tissues. A binary logistic regression analysis was conducted to examine the interactions in the expression of critical genes associated with bone metastasis in lung carcinoma patients. Results In total, 59 DEGs were identified in the GSE175601 and GSE10799 datasets through Venn diagram construction. The PPI network analysis revealed two significant modules and eight candidate genes (LAPTM5, LCP2, CD53, ARHGAP25, C1QA, DES, MYH11, and VIM). According to TCGA database analysis, in carcinogenic tissues of the lung, the expression of these eight critical genes is downregulated. Further, only the lung cancer patients who had high expressions of ARHGAP25 had an improved progress-free interval (PFI) (P<0.05), disease-specific survival (DSS), and overall survival (OS). Of the 49 with stage IV lung adenocarcinoma patients included in the study, 27 (55.10%) developed bone metastasis. The immunohistochemical (IHC) results indicated that the expression score of ARHGAP25 was significantly lower in the group with bone metastasis (3.93±2.95) than the group without bone metastasis (6.64±3.62) (P=0.006). The proportion of patients with low ARHGAP25 expression was significantly higher in the group with bone metastasis (70.37%, 19/27) than the group without bone metastasis (31.82%, 7/22) (P=0.007). The binary logistic regression analysis identified serum alkaline phosphatase (ALP) and ARHGAP25 expression levels as independent risk factors for the occurrence of secondary bone metastatic disease in lung carcinoma patients. Conclusions The key gene ARHGAP25 identified through bioinformatics for lung cancer bone metastasis was significantly downregulated. Its low expression constitutes an independent risk factor for secondary bone metastatic disease in patients with lung carcinoma.
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Affiliation(s)
- Qiaojun Hong
- Department of Oncology, Anhui No. 2 Provincial People’s Hospital, Hefei, China
| | - Haiyan Hu
- Department of Obstetrics and Gynaecology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Dandan Liu
- Department of Respiratory Medicine, Anhui No. 2 Provincial People’s Hospital, Hefei, China
| | - Xiaojian Hu
- Department of Thoracic Surgery, Anhui No. 2 Provincial People’s Hospital, Hefei, China
| | - Zhanggui Wang
- Department of Radiation Oncology, Anhui No. 2 Provincial People’s Hospital, Hefei, China
| | - Daoping Zhou
- Department of Oncology, Anhui No. 2 Provincial People’s Hospital, Hefei, China
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Wei J, Hu B, Fang H, Zhang F, Wang P. Single-molecule targeted therapy shrinks lung lesions and improves bone metastases: A case report. Medicine (Baltimore) 2024; 103:e38874. [PMID: 39029067 PMCID: PMC11398788 DOI: 10.1097/md.0000000000038874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2024] Open
Abstract
RATIONALE Bone metastasis is a common metastatic mode of advanced lung cancer and poses a great threat to the survival and quality of life of patients with this disease. However, the available literature has limited treatment options for advanced lung cancer with bone metastases. PATIENTS CONCERNS A 76-year-old married male patient was underwent CT due to cough and sputum for 1 month. On CT, space-occupying lesions were found in the left inferior lobe of the lung, as well as multiple bone metastases in the vertebral body and ilium. DIAGNOSES Pathologic sectioning of the lung lesion after puncture revealed invasive lung adenocarcinoma, and a genetic test revealed EGFR exon 21: L858R (64.60%). INTERVENTIONS Considering that the disease was not suitable for radiotherapy (extensive metastasis) and could not be treated with chemotherapy (poor underlying condition), the patient was given molecularly targeted therapy with osimertinib. OUTCOMES After 10 months of standard treatment (80 mg orally, once a day), the lung lesions of the patients became significantly smaller, and the bone metastases distinctly improved. And the patient's condition has not shown any signs of rebound with the one-year follow-up. LESSONS SUBSECTIONS In the present case, the bone metastases from lung adenocarcinoma almost completely disappeared after treatment with a single molecular targeted therapy agent, increasing the confidence in the treatment of advanced lung cancer.
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Affiliation(s)
- Jun Wei
- Department of Digestive Diseases, Wuhan Jinyintan Hospital, Tongji Medical College of Huazhong University of Science and Technology, Hubei Clinical Research Center Diseases, Wuhan Research Center for Communicable Disease Diagnosis and Treatment, Chinese Academy of Medical Sciences, Joint Laboratory Infectious of Diseases and Health, Wuhan Institute of Virology and Wuhan Jinyintan Hospital, Chinese Academy of Sciences, Wuhan, People's Republic of China
| | - Bei Hu
- Department of Radiology, General Hospital of Central Theater Command of the People's Liberation Army, Wuhan, People's Republic of China
| | - Huang Fang
- Department of Neurology, General Hospital of Central Theater Command of the People's Liberation Army, Wuhan, People's Republic of China
| | - Fangqi Zhang
- Department of Pulmonary and Critical Care Medicine, The 987th Hospital of Joint Logistics Support Force of People's Liberation Army, Baoji, People's Republic of China
| | - Peng Wang
- Department of Pharmacy, The 987th Hospital of Joint Logistics Support Force of People's Liberation Army, Baoji, People's Republic of China
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Wang Y, Zhang H, Qiang H, Li M, Cai Y, Zhou X, Xu Y, Yan Z, Dong J, Gao Y, Pan C, Yin X, Gao J, Zhang T, Yu Z. Innovative Biomaterials for Bone Tumor Treatment and Regeneration: Tackling Postoperative Challenges and Charting the Path Forward. Adv Healthc Mater 2024; 13:e2304060. [PMID: 38429938 DOI: 10.1002/adhm.202304060] [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: 11/19/2023] [Revised: 02/24/2024] [Indexed: 03/03/2024]
Abstract
Surgical resection of bone tumors is the primary approach employed in the treatment of bone cancer. Simultaneously, perioperative interventions, particularly postoperative adjuvant anticancer strategies, play a crucial role in achieving satisfactory therapeutic outcomes. However, the occurrence of postoperative bone tumor recurrence, metastasis, extensive bone defects, and infection are significant risks that can result in unfavorable prognoses or even treatment failure. In recent years, there has been significant progress in the development of biomaterials, leading to the emergence of new treatment options for bone tumor therapy and bone regeneration. This progress report aims to comprehensively analyze the strategic development of unique therapeutic biomaterials with inherent healing properties and bioactive capabilities for bone tissue regeneration. These composite biomaterials, classified into metallic, inorganic non-metallic, and organic types, are thoroughly investigated for their responses to external stimuli such as light or magnetic fields, internal interventions including chemotherapy or catalytic therapy, and combination therapy, as well as their role in bone regeneration. Additionally, an overview of self-healing materials for osteogenesis is provided and their potential applications in combating osteosarcoma and promoting bone formation are explored. Furthermore, the safety concerns of integrated materials and current limitations are addressed, while also discussing the challenges and future prospects.
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Affiliation(s)
- Yu Wang
- Department of Orthopedics, Jinshan Hospital, Fudan University, Shanghai, 201508, P. R. China
| | - Huaiyuan Zhang
- Department of Orthopedics, Jinshan Hospital, Fudan University, Shanghai, 201508, P. R. China
| | - Huifen Qiang
- Changhai Clinical Research Unit, The First Affiliated Hospital of Naval Medical University, Shanghai, 200433, P. R. China
- Shanghai Key Laboratory of Nautical Medicine and Translation of Drugs and Medical Devices, Shanghai, 200433, P. R. China
| | - Meigui Li
- School of Pharmacy, Henan University, Kaifeng City, Henan, 475004, P. R. China
| | - Yili Cai
- Department of Gastroenterology, Naval Medical Center, Naval Medical University, Shanghai, 200052, P. R. China
| | - Xuan Zhou
- School of Pharmacy, Henan University, Kaifeng City, Henan, 475004, P. R. China
| | - Yanlong Xu
- Department of Orthopedics, Jinshan Hospital, Fudan University, Shanghai, 201508, P. R. China
| | - Zhenzhen Yan
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, 200433, P. R. China
| | - Jinhua Dong
- The Women and Children Hospital Affiliated to Jiaxing University, Jiaxing, Zhejiang, 314000, P. R. China
| | - Yuan Gao
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, 200433, P. R. China
| | - Chengye Pan
- Department of Gastroenterology, The First Affiliated Hospital of Naval Medical University, Shanghai, 200433, P. R. China
| | - Xiaojing Yin
- Department of Gastroenterology, The First Affiliated Hospital of Naval Medical University, Shanghai, 200433, P. R. China
| | - Jie Gao
- Changhai Clinical Research Unit, The First Affiliated Hospital of Naval Medical University, Shanghai, 200433, P. R. China
- Shanghai Key Laboratory of Nautical Medicine and Translation of Drugs and Medical Devices, Shanghai, 200433, P. R. China
| | - Tinglin Zhang
- Changhai Clinical Research Unit, The First Affiliated Hospital of Naval Medical University, Shanghai, 200433, P. R. China
- Shanghai Key Laboratory of Nautical Medicine and Translation of Drugs and Medical Devices, Shanghai, 200433, P. R. China
| | - Zuochong Yu
- Department of Orthopedics, Jinshan Hospital, Fudan University, Shanghai, 201508, P. R. China
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Carsote M, Ciobica ML, Sima OC, Ciuche A, Popa-Velea O, Stanciu M, Popa FL, Nistor C. Personalized Management of Malignant and Non-Malignant Ectopic Mediastinal Thyroid: A Proposed 10-Item Algorithm Approach. Cancers (Basel) 2024; 16:1868. [PMID: 38791947 PMCID: PMC11120123 DOI: 10.3390/cancers16101868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024] Open
Abstract
We aimed to analyze the management of the ectopic mediastinal thyroid (EMT) with respect to EMT-related cancer and non-malignant findings related to the pathological report, clinical presentation, imaging traits, endocrine profile, connective tissue to the cervical (eutopic) thyroid gland, biopsy or fine needle aspiration (FNA) results, surgical techniques and post-operatory outcome. This was a comprehensive review based on revising any type of freely PubMed-accessible English, full-length original papers including the keywords "ectopic thyroid" and "mediastinum" from inception until March 2024. We included 89 original articles that specified EMTs data. We classified them into four main groups: (I) studies/case series (n = 10; N = 36 EMT patients); (II) malignant EMTs (N = 22 subjects; except for one newborn with immature teratoma in the EMT, only adults were reported; mean age of 62.94 years; ranges: 34 to 90 years; female to male ratio of 0.9). Histological analysis in adults showed the following: papillary (N = 11/21); follicular variant of the papillary type (N = 2/21); Hürthle cell thyroid follicular malignancy (N = 1/21); poorly differentiated (N = 1/21); anaplastic (N = 2/21); medullary (N = 1/21); lymphoma (N = 2/21); and MALT (mucosa-associated lymphoid tissue) (N = 1/21); (III) benign EMTs with no thyroid anomalies (N = 37 subjects; mean age of 56.32 years; ranges: 30 to 80 years; female to male ratio of 1.8); (IV) benign EMTs with thyroid anomalies (N = 23; female to male ratio of 5.6; average age of 52.1 years). This panel involved clinical/subclinical hypothyroidism (iatrogenic, congenital, thyroiditis-induced, and transitory type upon EMT removal); thyrotoxicosis (including autonomous activity in EMTs that suppressed eutopic gland); autoimmune thyroiditis/Graves's disease; nodules/multinodular goiter and cancer in eutopic thyroid or prior thyroidectomy (before EMT detection). We propose a 10-item algorithm that might help navigate through the EMT domain. To conclude, across this focused-sample analysis (to our knowledge, the largest of its kind) of EMTs, the EMT clinical index of suspicion remains low; a higher rate of cancer is reported than prior data (18.8%), incident imagery-based detection was found in 10-14% of the EMTs; surgery offered an overall good outcome. A wide range of imagery, biopsy/FNA and surgical procedures is part of an otherwise complex personalized management.
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Affiliation(s)
- Mara Carsote
- Department of Endocrinology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Clinical Endocrinology V, “C.I. Parhon” National Institute of Endocrinology, 011863 Bucharest, Romania
| | - Mihai-Lucian Ciobica
- Department of Internal Medicine and Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Internal Medicine I and Rheumatology, “Dr. Carol Davila” Central Military University Emergency Hospital, 010825 Bucharest, Romania
| | - Oana-Claudia Sima
- PhD Doctoral School, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Adrian Ciuche
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Thoracic Surgery Department, “Dr. Carol Davila” Central Military University Emergency Hospital, 010242 Bucharest, Romania
| | - Ovidiu Popa-Velea
- Department of Medical Psychology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania;
| | - Mihaela Stanciu
- Department of Endocrinology, Faculty of Medicine, Lucian Blaga University of Sibiu, 550024 Sibiu, Romania;
| | - Florina Ligia Popa
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550024 Sibiu, Romania;
| | - Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Thoracic Surgery Department, “Dr. Carol Davila” Central Military University Emergency Hospital, 010242 Bucharest, Romania
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Nistor C, Stanciu Gavan C, Birceanu A, Betianu C, Carsote M, Cucu AP, Stanciu M, Popa FL, Ciuche A, Ciobica ML. Primary Cardiac Intimal Sarcoma: Multi-Layered Strategy and Core Role of MDM2 Amplification/Co-Amplification and MDM2 Immunostaining. Diagnostics (Basel) 2024; 14:919. [PMID: 38732333 PMCID: PMC11083306 DOI: 10.3390/diagnostics14090919] [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: 03/23/2024] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
Primary cardiac tumours are relatively uncommon (75% are benign). Across the other 25%, representing malignant neoplasia, sarcomas account for 75-95%, and primary cardiac intimal sarcoma (PCIS) is one of the rarest findings. We aimed to present a comprehensive review and practical considerations from a multidisciplinary perspective with regard to the most recent published data in the specific domain of PCIS. We covered the issues of awareness amid daily practice clinical presentation to ultra-qualified management in order to achieve an adequate diagnosis and prompt intervention, also emphasizing the core role of MDM2 immunostaining and MDM2 genetic analysis. An additional base for practical points was provided by a novel on-point clinical vignette with MDM2-positive status. According to our methods (PubMed database search of full-length, English publications from January 2021 to March 2023), we identified three studies and 23 single case reports represented by 22 adults (male-to-female ratio of 1.2; male population with an average age of 53.75 years, range: 35-81; woman mean age of 55.5 years, range: 34-70) and a 4-year-old child. The tumour-related clinical picture was recognized in a matter of one day to ten months on first admission. These non-specific data (with a very low index of suspicion) included heart failure at least NYHA class II, mitral regurgitation and pulmonary hypertension, acute myocardial infarction, ischemic stroke, obstructive shock, and paroxysmal atrial fibrillation. Awareness might come from other complaints such as (most common) dyspnoea, palpitation, chest pressure, cough, asthenia, sudden fatigue, weakness, malaise, anorexia, weight loss, headache, hyperhidrosis, night sweats, and epigastric pain. Two individuals were initially misdiagnosed as having endocarditis. A history of prior treated non-cardiac malignancy was registered in 3/23 subjects. Distant metastasis as the first step of detection (n = 2/23; specifically, brain and intestinal) or during follow-up (n = 6/23; namely, intestinal, brain and bone, in two cases for each, and adrenal) required additional imagery tools (26% of the patients had distant metastasis). Transoesophageal echocardiography, computed tomography (CT), magnetic resonance imagery, and even 18F-FDG positronic emission tomography-CT (which shows hypermetabolic lesions in PCIS) represent the basis of multimodal tools of investigation. Tumour size varied from 3 cm to ≥9 cm (average largest diameter of 5.5 cm). The most frequent sites were the left atrium followed by the right ventricle and the right atrium. Post-operatory histological confirmation was provided in 20/23 cases and, upon tumour biopsy, in 3/23 of them. The post-surgery maximum free-disease interval was 8 years, the fatal outcome was at the earliest two weeks since initial admission. MDM2 analysis was provided in 7/23 subjects in terms of MDM2-positive status (two out of three subjects) at immunohistochemistry and MDM2 amplification (four out of five subjects) at genetic analysis. Additionally, another three studies addressed PCISs, and two of them offered specific MDM2/MDM2 assays (n = 35 patients with PCISs); among the provided data, we mention that one cohort (n = 20) identified a rate of 55% with regard to MDM2 amplification in intimal sarcomas, and this correlated with a myxoid pattern; another cohort (n = 15) showed that MDM2-positive had a better prognostic than MDM2-negative immunostaining. To summarize, MDM2 amplification and co-amplification, for example, with MDM4, CDK4, HMGA3, CCND3, PDGFRA, TERT, KIT, CCND3, and HDAC9, might improve the diagnosis of PCIS in addition to MDM2 immunostaining since 10-20% of these tumours are MDM2-negative. Further studies are necessary to highlight MDM2 applicability as a prognostic factor and as an element to be taken into account amid multi-layered management in an otherwise very aggressive malignancy.
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Affiliation(s)
- Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.N.); (A.C.)
- Thoracic Surgery Department, “Dr. Carol Davila” Central Military Emergency University Hospital, 010242 Bucharest, Romania; (C.S.G.); (A.-P.C.)
| | - Camelia Stanciu Gavan
- Thoracic Surgery Department, “Dr. Carol Davila” Central Military Emergency University Hospital, 010242 Bucharest, Romania; (C.S.G.); (A.-P.C.)
| | - Adelina Birceanu
- Pathology and Immunohistochemistry Laboratory, Pathoteam Diagnostic, 051923 Bucharest, Romania;
| | - Cezar Betianu
- Department of Interventional Imaging, “Doctor Carol Davila” Central Military Emergency University Hospital, 010825 Bucharest, Romania;
| | - Mara Carsote
- Department of Endocrinology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Clinical Endocrinology V, C.I. Parhon National Institute of Endocrinology, 020021 Bucharest, Romania
| | - Anca-Pati Cucu
- Thoracic Surgery Department, “Dr. Carol Davila” Central Military Emergency University Hospital, 010242 Bucharest, Romania; (C.S.G.); (A.-P.C.)
- PhD Doctoral School, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Mihaela Stanciu
- Department of Endocrinology, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550024 Sibiu, Romania;
| | - Florina Ligia Popa
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550024 Sibiu, Romania;
| | - Adrian Ciuche
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.N.); (A.C.)
- Thoracic Surgery Department, “Dr. Carol Davila” Central Military Emergency University Hospital, 010242 Bucharest, Romania; (C.S.G.); (A.-P.C.)
| | - Mihai-Lucian Ciobica
- Department of Internal Medicine and Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Internal Medicine I and Rheumatology, “Dr. Carol Davila” Central Military University Emergency Hospital, 010825 Bucharest, Romania
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Ke Z, Zhao M, Meng F, Zhang L, Zhang H, Ning Y, Zhu Y, Fan X, Zhang Y. Predictive nomogram for bone metastases in lung cancer based on monocyte infiltration. Am J Cancer Res 2024; 14:1217-1226. [PMID: 38590412 PMCID: PMC10998761 DOI: 10.62347/vzly9631] [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: 10/04/2023] [Accepted: 02/25/2024] [Indexed: 04/10/2024] Open
Abstract
The presence of bone metastases (BM) in patients with lung cancer is indicative of a worse prognosis. The present study aims to investigate the risk factors associated with BM in patients with lung cancer. Patients with lung cancer admitted to the First Affiliated Hospital of Anhui Medical University between June 2019 and September 2021 were enrolled in this study. A nomogram was constructed based on the outcomes derived from univariate and multivariate analyses. Concordance index, calibration plots, receiver operating characteristic curves, and decision curve analysis were used to evaluate the nomogram. To substantiate the influence of monocytes on lung cancer BM, various assays, including cell co-culture, Transwell, wound-healing assays, and immunohistochemistry and immunofluorescence staining, were conducted. Statistical analyses were performed using SPSS 22.0 software and GraphPad Prism 7.0. A total of 462 eligible patients were enrolled, comprising 220 with BM and 242 without. Multivariate analysis revealed that histological type, medical history, monocyte percentage, and LDH (Lactate Dehydrogenase) and ALP (Alkaline Phosphatase) levels were independent risk factors for BM in lung cancer. Transwell and wound-healing assays indicated that co-culture with monocytes significantly enhanced the migration and invasion capabilities of A549 cells in vitro. Immunohistochemistry and immunofluorescence analyses demonstrated a noteworthy increase in monocyte infiltration in the primary lesions of patients with lung cancer with BM. In conclusion, this study successfully constructed and validated a precise, straightforward, and cost-effective prognostic nomogram for patients with lung cancer with BM.
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Affiliation(s)
- Zhangyan Ke
- Department of Geriatric Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical UniversityHefei, Anhui, China
- Anhui Geriatric Institute, The First Affiliated Hospital of Anhui Medical UniversityHefei, Anhui, China
| | - Meiling Zhao
- Department of Gerontology, Bishan District People’s Hospital of ChongqingChongqing, China
| | - Furong Meng
- Department of Geriatric Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical UniversityHefei, Anhui, China
- Anhui Geriatric Institute, The First Affiliated Hospital of Anhui Medical UniversityHefei, Anhui, China
| | - Lulu Zhang
- Department of Geriatric Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical UniversityHefei, Anhui, China
| | - Hao Zhang
- Fuyang Second People’s HospitalFuyang, Anhui, China
| | - Yajing Ning
- Department of Geriatric Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical UniversityHefei, Anhui, China
- Anhui Geriatric Institute, The First Affiliated Hospital of Anhui Medical UniversityHefei, Anhui, China
| | - Yingying Zhu
- Department of Geriatric Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical UniversityHefei, Anhui, China
- Anhui Geriatric Institute, The First Affiliated Hospital of Anhui Medical UniversityHefei, Anhui, China
| | - Xiaoyun Fan
- Department of Geriatric Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical UniversityHefei, Anhui, China
- Anhui Geriatric Institute, The First Affiliated Hospital of Anhui Medical UniversityHefei, Anhui, China
| | - Yanbei Zhang
- Department of Geriatric Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical UniversityHefei, Anhui, China
- Anhui Geriatric Institute, The First Affiliated Hospital of Anhui Medical UniversityHefei, Anhui, China
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8
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He J, Liang G, Yu H, Lin C, Shen W. Evaluating the predictive significance of systemic immune-inflammatory index and tumor markers in lung cancer patients with bone metastases. Front Oncol 2024; 13:1338809. [PMID: 38264753 PMCID: PMC10805270 DOI: 10.3389/fonc.2023.1338809] [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: 11/15/2023] [Accepted: 12/13/2023] [Indexed: 01/25/2024] Open
Abstract
Objective This study aims to develop a predictive model for identifying lung cancer patients at elevated risk for bone metastases, utilizing the Unified Immunoinflammatory Index and various tumor markers. This model is expected to facilitate timely and effective therapeutic interventions, especially in the context of the growing significance of immunotherapy for lung cancer treatment. Methods A retrospective analysis was conducted on 324 lung cancer patients treated between January 2019 and January 2021. After meeting the inclusion criteria, 241 patients were selected, with 56 exhibiting bone metastases. The cohort was divided into a training group (169 patients) and a validation group (72 patients) at a 7:3 ratio. Lasso regression was employed to identify critical variables, followed by logistic regression to construct a Nomogram model for predicting bone metastases. The model's validity was ascertained through internal and external evaluations using the Concordance Index (C-index) and Receiver Operating Characteristic (ROC) curve. Results The study identified several factors influencing bone metastasis in lung cancer, such as the Systemic Immune-Inflammatory Index (SII), Carcinoembryonic Antigen (CEA), Neuron Specific Enolase (NSE), Cyfra21-1, and Neutrophil-to-Lymphocyte Ratio (NLR). These factors were incorporated into the Nomogram model, demonstrating high validation accuracy with C-index scores of 0.936 for internal and 0.924 for external validation. Conclusion The research successfully developed an intuitive and accurate Nomogram prediction model utilizing clinical indicators to predict the risk of bone metastases in lung cancer patients. This tool can be instrumental in aiding clinicians in developing personalized treatment plans, thereby optimizing patient outcomes in lung cancer care.
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Affiliation(s)
| | | | | | | | - Weiyu Shen
- Department of Thoracic Surgery, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China
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Dumitrascu CO, Gherghe M, Costache M, Cretu B, Cirstoiu C. The Role of Serum and Peritoneal Biomarkers in Predicting Sepsis and Septic Multiorgan Failure in Patients With Secondary Peritonitis. Cureus 2023; 15:e41724. [PMID: 37441100 PMCID: PMC10335813 DOI: 10.7759/cureus.41724] [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] [Accepted: 07/10/2023] [Indexed: 07/15/2023] Open
Abstract
Purpose Secondary peritonitis is still one of the most important causes of severe sepsis in the world; therefore, it is of utmost importance to identify biomarkers that could be employed for the purpose of selecting patients at high risk for developing life-threatening complications after emergency surgery. In view of this quest, our study seeks to reveal the possible role for serum and peritoneal concentrations of selected biomarkers, specifically presepsin, procalcitonin, monocyte chemoattractant protein-1 (MCP-1), high mobility group box 1 protein (HMGB-1) and interleukins (IL-6, -8, -10), in early prediction of sepsis and septic multiorgan failure for patients with secondary peritonitis. Methods We prospectively observed 32 selected patients with secondary peritonitis that underwent emergency surgery. Blood and peritoneal fluid samples were drawn at the time of surgery (T0), and after that, blood samples were taken at 24 (T1) and 48 (T2) hours postoperatively. Cytokines concentrations were determined using a sandwich enzyme-linked immunosorbent assay (ELISA), a non-competitive variant, both in peritoneal fluid and serum. For determining whole blood concentration of presepsin and procalcitonin, PATHFAST™ assays (Polymedco, Cortlandt, New York) were used, based on the principle of non-competitive chemiluminescent enzyme immune-assay (CLEIA). The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of University Emergency Hospital Bucharest (no. 40325/6 April 2023). Results We found significant elevations in the peritoneal concentrations of interleukins 6, 8, 10, HMGB-1, and MCP-1 in all patients with secondary peritonitis at the moment of surgery; however, no clear correlation could be made based on this data with patient evolution. With regards to blood concentrations of the aforementioned serum cytokines and presepsin, procalcitonin (as already established markers of sepsis), our results showed good predictive value of presepsin for developing sepsis and septic multiorgan failure from the first hours in this patient category. All other biomarkers, despite having higher concentrations than baseline, in particular at 24-48 hours after surgery, had unpredictable dynamics that couldn't be correlated with the severity of the disease. Conclusion Cytokine production is the mainstay in developing sepsis and septic multiorgan failure in patients with secondary peritonitis; therefore, studying the dynamics of said cytokines seems of interest in finding tools to predict the development of sepsis or sepsis-related mortality. However, at the time, there seemed to be no clear correlation between the values of these cytokines and the development of complications.
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Affiliation(s)
- Clementina O Dumitrascu
- Anesthesiology and Critical Care Department, University Emergency Hospital of Bucharest, Bucharest, ROU
| | - Mihai Gherghe
- Anesthesiology and Critical Care Department, University Emergency Hospital of Bucharest, Bucharest, ROU
| | - Mihai Costache
- Orthopedics and Traumatology Department, University Emergency Hospital of Bucharest, Bucharest, ROU
| | - Bogdan Cretu
- Orthopedics and Traumatology Department, University Emergency Hospital of Bucharest, Bucharest, ROU
| | - Catalin Cirstoiu
- Orthopedics and Traumatology Department, University Emergency Hospital of Bucharest, Bucharest, ROU
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10
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Cretu B, Costache M, Cursaru A, Serban B, Spiridonica R, Popa M, Cirstoiu C, Iordache S. Restoring Anatomical Features in Primary Total Knee Arthroplasty. Cureus 2023; 15:e40616. [PMID: 37342300 PMCID: PMC10278159 DOI: 10.7759/cureus.40616] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 06/22/2023] Open
Abstract
Today, the number of people affected by gonarthrosis symptoms is increasing proportionally. Total knee arthroplasty (TKA) is a successful intervention that aims to reduce pain and restore knee function. However, studies have shown that active young patients still have limitations in performing activities such as skiing, golfing, surfing, and dancing. Over the last few years, total knee arthroplasty has undergone significant changes. Most of the modern TKA implants are designed to reproduce the normal biomechanics of the knee joint, mimicking the physiological pattern with greater compliance in the medial compartment between the tibial insert and femoral condyle and less congruence on the lateral side. Unfortunately, functional outcomes are compromised in approximately half of TKA patients. This loss may be caused by the abnormal kinematics and inherent instability of many contemporary implants. The proper alignment of the femoral component during TKA is a crucial step that influences postoperative results. The position of the femoral component in the axial plane is responsible for flexion stability, knee joint kinematics, flexion alignment, and patellar tracking. The main goal when choosing a type of prosthesis is to achieve an adequate recovery that leads to an improvement in mobility and an increase in the efficiency of the quadriceps.
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Affiliation(s)
- Bogdan Cretu
- Orthopedics and Traumatology Department, University Emergency Hospital, Bucharest, ROU
| | - Mihai Costache
- Orthopedics and Traumatology Department, University Emergency Hospital, Bucharest, ROU
| | - Adrian Cursaru
- Orthopedics and Traumatology Department, University Emergency Hospital, Bucharest, ROU
| | - Bogdan Serban
- Orthopedics and Traumatology Department, University Emergency Hospital, Bucharest, ROU
| | - Razvan Spiridonica
- Orthopedics and Traumatology Department, University Emergency Hospital, Bucharest, ROU
| | - Mihnea Popa
- Orthopedics and Traumatology Department, University Emergency Hospital, Bucharest, ROU
| | - Catalin Cirstoiu
- Orthopedics and Traumatology Department, University Emergency Hospital, Bucharest, ROU
| | - Sergiu Iordache
- Orthopedics and Traumatology Department, University Emergency Hospital, Bucharest, ROU
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11
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Cretu I, Geoanta C, Bogheanu OI, Milicescu M, Bojinca M, Costache M, Cirstoiu C, Cretu B. Cerebral Tuberculosis in a Patient Following Treatment With Infliximab for Ankylosing Spondylitis: A Case Report. Cureus 2023; 15:e39117. [PMID: 37216132 PMCID: PMC10195647 DOI: 10.7759/cureus.39117] [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] [Accepted: 05/17/2023] [Indexed: 05/24/2023] Open
Abstract
Ankylosing spondylitis (AS) mainly belongs to the group of axial spondylitis. It is a chronic inflammatory disease that primarily affects the spine, but can also affect peripheral joints. It is characterized by inflammatory lower back pain and morning stiffness. Tuberculosis is still a cause of morbidity and mortality in developing countries. Management of patients with AS consists of patient education, spinal mobility exercises, non-steroidal anti-inflammatory drugs (NSAIDs), corticotherapy, and anti-tumor necrosis factor alpha (TNF-α) biological agents. Anti-TNF-α biological agents have changed the prognosis of patients with AS. They contain anti-TNF-α monoclonal antibodies (golimumab, infliximab, adalimumab, certolizumab) and the soluble TNF-α receptor (etanercept). Hip and knee involvement is common in patients with AS, as evidenced in radiographs as bone erosion and joint space narrowing. The patient may have severe pain, stiffness, and loss of mobility, and the treatment involves surgery for joint arthroplasty. We present the case of a 63-year-old patient with axial spondyloarthritis who was treated with infliximab and developed cerebral tuberculosis after three years of biological therapy. The purpose of the study is to determine the possibility of resuming biological therapy at the time of AS reactivation, given the long-term treatment and adverse reactions of cortisone therapy (aseptic necrosis of the femoral head).
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Affiliation(s)
- Ioana Cretu
- Internal Medicine & Rheumatology, Doctor Ion Cantacuzino Clinical Hospital, Bucharest, ROU
| | - Corina Geoanta
- Internal Medicine & Rheumatology, Doctor Ion Cantacuzino Clinical Hospital, Bucharest, ROU
| | - Oana-Irina Bogheanu
- Internal Medicine & Rheumatology, Doctor Ion Cantacuzino Clinical Hospital, Bucharest, ROU
| | - Mihaela Milicescu
- Internal Medicine & Rheumatology, Doctor Ion Cantacuzino Clinical Hospital, Bucharest, ROU
| | - Mihai Bojinca
- Internal Medicine & Rheumatology, Doctor Ion Cantacuzino Clinical Hospital, Bucharest, ROU
| | - Mihai Costache
- Orthopedics & Traumatology, Bucharest University Emergency Hospital, Bucharest, ROU
| | - Catalin Cirstoiu
- Orthopedics & Traumatology, Bucharest University Emergency Hospital, Bucharest, ROU
| | - Bogdan Cretu
- Orthopedics & Traumatology, Bucharest University Emergency Hospital, Bucharest, ROU
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12
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Iordache S, Costache M, Cursaru A, Serban B, Spiridonica R, Popa M, Cirstoiu C, Cretu B. A Narrative Review of Patellar Resurfacing Versus Non-resurfacing in Total Knee Arthroplasty. Cureus 2023; 15:e39362. [PMID: 37228351 PMCID: PMC10207997 DOI: 10.7759/cureus.39362] [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] [Accepted: 05/22/2023] [Indexed: 05/27/2023] Open
Abstract
The number of individuals who experience the symptoms of gonarthrosis rises proportionally as life expectancy rises and the population becomes more active. The purpose of total knee arthroplasty (TKA) is to lessen pain and restore knee function, and it has a high success rate. The restoration of patellar tracking in addition to the proper alignment of the femoral and tibial components contributes to the success of the arthroplasty and the patient's happiness. Replacement of the knee is not an easy process. One of the major objectives of total knee replacement is to achieve the proper rotation of the femoral components. A critical step that affects postoperative outcomes in total knee arthroplasty is the correct alignment of the femoral component. The axial plane of the femoral component is to blame for flexion stability, knee joint kinematics, flexion alignment, and patellar tracking. The patella is the largest sesamoid bone in the human body, and its major role is to enhance the quadriceps' moment arm, which allows the knee to expand. The distribution of patellofemoral compressive pressures during knee flexion and the centralization of the quadriceps muscles' multidirectional pull during extension are both critical functions of the patella. After primary knee arthroplasty, there are 8% more cases of anterior knee discomfort than there were before. Whether or not the patella was resurfaced, patients with primary TKA experience anterior knee discomfort. Patella baja is caused by excessive joint line elevation, which causes persistent overload and discomfort. The design of the TKR might have an impact on postoperative patellofemoral problems. After TKR, patellofemoral maltracking and patellar dislocation are often caused by surgical mistakes.
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Affiliation(s)
- Sergiu Iordache
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Mihai Costache
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Adrian Cursaru
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Bogdan Serban
- Orthopedics and Traumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Razvan Spiridonica
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Mihnea Popa
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Catalin Cirstoiu
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Bogdan Cretu
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
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13
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Hu X, Jiang C, Hu N, Hong S. ADAMTS1 induces epithelial-mesenchymal transition pathway in non-small cell lung cancer by regulating TGF-β. Aging (Albany NY) 2023; 15:2097-2114. [PMID: 36947712 PMCID: PMC10085599 DOI: 10.18632/aging.204594] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/16/2023] [Indexed: 03/24/2023]
Abstract
Non-small cell lung cancer (NSCLC) accounts for approximately 80% of all lung cancers. Identifying key molecular targets related to the initiation, development, and metastasis of lung cancer is important for its diagnosis and target therapy. The ADAMTS families of multidomain extracellular protease enzymes have been reported to be involved in many physiological processes. In this study, we found that ADAMTS1 was highly expressed in NSCLC tissues, which promoted cell proliferation, migration, invasion, and epithelial to mesenchymal transition (EMT) of NSCLC cells. In the NSCLC tumor metastasis model involving nude mice, overexpression of ADAMTS1 promoted EMT and lung metastasis of tumor cells. Moreover, ADAMTS1 positively regulated TGF-β expression, and TGF-β was highly expressed in NSCLC tumor tissues. si-TGF-β or inhibition of TGF-β expression through the short peptide KTFR on ADAMTS1 protein could reverse the oncogenic effects of ADAMTS1 on lung cancer cells. Taken together, ADAMTS1 functioned as an oncogene in NSCLC cells by promoting TGF-β expression, indicating that ADAMTS1 has important regulatory roles in the progression of NSCLC.
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Affiliation(s)
- Xueqian Hu
- Department of Oncology, Ningbo Municipal Hospital of TCM, Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, China
| | - Chunqi Jiang
- Department of Oncology, Ningbo Municipal Hospital of TCM, Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, China
| | - Ning Hu
- Department of Cardiovascular Division, Ningbo Municipal Hospital of TCM, Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, China
| | - Shanyi Hong
- Department of Internal Medicine, Ningbo Municipal Hospital of TCM, Affiliated Hospital of Zhejiang Chinese Medical University, Ningbo, China
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