Anus preservation in low rectal adenocarcinoma based on MMR/MSI status (APRAM): a study protocol for a randomised, controlled, open-label, multicentre phase III trial

BACKGROUND

Anus preservation has been a challenge in the treatment of patients with low rectal adenocarcinoma (within 5 cm from the anal verge) because it is difficult to spare the anus with its functioning sphincter complex under the safe margin of tumour resection. Patients with dMMR/MSI-H can achieve a favourable complete response (CR) rate by using a single immune checkpoint inhibitor. For patients with pMMR/MSS/MSI-L, intensified neoadjuvant three-drug chemotherapy may be the preferred option for anal preservation. In addition, the watch and wait (W&W) strategy has been proven safe and feasible for patients with rectal cancer who achieve a clinical complete response (cCR). Therefore, we initiated this clinical trial to explore the optimal neoadjuvant treatment pattern for patients with low locally advanced rectal cancer (LARC) with different MMR/MSI statuses, aiming to achieve a higher cCR rate with the W&W strategy and ultimately provide more patients with a chance of anus preservation.

METHODS

This is a randomised, controlled, open-label, multicentre phase III trial. Patients with clinical stage T2-4 and/or N + tumours located within 5 cm from the anal verge are considered eligible. Based on the results of pathological biopsy, the patients are divided into two groups: dMMR/MSI-H and pMMR/MSS. Patients in the dMMR/MSI-H group will be randomly allocated in a 1:1 ratio to either arm A (monoimmunotherapy) or arm B (short-course radiotherapy followed by monoimmunotherapy). Patients in the pMMR/MSS group will be initially treated with long-term pelvic radiation with concurrent capecitabine combined with irinotecan. Two weeks after the completion of chemoradiotherapy (CRT), the patients will be randomly allocated in a 1:1 ratio to arm C (XELIRI six cycle regime) or arm D (FOLFIRINOX nine cycle regime). The irinotecan dose will be adjusted according to the UGT1A1-genotype. After treatment, a comprehensive assessment will be performed to determine whether a cCR has been achieved. If achieved, the W&W strategy will be adopted; otherwise, total mesorectal excision (TME) will be performed. The primary endpoint is cCR with the maintenance of 12 months at least, determined using digital rectal examination, endoscopy, and rectal MRI or PET/CT as a supplementary method.

DISCUSSION

APRAM will explore the best anus preservation model for low LARC, combining the strategies of consolidation chemotherapy, immunotherapy, and short-course radiotherapy, and aims to preserve the anus of more patients using W&W. Our study provides an accurate individual treatment mode based on the MMR/MSI status for patients with low LARC, and more patients will receive the opportunity for anus preservation under our therapeutic strategy, which would transform into long-term benefits.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05669092 (Registered 28th Nov 2022).

Lidocaine alleviates inflammation and pruritus in atopic dermatitis by blocking different population of sensory neurons

BACKGROUND AND PURPOSE

Atopic dermatitis is a common chronic pruritic inflammatory disease of the skin involving neuro-immune communication. Neuronal mechanism-based therapeutic treatments remain lacking. We investigated the efficacy of intravenous lidocaine therapy on atopic dermatitis and the underlying neuro-immune mechanism.

EXPERIMENTAL APPROACH

Pharmacological intervention, immunofluorescence, RNA-sequencing, genetic modification and immunoassay were performed to dissect the neuro-immune basis of itch and inflammation in atopic dermatitis-like mouse model and in patients.

KEY RESULTS

Lidocaine alleviated skin lesions and itch in both atopic dermatitis patients and calcipotriol (MC903)-induced atopic dermatitis model by blocking subpopulation of sensory neurons. QX-314, a charged Na_V blocker that enters through pathologically activated large-pore ion channels and selectivity inhibits a subpopulation of sensory neurons, has the same effects as lidocaine in atopic dermatitis model. Genetic silencing Na_V 1.8-expressing sensory neurons was sufficient to restrict cutaneous inflammation and itch in the atopic dermatitis model. However, pharmacological blockade of TRPV1-positive nociceptors only abolished persistent itch but did not affect skin inflammation in the atopic dermatitis model, indicating a difference between sensory neuronal modulation of skin inflammation and itch. Inhibition of activity-dependent release of calcitonin gene-related peptide (CGRP) from sensory neurons by lidocaine largely accounts for the therapeutic effect of lidocaine in the atopic dermatitis model.

CONCLUSION AND IMPLICATIONS

Na_V 1.8⁺ sensory neurons play a critical role in pathogenesis of atopic dermatitis and lidocaine is a potential anti-inflammatory and anti-pruritic agent for atopic dermatitis. A dissociable difference for sensory neuronal modulation of skin inflammation and itch contributes to further understanding of pathogenesis in atopic dermatitis.

[Spatiotemporal distribution of measles in China, 2001-2016]

Objective: To understand the spatial-temporal distribution and spatial clusters of measles cases in China. Methods: Measles incidence data was collected from the National Notifiable Disease Reporting System of Chinese Center for Disease Control and Prevention. The global and local spatial autocorrelation analyses were conducted by using software ArcGIS 10.2 and spatial-temporal scan was conducted by using software SaTScan 9.6. Results: A total of 1 012 537 cases of measles were reported in China from 2001 to 2016 and the annual incidence showed a sharp downward trend. There was global spatial clustering of measles cases during 2001-2004, 2005-2008, and 2009-2012, and their Moran's I coefficients were 0.29, 0.26, and 0.31, respectively. The results of local spatial autocorrelation analysis showed that there were high- high clustering areas of measles at all time periods, especially in western China. Guangdong province was detected as a separate high-low scattered area from 2005 to 2008 and no low-low clustering area was detected. The spatial-temporal scan statistics showed that there was a wide clustering area covering western, central and northern China, and Shanxi province and Guangxi Zhuang Autonomous Region from 2001-2008. Conclusion: The incidence of measles in China has a certain clustering in both space and time during 2001-2016, the results provide evidence for the development of future strategy of measles prevention and control in China.

Physicochemical properties and bioactivities of original and Se-enriched polysaccharides with different molecular weights extracted from Pleurotus ostreatus

Three polysaccharides (WZP1, WZP2, WZP3) and their Se-enriched products (SeWZP1, SeWZP2 and SeWZP3) were obtained from Pleurotus ostreatus using a simple, rapid method and HNO3-Na2SeO3 method, respectively. The molecular weight distribution profiles of all samples except SeWZP2 showed double peaks. The average molecular weights (Mw) of WZP1-3 were 48.6 kDa, 20.2 kDa and 11.8 kDa, respectively, and of SeWZP1-3 were 19.6 kDa, 37.7 kDa, 14.5 kDa, respectively. The complexity of monosaccharide composition of WZP1-3 was inversely proportional to the ethanol concentration used in the ethanol precipitation process. Additionally, the results of biological activity tests indicated that α-glucosidase inhibitory activity of WZP1-3 was related to the molecular weight and the monosaccharide composition complexity. The selenized modification can improve the α-glucosidase-inhibiting, hydroxyl radical-scavenging activity of P. ostreatus polysaccharides. Therefore, by improving their bioactivities by selenization, the polysaccharides of P. ostreatus could be utilized as a natural health food supplement.

[A study on measles and rubella antibody level in 319 pairs of mothers and infants in Songjiang District of Shanghai]

Objective: To explore serum levels of measles and rubella IgG antibodies among mothers and infants. Methods: According to the inclusion and exclusion criteria, we selected 319 puerperae and their infants in maternal hospitals of Songjiang district November 2016 to February 2017, venous blood were collected and serum measles and rubella IgG antibodies were measured using ELISA. To study the correlation between the level of measles and rubella antibodies in infants and mothers' by using the Spearman's correlation analysis. Results: The age at delivery was (29.71±4.25) years old; and the gestational age at delivery was (39.06±1.30) weeks. The positive rate and protection rate of measles antibody in puerperae were 82.5% (243/319) and 43.3% (135/319), the GMC [M (QR)] was 655.74 (251.21-1 299.02) mIU/ml. The positive rate of rubella antibody in puerperae was 61.1% (195/319), the GMC [M (QR)] was 31.34 (11.65-73.61) IU/ml. The positive rate and protection rate of measles antibody in infants were 84.1% (270/321) and 46.1% (148/321), the GMC [M (QR)] was 665.07 (279.63-1 544.07) mIU/ml. The positive rate of rubella antibody in infants was 69.5% (223/321), the GMC [M (QR)] was 40.30 (16.12-98.48) IU/ml. There was statistical difference in measles (Z=-14.64, P<0.001) and rubella (Z=-8.66, P<0.001) antibody levels between mothers and infants. There was positive correlation in measles (r=0.76, P<0.001) and rubella (r=0.86, P<0.001) antibody level between mothers and infants. Conclusion: The maternal antibody of measles and rubella had a concentration effect. The level of measles and rubella antibodies in the infants was higher than that in the mothers' and increased with the increase of the level of measles and rubella antibodies in the mothers.

Lycorine: a potential broad-spectrum agent against crop pathogenic fungi

A screening test showed that lycorine exhibited significant antifungal activity against 24 pathogenic crop fungi at concentrations of 500 μg/ml and 100 μg/ml, respectively. Fusarium graminearum was selected for antifungal mechanism studies by observing its mycelial morphology and investigating the variations in its conductivity. In addition, the substance absorption and metabolism of F. graminearum were explored. The mechanism was revealed as being one by which lycorine destroyed the cellular membrane and further influenced substance absorption and cell metabolism.

Activity of armillarisin B in vitro against plant pathogenic fungi

The methanolic extract of the fruiting bodies of the mushroom Armillariella tabescens was found to show antifungal activity against Gibberella zeae. The active compound was isolated from the fruiting bodies of A. tabescens by bioassay-guided fractionation of the extract and identified as armillarisin B. Armillarisin B eventually corresponds to 2-hydroxy-2-phenylpropanediamide and its structure was confirmed on the basis of spectroscopic studies including 2D NMR experiments.

Diterpenoids of macromycetes

This review surveys the chemical and biological literature dealing with the isolation, structure elucidation and bioactivity of diterpenoids from the fruiting bodies of macromycetes, concentrating on work that has appeared in the literature up to December 2007. In addition, this paper examines the research of diterpenoids produced by macromycetes grown in mycelial culture and the culture conditions for the fermentation of macromycetes.

A research on the relationship between ejaculation and serum testosterone level in men

The purpose of this study is to gain understanding of the relationship between ejaculation and serum testosterone level in men. The serum testosterone concentrations of 28 volunteers were investigated daily during abstinence periods after ejaculation for two phases. The authors found that the fluctuations of testosterone levels from the 2nd to 5th day of abstinence were minimal. On the 7th day of abstinence, however, a clear peak of serum testosterone appeared, reaching 145.7% of the baseline ( P < 0.01). No regular fluctuation was observed following continuous abstinence after the peak. Ejaculation is the precondition and beginning of the special periodic serum testosterone level variations, which would not occur without ejaculation. The results showed that ejaculation-caused variations were characterized by a peak on the 7th day of abstinence; and that the effective time of an ejaculation is 7 days minimum. These data are the first to document the phenomenon of the periodic change in serum testosterone level; the correlation between ejaculation and periodic change in the serum testosterone level, and the pattern and characteristics of the periodic change.

The 170-kDa glucose-regulated stress protein is an endoplasmic reticulum protein that binds immunoglobulin

Anoxia, glucose starvation, calcium ionophore A23187, EDTA, glucosamine, and several other conditions that adversely affect the function of the endoplasmic reticulum (ER) induce the synthesis of the glucose-regulated class of stress proteins (GRPs). The primary GRPs induced by these stresses migrate at 78 and 94 kDa (GRP78 and GRP94). In addition, another protein of approximately 150-170 kDa (GRP170) has been previously observed and is coordinately induced with GRP78 and GRP94. To characterize this novel stress protein, we have prepared an antisera against purified GRP170. Immunofluorescence, Endoglycosidase H sensitivity, and protease resistance of this protein in microsomes indicates that GRP170 is an ER lumenal glycoprotein retained in a pre-Golgi compartment. Immunoprecipitation of GRP170 with our antibody coprecipitates the GRP78 (also referred to as the B cell immunoglobulin-binding protein) and GRP94 members of this stress protein family in Chinese hamster ovary cells under stress conditions. ATP depletion, by immunoprecipitation in the presence of apyrase, does not affect the interaction between GRP78 and GRP170 but results in the coprecipitation of an unidentified 60-kDa protein. In addition, GRP170 is found to be coprecipitated with immunoglobulin (Ig) in four different B cell hybridomas expressing surface IgM, cytoplasmic Ig light chain only, cytoplasmic Ig heavy chain only, or an antigen specific secreted IgG. In addition, in IgM surface expressing WEHI-231 B cells, anti-IgM coprecipitates GRP78, GRP94, as well as GRP170; antibodies against GRP170 and GRP94 reciprocally coprecipitate GRP94/GRP170 as well as GRP78. Results suggest that this 170-kDa GRP is a retained ER lumenal glycoprotein that is constitutively present and that may play a role in immunoglobulin folding and assembly in conjunction or consecutively with GRP78 and GRP94.

Induction of glucose regulated proteins during growth of a murine tumor

Chronic anoxia, glucose starvation, low pH, and numerous other conditions induce the glucose-regulated system of stress proteins (GRPs), whose principal members are observed at 78, 94, and 170 kDa. These stresses may be expected to occur during growth in untreated tumors. To examine the possibility that GRPs are correspondingly induced, we have examined the protein profiles of small (< 0.1 g), intermediate (0.2-0.8 g), and large (> 1.8 g) radiation-induced fibrosarcoma (RIF) tumors grown on C3H mice. One and two-dimensional gel electrophoresis indicate that the principal GRPs at 78 and 94 are coordinately and substantially increased in large tumor masses, relative to the small, and may be partially increased in the intermediate tumors. Necrotic material removed from large tumors exhibited an identical pattern of GRP induction with no visible indication of protein degradation and also contained a significant fraction of viable cells. Western blot analysis using rabbit antisera raised against the 78 and 170 kDa GRPs also demonstrated the enhanced accumulation of these proteins in the large tumors. The antibody against the 170 kDa GRP was also capable of detecting the induction of this stress protein in large tumors by indirect immunofluorescence analysis. Northern blot studies using a probe for the GRP 78 gene also showed an increase in GRP 78 message in large tumors as well as in RIF cells exposed to anoxic stress in vitro. Two-dimensional gel electrophoresis indicated that the major heat shock proteins at 70 and 90 kDa were not increased in the larger tumors, and the amount of the 90 kDa species was reduced. Finally, the quantity of vimentin and its degradation products is significantly diminished in large tumors and in anoxic cells. This study demonstrates that RIF tumor cells undergo a glucose regulated stress response in situ during tumor growth.

Induction of heat-shock proteins by glutamine. The 'feeding effect'

Subconfluent, log-phase Chinese hamster ovary cells induced the major heat-shock proteins (hsp) when cells were refed, 40 hours after seeding. This method of inducing heat-shock proteins was also obtained by refeeding with fresh serum-free media, but not with media with a long shelf life or with media prepared without glutamine. It was observed that addition of glutamine alone to cultures at 40 hours post-seeding induced heat-shock proteins. Addition of ammonium chloride, however, had no discernible effect on heat-shock protein synthesis. Northern blot analysis indicated that this phenomenon reflected an increase in the levels of message for the constitutive/inducible member of the hsp 70 family, but not the non-constitutive member. To determine the effect of this induction on heat sensitivity, unfed and 'heat-shock-induced' refed cultures were heated at 45 degrees C. No significant difference in cell survival was observed. Therefore glutamine is the necessary ingredient required for the induction of heat-shock proteins and this method of inducing heat-shock proteins does not alter heat sensitivity.

Resistance to etoposide induced by three glucose-regulated stresses in Chinese hamster ovary cells

The induction of glucose-regulated proteins by a variety of specific inducers leads to an increase in resistance to Adriamycin (Shen et al., Proc. Natl., Acad. Sci. USA, 84: 3278, 1987). In this study we examine several additional agents for cross-resistance induced during a glucose-regulated response in an attempt to better define the mechanism through which this phenomenon occurs. When anoxia, calcium ionophore A23187, or 2-deoxyglucose are used, a substantial resistance is obtained against the topoisomerase II-targeted agent, etoposide. Partial resistance is induced against vincristine and actinomycin D. Glucose-regulated protein inducers do not substantially alter cellular response to either bleomycin or radiation. In the case of mitomycin C there is a cellular sensitization with anoxia and 2-deoxyglucose while calcium ionophore A23187 had no effect on survival. This study suggests that the resistance obtained during a glucose-regulated response against etoposide and Adriamycin may involve topoisomerase II.

Depletion of topoisomerase II in isolated nuclei during a glucose-regulated stress response

Conditions, such as anoxia or glucose starvation, which induce the glucose-regulated set of stress proteins also lead to resistance to adriamycin (J. Shen, C. Hughes, C. Chao, J. Cai, C. Bartels, T. Gessner, and J. Subjeck, Proc. Natl. Acad. Sci. USA 84:3278-3282, 1987) and etoposide. We report here that chronic anoxia, glucose starvation, 2-deoxyglucose, the calcium ionophore A23187, glucosamine, ethylene glycol-bis(beta-aminoethyl ether)-N,N,N',N'-tetraacetic acid (EGTA), and tunicamycin (all specific inducers of the glucose regulated system) lead to a rapid and selective depletion of topoisomerase II from isolated nuclei of Chinese hamster ovary cells. This effect precedes a decline in tritiated thymidine incorporation and a redistribution of cells from S into G1/G0. The depletion of the enzyme is not accompanied by a decline in mRNA levels. We have also examined the mutant Chinese hamster K12 cell line which is temperature sensitive for expression of glucose-regulated proteins. When nuclei were isolated from K12 cells incubated at the nonpermissive temperature, a loss of topoisomerase II was again observed in congruence with the expression of stress proteins and cellular resistance to etoposide. These changes were not obtained in parental Wg1A cells incubated at the same temperature. These studies indicate that topoisomerase II is highly sensitive to glucose-regulated stresses and that its depletion from the nucleus, with the associated changes in cell cycle parameters, may represent general characteristics of the glucose-regulated state. Since anoxia and glucose starvation can occur during tumor development, this pathway for expression of drug resistance may have clinical ramifications.

Multiparameter evaluation of the expression in situ of normal and tumor-associated antigens in human colorectal carcinoma

The immunoreactivity of a panel of monoclonal antibodies (MoAb) was studied in a series of patients with colorectal carcinomas to test the association of antigen expression with other parameters such as histopathologic stage, differentiation, and clinical outcome. Low-level binding to normal tissue and high-level binding to malignant tissue were observed with MoAb defining, respectively, a gastrointestinal cancer antigen (GICA), Leb (distal colon only), A, H type 2 antigen, X-like antigen, and the 200-kilodalton (Kd) protein of carcinoembryonic antigen (CEA). The degree of histologic differentiation correlated with the expression of Lea antigen, A, and Y haptens, whereas a progressive loss of these antigens coincided with loss of differentiation. Two undifferentiated carcinomas expressed only two, H type 2 antigen and a highly glycosylated protein of 20-50 Kd, of the 14 antigens investigated. An interesting, but not significant, association between Leb antigen expression and more extensive disease was found: Whereas 71% of Dukes C tumors were positive for Leb, only 48% of patients with Dukes A and B2 tumors showed the presence of Leb antigen. On the other hand, the presence of B72.3-defined antigen is significantly associated with an earlier stage of disease. Chi-square tests to assess the association of antigen positivity with disease recurrence indicated a significant binding association with tumor recurrence over a broad range of percent positive cells for two MoAb defining different determinants of GICA. Similar associations, but over a narrow range of positive cells, were found for H type 2 antigen and the 200-Kd protein of CEA.

The infrahyoid myocutaneous flap for reconstruction after resection of head and neck cancer

From May 1979 to August 1984, 112 infrahyoid myocutaneous flaps (IHMCFs) were used for reconstruction of the tongue after resection of lingual carcinoma (67 flaps in 63 consecutive cases) and for repair of defects after resection of carcinomas of buccal mucosa (23 cases), floor of mouth (8 cases), parotid gland (7 cases), and other malignancies (7 cases). Ten IHMCFs were extended to Ludwig's angle for repairing the open defect of the cheek or combined defect in the buccal mucosa and hard palate. The donor sites of 76 IHMCFs could be sutured primarily. The flap was successful in 90% of the cases (101 of 112 cases). Postoperatively, 94% of the cases (60 of 64 cases) of reconstructed tongue had good deglutition and 78% of the cases (50 of 64 cases) gave satisfactory enunciation. IHMCF is a new, versatile, reliable, and convenient flap suitable for repairing the defects in and around the oral cavity, particularly in the tongue, even in aged and weak patients.

Circulating tumor markers and assessment of response to intrahepatic chemotherapy of colon carcinoma

To assess the change in concentrations of circulating gastrointestinal cancer-associated antigens in response to therapy, we analyzed the sera of patients with hepatic metastasis from colorectal carcinoma who were treated with intrahepatic arterial chemotherapy. Serial serum samples were assessed for the tumor-associated antigens, carcinoembryonic antigen (CEA) and the gastrointestinal cancer antigen CA 19-9. Computed axial tomographic (CAT) scans were made to assess the size of the hepatic metastasis. In 9/10 of these patients the CEA predicted tumor response within 2-6 weeks after initiation of treatment, and in 7/10 the information was supported or more dramatically demonstrated by the CA 19-9. Combining data from both tumor markers may provide a more accurate assessment of the clinical response than one antigen alone. Recurrence of hepatic metastatic growth or extrahepatic tumor also was identified by elevation of one or both circulating tumor-associated antigens prior to other laboratory or clinical evidence of tumor growth.

Binding of murine immunoglobulin to human tissues after immunotherapy with anticolorectal carcinoma monoclonal antibody

An anticolorectal carcinoma antibody, 17-IA, that is of gamma 2a isotype and has been used in previous immunotherapy trials, binds to an antigen on most human colon tumors. This antigen is destroyed by the fixative and embedding procedures employed for routine histologic evaluation of tissues. It can be demonstrated by the avidin/biotin-labelled peroxidase complex (ABC) immunoperoxidase technique on briefly fixed, frozen sections of fresh human tissues. With this assay technique, the antibody is found to bind in vitro to both human colonic carcinoma and normal gastrointestinal epithelia. Tissues removed from patients having received the 17-IA antibody intravenously in an immunotherapy trial show bound antibody 1-2 after administration. This is no longer evident 3 weeks later though the antigen is present on the cell surface and is still capable of binding antibody in vitro.

Detection of a circulating gastrointestinal cancer antigen in sera of patients with gastrointestinal malignancies by a double determinant immunoassay with monoclonal antibodies against human blood group determinants

Monoclonal antibodies (MoAbs) produced against determinants A and B of the human ABO blood group system and against the Lea and Leb determinants of the Lewis (Le) blood group system detected these determinants on molecules released by cultured cells of human colorectal, gastric and/or pancreatic carcinoma (Ca) but not by a variety of other cells maintained in culture. Circulating Le antigen could be demonstrated in sera of patients by inhibiting the binding of MoAbs to a target preparation. A double determinant radioimmunoassay (DDIA) was then developed to detect the association of blood group determinants with a previously defined gastrointestinal cancer antigen (GICA). The DDIA with the anti-blood group and anti-GICA antibody was in some cases more sensitive in detecting GICA in sera than using the anti-GICA MoAb alone. Of 55 sera from patients with primary and early recurrent colorectal carcinoma (CRC), 10 (18%) were scored positive in the DDIA using only anti-GICA MoAb. When MoAb binding to a determinant on Leb and on H, type I, was used as first antibody in DDIA followed by anti-GICA MoAb 11 additional sera were reactive, increasing the percentage of positive sera to 38. Using the same combinations of MoAbs, the sensitivity of detection of GICA was only slightly improved from 63 to 66% in sera of patients with advanced CRC. The number of false positive sera from patients with non-malignant gastrointestinal diseases or from healthy donors remained at low levels when anti-blood group determinant antibodies were used together with anti-GICA MoAb. The results indicate that DDIAs with MoAbs against different blood group determinants and tumour associated antigens can improve the detection of circulating antigens in patients with early stage cancer.