The mechanism by which adamantinomatous craniopharyngioma (ACP) damages the hypothalamus is still unclear. Cyst fluid rich in lipids and inflammatory factors is a characteristic pathological manifestation of ACP and may play a very important role in hypothalamic injury caused by tumors.The objective of this study was to construct a reliable animal model of ACP cyst fluid-induced hypothalamic injury and explore the specific mechanism of hypothalamic injury caused by cyst fluid.An animal model was established by injecting human ACP cyst fluid into the bilateral hypothalamus of mice. ScRNA-seq was performed on the mice hypothalamus and on an ACP sample to obtain a complete gene expression profile for analysis. Data verification was performed through pathological means.ACP cystic fluid caused growth retardation and an increased obesity index in mice, affected the expression of the Npy, Fgfr2, Rnpc3, Sst, and Pcsk1n genes that regulate growth and energy metabolism in hypothalamic neurons, and enhanced the cellular interaction of Agrp–Mc3r. ACP cystic fluid significantly caused inflammatory activation of hypothalamic microglia. The cellular interaction of CD74–APP is significantly strengthened between inflammatory activated microglia and hypothalamic neurons. Beta-amyloid, a marker of neurodegenerative diseases, was deposited in the ACP tumor tissues and in the hypothalamus of mice injected with ACP cyst fluid.In this study, a novel animal model of ACP cystic fluid-hypothalamic injury was established. For the first time, it was found that ACP cystic fluid can trigger inflammatory activation of microglia to damage the hypothalamus, which may be related to the upregulation of the CD74–APP interaction and deposition of β-amyloid, implying that there may be a similar mechanism between ACP cystic fluid damage to the hypothalamus and neurodegenerative diseases.The online version contains supplementary material available at 10.1186/s12974-022-02470-6. Adamantinomatous craniopharyngioma (ACP) is a rare epithelial tumor that originates from the residual cells of the Rathke sac during embryonic development , 2. Its The hypothalamus, which regulates energy metabolism , 6 and bACP is mostly composed of cyst fluid and its surrounding cyst wall, with a few substantial components . The comThe lack of stable cell lines and benign characteristics make it difficult for ACP cells to form the transplanted tumor in hypothalamus; therefore , a study on the cystic fluid, product of ACP cells lipid metabolism disorder, is very necessary and feasible. To explore the effect of ACP cystic fluid on the hypothalamus, this study used stereotactic technology to inject human ACP cystic fluid into the bilateral hypothalamus of 6-week-old male C57 mice as the cystic fluid group, injected the same amount of PBS as the sham operation group, a blank control group received no treatment. After 8 weeks, ACP cystic fluid caused growth retardation, increased the obesity index, and decreased plasma GH and GHRH levels. To determine whether changes in the expression of genes regulating body growth and energy metabolism occurred in hypothalamic neurons, we performed single-cell RNA sequencing on the hypothalamus of mice from the cystic fluid group and the sham operation group and found that ACP cyst fluid significantly affected the expression of the Sst, Fgfr2, and Rnpc3 genes, which regulate body growth and development , 25–28, We report here that ACP cystic fluid induces inflammatory activation of mouse hypothalamic microglia. Activated microglia may mediate a mechanism similar to that observed in neurodegeneration of hypothalamic neurons and participate in this process, which may damage the hypothalamus, leading to growth retardation and obesity.1/3 divided by body length). All animals were performed in accordance with The Basel Declaration. All operations were approved by the Laboratory Animal Center and the Ethics Committee of Southern Medical University and complied with the National Institute of Health Guidelines for the Protection and Use of Laboratory Animals.Animals: Young 6-week-old C57 male mice weighing 19–20 g were screened as experimental subjects. After stereotactic surgery, the mice were placed in the same environment as before the operation and fed normal food and water. The average food intake, average water intake, and average weight of each group of the mice were recorded every 3 days, and the body length (distance from the tip of the nose to the anus) was recorded every 7 days. The above indicators were recorded to 8 weeks after the operation, and the rodent obesity formula was used to calculate the obesity index  (Lee indCollection of childhood ACP cystic fluid and tumor tissue: Childhood ACP (5–12 years old) patients, whose hypothalamus were infringed by the tumor, were screened and the ACP cystic fluid and the ACP tissue with gliosis zone were collected from clinical surgery. These children received tumor resection and surgery at the Neurosurgery Department of Southern Hospital of Southern Medical University. The ACP cystic fluid was collected with a syringe during the surgery, and the cerebrospinal fluid and blood were not mixed. Tumor tissues and cystic fluids were performed in accordance with the Declaration of Helsinki. The patients’ parents all signed an informed consent form expressing their willingness to allow the use of the excised tumor tissue and cystic fluid for scientific research, and the study received approval from the Ethics Committee of Southern Medical University. The collected tumor tissue and cystic fluid from surgery were immediately stored in a freezer at -80 °C. Finally, we collected tumor tissues and cystic fluid from 8 pediatric patients.Stereotactic surgery: The mice were anesthetized by inhalation with isoflurane , and the head was fixed with a stereotaxic instrument . The skull was milled out in the target area, the microsyringe was filled with 20 µl of cystic fluid or PBS, and 10 µl was injected into the hypothalamus on each side. Cystic fluid group: ACP cystic fluid was injected into the bilateral hypothalamus. Sham operation group: Same amount of PBS was used to inject into the bilateral hypothalamus. Control group: No treatment was administered. Each group included 8 mice, and each mouse in the cystic fluid group was injected with cystic fluid from a different patient.Single-cell RNA sequencing: Eight weeks after the operation, a mouse was randomly selected from the cystic fluid group and the sham operation group, respectively. After anesthetization, their hypothalamus was removed immediately under a light microscope for single-cell RNA sequencing. At the same time, a sample of fresh childhood ACP tumor tissue (with gliosis zone) collected during clinical surgery was also used for single-cell RNA sequencing. Details are provided in Additional file Immunohistochemistry and immunofluorescence: Eight weeks after surgery, the mice were anesthetized and perfused transcardially with saline, followed by internal fixation with 4% paraformaldehyde in PBS . The brain was removed and soaked with 4% formaldehyde for 48 h. The entire hypothalamus was coronally cut out with stainless steel brain matrices (BB-NMJ), and then 2 µm sections were made. After dewaxed with xylene and alcohol (100%–70%), washed with PBS (pH = 7), and EDTA (pH = 9) for antigen retrieval, the sections were incubated with primary antibody at 4 °C overnight. And then incubated with secondary antibody for 1 h at room temperature. The sections were observed and images were captured under an Olympus microscope .ELISA test for plasma hormone levels: Eight weeks after the operation, the mice were anesthetized with isoflurane, and then 600 µl of blood was drawn from the tail veins to collect serum. Serum was used immediately for ELISA. Samples were diluted and subjected to standard ELISA to determine GH and GHRH levels in accordance with the manufacturer's protocol .Mouse microglia (BV2) were stimulated with cystic fluid in vitro. In vitro, cystic fluid was added to culture medium at a ratio of 1:20, in which mouse microglia (BV2) were cultured for 24 h at 37℃.The control group of BV2 cells was cultured in saline-mixed culture medium  for 24 h at 37℃.−ΔΔCt method with glyceraldehyde-3-phosphate dehydrogenase (GAPDH) as the endogenous control.RT-qPCR test: Total RNA was extracted from the mouse hypothalamus. The quantity and concentration of RNA were assessed by measuring absorbance. The reverse transcription reactions were performed. Then RT-qPCR was performed following the manufacturer's instructions. The relative expression levels of each sample were calculated using the 2Statistical analysis. All values are expressed as the mean ± SEM and represent data from at least 3 repeated experiments. Data were analyzed using SPSS 22  and GraphPad  software. If the mean satisfied the normal distribution, a parameter test was used, one-way ANOVA was used for data with a homogeneous variance, and Welch ANOVA was used for data with a heterogeneous variance. If the normal distribution was not satisfied, the Kruskal–Wallis test was used. P < 0.05 (*), P < 0.01 (**), P < 0.001 (***), and P < 0.0001 (****) were considered to indicate statistical significance. NS (P > 0.05) means that there was no significant difference.Details are provided in Additional file P < 0.05) ; this trend continued until the 24th day after the surgery, and the food intake then gradually decreased to a level similar to that of the sham operation group and the control group and was stable until 8 weeks after the operation  Fig. E. Althouion Fig. B. 6 to 2ion Fig. D. Surpriion Fig. E. There To further clarify the causes of the growth retardation and the increased obesity index observed in the cystic fluid group, we performed single-cell RNA sequencing on the hypothalamus of the mice from the cystic fluid group and the sham operation group Fig. A. After In the hypothalamus, neurons that control body growth –8 and enWe discovered for the first time that ACP cystic fluid significantly changed the expression of genes regulating body growth and energy metabolism in neurons cluster 3) from the ARC. Based on this finding, we conducted further studies on cluster 3. We found that in addition to the specific expression of Tbx3 (marker of ARC), cluster 3 also specifically expressed Prlr, Npy, Agrp, and Ghrh, which are also ARC-specific marker genes . Therefo from theIt was previously reported that ACP cyst fluid may have a direct toxic effect on neurons , and we The GO enrichment of cluster 3 and its subclusters in the cystic fluid group indicated that the activation of pathways related to neuronal apoptosis and APP (precursor of Aβ) processing was significantly higher than that in the sham operation group Fig. F. In theTo obtain the ACP single-cell gene expression profile of clinical samples, we collected and pretreated childhood ACP specimens obtained during the operation according to the procedures described in the methods and then performed single-cell RNA sequencing. After filtering low-quality samples and cells, 6632 cells were obtained. The median UMI was 4653.5/cell, and the median number of genes per cell was 2106/cell. As a result, 35954 genes were detected in all cells. After removing the mitochondrial genes from all the cells through an unsupervised strategy, clustering was performed, and 16 populations were found. Through the expression of markers expressed by some specific cell clusters –46, we dAlthough ACP is a benign tumor, the poor quality of life caused by hypothalamic injury has been difficult to solve . The hypAs previously shown, ACP cystic fluid has a damaging effect on neurons in vitro  ; the abIn ACP tumor tissues, we also verified the same phenomenon of inflammatory activation of microglia observed in mice. Activated microglia also showed inflammatory activation, increased synthesis of proinflammatory factors, activation of inflammation-related pathways, increased response to lipoprotein granule stimulation, and increased synthesis and response of beta-amyloid (Aβ). Interestingly, in ACP tumor tissues, we found that CD74–APP and CD74–COPA interactions were also significantly strengthened between inflammatory activated microglia and neurons. CD74–APP, an intercellular interaction that is unique to Alzheimer's disease , was disIn addition, the single-cell RNA sequencing data indicated that the expression of CD68, an index of phagocytosis of microglia , was incThe ACP cystic fluid we injected into the hypothalamus of mice is present only temporarily. Although we simulated the leakage process of cyst fluid during ACP resection, Aβ, observed in the mouse hypothalamus injected with ACP cystic fluid, is also expressed in whorl-like cells and gliotic tissues of ACP tumors. In current studies, no Aβ was found in the analysis of the composition of ACP cystic fluid , 66, whiIn short, we have an unprecedented understanding of ACP cystic fluid. Avoiding leakage of cystic fluid during surgical resection is a good measure to protect the hypothalamus from hormonal and energy metabolism disorders. The animal model established in this study is helpful for the research and treatment of ACP-related hypothalamic injury. At the same time, the Npy, Fgfr2, Rnpc3, Sst, and Pcsk1n genes, and the cell-to-cell interactions CD74–APP, CD74–COPA, and Agrp–Mc3r, and Aβ may provide potential targets for further study of ACP. In this study, a pathological phenomenon very similar to neurodegenerative diseases was found in the ACP tumor tissue, implying that medicines used to treat neurodegenerative diseases may help prevent ACP damage to the hypothalamus.In this study, a novel animal model of ACP cystic fluid-hypothalamic injury was established. For the first time, it was found that ACP cystic fluid affects the expression of the Npy, Fgfr2, Rnpc3, Sst, and Pcsk1n genes and the cellular interaction of Agrp–Mc3r in hypothalamic neurons and can trigger inflammatory activation of microglia to damage the hypothalamus, which may be related to the upregulation of the CD74–APP interaction and deposition of β-amyloid, implying that there may be a similar mechanism between ACP cystic fluid damage to the hypothalamus and neurodegenerative diseases.This research is limited by the inherent limitation related to the depth of sequencing that plagues all mononuclear and single-cell RNA-seq research: changes in the expression of low-abundance transcripts cannot be detected. The current sample size was chosen for pragmatic reasons, including cost. Although the sample size was small, we verified the finding through a variety of experimental methods and obtained similar results. As the cost of single-cell RNA-seq research decreases, future research may verify our findings in a large sample.Additional file 1:Figure S1. A. Schematic diagram of mouse stereotactic surgery. The injection coordinates were 1.80 mm behind the bregma, 0.35 mm on both sides of the sagittal sinus, and 5.00 mm from the brain surface. B. In each subcluster of cluster 3 of mice from the cystic fluid group, the pathways related to APP synthesis and feeding behavior were more significantly upregulated than in the subclusters of cluster 3 of mice from the sham operation group. Subcluster 3-0 mainly upregulated pathways related to APP synthesis and neuronal apoptosis, subcluster 3-1 and subcluster 3-2 mainly upregulated pathways related to APP synthesis, and subgroups 3-3 and 3-4 mainly upregulated pathways related to feeding. C. The results of immunohistochemistry. The expression of Npy in the hypothalamus of mice in the cystic fluid group was upregulated, and the number of Npy+ cells in the ARC also increased. 3V: The third ventricle. The needle track (*indication) can be seen above the third ventricle in the cystic fluid group and the sham operation group. D. PCR detection results. The expression of the Sst gene and Pcsk1n gene was significantly upregulated, and the expression of the Fgfr2 and Rnpc3 genes was significantly downregulated in the hypothalamus of mice in the cystic fluid group. E. The ratio of cells in the cystic fluid group and the sham operation group detected by single-cell RNA sequencing. Cluster 11 (microglia activated by inflammation) was mainly contributed by the cystic fluid group. The high proportions of meningeal cells (clusters 14 and 16) in the cystic fluid group was caused by the incorporation of meningeal tissue during the collection of the mouse hypothalamus, which did not affect the experimental results.Additional file 2: Figure S2. A. ACP cystic fluid activates mouse microglial BV2 cells in in vitro experiments. The activated microglia showed amebic-like changes: enlarged cell bodies, short axons, and increased numbers of axons. B. Single-cell RNA sequencing detected a significant upregulation of CD68 expression in cluster 7 (microglia) in the cyst fluid group. C. PCR results showed that the expression of IL-6 and CD68 in the hypothalamus of mice in the cystic fluid group was significantly upregulated. D. The results of immunohistochemistry showed that the expression of CD68 in the hypothalamus of mice in the cystic fluid group was upregulated. 3V: The third ventricle. The needle track (*indication) can be seen above the third ventricle in the cystic fluid group and the sham operation group. E. The immunofluorescence results showed the expression of CD68 in microglia in the gliosis zone of childhood ACP. Iba1 indicates microglia, DAPI indicates nuclei, and asterisks indicate tumor tissue.Additional file 3: Figure S3. Single-cell RNA sequencing showed the cell interaction between each subcluster of cluster 3 in the cystic fluid group and the sham operation group. T: cystic fluid, H: sham. Agrp–Mc3r was significantly strengthened between subcluster 3-3 (Agrp/Npy neurons) and subcluster 3-4 (Ghrh neurons) in the cystic fluid group. In the interaction relationship, subclusters 3-3 express the ligand gene Agrp, and subclusters 3-4 express the receptor gene Mc3r.Additional file 4: Figure S4. A, B. Single-cell RNA sequencing showed that in childhood ACP tissues with gliosis, Wnt pathways and pathways related to ossification, osteoblast differentiation, and chondrocyte differentiation and development were specifically and highly expressed in cluster 0 and cluster 11, further clarifying that they are ACP cells. C. Single-cell RNA sequencing showed the cell ratio of each cluster in childhood ACP tissue. In addition to ACP cells, microglia, T cells and B cells and a very small number of neurons are present.Additional file 5.The details for materials and methods.Additional file 6.The details for ScRNA-seq data analysis.


Mesenteric desmoplasia in small intestinal neuroendocrine neoplasms (SINENs) is associated with increased morbidity and mortality. In this paper, we discuss the development of desmoplasia in SINENs.The fibrotic reactions associated with these tumours could be limited to the loco-regional environment of the tumour and/or at distant sites. Mesenteric fibrotic mass forms around a local lymph node. Formation of desmoplasia is mediated by interactions between the neoplastic cells and its microenvironment via number of profibrotic mediators and signalling pathways. Profibrotic molecules that are mainly involved in the desmoplastic reaction include serotonin, TGFβ (transforming growth factor β) and CTGF (connective tissue growth factor), although there is some evidence to suggest that there are a number of other molecules involved in this process.Desmoplasia is a result of autocrine and paracrine effects of multiple molecules and signalling pathways. However, more research is needed to understand these mechanisms and to develop targeted therapy to minimise desmoplasia. Desmoplasia could be defined as formation of fibrous connective tissue and forms a key component of solid tumour stroma , 2. NENsA study involving 824 patients with SINENs showed that 88% of all participants had mesenteric lymph node metastases. Among 538 patients with stage IV SINENs in this study had fibrosis associated with mesenteric nodal metastases which were detected among 50% of the participants [Small intestinal NENs (SINENs) are derived from the enterochromaffin cells and may give rise to carcinoid syndrome , 7 and rMesenteric desmoplasia is known to cause intestinal obstruction due to fibrotic adhesions or from mass effect. In addition, superior mesenteric vessels could be effected with arterial involvement causing small bowel ischaemia and superior mesenteric venous occlusion leading to ascites, small bowel venous ischaemia and varices , 10. It Desmoplasia is radiologically diagnosed through its characteristic spoke wheel appearance with linear soft tissue opacities radiating outward from a central mesenteric mass , 9. The This paper elaborates the current evidence on pathogenesis of desmoplasia in SINENs with an emphasis on tumour microenvironment, molecular mediators and downstream intracellular signalling pathways.It is believed that the nidus of mesenteric desmoplasia is a small bowel lymph node. Desmoplasia is the result of complex interactions mediated via profibrotic and anti-fibrotic factors between the SINEN cells and the tumour microenvironment . These mNENs do not only comprise proliferating cancer cells, but also consist of a plethora of heterogeneous non-cancerous cells and a non-cellular matrix which composite the tumour microenvironment •, 12–14.The tumour microenvironment consists of stromal cells, extracellular matrix (ECM), endothelial cells and inflammatory cells •, 12–14.The stromal cells in the tumour microenvironment predominately consist of fibroblasts. However, these fibroblasts are of a modified activated phenotype and are best named as cancer-associated fibroblasts (CAF) ••, 17, aSINENs demonstrate a high rate of α smooth muscle actin expressing fibroblasts than the other NENs ••, 17. AThe ECM consists of a complex network of crosslinked collagens, glycoproteins and water that continuously undergoes remodelling through enzymatic and non-enzymatic post-translational changes , 18. TheThe inflammatory cells in the tumour microenvironment is known to contain a large number of tumour-associated macrophages which effectively supress the immune system and promote tumour growth and fibrosis by secreting profibrotic factors ••, 20. ISINENs originate from the enterochrromafin cells of the diffuse endocrine system and secrete various amines and peptides promoting the tumour growth via autocrine and paracrine effects , 7. SomeSerotonin (5 HT) is an amine derived from the amino acid tryptophan and is produced in SINENs and excreted by the body predominantly in the urine in the form of 5 hydroxyindole acetic acid (5 HIAA) , 6. SeroSvejda and colleagues developed an in vitro co-culture model containing small intestinal neuroendocrine tumour cells (KRJ-I) , which wTransforming growth factor-β (TGF-β) is also a pro-fibrotic agent that is secreted by the SINENs ••, 27. AConnective tissue growth factor (CTGF) is a downstream mediator of TGF-β and serotonin  and it iCTGF may enhance profibrotic actions of TGF-β, FGF and EGF by stimulating fibroblast proliferation, collagen production and differentiation of fibroblasts into α smooth muscle actin producing fibroblasts. The location of these CTGF-secreting neoplastic cells was identified close to the α smooth muscle actin producing fibroblasts which could also suggest a potential role of CTGF to desmoplastic reaction of SINENs , 18. MorPlatelet-derived growth factor (PDGF) is a strong profibrotic agent and exerts its effect via PDGF-α and PDGF-β receptors and also stimulates the proliferation of fibroblasts. In SINENs, PDGFβ receptors are found in 65–85% of the cases and the receptors are probably on α smooth muscle actin producing fibroblasts but not on tumour cells. Evidence suggests that the tumour cells and the macrophages in the tumour microenvironment induce PDGFRβ expression on adjacent fibroblasts and upregulate PDGFRβ activity in a paracrine fashion promoting PDGF-mediated fibrogenesis .Transforming growth factor α (TGF α) is a peptide related to epithelial growth factor (EGF) and is known to express its effects via the EGF receptors. While it is overly expressed by the SINEN cells (> 90%), it also plays a crucial role in fibrosis and induce tumoural angiogenesis and proliferation. TGF-α produced by tumour cells acts on fibroblasts via the EGF receptors located on the fibroblasts ••, 30.Fibroblast growth factor (FGF) type 2/acidic FGF is known to be expressed by the SINEN cells and the adjacent stromal cells indicating its possible role in fibrosis , 31. HowInsulin-like growth factors (IGFs) 1 and 2 are known to increase the proliferation of fibroblasts in chick embryos, mammals and humans . These gSubstance P (SP) is tachykinin that is secreted by SINENs and is a known mediator of carcinoid syndrome . In addiNerve growth factor (NGF) is known to potentiate effects of TGF-β and is considered a profibrotic agent. SINENs are known to express NGF , 40. In Histamine produced by the SINENs is considered as a mediator of carcinoid syndrome  and is aWhile the above details express the potential roles of individual profibrotic growth factors in the development of desmoplasia, there is developing evidence to suggest that complex cross-talk between the above molecules and post-receptor signalling intracellular cascades is involved in the development of SINEN-associated desmoplasia ••, 42. IMoreover, cancer-associated fibrosis is known to be mediated via complex intracellular signalling pathways namely Hedgehog (Hh), Notch and Wnt/β-catenin and it is worth to discuss the evidence for these complex pathways in the context of SINEN-associated desmoplasia ••, 44.Hh cascade is activated by several ligands  which bind to Patch receptors stimulating production of transcription factors (Gli 1–3). Gli 1 transcriptional factor increases the expression of Snail which in turn leads to suppression of E-cadherin promoting epithelial to mesenchymal transition (EMT) and formation of myofibroblasts and subsequent desmoplasia , 16••. FNotch signalling also drives the epithelial to mesenchymal transition increasing the production of fibroblasts/myofibroblast population and thus promoting extensive fibrosis. In addition, activation of this pathway also stimulated TGFβ production which may further stimulate the fibrotic process . A studyβ catenin levels in the cytoplasm are maintained by binding to a destructive protein complex. Upon activation of Wnt signaling pathway, β catenin levels in the cytoplasm rise and then these molecules translocate to the nucleus activating target gene transcription . HoweverDespite our existing knowledge of the pathogenesis of mesenteric fibrosis, there are hardly any medical therapeutic strategies to treat mesenteric desmoplasia to the date . AvailabTherefore, the treatment of mesenteric fibrosis mainly involves surgical resection of the mesenteric fibrotic mass, palliative bypass surgeries in the presence of inoperable tumour and obstruction and stenting .SINEN-associated desmoplasia is associated with increased morbidity and mortality. Desmoplasia is the result of a complex interaction between SINEN cells and the tumour microenvironment mediated via a plethora of molecules potentiating their profibrotic effects independently or via a cascade of downstream signalling pathways. The key molecules known to be involved in the pathogenesis of SINEN-associated desmoplasia are serotonin, TGFβ and CTGF. Yet, to date, there is no effective medical therapy to treat or reverse this phenomenon. Further research into the pathophysiology of this desmoplastic reaction should provide insights into future development of targeted anti fibrotic therapies for SINEN-associated desmoplasia.


Orbital apex syndrome (OAS) is a rare disease. One of the causes of OAS is herpes zoster ophthalmicus (HZO). A 73-year-old man developed herpes zoster around the right eye, and oral amenamevir treatment was given for seven days. The right eyelid ptosis was observed on the third day, and right eye movement was restricted in all directions on the ninth day. His eyesight was also poor, and he was diagnosed with OAS associated with HZO. Cerebrospinal fluid examination revealed mononuclear cell increase; however, VZV-DNA was not detected. Intravenous infusion of acyclovir and oral prednisolone administration were started. Two weeks after the start of treatment, ptosis, eye movements, and visual acuity improved. If HZO is found, it is necessary to consider the possibility of developing OAS. Herpes zoster results from reactivation of the varicella zoster virus (VZV) and has been increasing in recent years . ReactivThe case is of a 73-year-old male. On May 25, 2022, he noticed swelling of the upper right eyelid. He visited a nearby clinic and was diagnosed with HZO. From May 27, he was prescribed amenamevir 400 mg for one week and acyclovir eye ointment three times a day. From May 28, he became aware of ptosis and was introduced to the Department of Ophthalmology at Tsukazaki Hospital on June 3. Right eyelid ptosis and right omnidirectional eye movement restriction were noted Figure .In addition to Hutchinson's sign, conjunctival hyperemia, corneal epithelial disorder, and iritis were observed in the right eye, but retinal necrosis was not observed. The right corrected visual acuity was 0.1, and the critical fusion frequency was 34 Hz on the right eye and 41 Hz on the left eye. On the same day, he was hospitalized and underwent a cerebrospinal fluid test, which confirmed mononuclear cell predominant pleocytosis  and an increase in varicella-shaped herpes IgG antibody in the cerebrospinal fluid. Cerebrospinal fluid PCR did not detect VZV DNA. No abnormal findings were found on head and orbital MRI examinations. After admission, intravenous infusion of acyclovir 750 mg was started and terminated for eight consecutive days. In addition, prednisolone 30 mg was orally administered for nine days. Then, the dose of prednisolone was reduced to 25 mg. One week later, ptosis, ocular motility disorder (Figure The number of English reports regarding OAS by HZO is not abundant -12. The In our case, anti-VZV antibody was confirmed in the cerebrospinal fluid, but VZV DNA was not detected. This may be due to the fact that 10 days have passed since the onset and that he had been receiving amenamevir treatment for one week. Furthermore, abnormal findings were not found on MRI. However, ocular motility disorder was noted. It could be possible that VZV have spread along the traffic branches of the interneuron, as reported before .HZO is initiated by VZV infection, and then cellular immunity against VZV follows and induces immune-mediated pathologies in the central nervous system -10. ThusIf VZV DNA is not detected in the cerebrospinal fluid such as in our case, concomitant use of steroids may be more effective to suppress excessive immune responses against VZV.It is necessary to consider the possibility of OAS development in HZO. Furthermore, properly grasping the status of viral inflammation by cerebrospinal fluid examination and MRI examination will help select a treatment method.


EditorialDespite impressive clinical successes, significant challenges persist in treatment of solid tumours with immune checkpoint inhibitor (ICI) therapy, including adverse effects and inability to reliably predict treatment response. Importantly, these challenges are not intrinsically linked to the underlying strategy of activating tumour‐specific T cells, but merely reflect that our current treatment methods are not selectively targeting intratumoural or tumour‐specific T cells. Such selective targeting of intratumoural immune processes has not been feasible in large part due to a gap in our knowledge about how these processes differ in inflamed and tumour tissues Figure .1We recently compared the immune infiltrate in non‐malignant inflamed and tumour tissues using two different human cohorts – a cohort with inflamed oral mucosa  and a cohort of both p16‐positive and p16‐negative head and neck squamous cell carcinoma (HNSCC) patients undergoing primary surgery.2In an effort to identify tumour‐unique immune processes, we applied novel machine learning approaches to our single‐cell data sets from inflamed oral mucosa and HNSCC tissues. We used ‘full annotation using shape‐constrained trees’ (FAUST),3Our study provides a path forward to targeting intratumoural Tregs for depletion in HNSCC, and possibly other solid tumours as well.If targeting of intratumoural Tregs is feasible, could it also be possible to specifically target intratumoural CD8 T cells? Antibodies against PD‐1 or PD‐L1 were initially thought to disrupt the negative signals that PD‐1‐expressing T cells receive when PD‐1 interacts with its ligands PD‐L1, thereby rejuvenating exhausted T cells. However, it may actually also rely on additional indirect effects that induce pro‐inflammatory cytokines.4Finally, our comparison of the immune infiltrate in inflamed oral and HNSCC tissues also highlights the feasibility of analysing human tissues to discover novel potential therapeutic targets. In the past, the field has typically relied on discoveries originating from the mouse model system to translate well to human disease. Similarly to immunotherapies, the mouse to human discovery approach has had great successes, but also has often failed. We hope that other groups will use either the data sets from our study  or our general analysis strategy as a blueprint to discover more tumour‐ and disease‐specific targets by directly analysing human tissues, which would help ensure that potential therapeutic targets are of relevance. If discovery‐based approaches using human tissues continue at their current pace, more tumour‐ and pathology‐specific therapeutic targets should become available and find their way to the clinic. This increase in targeting specificity should go hand in hand with fewer toxic side effects and an improved ability to predict treatment response.The experimental overview schemes in Figures


Early bacterial survival in the postsurgical joint is still a mystery. Recently, synovial fluid-induced aggregation was proposed as a potential mechanism of bacterial protection upon entry into the joint. As synovial fluid is secreted back into the joint cavity following surgery, rapid fluctuations in synovial fluid concentrations, composition, and viscosity occur. These changes, along with fluid movement resulting from postoperative joint motion, modify the environment and potentially affect the kinetics of aggregate formation. Through this work, we sought to evaluate the influence of exposure time, synovial fluid concentration, viscosity, and fluid dynamics on aggregation. Furthermore, we aimed to elucidate the primary mechanism of aggregate formation by assessing the interaction of bacterial adhesins with the synovial fluid polymer fibrinogen. Following incubation under each simulated postoperative joint condition, the aggregates were imaged using confocal microscopy. Our analysis revealed the formation of two distinct aggregate phenotypes, depending on whether the incubation was conducted under static or dynamic conditions. Using a surface adhesin mutant, we have narrowed down the genetic determinants for synovial fluid aggregate formation and identified essential host polymers. We report here that synovial fluid-induced aggregation is influenced by various changes specific to the postsurgical joint environment. While we now have evidence that select synovial fluid polymers facilitate bridging aggregation through essential bacterial adhesins, we suspect that their utility is limited by the increasing viscosity under static conditions. Furthermore, dynamic fluid movement recovers the ability of the bacteria with surface proteins present to aggregate under high-viscosity conditions, yielding large, globular aggregates. Staphylococcus aureus has been heavily investigated as a bacterial survival mechanism in the development of periprosthetic joint infections (PJIs). Numerous in vitro studies have provided novel insights into both the composition and pathogenic attributes of staphylococcal aggregates , porcine synovial fluid, or equine synovial fluid , 8. In pin vitro . These sThe synovial joint environment during and following surgery is highly dynamic, with several characteristics distinguishing it from a native joint. Following surgical site closure, invading bacteria encounter synovial fluid that is in compositional flux. The infiltration of blood into the joint dilutes the overall concentration of synovial fluid polymers that are suspected to facilitate aggregate formation . Further10–14–After a surgical procedure, the joint cavity is predominantly filled with blood. Over time, host cells lining the synovial membrane secrete synovial fluid back into the cavity, subsequently displacing the blood and changing the rheological properties of the fluid , 18. TogFollowing incubation in different concentrations of BSF, the average aggregate size and branch lengths were quantified using confocal microscopy followed by image analysis software. Because the overall viscosity changes over time due to both surgery-induced inflammation and synovial fluid infiltration, we next evaluated the influence of viscosity on aggregation, independent of increasing synovial fluid polymers. Finally, the postoperative synovial joint is seldom a static environment, with joint motion being encouraged immediately following surgery. Inducing joint flexion stimulates the movement of synovial fluid and blood in the joint, creating a dynamic environment . To inveS. aureus quadruple surface adhesin mutant, AH4413 (ΔclfA ΔfnbAB clfB::Tn), we probed the necessity of fibrinogen and fibronectin-binding proteins under static incubation as well as on a shaker. Taken together, this work demonstrates that the unique characteristics of the postsurgical joint environment, including changes in fluid dynamics, synovial fluid concentrations, and viscosity, influence early aggregation, potentially contributing to the efficacy of synovial fluid-induced aggregation as a survival mechanism. Furthermore, we report evidence of a polymer bridging mechanism for aggregate formation, which requires the presence of specific bacterial surface adhesins.During our study, we noticed distinct phenotypic differences between aggregates formed under static and dynamic conditions. Because both conditions would likely exist at some point following surgical site closure, we wanted to understand the mechanics of aggregate formation under both conditions. With the use of a S. aureus rapidly aggregates upon contact with BSF . Following 1 h of static incubation in either PBS or 10% BSF in PBS, both the wild-type S. aureus strain and the adhesin mutant were imaged using confocal microscopy  using a croscopy . While bcroscopy , with a croscopy . When incroscopy .We hypothesized that this defect was due to a lost interaction between one or more bacterial surface adhesins and the synovial fluid polymer. We repeated the experiment using purified Alexa Fluor-conjugated fibrinogen. Fibrinogen alone was selected because it was documented previously to play an important role in staphylococcal aggregation , 4. SimiQuantification through image analysis revealed that fibrinogen alone produced aggregates that were 2-fold larger than those of the untreated wild-type bacteria and 2-fold smaller than the 10% BSF aggregates . There wS. aureus was incubated in 10% BSF and assessed for aggregation. Confocal imaging revealed that, throughout a 1-h incubation, the dead bacteria were still able to aggregate in the 10% BSF , we conducted aggregation assays with antibiotic-treated bacteria. Following treatment with gentamicin, nonviable  BSF see . These d10.1128/mbio.00236-22.6FIG S3S. aureus retains the capacity to aggregate in BSF. S. aureus strain AH1726 was treated with gentamicin for 3 h before the addition of 10% BSF. Time-lapse imaging was conducted to confirm that aggregation occurred over time upon contact with BSF (a). After 1 h of exposure, the average aggregate size was quantified using Fiji image analysis software for both gentamicin-treated and untreated bacteria (b). The bacterial killing was confirmed by CFU counts (c). Data points represent 3 replicates of gentamicin-treated bacteria and 2 replicates of untreated bacteria, with 5 representative images being collected for each replicate. Error bars indicate the mean ± SEM. Statistical significance was determined by Student’s t test to compare the mean aggregate size between treated and untreated bacteria. **, P ≤ 0.01; ****, P ≤ 0.0001. Download FIG S3, TIF file, 1.1 MB.Gentamicin-killed Copyright © 2022 Staats et al.2022Staats et al.https://creativecommons.org/licenses/by/4.0/Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the As mentioned previously, blood predominantly occupies the joint cavity following surgical site closure. To mimic the influence of the transition from a blood-dominated cavity to a synovial fluid-dominated one, we conducted macroscopic imaging after 1 h of dynamic incubation in synovial fluid supplemented with human blood . ComparaS. aureus is under investigation as a potential pathogenic survival mechanism in the occurrence of (PJIs). While a considerable amount of work characterizing this process has been conducted, until now the influence of surgical site-specific conditions on aggregate formation has been neglected. Following prosthetic joint surgery, numerous changes associated with inflammation and joint flexion occur. These changes are highly distinct from a native joint environment and should be taken into consideration when studying the establishment and progression of bacterial infections. Furthermore, analysis of synovial fluid-induced aggregates has been confined to long incubations (<90 min), leaving the initial kinetics of aggregation unclear.Synovial fluid-induced aggregation of S. aureus was imaged immediately following exposure to either 10% BSF in PBS, 10% human serum in PBS, or PBS alone. Our videos reveal that not only does aggregation occur immediately upon contact with the BSF but also the resulting aggregates form distinctive branched structures as they develop. In contrast to tightly packed, globular bacterial clusters that form from polymer depletion, the branching structures we observed appear visually similar to those generated through diffusion-limited cluster aggregation (DLCA) and reaction-limited cluster aggregation (RLCA)  . This mon (RLCA) .Two dominating mechanisms of bacterial aggregation when either host-produced or bacterial polymers are present have recently been proposed . DepletiS. aureus is dominated by the bridging aggregation mechanism, with fibrinogen or fibronectin serving as bridging polymers , there is a significant elevation in the expression of SigB, a stress-responsive alternative sigma factor , 27. Sig28–Pseudomonas aeruginosa, yielding compact, aligned bacterial aggregates  was used for all confocal microscopy, image analysis quantification, and growth curves. For macroscopic imaging experiments, the quadruple mutant AH4413 (ΔclfA ΔfnbAB clfB::Tn) was utilized along with the wild-type strain, AH1263  of 0.2. One milliliter of the diluted culture was pelleted at 21,000 × g for 1 min in a centrifuge before resuspension in 1 mL of PBS. The cells were then transferred into a glass-bottomed confocal dish  containing 2 mL of PBS or PBS supplemented with synovial fluid and/or hyaluronic acid. Confocal microscopy was conducted 1 h after bacterial incubation in PBS, 10% BSF in PBS, 20% BSF in PBS, or 50% BSF in PBS at room temperature. Additionally, the effect of viscosity on synovial fluid-induced aggregation was assessed by imaging 1 h after incubation in 10% BSF supplemented with increasing concentrations of high-molecular-weight hyaluronic acid sodium salt  in PBS. The pH value was measured for each solution to ensure that pH was not influencing aggregation phenotypes -approved protocol (protocol number: 2009H0314). Pelleted bacteria were diluted to an OD600 of 0.5 and resuspended in blood supplemented with increasing concentrations of BSF.Macroscopic analysis of the dynamically formed aggregates was carried out as described in a previous work . The GFPP value of 0.05. All error bars indicate the standard error of the mean (SEM). Statistically significant differences were determined using the tests specified in the descriptions.GraphPad Prism v9.20 software was used for statistical analysis of the following data. The threshold significance was set at a 10.1128/mbio.00236-22.7TEXT S1Text S1, DOCX file, 0.01 MB.Supplemental methods. Download Copyright © 2022 Staats et al.2022Staats et al.https://creativecommons.org/licenses/by/4.0/Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the


COL11A1) is a central component of the extracellular matrix in many carcinomas, which is considered to be mainly produced by cancer associated fibroblasts (CAFs). As COL11A1 expression correlates with adverse prognosis and is implicated in chemoresistance, it is a promising putative target. For the first time, we used RNA in-situ hybridization to systematically identify the cells that produce COL11A1 in the ten most prevalent carcinoma types, lymphomas (n = 275) and corresponding normal tissue . Moreover, as most salivary gland carcinomas (SGC) display distinct stromal architectures, we also analysed 110 SGC. The corresponding protein formation of COL11A1 was determined by MALDI-TOF–MS-Imaging. We report that colon, breast and salivary duct carcinomas are highly infiltrated by COL11A1 positive CAFs (CAFsCOL11A1) and might thus be promising candidates for antidesmoplastic or COL11A1-targeted therapies. The amount of CAFsCOL11A1 correlated significantly with tumour grade, tumour stage and nodal spread in the panCancer cohort. Significant associations between CAFsCOL11A1 and vascular invasion, perineural spread and nodal spread were observed in the SGC cohort. Also, we discovered that tumour cells of intercalated duct derived SGC and CAFs produce COL11A1 in a mutually exclusive manner. Our findings represent a novel mode of extracellular matrix production in carcinomas and could be highly relevant in the future. Our findings elucidate the mode of COL11A1 expression in very different carcinoma types and may aid to categorise tumours in the setting of possible future COL11A1-related therapies.Procollagen 11A1 (The online version contains supplementary material available at 10.1007/s12105-021-01370-0. As the efficacy of mutation-specific therapies is limited by resistance mechanisms, more recently, the interest of cancer research has expanded towards the non-neoplastic tumour microenvironment (TME). It provides tumour promoting growth factors, an aberrant neo-vasculature and an immune milieu that supports the growth of neoplastic cells –4. More COL11A1), the α1 chain of collagen XI, has been found to be consistently upregulated in the ECM of different carcinoma types . From this peptide, four adducts, [M + H] + (1546.828 m/z), [M + NH4] + (1563.854 m/z), [M + Na] + (1568.81 m/z) and [M + K] + (1584.784 m/z) were recognised. As all adducts were distributed equally among the different tumour types, only the measurements for the [M + H] + adduct were used for further comparisons.For the detection of the protein expression, TMAs with samples from 41 patients of the SGC cohort and from 100 patients of the panCancer cohort  were used. Sample preparation, MSI data acquisition as well as data and imaging analysis were performed as previously published . We deteStatistical analysis was carried out with SPSS statistical software . Bar plots and dot plots were drawn with RStudio  and the R package ggplot2 . InterdeCOL11A1 using a semiquantitative score (Score 0—4) that reflected the percentage of stromal surface stained by the COL11A1 RNA-ISH. Additionally, we assessed the percentage of tumour cells with COL11A1 staining (TCCOL11A1). CAFsCOL11A1 were almost exclusively observed in tumour tissues with an overall positivity rate of 34.5% compared to 1.6% in normal tissue (one positive endometrium sample). We observed dramatic differences of CAFsCOL11A1 infiltration across different primary sites , reaching 29.2%, 33.3% and 28%, respectively. Conversely, only 8% of all stomach carcinomas were assigned to this category. None of the cases from the panCancer cohort exhibited confluent stromal COL11A1 staining required for the maximum CAFsCOL11A1 Score of 4, which was observed in several SGC subgroups.The panCancer cohort (n = 275) comprised the ten most prevalent carcinoma types as well as lymphomas (25 cases each). Additionally, five samples of normal tissue of each respective organ were included (n = 55). We measured the infiltration by CAFsCOL11A1 score strongly correlated with tumour grade (p = 0.001) and tumour stage (p < 0.001). To a lesser extent, but still significantly, CAFsCOL11A1 score also correlated with nodal spread (p = 0.048). Moreover, a trend for a higher rate of lymphatic invasion and higher age and was observed for tumours with infiltration by CAFsCOL11A1 . The trend for a higher percentage of CAFsCOL11A1 infiltrated carcinomas among females (p = 0.078) resulted from the high percentage of MCs.When all cases of the panCancer cohort were pooled Table , the CAFCOL11A1 in over 50% of the cases and were consecutively studied in more detail. For MC (Table S2), a significant positive correlation with stromal CAFsCOL11A1 score was observed for tumour grade and Ki67 index . Also, the presence of CAFsCOL11A1 was associated with negativity for oestrogen receptor (ER), as 100% of ER- and only 54.5% of ER + MC were infiltrated by CAFsCOL11A1 (p = 0.011). In this subgroup analysis, no significant dependency between CAFsCOL11A1 score and progesterone or androgen receptor status or clinicopathological criteria was observed. Also, no significant association between CAFsCOL11A1 score and clinicopathological parameters, including microsatellite instability was observed for CRC. Of note, tumour cells with staining for COL11A1 (TCCOL11A1) were detected in one OC as well as one endometrial carcinoma with a percentage of 5% and 70% of tumour cells, respectively.MC and CRC were infiltrated by CAFsCOL11A1 mRNA-ISH, containing 29 MuEp, 25 AdCy, 19 salivary duct carcinomas (SaDu), 10 acinic cell carcinomas (Acin), 7 secretory carcinomas (Sec), 6 epithelial-myoepithelial carcinomas (EpMy), 6 adenocarcinomas not otherwise specified (ANOS) as well as 4 basal cell (Bas) and 4 myoepithelial carcinomas (MyEp). We observed CAFsCOL11A1 in the peritumoural stroma with marked differences across the different subtypes , SaDu (78.9%) and Acin (50.0%), MyEp and Bas showed no CAFsCOL11A1 at all. A heterogeneous distribution was observed in EpMy (33.3%), AdCy (28.0%) and Sec (14.3%). A CAFsCOL11A1 score of 4 was only detected among MuEp and SaDu—none of the tumours from other organs exhibited such intense staining.110 SGC were available for COL11A1 score positively correlated with higher N-status and CD8 + T cell infiltration . Moreover, the presence of CAFsCOL11A1 was associated with perineural spread (p = 0.004). No association between CAFsCOL11A1 and either tumour grade or pT-status was observed in the SGC cohort. On single-entity level, AdCy with CAFsCOL11A1 were more likely to exhibit perineural spread (p = 0.007) or a TP53 mutation . No other significant associations of CAFsCOL11A1 with clinicopathological parameters were observed in the other tumour types.When all SGC cases were pooled, CAFsCOL11A1. 35.7% were positive in the primary but not in the nodal metastasis while in the opposite was the case in 14.3%.For 14 cases, both the primary and a nodal metastasis were analysed (Table S4). In 50% of the cases, both the primary and the metastasis were either positive or negative for CAFsCOL11A1. The highest rate of tumours with TCCOL11A1 was observed among MyEp , AdCy  and EpMy . Similarly, the mean percentage of TCCOL11A1 in individual tumours was highest in MyEp followed by EpMy and AdCy (Table S5). Conversely, these entities showed low frequencies of cases with CAFsCOL11A1 of 0.0%, 28.0% and 33.3%, respectively GEKGEAGPPGAAGPPGAK(G); m/z value: 1545.82]. Among the different primary sites, the highest intensities were noted for SGC, breast and colon carcinomas, which largely confirmed our results from the RNA-ISH analysis  which confers cisplatin resistance [Moreover, several studies have recently revealed that rcinomas , 42 inclrcinomas  and has sistance . The facsistance , 44, alssistance –47. ThusCOL11A1 varied dramatically among the different SGC subtypes. SaDu displayed the highest frequencies of scores 3 and 4, the latter being a staining intensity that has not been observed in any of the tumours from the panCancer cohort. Since SaDu have many overlapping features with ductal MC, it is not surprising that SaDu and MC are both characterised by high frequencies of CAFsCOL11A1 and an absence of TCCOL11A1. Together, our results provide a strong rationale to further investigate the potential of anti-desmoplastic therapies in SaDu and MC.The frequency of CAFsCOL11A1 positive AdCy cases was significantly higher among TP53 mutated tumours. The fact that p53 mutation is an adverse prognosticator for AdCy [COL11A1 are associated to surrogates of poor outcome. As some CAF subtypes have been attributed immunomodulatory properties, we also scored the number of CD8 + T-lymphocytes but did not find a correlation with CAFsCOL11A1. This is in line with current evidence, that immunomodulatory functions are exerted by specialised iCAFs rather than by mCAFs which are instead involved in ECM production [Interestingly, we found that the rate of CAFsfor AdCy  further oduction , 50.COL11A1 expression in the latter is nearly restricted to CAFsCOL11A1 in their vicinity, SOX10 + tumours produce COL11A1 in the tumour cells at varying rates. Interestingly, the mode of COL11A1 production was nearly mutually exclusive as only 4% of the tumours exhibited both CAFsCOL11A1 and TCCOL11A1. This suggests that tumours with TCCOL11A1 “do not require” CAFsCOL11A1 in their TME. Together with the fact that 73% of all SGC produced COL11A1 in either way, it indicates that COL11A1 might play a major role in SGC tumourigenesis. Interestingly, we revealed that while the RNA expression of COL11A1 in AdCy was not particularly high, the protein deposition in the tumours was marked. We speculate, that this seeming discrepancy might be traced back to a slow turnover of COL11A1 in AdCy, possibly due to a relative absence of CAFs in these tumours. As outlined above, COL11A1 production strongly correlates with expression of several other ECM molecules. Thus, we hypothesise that SOX10 + SGC cells might produce most of their ECM themselves. Even though COL11A1 production by tumour cells has been reported for mesenchymal neoplasms [COL11A1 production might have implications on the effectiveness of COL11A1- and FAO-targeting drugs and might thus impact clinical decision making in the future.Ohtomo et al. found that SGC which derive from the acini  and the intercalated duct  express the neural crest transcription factor SOX10, while tumours emerging from the excretory duct  do not . Strikineoplasms , we are The descriptive character of this study does not allow for mechanistic conclusions concerning the function of COL11A1. Moreover, as the size of each individual tumour group was rather small, correlations with clinicopathological parameters must be interpreted with caution and should be further validated in larger, individual studies.COL11A1 and TCCOL11A1 in the most prevalent carcinoma types and SGC. We report that (1) MC, CRC and SaDu do not produce COL11A1 themselves but are highly infiltrated by CAFsCOL11A1 and might thus be promising candidates for antidesmoplastic or COL11A1-targeted therapies. (2) COL11A1 is produced by CAFsCOL11A1 and intercalated duct SGC cells in a mutually exclusive manner which represents a novel mode of ECM production in carcinomas. (3) Finally, we propose a 4-tiered RNA-ISH-based scoring system for CAFsCOL11A1 which could be highly relevant for future ECM or COL11A1-targeted therapies.We systematically assessed the frequency of CAFsSupplementary file1 (PDF 263 kb)Below is the link to the electronic supplementary material.


Background. Wilms’ tumour or nephroblastoma is the most common renal malignancy encountered in the paediatric population. Imaging findings are of great importance to the surgeon, the oncologist and the radiologist in the diagnosis and the staging and surveillance of this tumour. Material and Methods. This study was carried out as a 10-year retrospective study of patients who were diagnosed with Wilms’ tumour. Results. The study included 12 boys and 11 girls. Ultrasound and computed tomography were performed in all cases. Ultrasonography was found to be superior to the CT examination when approximating the antero-posterior and transverse diameters; the computer-tomographic examination is cited as superior for estimating the invasion of nephroblastomas. Conclusions: Ultrasound has been shown to be effective in detecting the rupture of the renal capsule, tumour calcifications and invasion of the renal vein, pelvis and ureter. However, ultrasound cannot replace CT in the detection of lymphadenopathy and the invasion of adjacent organs. Wilms’ tumour (WT) or nephroblastoma is the most common renal malignancy in the paediatric population, with about 1000 new cases being diagnosed in Europe each year. In total, 95% of all renal cancers and 6% of cancers in children under the age of 15 are found to be nephroblastomas ,3.WT tends to grow into the vena cava and can sometimes even invade the atrium, which usually increases intraoperative complication rates . The 5-yBased on previous experience, the UMBRELLA SIOP-RTSG 2016 calls for the management of patients with renal neoplasm with initial chemotherapy without biopsy followed by surgery and adjuvant therapy with chemotherapy and/or radiation. This being the case, imaging studies play an important role in determining the stage of the neoplasm and establishing the diagnosis of WT, minimising the risk of using chemotherapy in treating patients with lesions different from WT ,8.Imaging findings are of great importance to the surgeon, the oncologist and the radiologist in the diagnosis and to the staging and surveillance of WT. Initial imaging of a renal mass begins with an abdominal ultrasound (US) that identifies the point of origin, which can sometimes be challenging due to the size of the tumour mass ,9.The advantage of using ultrasound in the initial diagnosis of WT is that this a non-invasive imaging method that can also be applicable at the patient’s bedside whenever necessary and does not require patient sedation. Doppler US is also useful when examining the patency of the renal vein and the inferior vena cava (IVC) while searching for tumour thrombus ,7,10.According to the UMBRELLA protocol, magnetic resonance imaging (MRI) of the abdomen is the first choice in complementary imaging, as this technique is not associated with ionizing hazards as is the case when using computed tomography (CT) . HoweverWe retrospectively reviewed the medical records of 23 patients diagnosed and surgically treated for nephroblastoma at our institution in order to assess the value of the two imaging modalities, ultrasound and computed tomography, in the initial evaluation of nephroblastomas. The clinical translation of the paper consists of the evaluation of the possibility of using a non-invasive, non-irradiating method as the initial imagistic tool for the diagnosis and staging of nephroblastoma or whether it is of greater sensibility in the evaluation of the essential imagistic characteristics of nephroblastomas, such as tumour dimension, bilaterality, vascular invasion, pelvic or ureteral extension, renal capsule involvement, invasion of adjacent organs, lymph node involvement and the presence of metastases. We hypothesise that ultrasonography can be of great value in the diagnosis and evaluation of tumour dimensions and local extension, but computed tomography is mandatory for the accurate staging of nephroblastoma in children.The aim of this study is to elucidate the place and the advantages that ultrasonography has for patients with Wilms’ tumour compared to computed tomography, using as state-of-the-art intraoperative examination and histopathological examination.The present study is an analytical, observational study involving a cohort of 23 patients with Wilms’ tumours whose data were collected retrospectively over a period of 10 years from the medical archive of the “Grigore Alexandrescu” Emergency Hospital. Despite the fact that the small number of patients is an obvious shortcoming, this cohort belonged to a single surgical team, which greatly reduces the variability and heterogeneity often present in surgical studies. Additionally, it is worth mentioning that in the literature most studies involving Wilms’ tumour include a small number of patients.The inclusion criteria in this study were the presence of Wilms’ tumour in children who were investigated by laboratory analysis and of course imaging by ultrasonography and computed tomography. Children who were insufficiently investigated or those who were lost to follow-up were excluded from the study.In most cases of clinical examination, an intraabdominal tumour mass was identified. Ultrasound was then performed in order to confirm initial diagnosis and to establish the origin of the tumour mass. Contralateral kidney was also evaluated and Doppler US was performed in order to assess for vascular invasion. Patients then underwent chest/abdominal/pelvic contrast-enhanced CT scan and, depending on the age, in certain cases required sedation.t test to determine the mean with standard deviation, standard error and median. To determine the difference between three or more averages, we used the ANOVA test for repeated measurements with Bonferroni correction. The correlation analysis took into account the data distribution, thus choosing the Pearson or Spearman coefficient and the Bland–Altman test was used to compare imaging methods. The correlation coefficients were represented by a heat-map. To calculate the differences between the distribution frequencies we used Chi-Square test, and the graphical representations were exported from the statistical program.The statistical analysis was performed with GraphPad 9. For each data set analysed, the normality of the distribution was tested with the Anderson–Darling, D’Agostino–Pearson, Shapiro–Wilk and Kolmogorov–Smirnov tests. We used the one sample We reviewed the records of 23 patients who were diagnosed and underwent surgical treatment for nephroblastoma at our centre. The median age at diagnosis was 3 years ranging from 0 to 11 years. There were 16 patients (70%) from rural areas and 6 (30%) from urban areas. There were 15 patients that presented with abdominal pain, 14 with palpable abdominal mass, 9 with weight loss and 6 with haematuria. Less frequent manifestations were fever, loss of appetite, vomiting and acute urine retention. Thoraco-abdominopelvic computed tomography (CT) studies were used for diagnosis and staging in all cases. Abdominal ultrasound was also used in all cases as the initial diagnostic method. For CT examination, various elements were analysed for precise tumour staging: tumour dimension, bilaterality, vascular invasion, pelvic or ureteral extension, renal capsule involvement, invasion of adjacent organs, lymph node involvement and the presence of metastases. All patients underwent surgery at our centre. Nephrectomy was performed in 21 patients (91%), and partial nephrectomy in 2 patients (9%). In most cases the entire tumour was received as a resection specimen and histologically studied. Three tumours had a biphasic pattern and the majority, 14, had a triphasic pattern. In all monophasic tumours, blastemal cells were predominant. Based on predominant cell types, tumours were classified into low, intermediate or high risk. Most patients had an intermediate risk 14 (60%), while low risk was attributed to only 3 patients (13%) and high risk to 6 patients (26%). Most of the tumours were classified as stage III 10 (43.47%), followed by stage II and stage IV, 21.73% each. Two children had stage I nephroblastoma (8.69%). Only one patient had bilateral nephroblastoma—stage V (4.34%). All patients received adjuvant chemotherapy and seven received adjuvant radiotherapy.p = 0.91  represented with green in the graphic representation, being obviously statistically insignificant p = 0.91 . Based oIn order to respond to the main objective of this study, it was necessary to compare the antero-posterior and transverse diameter of the tumours obtained using computed tomography and ultrasound. The measurements considered to be of reference were those performed intraoperatively. For the following analysis we used the ANOVA analysis for repeated measurements and the Bonferroni correction .p = 0.046 [From the analysis of the differences between the mean value of the antero-posterior diameter, we can say that both CT (85.08 mm) and ultrasonography (92 mm) tend to underestimate the actual diameter of the tumour measured intraoperatively (118.47 mm). This difference is statistically significant  = 0.046 .p = 0.054 [The one-way ANOVA analysis performed for the transverse diameter of the tumour reveals an interesting result when comparing the three mean values obtained by computed tomography, ultrasonography and intraoperative. The transverse diameter seems to be overestimated using CT and underestimated using ultrasonography (94.27 mm and 67.95 mm) if we compare it with the intraoperative measurements (81.81 mm). The analysis is not statistically significant  = 0.054 .However, in order to see for sure whether ultrasonography can give reference results for nephroblastomas, we made two correlation matrices, represented graphically by a heat-map. For this analysis, the data distribution was taken into account, so that, as appropriate, the Pearson or Spearman correlation coefficient was chosen .r = 0.73 p = 0.003 vs. r = 0.46 p = 0.038). The superior correlations of the dimensions from ultrasonography with those measured intraoperatively remain superior in the case of the antero-posterior diameter . In our study, ultrasonography is superior to CT examination when approximating the antero-posterior and transverse diameters, and the computer-tomographic examination is cited as superior for estimating the invasiveness of nephroblastomas.Regarding the transverse diameter, the dimensions found using ultrasonography correlate better than those revealed by the CT examination  using the intraoperatively measured diameter as a reference value. To calculate the measurement bias, two analyses were performed with the same calculation procedure . Both ultrasonography  and computed tomography  tend to systematically underestimate the real value of the anterior-posterior diameter. .The Bland–Altman analysis comparing the transversal diameter measurements obtained using ultrasound and CT with that obtained intraoperatively reveals that ultrasonography tends to underestimate while computed tomography tends to systematically overestimate. The bias of ultrasonography is −17.65 mm (SD = 39.36 mm and 95% CI of agreement is between −94.79 and 59.49 mm). The computed tomography bias is 20.04 mm (SD = 51.49 mm and 95% CI of agreement between −80.88 mm and 121 mm) .In order to increase the accuracy of the statistical analysis regarding the invasion of nephroblastomas, this time we used as a reference the histopathological examination of the tumour, which includes three essential characteristics: rupture of the renal capsule, invasion of the pelvis and ureter and invasion of the renal vein.p = 0.02) from the histopathological one, which makes ultrasonography a poor diagnostic method , Denys-Drash syndrome, Beckwith-Wiedermann syndrome or isolated hemihypertrophy are at higher risk of developing WT . In our When trying to identify if the origin of the tumour mass is the kidney, radiologists often observe the movement of the mass with the kidney during normal breathing. However, one should be aware that this is not the case when the tumour mass infiltrates adjacent organs. US can determine initial staging by detecting possible lymph nodes metastases, hepatic or intraperitoneal lesions and the presence or absence of abdominal or pelvic fluid when examining the peritoneal recesses. US can distinguish between a solid and a cystic mass. It also allows for contralateral kidney evaluation in cases of bilateral tumours and can detect congenital renal or genitourinary malformations that may affect renal function ,8. We peOn an ultrasound, WT appears as a large, solid intrarenal mass with smooth and well-defined margins, with a pseudo capsule and areas of heterogeneous echogenicity (tumour necrosis) and hypoechoic and anechoic cystic areas. Renal masses can distort the normal parenchyma, with a “claw sign” of the normal parenchyma surrounding the mass and calyceal dilatations may also be present due to the compressive effect of the tumour mass ,8.p = 0.02) from the histopathological one, which makes ultrasonography a poor diagnostic method. Due to the risk of tumour rupture, tumour outline, the presence of hyperechoic areas (that may represent haemorrhage) and the presence of blood in the abdominal cavity should be carefully assessed [It is of absolute importance that once the diagnosis of a renal mass is established the radiologist evaluates the renal vein and the inferior vena cava with both grey-scale and colour Doppler due to the vascular extension of the tumour . Ultrasoassessed .In some cases, WT can completely obstruct the IVC without invasion. US can better and more accurately assess the IVC in multiple planes and degrees of obliquity, as the radiologist is able to appreciate if the tumour is simply compressing the IVC or actually invading it .An important drawback of US that was shown in previous studies was the less than accurate tumour staging when compared to a CT scan . In our After the renal mass is confirmed on an ultrasound, cross-sectional chest/abdominal/pelvis CT or MRI is then further used in order to evaluate the primary site, the status of the contralateral kidney, tumour involvement of renal veins or inferior vena cava, to identify possible metastases, preoperative tumour rupture and the existence of ascites. CT evaluation of the lungs is mandatory in order to assess for small lung nodules that may not be visible on radiograph, known as CT-only nodules. Administration of intravenous contrast is also mandatory in order to fully evaluate the renal hilum and the potential intravascular thrombi and usually only one portal venous phase is sufficient for the diagnosis of WT. Delayed-phase imaging can help when evaluating the status of the renal collecting system with regard to the tumour, especially when dealing with a small tumour, in which case nephron-sparing surgery can be performed ,9.On a CT scan, WT appears as a heterogenous soft-tissue mass that shows less enhancement than normal renal parenchyma. Enhancement is also patchy and allows for a better delineation between the tumour and the kidney. WT usually presents with hypodense areas due to necrosis, old haemorrhage and cysts, and in some cases, calcifications, infiltration and the distortion of the calyceal system, vascular invasion and lymph node metastases can also be found . Some tuIn their study, Le Rouzic et al. reported that a CT scan has a good sensitivity in detecting acute haemorrhage. Tumour necrosis, perinephric extension, lymph node involvement were also more often detected on a CT scan then on US . In our It is certain that patients with WT require life-long follow-up as most of them end up having a single kidney and there is still a risk of developing late effects of treatment or secondary tumours (the risk of a second neoplasm is 5–7% at the 30-year mark-up) [According to the SIOP guidelines, ultrasound examination should be performed 5–8 times during the first 5 years after treatment in single kidney disease with no metastases, in order to detect possible tumour recurrences . About 1The best method of treatement and the surveillance for patients with WT after treatment are still under debate. Strategies vary in different centres, depending on the available resources and can sometimes be a burden both for the family and for the healthcare system .Bearing that in mind, ultrasonographic examination is of great value in the prompt detection of abdominal relapse as it is a non-invasive imaging method that can also be applicable whenever necessary, and when compared with a CT scan or an MRI, is a more inexpensive investigation method . NonetheIn our clinic, ultrasonography tends to be superior to computed tomographic examination in terms of measuring the antero-posterior and transverse diameter, but it is inferior in the assessment of neoplastic invasion .Our study has several limitations. First, it is a retrospective study from a single centre, with a small number of cases. Preoperative imagistic evaluation of the patients was performed by different members of the radiological team of our institution, resulting in variations in describing the key elements of the preoperative assessment of nephroblastoma.


Giant cell tumour of the tendon sheath (GCTTS) is a rare benign soft tissue tumour with no known cause. It is more prevalent in the hand than in the ankle and foot. It appears as a non-painful, perceptible enlargement. Although pre-operative imaging and fine-needle aspiration cytology (FNAC) corroborate suspicion, histology following surgical resection is used to confirm the diagnosis. Due to its rarity, a case of giant cell tumour (GCT) of the extensor tendon sheath of the left ring finger is reported here. A 39-year-old female presented with a six-month history of painless swelling over left ring finger. The swelling was spontaneous, slowly progressive and painless. On clinical examination, a 1.5 cm x 1 cm firm swelling was seen on the dorsal surface of the left ring finger extending from the distal portion of the middle phalanx to the proximal half of the distal phalanx. The swelling was well-defined, smooth, firm, and uniform in consistency. The swelling was movable sideways with no attachment to the bone when examined clinically. X-ray of the hand showed soft tissue mass without the involvement of the bone. Soft tissue mass was seen on ultrasonography. An excisional biopsy was done. Histopathology showed typical features of GCTTS. Our case is a rare example of GCTTS in a single digit of the hand. Furthermore, considering its high recurrence risk, the tumour should be totally excised. Finally, if required, the hand's function should be recreated to minimise the loss. Giant cell tumour of the tendon sheath (GCTTS) is a benign soft tissue tumour that appears as a solitary, extra-articular, and firm swelling that lasts for years. Overall the prevalence is one in 50,000 people, and it primarily affects women between the ages of 30 and 50, adults. It is more prevalent in females with a female-to-male ratio of 3:2 . It primFibrous xanthoma was the name given to the condition by Chassaignac in 1852 . GCTTS iIt is divided into two types based on clinical and biological manifestations: localized and diffuse forms. These can also be intra-articular and extra-articular. The benign localized type affects the hand and fingers, but the more aggressive diffuse form affects major joints . It was GCTTS is most commonly found around the index or long finger's distal interphalangeal joint followed by ring and little finger. The following case presents with the features suggesting GCTTS of ring finger .A 39-year-old female patient came to the hospital with a six-month history of painless swelling over left ring finger. The swelling was spontaneous with no history of trauma. It gradually increased in size, hampering the activities of daily living of the patient.On clinical examination, a 1.5 cm x 1 cm firm swelling was seen on the dorsal surface of the left ring finger  and oblique view of left hand Figure  showed sThe patient was surgically fit and an excisional biopsy of the underlying swelling was performed. It was done under local anaesthesia and sedation. Cutting the little finger of the sterile gloves, tourniquet was prepared and used for the surgery. A curvilinear incision was taken over the swelling Figure . Soft tiThe excised tumour was sent for histopathological examination, which showed polygonal to round histiocytes surrounded by multinucleated giant cells, fibro-fatty tissue Figure  suggestiGCTTS is a benign fibrous tissue tumour that starts in the teno-synosheath, bursae, and synovium of the joint . This tuGCTTS is mostly not adherent to the overlying structures but if it is big in size, maybe due to its prolonged duration, it may cause dent on the underlying bone. Patients present in the hospital late as this does not result in any functional disability. It is most commonly seen in hands but may also be seen in the foot and ankle -3. In haAs reported by Levi and Crafton, MRI has a crucial role in diagnosing GCTTS early . On T1 aRecurrence and damage to the joints are the highest risk of GCTTS that require resection of tumour surgically . A recurThe case reported in this article presented to the hospital as a benign tumour which was diagnosed and confirmed on histo-pathological examination after excision of tumour surgically. At six months follow-up, the patient showed no ultrasound, clinical, or radiological evidence of recurrence. In addition, a minimum of two years of follow-up is planned to detect any recurrence.Our case is an example of GCTTS in a single digit of the hand. Furthermore, considering its high recurrence risk, the tumour should be totally excised. Although FNAC followed by excisional biopsy is diagnostic and curative, the patient should be monitored for recurrence detection and treatment. Additionally, a proper radiographic and histopathological examination is to be done on the tumour to rule out whether it's malignant or benign, which may or may not require any further treatment. Finally, if required, the hand's function should be recreated to minimize the loss.


The geroscience hypothesis posits that common biological mechanisms of aging drive susceptibility of aged individuals to functional decline, multi-morbidity, and death. The promise of geroscience is that some of these mechanisms may be intervenable, thereby preventing or delaying declines, and providing new therapeutic opportunities for hard-to-treat chronic diseases. This is supported by specific examples of translational research models, and interventions that are at the point of entering human clinical trials. This award presentation will review how we are reimagining existing resources and creating new translational frameworks to test the geroscience hypothesis in humans.


Recent evidence suggests that ultrasound measurements of carotid and brachial artery corrected flow time (FTc) and respirophasic variation in blood flow peak velocity (ΔVpeak) are valuable for predicting fluid responsiveness in mechanical ventilated patients. We performed the study to reveal the performance of ultrasonic measurements of radial artery FTc and ΔVpeak for predicting fluid responsiveness in mechanical ventilated patients undergoing gynecological surgery.A total of eighty mechanical ventilated patients were enrolled. Radial artery FTc and ΔVpeak, and non-invasive pulse pressure variation (PPV) were measured before and after fluid challenge. Fluid responsiveness was defined as an increase in stroke volume index (SVI) of 15% or more after the fluid challenge. Multivariate logistic regression analyses and receiver operating characteristic (ROC) curve were used to screen multivariate predictors of fluid responsiveness and identify the predictive abilitie of non-invasive PPV, ΔVpeak and FTc on fluid responsiveness.Forty-four (55%) patients were fluid responders. Multivariate logistic regression analysis showed that radial artery FTc, ΔVpeak, and non-invasive PPV were the independent predictors of fluid responsiveness, with odds ratios of 1.152 [95% confidence interval (CI) 1.045 to 1.270], 0.581 (95% CI 0.403 to 0.839), and 0.361 , respectively. The area under the ROC curve of fluid responsiveness predicted by FTC was 0.802 , and ΔVpeak was 0.812 , which were comparable with non-invasive PPV . The optimal cut-off values of FTc for fluid responsiveness was 336.6 ms , ΔVpeak was 14.2% . The grey zone for FTc was 313.5–336.6 ms and included 40 (50%) of the patients, ΔVpeak was 12.2–16.5% and included 37(46%) of the patients.Ultrasound measurement of radial artery FTc and ΔVpeak are the feasible and reliable methods for predicting fluid responsiveness in mechanically ventilated patients.The trial was registered at the Chinese Clinical Trial Registry (ChiCTR)(www.chictr.org), registration number ChiCTR2000040941.The online version contains supplementary material available at 10.1186/s12871-022-01837-9. Perioperative volume management is an important part of clinical anesthesia work and is crucial to prevent postoperative complications and smooth recovery of patients. Insufficient infusion can cause low perfusion of heart, kidney, brain and other important organs, microcirculation disorder, and organ dysfunction, while excessive infusion can cause postoperative intra-abdominal hypertension, affect the recovery of gastrointestinal function after anastomotic healing, and increase the probability of systemic infection. In this context, a proper assessment of volume status, coupled with proper fluid management, can optimize the hemodynamics of patients and avoid ineffective or even harmful fluid infusion –3. Over Recently, ultrasonic Doppler for measuring blood flow of superficial artery has been reported to be used in operation care settings due to its advantages of convenience, non-invasive, far away from the surgical field, and low technical requirements , 10. ImpAfter approved by the Research Ethics Committee of Women’s Hospital, Zhejiang University School of Medicine (IRB-20200197-R), this study was registered at the Chinese Clinical Trial Registry (ChiCTR)(www.chictr.org) on 16/12/2020 with the registration number ChiCTR2000040941. All methods of the study was conducted in accordance with the Declaration of Helsinki after written informed consent was obtained from all patients. Eighty patients, American Society of Anesthesiologists (ASA) Class I-II, undergoing gynecological surgery under general anesthesia from 2020/12/14 to 2021/02/28 were recruited into the study. Exclusion criteria were pregnancy, ≤18 years of old, BMI > 30 or < 15 kg/m-2, patients receiving vasoactive or inotropic support before induction of anaesthesia, or with left ventricular ejection fraction (LVEF) less than 45%, pre-existing peripheral arterial occlusive disease, cardiovascular disease, hypertension, pulmonary hypertension, chronic lung disease, abnormal chest wall, atrial or ventricular arrhythmia, diabetes mellitus, cerebrovascular disease and so on.2), and non-invasive arterial pressure monitoring were applied. After anesthesia induction of midazolam 0.04 mg/kg cisatracurium 0.2 mg/kg propofol 2 mg/kg sufentanil 0.5 μg/kg, endotracheal intubation was performed. Respiratory setting of anesthesia machine  are set as follows: volume-controlled ventilation (VCV), inspiratory-expiratory (I:E) ratio of 1:2, respiratory rate of 8–10 bpm, tidal volume of 8 mL/kg of ideal weight [45.5 + 0.91x (height in cm-152.4)], and PEEP of 5 cm H2O in 50% oxygen with air. Respiratory settings were adjusted to maintain the PETCO2 at less than 50 mmHg. Anesthesia was maintained with continuous infusion of remifentanil (0.05–0.2 μg/kg− 1 min− 1), propofol (50-100 μg/kg− 1 min− 1), and sevoflurane (1.5–2.5%) and intermittent injection of cisatracurium 0.05 mg/kg as needed to keep the entropy scale between 40 and 60 and for muscle relaxation. The mean arterial pressure was keep between 60 and 80 mmHg.Upon arrival in the operating theatre, a three-lead electrocardiogram (ECG), pulse oximetry , and stroke volume index (SVI) were recorded 15 min after anesthesia induction and 10 min after a fluid loading of 6 ml/kg of 6% hydroxyethyl starch 130/0.4. The fluid challenge was performed over 10 min. All measurements were performed prior to the start of surgery. Non-invasive PPV was acquired from the right radial artery pressure waveform, using a real-time radial artery blood pressure and hemodynamics monitoring system . Averages of PPV auto over four cycles of 8 s were displayed in real time on the monitor and was calculated by automatic detection algorithms without airway pressure acquisition. The parameters were recorded by an anesthesiologist who was unaware of this study to avoid any personal bias. Rartery FTc and ΔVpeak consecutively measured by two independent sonographer who were blinded to each other’s Doppler results and haemodynamic variables of the patients, using an 6–13 MHz variable frequency linear probe   in mechanically ventilated patients .SPSS 23  and PASS 14.0.5  were applied for statistical analysis and calculating the sample size. It has been reported that the area under the receiver operating characteristic (AUROC) curve of FTc measured in the radial artery to predict fluid responsiveness was 0.84 , so we a2 test were used for normally distributed data, non-normally distributed data, and categorical variables, respectively. Moreover, we used pearson correlation coefficient to detect the relationship between percentage change in SVI and relative changes in haemodynamic variables during fluid challenge. We also performed multivariate logistic regression analyses to screen multivariate predictors of fluid responsiveness and receiver operating characteristic (ROC) curve to identify the abilities of non-invasive PPV, ΔVpeak and FTc to predict fluid responsiveness. Furthermore, we defined the predictive accuracy of the ROC analysis as excellent [area under the curve (AUC) 0.9–1.0], good (AUC 0.8–0.9), fair (AUC 0.7–0.8), and poor 0.6–0.7 (AUC), calculated the 95% confidence interval (CI), and accepted statistical significance as p < 0.05  and 0.41% (with 95% LOA between − 1.19 and 2.00%), respectively , and ΔVpeak was 0.812 . These results demonstrated that the two parameters assessed by Doppler ultrasound were valid and reliable predictor for determining fluid responsiveness in mechanical ventilated patients undergoing gynecological surgery.Recently, ultrasonic Doppler for measuring blood flow of superficial artery has been proved to be successful in predicting the fluid responsiveness , 10. FTcUp to now, numerous studies have been conducted to determine the ability of ΔVpeak to predict fluid responsiveness and its cut-off value in discriminating between responders and non-responders to fluid resuscitation , 31, 32.P values with high accuracy (low mean difference) and precision (narrow limits of agreement) and is feasible in medical ICU patients [Among the dynamic indices, PPV originated from arterial waveform analysis is the representative indices for fluid responsiveness and reflects the percentage change in pulse pressure attributable to periodic changes in intrathoracic pressure caused by mechanical ventilation . Colquhopatients . In genepatients , 8.There are several limitations in our study. First, we did not study the ability of FTc and ΔVpeak of radial artery and non-invasive PPV to predict fluid responsiveness in patients during persistent hypotension, hypothermia, septic shock, heart failure, significant valvular heart diseases, or significant radial artery stenosis, therefore, our results cannot be extrapolated to these patients and the generalization of these results may be limited. Further researches are needed to more clearly identify the confounders in order to determine the limitations and indications of these non-invasive assessments of fluid responsiveness. Second, as other dynamic indices based on heart-lung interactions, FTc and ΔVpeak of radial artery and non-invasive PPV have their limitations and could not be used in patients with cardiac arrhythmias or spontaneous breathing. Nevertheless, as previous studies reported , few stuP = -28.153 + 0.142FTc-0.543ΔVpeak-1.018PPV. In the future, more clinical investigations and application experience remained to furtherly illuminate and verify their ability for predicting fluid responsiveness and guiding clinic fluid therapy.In conclusion, the principal finding of this study is that the measures of FTc and ΔVpeak in the radial artery assessed by Doppler ulrasound appears to be the highly feasible and reliable methods to predict fluid responsiveness, which are valuable and interchangeable with non-invasive PPV in patients undergoing gynecological surgery. Thereby, these results suggested that a non-invasive approach using the dynamic variables of fluid responsiveness in order to maintain or to achieve euvolaemia could serve as useful indices to guide fluid therapy during gynecological surgery. Nevertheless, there may be no single index that can guide fluid therapy in all cases, so every clinical finding and all haemodynamic data should be applied when needed. Combining FTc, ΔVpeak, and non-invasive PPV can be used to predict fluid responsiveness in gynecologic surgical patients and the regression equation for predicting fluid responsiveness is logit Additional file 1: Supplementary Fig. 1. Subject selection process.Additional file 2: Supplementary Fig. 2. BlandeAltman plots for inter-observer agreement of radial artery FTc and ΔVpeak.


Gastric leiomyosarcoma is a rare type of tumour that is far less prevalent than gastrointestinal stromal tumours. We describe a case of a 42-year-old male patient who consulted for upper abdominal pain. Blood work revealed low haemoglobin levels, requiring red blood cell transfusions. An esophagogastroduodenoscopy was performed, showing a submucosal tumour with central ulceration in the greater gastric curvature. The patient underwent an endoscopic ultrasound with fine needle biopsy and the sample showed a spindle cell neoplasia. Computed tomography scan demonstrated absence of distant metastases. Upon multidisciplinary consensus, it was decided to perform surgery. A laparoscopic approach was conducted, where no peritoneal lesions were observed. Transgastric resection of the tumour was performed. Free tumour margins were achieved following oncologic criteria (minimum tumour manipulation and one-piece resection without damaging the tumour capsule). After exhaustive sampling, the final pathology report informed an 11 × 9 × 5 cm gastric leiomyosarcoma. Immunohistochemical examination showed positivity with smooth muscle actin, muscle-specific actin, calponin and desmin. The patient had an uneventful recovery, and 6 post-operative months’ clinical, tomographic and endoscopic control informed no disease recurrence. To the best of our knowledge, there are less than 20 published cases of patients with diagnosis of gastric leiomyosarcoma. This study highlights the importance of reporting this entity, in order to contribute to the available literature concerning this topic. Leiomyosarcomas (LMS) are a type of sarcoma originating from smooth muscle cells, which have the ability to grow almost anywhere in the human body. LMS of the gastrointestinal (GI) tract are rare neoplasms and are far less prevalent than other mesenchymal tumours, such as GI stromal tumours (GISTs), which, although they originate from the cells of Cajal, have similar macroscopic and microscopic features. GISTs and LMS were misdiagnosed until early 2000s, when GISTs became recognised as a distinct entity . The maiThe importance in the difference between these two entities relies on the response that GISTs show to KIT-directed therapy, such as Imatinib or Sunitinib, and also their different prognosis.The aim of this article is to present a case of a rarely encountered tumour, contributing to the international literature.On July 2021, a 42-year-old man consulted our hospital referring upper abdominal pain associated to asthenia for the last 4 days. His past medical history revealed grade II obesity (body mass index = 38.5). Physical examination evidenced mild epigastric tenderness and a non-complicated umbilical hernia, but was otherwise unremarkable. Blood work revealed a haemoglobin value of 6.6 mg/dl, requiring transfusions of two red blood cell units.The patient underwent an esophagogastroduodenoscopy, finding an 80 mm submucosal tumour with central ulceration located along the greater curvature and anterior wall of the upper gastric body. The biopsy revealed superficial mucosal erosions without atypical cells.Thereafter, and upper endoscopic ultrasound (EUS) was performed, evidencing a hypoecoic lesion of 60 × 58 mm with well-defined borders . This leA computed tomography (CT) scan was performed, showing a highly vascularised tumour with an endophytic growth in the upper gastric body measuring 90 × 89 × 70 mm . No distAfter multidisciplinary consensus, a surgical resection was decided, performing a laparoscopic transgastric resection with minimal tumour manipulation.We began with a diagnostic laparoscopy in which no distant metastases were seen and multiorgan invasion was ruled out. Because of the predominant endophytic growth of the tumour, we performed an intraoperative EGD in order to assess tumour-free resection margins and make sure an R0 resection was feasible. Under maximum gastric insufflation, free margins were identified and thus we continued with the resection. Gastrostomy across the non-pathological gastric wall was performed with ultrasonic shears achieving at least a 1 cm margin along the whole tumour circumference. Complete resection with tumour-free margins was accomplished. Gastrostomy was closed with a combined technique of stapled 60 mm sutures and manual continuous suturing with an absorbable material. Hydropneumatic test was performed during endoscopy without evidencing any leakage. The specimen was retrieved in an endobag through the patient’s umbilical hernia which was opened up to a total length of 10 cm. The patient had an uneventful recovery and was discharged home on the third post-operative day.Macroscopic examination of the specimen showed an 11 x 9 x 5 cm solid endophytic mass covered with eroded mucosa compromising the gastric wall . ExhaustMicroscopic examination showed neoplastic proliferation of spindle cells arranged in fascicles, some of them marked with atypia and areas of myxoid background . The neoThis case was discussed in the multidisciplinary tumour board and follow-up without adjuvant therapy was decided. After 6 months of post-operative follow-up, the patient remains free of disease, with unremarkable CT scan and endoscopic control.We present a rare case of a gastric leiomyosarcoma in a 42-year-old man resected with a laparoscopic transgastric approach. To the best of our knowledge, there are less than 20 cases reported worldwide [LMSs of the GI tract are rare entities, with gastric localisation being one of the least common sites. The most frequent clinical presentations consist of obstruction, perforation, pain or subclinical bleeding. Although there has been a case of massive haematemesis reported , massiveEGD usually reveals submucosal tumours with normal or ulcerated mucosa. EUS has been proved to be the best diagnostic tool in this type of tumours, with a sensitivity close to 97% . Biopsy Immunohistochemistry is the key to achieve a definitive diagnosis. GISTs present pathognomonic findings, such as KIT positivity and DOG-1 immunoreactivity, even in rare KIT-negative GISTs . These tet al [The type of surgery depends on the size and localisation of the tumour, ranging from limited organ-preserving procedures (such as wedge gastrectomies or endoscopic resections) to major surgeries, such as total gastrectomies or multiorganic resections . The onlet al  in a patSurgical resections with organ preservation vary with many different options. The most common ones are wedge gastrectomies and transgastric resections. Wedge gastrectomies are usually preferred in tumours located in the greater curvature with an exophytic growth, while transgastric resections are preferred in tumours located close to the EG junction, or those with a predominantly endophytic growth. The reason for this is the difficulty in ensuring an R0 resection of an endophytic tumour with a closed wedge resection, and with this technique we can preserve more normal gastric tissue .It has been demonstrated that tumour-free resection margins and tumour size directly affect the patient’s prognosis , and thaConcerning systematic lymphadenectomy, it has not been proved to have clear benefits for patient survival, given that LMSs have predilection for haematogenous spread . In our The overall median survival reported for primary GI LMS is 32 months and the estimated 5-year survival is about 22% . The proGastrointestinal LMSs are rare malignant neoplasms which must be differentiated from GISTs and other spindle cell tumours in relation to their different prognosis and response to targeted therapies. To the best of our knowledge, there have been less than 20 reported cases of this entity. We present the case of a young patient with a gastric LMS suspected by EUS–FNB and confirmed by surgical specimen samples, who was successfully treated by a laparoscopic transgastric approach with optimal accomplishment of the oncological principles.None.No source of funding.