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The significance of postoperative adjuvant radiotherapy (PORT) on the survival of resected IIIA-N2 non-small cell lung cancer (NSCLC) remains controversial. Here, we aimed to determine the predictive value of the three nodal classifications which might aid in PORT decision-making.A total of 4797 patients with stage IIIA-N2 resected NSCLC were identified in the Surveillance, Epidemiology and End Results (SEER) database and were grouped by whether PORT was administered. Survival analysis was used to identify the patient groups who can benefit from PORT. Multivariate analysis was performed to confirm the independent risk factors for lung cancer-specific survival (LCSS) and overall survival (OS). A validation cohort of 1184 patients from three medical centers in China were also included.PORT was not associated with better LCSS and OS in the entire cohort after propensity score matching (PSM). However, in the subgroups of positive lymph nodes 4 (PLN4), lymph node ratio 4 (LNR4), and log odds of positive lymph nodes 4 (LODDS4), PORT exhibited its role in improving LCSS (p lt; 0.05). Although the three nodal classifications were all identified as independent predictors of LCSS and OS, LODDS classification had the best discriminatory ability and prognostic accuracy for stage IIIA-N2 patients. Similar results were also obtained in the validation cohort.The LODDS classification not only exhibited the best prognostic performance in predicting LCSS and OS in stage IIIA-N2 disease, but also could help tailor individualized PORT.

OBJECTIVESThis study aimed to investigate the potential of complex glandular patterns (CGP) in lymph node micrometastasis (LNMM) and to determine the clinical beneficiaries in stage I lung adenocarcinoma (LUAD) with CGP. Meanwhile, the feasibility of detecting CGP on frozen section was also evaluated.METHODSWe retrospectively analysed the clinicopathological characteristics of 848 pathologic-stage I LUADs. A logistic regression model and a Cox proportional-hazards model were conducted to define the risk factors for LNMM and survival respectively. Furthermore, 5 pathologists reviewed frozen sections of 100 LUADs independently.RESULTSThe logistic regression model indicated that CGP [odds ratio 3.89, 95% confidence interval (CI) 2.46–6.15; P CONCLUSIONSLNMM was more frequently observed in stage I LUAD with CGP. Adequate lymphadenectomy and adjuvant chemotherapy were associated with improved survival in CGP-present patients, especially in CGP-present/LNMM-positive subgroup. Additionally, it is feasible to identify CGP on frozen section intraoperatively.

Apoptosis of cardiomyocytes is a critical outcome of myocardial ischemia-reperfusion injury (MIRI), which leads to the permanent impairment of cardiac function. Upregulated E2F1 is implicated in inducing cardiomyocyte apoptosis, and thus intervention of the E2F1 signaling pathway

Lung adenocarcinoma (LUAD) is the most common histological type of non-small cell lung cancer (NSCLC). Due to the nonspecific early symptoms, the majority of the diagnosed LUAD patients are in the middle and late stages, with multiple metastases, and have missed the optimal period for treatment. Current studies have reported lncRNA DARS-AS1 as a cancer-promoting gene that expedites tumorigenesis. This is the first study demonstrating that DARS-AS1 is involved in the mediating process of LUAD. Cell functional experiments revealed that lncRNA DARS-AS1 participated in enhancing LUAD proliferation, invasion, and migration by inhibiting miR-188-5p. The investigation on DARS-AS1/miR-188-5p led to the discovery of KLF12 as a downstream target of miR-188-5p, and the regulatory pathway was established as DARS-AS1/miR-188-5p/KLF12. According to western blot results, DARS-AS1 promoted LUAD cell growth, migration, and invasion via stimulation of the PI3K/AKT pathway, activating the EMT process, and up-regulating the CyclinD1 and Bcl-2 proteins. This was the first report on the DARS-AS1/miR-188-5p/KLF12 axis and offered a novel strategy for early diagnosis, a new therapeutic method, and an improved prognosis for LUAD.

Cytosolic protein delivery holds great potential for the development of protein-based biotechnologies and therapeutics. Currently, cytosolic protein delivery is mainly achieved with the assistance of various carriers. Herein, we present a universal and effective strategy for carrier-free cytosolic protein delivery via metabolic glycoengineering and bioorthogonal click reactions. Ac4ManNAz (AAM), an azido-modified N-acetylmannosamine analogue, was first employed to label tumor cell surfaces with abundant azido groups via glycometabolism. Then, proteins including RNase A, cytochrome C (Cyt C), and bovine serum albumin (BSA) were covalently modified with dibenzocyclooctyne (DBCO). Based on the highly efficient bioorthogonal click reactions between DBCO and azido, DBCO-modified proteins could be efficiently internalized by azido-labeled cancer cells. RNase A-DBCO could largely maintain its enzymatic activity and, thus, led to notable anti-tumor efficacy in HeLa and B16F10 cells in vitro and in B16F10 xenograft tumors in vivo. This study therefore provides a simple and powerful approach for carrier-free protein delivery and would have broad applicability in anti-tumor protein therapy.

Background T-cell immunoglobulin and mucin-domain containing-3 (TIM-3) is a promising checkpoint. However, its features and prognostic value remain undetermined in esophageal squamous cell carcinoma (ESCC). This study evaluated the prognostic value of TIM-3 expression and its relationship with programmed cell death 1 (PD-1) and CD8+ tumor-infiltrating lymphocytes (TILs) in patients with surgically resected ESCC. Methods Expression levels of TIM-3, PD-1, and CD8+ TILs in ESCC were determined by immunohistochemistry. The association between clinicopathologic features or clinical outcomes and TIM-3 expression was analyzed. Results A total of 183 patients with ESCC who had undergone esophagectomy without implementation of neoadjuvant therapy at the Second Affiliated Hospital of Soochow University in Suzhou, China from January 2009 to December 2014 were included. PD-1 positivity (P = .032) and high CD8+ TIL density (P = .035) significantly correlated with positive TIM-3 expression. TIM-3 positivity was an independent risk factor for recurrence-free survival (RFS) (P Conclusions Positive TIM-3 expression was associated with PD-1 positivity and high CD8+ TIL density and was an independent risk factor for RFS and OS in ESCC. Furthermore, the combination of TIM-3 and PD-1 expression or CD8+ TIL density could further stratify patients into different groups with distinct prognosis.

siRNA-mediated RNA interference (RNAi) against inflammation-related genes provides a promising modality for the treatment of myocardial ischemia reperfusion (IR) injury, and its success is critically dependent on the development of efficient yet safe siRNA delivery vehicles. Herein, we developed a bioreducible, branched poly(β-amino ester) with built-in redox-responsive domains (BPAE-SS) for the effective ICAM-1 siRNA delivery into injured rat cardiac microvascular endothelial cells (RCMECs). The branched BPAE-SS with a multivalent structure afforded potent siRNA binding affinity compared to its linear analogue, while upon internalization into RCMECs it was instantaneously degraded by intracellular glutathione (GSH) into small segments to mediate "on-demand" siRNA release and diminish the toxicity of post-transfection materials. By synchronizingly overcoming these critical barriers, BPAE-SS mediated remarkable ICAM-1 knockdown in IR-injured rats at 400 μg siRNA per kg via single i.v. injection, and subsequently suppressed myocardial inflammation, apoptosis, and fibrosis to recover the cardiac function. This study therefore provides a unique delivery system that can address the multiple critical challenges against non-viral siRNA delivery, and the potent therapeutic efficacy of BPAE-SS-mediated ICAM-1 silencing provides a promising strategy for the anti-inflammatory treatment of myocardial IR injury.

BACKGROUND: Anatomical segmentectomy by uniportal video-assisted thoracoscopic surgery (U-VATS) is a delicate surgical procedure. Hitherto, only few studies have assessed the learning curves of anatomical segmentectomy by U-VATS, with varying data available. The present study aimed to investigate the learning curve and clinical advantages for U-VATS segmentectomy. METHODS: The medical records of patients who underwent U-VATS or non-U-VATS segmentectomy between August 2017 and May 2020 were retrospectively reviewed. Cumulative sum (CUSUM) analysis was employed to illustrate the learning curve of U-VATS segmentectomy. Perioperative parameters were used to determine the structural intervals of the learning curve, and to compare U-VATS and non-U-VATS segmentectomy. RESULTS: In total, 122 patients receiving U-VATS segmentectomy and 98 patients receiving non-VATS segmentectomy were included. Of these, 116 patients underwent successful U-VATS segmentectomy, while the other six patients underwent conversions. The structural intervals of 20–29 cases and 58–63 cases were determined as the threshold according to the CUSUM analyses. The learning process of U-VATS segmentectomy was therefore divided into three phases. Interestingly, the perioperative parameters differed significantly between Phases 1 and 3, including operative time (Op-T), postoperative hospital stays (Po-Hst), postoperative thoracic drainage (Po-D), and operative failure (Po-F) rates (P

Increased evidence reveals that miR-940 inhibits the migration and invasion of cancer cells. Considering transforming growth factor β (TGF-β) signaling is crucial to cellular epithelial-mesenchymal transition (EMT) process and metastasis of cancer, it is in urgent to explore whether and how miR-940 plays an essential role in regulating TGF-β-induced EMT in lung cancer progression. In the present study, we observed a reciprocal expression with down-regulated miR-940 and up-regulated Snail mRNA in non-small-cell lung cancer (NSCLC) tissues. we further found that the expression of miR-940 was decreased in NSCLC tissues with lymph node metastasis, advanced TNM stages and poor cell differentiation, in which, on the contrary, the expression of Snail was increased. Overexpression of miR-940 significantly inhibited Snail mRNA and protein expression in A549 and H226 cells. Mechanistically, Snail mRNA was identified as target of miR-940. In addition, miR-940 repressed TGF-β-induced EMT and further hampered the cell migration and invasion. Finally, siRNA-mediated knockdown of Snail copied the phenotype of miR-940 overexpression in A549 and H226 cells. Taken together, our study reveals that miR-940 can suppress TGF-β-induced EMT and cell invasion by targeting Snail 3'-UTR mRNA in NSCLC.

BACKGROUND The mechanism underlying tumor spread through air spaces (STAS) has not been well studied. We investigated the role of tumor stromal cells in the pathogenesis of STAS from a pathological perspective and evaluated the prognostic significance of tumor stromal cells and STAS in postoperative patients with lung adenocarcinoma. METHODS We retrospectively analyzed 208 postsurgical patients with stage I-IIIA lung adenocarcinoma. The presence of STAS was evaluated by hematoxylin and eosin staining. The expression of α-smooth muscle actin (SMA)-positive cancer-associated fibroblasts (CAFs) and CD204-positive tumor-associated macrophages (TAMs) was analyzed by immunohistochemistry. A logistic regression model was applied to confirm the predictive factors of STAS. Survival analysis was performed to evaluate the effect of α-SMA-positive CAFs, CD204-positive TAMs, and STAS on prognosis. A nomogram was generated to evaluate the prognosis of postoperative patients. RESULTS Logistic regression suggested that the expression of α-SMA-positive CAFs (P < 0.001) and the number of CD204-positive TAMs (P < 0.001) were related to the presence of STAS. The multivariate Cox proportional hazards model suggested that STAS (P = 0.004), α-SMA-positive CAFs (P < 0.001), and CD204-positive TAMs (P < 0.001) were independent risk factors for prognosis. Harrell's c-indexes for overall and recurrence-free survival prediction based on nomograms were 0.84 (95% confidence interval 0.76-0.91) and 0.82 (95% confidence interval 0.76-0.89), respectively. CONCLUSIONS The presence of STAS was associated with high expression of α-SMA and CD204 in lung adenocarcinoma. Nomograms including STAS and stromal cells as variables are recommended as practical models to evaluate the prognosis of lung adenocarcinoma patients.

Systemic immunosuppression mediated by tumor-derived exosomes is an important cause for the resistance of immune checkpoint blockade (ICB) therapy. Herein, self-adaptive platelet (PLT) pharmacytes are engineered to mediate cascaded delivery of exosome-inhibiting siRNA and anti-PD-L1 (aPDL1) toward synergized antitumor immunity. In the pharmacytes, polycationic nanocomplexes (NCs) assembled from Rab27 siRNA (siRab) and a membrane-penetrating polypeptide are encapsulated inside the open canalicular system of PLTs, and cytotoxic T lymphocytes (CTLs)-responsive aPDL1 nanogels (NGs) are covalently backpacked on the PLT surface. Upon systemic administration, the pharmacytes enable prolonged blood circulation and active accumulation to tumors, wherein PLTs are activated to liberate siRab NCs, which efficiently transfect tumor cells, silence Rab27a, and inhibit exosome secretion. The immunosuppression is thus relieved, leading to the activation, proliferation, and tumoral infiltration of cytotoxic T cells, which trigger latent aPDL1 release. As such, the competitive aPDL1 exhaustion by PD-L1-expressing exosomes is minimized to sensitize ICB. Synergistically, siRab and aPDL1 induce strong antitumor immunological response and memory against syngeneic murine melanoma. This study reports a bioinspired mechanism to resolve the blood circulation/cell internalization contradiction of polycationic siRNA delivery systems, and renders an enlightened approach for the spatiotemporal enhancement of antitumor immunity.

Background The radial artery (RA) is increasingly being used for coronary artery bypass grafting (CABG). Endoscopic thoracic sympathectomy (ETS) has been shown to block innervation of sympathetic nerves of upper limbs, which reduces sweating of hands and dilates blood vessels. The modified Allen's test (MAT) is one of the commonest methods of assessing collateral arm flow prior to RA harvest, though it has limitations. However, the reliability of MAT after ETS remains unclear. We therefore investigated the effects of ETS on the results of MAT. Methods A retrospective cohort study was conducted on 164 consecutive Chinese patients with palmar hyperhidrosis who underwent ETS between January 2016 and January 2019. The medical records were reviewed concerning the ultrasound examination and MAT results of their RAs and ulnar arteries (UAs) in both forearms before and after ETS. Results The performance of ETS significantly increased the diameter of the right RA from 2.731±0.122 to 3.102±0.114 mm in men and from 2.347±0.074 to 2.915±0.162 mm in women. Similar effects of ETS were observed in expanding the diameters of the left RA and the UA. Meanwhile, there was no significant effect of ETS on systolic blood pressure (BP) and heart rate (HR). Overall, retesting of patients following ETS with a preoperative positive MAT result revealed a transition to a negative result. Conclusions ETS was effective in dilating RA in both men and women, which could lead to a false negative preoperative MAT result. Patients should be questioned about their history of ETS if their RAs are to be harvested for CABG. More studies are warranted to evaluate the safety of RA as a coronary artery graft after ETS.

The mucus layer and cell membrane are two major barriers against pulmonary siRNA delivery. Commonly used polycationic gene vectors can hardly penetrate the mucus layer due to the adsorption of mucin glycoproteins that trap and destabilize the polyplexes. Herein, guanidinated and fluorinated bifunctional helical polypeptides were developed to synchronizingly overcome these two barriers. The guanidine domain and α-helix facilitated trans-membrane siRNA delivery into macrophages, whereas fluorination of the polypeptides dramatically enhanced the mucus permeation capability by ∼240 folds, because incorporated fluorocarbon segments prevented adsorption of mucin glycoproteins onto polyplexes surfaces. Thus, when delivering TNF-α siRNA intratracheally, the top-performing polypeptide P7F7 provoked highly efficient gene knockdown by ∼96% at 200 μg/kg siRNA and exerted pronounced anti-inflammatory effect against acute lung injury. This study thus provides an effective strategy for transmucosal gene delivery, and it also renders promising utilities for the noninvasive, localized treatment of inflammatory pulmonary diseases.

To characterize the relationship between metastasis-associated protein 1 (MTA1) and spread through air spaces (STAS), and to investigate the joint prognostic value of MTA1 and STAS in resected lung adenocarcinomas.We retrospectively reviewed 208 operated patients with stage I-III lung adenocarcinoma from January 2009 to December 2014. STAS was identified by HE staining. Expression level of MTA1 was determined by immunohistochemistry. The relationship between MTA1 and STAS was determined by using a logistic regression model. The synergistic effects of MTA1 and STAS on prognosis were analyzed using a Cox proportional hazards regression model.Patients with either STAS or high expression of MTA1 had significantly worse overall survival (OS) and shorter recurrence-free survival (RFS) than those without STAS or with low expression of MTA1 (p 0.001). Among 107 patients with STAS presence in lung adenocarcinomas, 57 (53.3%) cases had high expression of MTA1. High expression of MTA1 was positively associated with the increased frequency of STAS presence (p 0.01). Subgroup analysis showed that the patients with both high expression of MTA1 and STAS-positive presence had significantly worst OS and shortest RFS compared with the others (p 0.001), while the patients with high expression of MTA1 /STAS-negative presence shared similar RFS with those with high expression of MTA1 /STAS-positive presence. Furthermore, high MTA1 levels in STAS-positive patients was associated with a higher risk of postoperative metastasis and recurrence (p 0.001).STAS was more frequently observed in adenocarcinomas with high MTA1 expression levels. MTA1 was associated with a higher risk of worse overall survival among patients with STAS and could provide helpful prognostic information in STAS-positive patients with stage I-III lung adenocarcinoma.

The performance of non-viral gene delivery vehicles, especially cationic polymers, is often challenged by the multiple cellular barriers that pose inconsistent requirements for material properties. A most pronounced inconsistency is exemplified by the molecular weight (MW)-related transfection efficiency and cytotoxicity. In this study, we report the development of photo-degradable, branched poly(β-amino ester)s (BPAE-NB) to realize efficient and photo-controlled DNA and siRNA delivery. BPAE-NB possessing built-in light-responsive 2-nitrobenzene moieties in the polymer backbone was synthesized via the A2 (amine) + B3 (triacrylate) + C2 (diacrylate) polycondensation reaction from 4-amino-1-butanol (A2), trimethylolpropane triacrylate (B3), and (2-nitro-1,3-phenylene)bis(methylene) diacrylate (NPBMDA, C2). The highly branched BPAE-NB with the multivalent arrangement of cationic groups provides stronger nucleic acid binding capacity than its linear analogue LPAE-NB, and thus features stronger trans-membrane gene delivery capabilities and higher transfection efficiencies. Upon UV light irradiation, the backbone of BPAE-NB can quickly degrade into low-MW fragments as a consequence of the cleavage of the light-responsive 2-nitrobenzene, thus promoting intracellular gene release and diminishing the toxicity of materials at the post-transfection state. As such, in multiple mammalian cells, BPAE-NB exhibited remarkably higher DNA/siRNA transfection efficiency yet lower cytotoxicity than its non-responsive analogue BPAE-CC upon light irradiation, notably outperforming commercial reagents PEI 25k and Lipofectamine 2000. This study therefore provides an effective topology- and photo-controlled approach to precisely manipulate the transfection efficiency and toxicity of polycationic gene vectors, and may also provide promising additions to the existing non-viral gene delivery vectors.

Esophageal bronchogenic cysts are extremely rare. Here we report a case of massive upper digestive tract hematoma and bronchogenic cyst mimicking aortic dissection that was safely removed without esophagectomy. A 30-year-old man was referred to our hospital for the treatment of a mediastinal cystic tumor located in the submucosa of the distal esophagus. His chief complaints were dysphagia > 1 week and severe persistent upper abdominal pain mimicking aortic dissection with constant vomiting for 1 day after gastroscopy examination. The serum level of carbohydrate antigen (CA)199 was > 1,000 U/mL and CA125 was 4,816 U/mL. Hemoglobin levels decreased from 122 g/L to 85 g/L in 5 days. Imaging examinations detected a huge hematoma of the gastric wall. Preoperative diagnosis was difficult. Although the pain indicated a possible aortic dissection, the abnormal levels of tumor biomarkers suggested malignancy. The patient underwent left thoracotomy. The cyst showed an exophytic lesion connected to the esophageal wall at the level of the gastroesophageal junction. Muddy brown contents were obtained by aspiration of the mass intraoperatively. Because enucleation could not be performed, esophageal myotomy in the distal esophagus and partial resection of the cyst were selected. Histopathological examination indicated a bronchogenic cyst of the esophagus. At a follow-up visit 3 months later, the patient had no signs of disease recurrence or any complaints. Postoperative tumor biomarkers returned to normal range. The present report summarizes the clinical details of the case and reviews the literature in order to improve the accuracy of diagnosis.

Drug resistance diminishes the efficacies of anticancer therapeutics and causes the failure of clinical cancer chemotherapy. Herein, we reported a promising strategy to reverse drug resistance via RNA interference (RNAi)-assisted intervention of cancer bioenergetics. Densely packed, guanidine-rich, spherical helical polypeptide (DPP) was developed to encapsulate doxorubicin (DOX) inside its hydrophobic cavity and form polyelectrolyte nanocomplexes (NCs) with PKM2 siRNA. The NCs were further surface-decorated with hyaluronic acid (HA) to enhance the serum stability and promote tumor targeting via binding to over-expressed CD44 on cancer cell membranes. DPP with multivalent topology mediated potent trans-membrane delivery of PKM2 siRNA into DOX-resistance cancer cells. PKM2 down-regulation suppressed the glycolysis metabolism and depleted energy supply for ATP-binding cassette (ABC) transporters, thus inhibiting drug efflux to reverse drug resistance. Meanwhile, PKM2 silencing starved tumor cells, induced intracellular reactive oxygen species (ROS) generation, and triggered mitochondrial collapse, which aggravated cell apoptosis to achieve potent and cooperative anti-cancer effect with chemotherapy. This study thus provides an effective topology-controlled approach for designing trans-membrane siRNA delivery vehicles, and it also renders a promising tool in rejuvenating chemotherapy against drug-resistant tumors via a unique anti-bioenergetics mechanism.

Increased evidence reveals that miR-940 inhibits the migration and invasion of cancer cells. Considering transforming growth factor β (TGF-β) signaling is crucial to cellular epithelial-mesenchymal transition (EMT) process and metastasis of cancer, it is in urgent to explore whether and how miR-940 plays an essential role in regulating TGF-β-induced EMT in lung cancer progression. In the present study, we observed a reciprocal expression with down-regulated miR-940 and up-regulated Snail mRNA in non-small-cell lung cancer (NSCLC) tissues. we further found that the expression of miR-940 was decreased in NSCLC tissues with lymph node metastasis, advanced TNM stages and poor cell differentiation, in which, on the contrary, the expression of Snail was increased. Overexpression of miR-940 significantly inhibited Snail mRNA and protein expression in A549 and H226 cells. Mechanistically, Snail mRNA was identified as target of miR-940. In addition, miR-940 repressed TGF-β-induced EMT and further hampered the cell migration and invasion. Finally, siRNA-mediated knockdown of Snail copied the phenotype of miR-940 overexpression in A549 and H226 cells. Taken together, our study reveals that miR-940 can suppress TGF-β-induced EMT and cell invasion by targeting Snail 3'-UTR mRNA in NSCLC.

This study aimed to investigate the effects and mechanisms of X-linked inhibitor of apoptosis protein (XIAP)-associated factor 1 (XAF1) and tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) on the apoptosis of A549 lung adenocarcinoma cell lines. Recombinant lentiviral vector of Ad5/F35-XAF1 and controlled lentiviral vector of Ad5/F35-Null were transfected into A549 cells at same multiplicity of infection (MOI), respectively. Based on whether recombinant human TRAIL (rhTRAIL) was added or not, cells were divided into different groups as follows: XAF1 group, XAF1 + TRAIL group, XAF1-Null group, and XAF1-Null + TRAIL group. Following culturing for 48 h, the mRNA and protein expression levels of related genes were determined by reverse transcription-quantitative polymerase chain reaction and western blotting analyses, respectively. Cell proliferationand cell apoptosis were detected by MTT assay and Annexin V-FITC/PI double staining, respectively. Xenograft mice models were established with A549 lung adenocarcinoma cells and treated with recombinant virus Ad5/F35-XAF1 and controlled virus Ad5/F35-Null for immunohistochemical analysis. Expression levels of XAFl at the mRNA and protein levels were significantly higher in the XAF1 group and XAF1 + TRAIL groups when compared with the levels in the other groups (P

Purpose/Objective(s): Treatments for superior sulcus non-small cell lung cancer (SS-NSCLC) have evolved, but adequate treatments of T4 disease have not been found. The aim of our study was to evaluate the prognostic factors and optimal treatment strategy for patients with T4 SS-NSCLC. Materials/Methods: We utilized the Surveillance, Epidemiology, and End Results (SEER) database (1973–2015) to identify patients diagnosed with T4 stage SS-NSCLC (according to the 7th edition American Joint Committee on Cancer (AJCC) staging system) from 2004 to 2015; those with M1 disease were excluded. Propensity score matching (PSM) with Kaplan–Meier and Cox proportional hazards’ models was performed to estimate prognosis. Results: A total of 384 patients were included. The majority was male (59.4%) at stage IIIB (56.6%), with N2 accounting for 45.3%. A total of 47 patients underwent cancer-directed surgery, while radiotherapy alone was received by 60.2% of patients. Median overall survival (OS) and lung cancer-specific survival (LCSS) were 12 and 17 months, respectively, and the 5-year OS and LCSS rates were 15.8 and 25.4%, respectively. In the matched population, the median survival outcomes were better following surgery (OS: 25 compared with 9.0 months, P

Background: Erlotinib (ELTN)-based targeted therapy as first-line treatment for epidermal growth factor receptor (EGFR)-mutant lung cancers suffers from insufficient selectivity, side effects, and drug resistance, which poses critical challenges in the clinical setting. Acquired resistance of ELTN results in extremely poor prognoses of non-small cell lung cancer (NSCLC) patients, wherein activation of the JAK2/STAT3 signaling pathway has been proven to induce acquired ELTN resistance.Methods: In this study, we developed a nanoparticle (NP) delivery system based on Food and Drug Administration (FDA)-approved poly(ethylene glycol) (PEG)-poly(lactic acid) (PLA) for the co-delivery of ELTN and fedratinib (FDTN, a small-molecular, highly selective JAK2 inhibitor). Both ELTN and FDTN could be encapsulated into the PEG-PLA NPs via optimization of the encapsulation method. The effect of NPs on NSCLC cells was evaluated by MTT assay. Western blotting was performed to study the molecular mechanisms of NPs inhibiting the downstream pathways of EGFR in vitro. The histological analysis and protein expression in vivo were assessed by hematoxylin/eosin (H&E) staining and immunohistochemistry, respectively.Results: The drug cargoes exhibited great stability, and could be released more efficiently in the acidic tumorous condition. Mechanistic study showed that FDTN notably down-regulated the expression levels of proteins in the JAK2/STAT3 signaling pathway, including p-EGFR, p-JAK2, p-STAT3 and Survivin, therefore reversing the ELTN resistance. As a result, synergistic anti-cancer effect was achieved by PEG-PLA NPs encapsulating both ELTN and FDTN in ELTN-resistant NSCLC tumors both in vitro and in vivo, and lower systemic side effect was noted for the co-delivery NPs compared to free drugs.Conclusion: This study provides a promising approach to overcome the ELTN resistance in the treatment of NSCLC, and the use of FDA-approved materials with clinically applied/investigated chemical drugs may facilitate the translation of the current delivery system.

Cisplatin-resistant A549 and H157 (A549CisR and H157CisR) non-small cell lung cancer cells show increased stemness of cancer stem cells (CSCs) compared to their parental cells. We investigated whether interleukin-6 (IL-6) signaling contributes to this increased stemness in cisplatin-resistant cells. When A549CisR and H157CisR cells were treated with neutralizing IL-6 antibody, decreased cisplatin resistance was observed, whereas IL-6 treatment of parental cells resulted in increased cisplatin resistance. Expression of the CSC markers was significantly upregulated in IL-6-expressing scramble cells (in vitro) and scramble cell-derived tumor tissues (in vivo) after cisplatin treatment, but not in IL-6 knocked down (IL-6si) (in vitro) cells and in IL-6si cell-derived tumor tissues (in vivo), suggesting the importance of IL-6 signaling in triggering increased stemness during cisplatin resistance development. Hypoxia inducible factors (HIFs) were upregulated by IL-6 and responsible for the increased CSC stemness on cisplatin treatment. Mechanism dissection studies found that upregulation of HIFs by IL-6 was through transcriptional control and inhibition of HIF degradation. Treatment of HIF inhibitor (FM19G11) abolished the upregulation of CSC markers and increased sphere formations in IL-6 expressing cells on cisplatin treatment. In all, IL-6-mediated HIF upregulation is important in increasing stemness during cisplatin resistance development, and we suggest that the strategies of inhibiting IL-6 signaling or its downstream HIF molecules can be used as future therapeutic approaches to target CSCs after cisplatin treatment for lung cancer.

Additional file 1. Additional tables.

Background: We previously reported that IL-6 was associated with therapy resistance to radiotherapy and cisplatin chemotherapy, the two most common treatments for non-small cell lung cancer (NSCLC). Emerging in vivo evidence shows that natural killer (NK) cells have an important role in immune defense. In this study, we examined the role of IL-6 modulation in lung cancer PD-L1 expression and the impact on NK cell cytotoxicity. We also revealed the key molecular signaling pathway involved in this process, which serves as the potential therapeutic target to improve clinical lung cancer treatments. Methods: We examined the prevalence of IL-6 in tumors of NSCLC in immunohistochemical staining. The susceptibility of IL-6 expressing scramble control (A549sc and H157sc) cells and IL-6 knocked down (A549siIL-6 and H157siIL-6) cells were investigated in in vitro and in vivo human tumor xenograft studies in mice. In in vivostudies, tumors were developed by luciferase tagged A549siIL-6 vs. A549sc cell injection, and primary human NK cells were injected intravenously at the early stage of tumor development. IL-6 regulation of PD-L1 at the transcriptional level was investigated and NK cell binding to tumor cells was also examined. Results: We found the ubiquitous presence of IL-6 in NSCLC. We found IL-6 expressing lung cancer cells were more resistant to NK cell cytotoxicity than IL-6 knocked-down cells. In addition, we found higher expressions of programmed death receptor 1 ligand (PD-L1) in IL-6 expressing lung cancer cells than IL-6 knocked-down cells. In excised human tumor xenografts and in human NSCLC tumors, co-localization of IL-6 signaling and PD-L1 expression was observed. Furthermore, we discovered that IL-6 promoted PD-L1 expression at the transcriptional level via the regulation of its downstream MEK/Erk signaling pathway. In addition, we found that IL-6-MEK/Erk signaling also contributed to diverting NK cells away from binding to tumor cells. Conclusions and Impact: In conclusion, we found that IL-6 develops the resistance to NK cell actions by inducing PD-L1 in NSCLC cells and diverts NK cells away from tumor cells via its downstream MEK/Erk signaling. NK cell-mediated immune function plays an important role in cancer surveillance, invasion, and metastasis, but its role in lung cancer is not clear. In in vivo studies, we proved the importance of NK cell-mediated immune reaction. Our discovery of revealing the IL-6 downstream signaling, MEK/Erk, in triggering the PD-L1 up-regulation and in blocking NK cell binding with lung cancer cells is novel. Data from this investigation support that blocking MEK/Erk signaling pathway has the potential to enhance NK cell immune function to NSCLC by overcoming IL-6 mediated NK cell resistance. Citation Format: Soo Ok Lee, Rongying Zhu, Xiang Xue, Donglai Cchen, Shanzhou Duan, Mingjing Shen, Feng Chen, Ying Tsai, Peter Keng, Yongbing Chen, Yuhchyau chen. IL-6 up-regulates pd-l1 and facilitates lung cancer escape from NK cell immune function through its downstream MEK-ERK signaling [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1520.

Background Local tumor control by standard fractionated radiotherapy (RT) remains poor because of tumor resistance to radiation (radioresistance). It has been suggested that cancer stem cells (CSCs) are more radioresistant than non-CSCs. In previous studies, we have shown IL-6 promotes self-renewal of CD133+ CSC-like cells. In this study, we investigated whether IL-6 plays roles not only in promoting self-renewal of CD133+ cells after radiation, but also in conferring radioresistance of CD133+ cells in NSCLC. Materials and methods To compare radiation sensitivity of CSCs and non-CSCs, CD133+ CSC-like and CD133- cell populations were isolated from two NSCLC cell lines, A549 and H157, by immunomagnetic separation and their sensitivities to ionizing radiation were investigated using the clonogenic survival assay. To further study the IL-6 effect on the radiosensitivity of CD133+ CSC-like cells, CD133+ cells were isolated from A549IL-6si/sc and H157IL-6si/sc cells whose intracellular IL-6 levels were manipulated via the lentiviral transduction with IL-6siRNA. Post-irradiation DNA damage was analyzed by γ-H2AX staining and Comet assay. Molecular mechanisms by which IL-6 regulates the molecules associated with DNA repair and anti-apoptosis after radiation were analyzed by Western blot and immunofluoresecence (IF) staining analyses. Results NSCLC CD133+ CSC-like cells were enriched upon radiation. Survival of NSCLC CD133+ cells after radiation was higher than that of CD133- cells. Survival of IL-6 expressing NSC LC CD133+ cells (sc) was higher than that of IL-6 knocked-down cells (IL-6si) after radiation. IL-6 played a role in protecting NSCLC CD133+ cells from radiation-induced DNA damage and apoptosis. Conclusions IL-6 signaling promotes DNA repair while protecting CD133+ CSC-like cells from apoptotic death after radiation for lung cancer. A combined therapy of radiation and agents that inhibit IL-6 signaling (or its downstream signaling) is suggested to reduce CSC-mediated radioresistance in lung cancer.

Local tumor control by standard fractionated radiotherapy (RT) remains poor because of tumor resistance to radiation (radioresistance). It has been suggested that cancer stem cells (CSCs) are more radioresistant than non-CSCs. In previous studies, we have shown IL-6 promotes self-renewal of CD133+ CSC-like cells. In this study, we investigated whether IL-6 plays roles not only in promoting self-renewal of CD133+ cells after radiation, but also in conferring radioresistance of CD133+ cells in NSCLC.To compare radiation sensitivity of CSCs and non-CSCs, CD133+ CSC-like and CD133- cell populations were isolated from two NSCLC cell lines, A549 and H157, by immunomagnetic separation and their sensitivities to ionizing radiation were investigated using the clonogenic survival assay. To further study the IL-6 effect on the radiosensitivity of CD133+ CSC-like cells, CD133+ cells were isolated from A549IL-6si/sc and H157IL-6si/sc cells whose intracellular IL-6 levels were manipulated via the lentiviral transduction with IL-6siRNA. Post-irradiation DNA damage was analyzed by γ-H2AX staining and Comet assay. Molecular mechanisms by which IL-6 regulates the molecules associated with DNA repair and anti-apoptosis after radiation were analyzed by Western blot and immunofluoresecence (IF) staining analyses.NSCLC CD133+ CSC-like cells were enriched upon radiation. Survival of NSCLC CD133+ cells after radiation was higher than that of CD133- cells. Survival of IL-6 expressing NSC LC CD133+ cells (sc) was higher than that of IL-6 knocked-down cells (IL-6si) after radiation. IL-6 played a role in protecting NSCLC CD133+ cells from radiation-induced DNA damage and apoptosis.IL-6 signaling promotes DNA repair while protecting CD133+ CSC-like cells from apoptotic death after radiation for lung cancer. A combined therapy of radiation and agents that inhibit IL-6 signaling (or its downstream signaling) is suggested to reduce CSC-mediated radioresistance in lung cancer.

Cisplatin-based chemotherapy is currently the most effective treatment regimen for non-small cell lung cancer (NSCLC), but eventually tumor resistance develops which limits its success. The potential implication of IL-6 signaling in the cisplatin resistance of NSCLC was explored by testing whether NSCLC cells with different levels of intracellular IL-6 show different responses to the cytotoxic treatment of cisplatin. When the cisplatin cytotoxicity of the IL-6 knocked down human NSCLC cells (A549IL-6si and H157IL-6si) were compared with their corresponding scramble control cells (A549sc and H157sc), higher cisplatin cytotoxicity was found in IL-6 si cells than sc cells. Subcutaneous xenograft mouse models were developed using a pair of A549sc and A549IL-6si cells. When the tumor grew to about 400 mm2, mice were treated with cisplatin and tumor regression was monitored. Higher tumor regression was detected in the A549IL-6si xenografts compared to A549sc xenografts following cisplatin treatment. Immunostaining study results from tumor tissues also supported this finding. Expression of anti-apoptotic proteins Bcl-2 and Mcl-1 and DNA repair associated molecules ATM, CHK1, TP73, p53, and ERCC1 were significantly up regulated in cisplatin-treated A549sc and H157sc cells, but no increase was detected in A549IL-6si and H157IL-6si cells. Further inhibitor studies revealed that up regulation of these molecules by IL-6 may be through activation of IL-6 downstream signaling pathways like Akt, MAPK, Stat3, and Erk. These results provide potential for combining cisplatin and inhibitors of IL-6 signaling or its downstream signaling pathway as a future therapeutic approach in preventing development of cisplatin resistant NSCLC tumors.

Non-small cell lung cancer (NSCLC) patients with epidermal growth factor receptor (EGFR) mutations are responsive to EGFR-tyrosine kinase inhibitor (EGFR-TKI). However, NSCLC patients with secondary somatic EGFR mutations are resistant to EGFR-TKI treatment. In this study, we investigated the effect of TG101348 (a JAK2 inhibitor) on the tumor growth of erlotinib-resistant NSCLC cells. Cell proliferation, apoptosis, gene expression and tumor growth were evaluated by diphenyltetrazolium bromide (MTT) assay, flow cytometry, terminal deoxynucleotidyl transferase biotin-dUTP nick end labeling (TUNEL) staining, Western Blot and a xenograft mouse model, respectively. Results showed that erlotinib had a stronger impact on the induction of apoptosis in erlotinib-sensitive PC-9 cells but had a weaker effect on erlotinib-resistant H1975 and H1650 cells than TG101348. TG101348 significantly enhanced the cytotoxicity of erlotinib to erlotinib-resistant NSCLC cells, stimulated erlotinib-induced apoptosis and downregulated the expressions of EGFR, p-EGFR, p-STAT3, Bcl-xL and survivin in erlotinib-resistant NSCLC cells. Moreover, the combined treatment of TG101348 and erlotinib induced apoptosis, inhibited the activation of p-EGFR and p-STAT3, and inhibited tumor growth of erlotinib-resistant NSCLC cells in vivo. Our results indicate that TG101348 is a potential adjuvant for NSCLC patients during erlotinib treatment.