Amide proton transfer (APT) weighted chemical exchange saturation transfer (CEST) imaging is increasingly used to investigate high-grade, enhancing brain tumours. Non-enhancing glioma is currently less studied, but shows heterogeneous pathophysiology with subtypes having equally poor prognosis as enhancing glioma. Here, we investigate the use of CEST MRI to best differentiate non-enhancing glioma from healthy tissue and image tumour heterogeneity.A 3D pulsed CEST sequence was applied at 3 Tesla with whole tumour coverage and 31 off-resonance frequencies (+6 to -6 ppm) in 18 patients with non-enhancing glioma. Magnetisation transfer ratio asymmetry (MTRasym) and Lorentzian difference (LD) maps at 3.5 ppm were compared for differentiation of tumour versus normal appearing white matter. Heterogeneity was mapped by calculating volume percentages of the tumour showing hyperintense APT-weighted signal.LDamide gave greater effect sizes than MTRasym to differentiate non-enhancing glioma from normal appearing white matter. On average, 17.9 % ± 13.3 % (min–max: 2.4 %–54.5 %) of the tumour volume showed hyperintense LDamide in non-enhancing glioma.This works illustrates the need for whole tumour coverage to investigate heterogeneity in increased APT-weighted CEST signal in non-enhancing glioma. Future work should investigate whether targeting hyperintense LDamide regions for biopsies improves diagnosis of non-enhancing glioma.The online version of this article (10.1007/s10334-021-00911-6) contains supplementary material, which is available to authorized users. Chemical exchange saturation transfer (CEST) is a technique to create magnetic resonance imaging (MRI) contrasts by selective targeting of labile protons in endogenous and mobile proteins. An emerging clinical application of CEST imaging is the assessment of glioma via amide proton transfer (APT) weighted CEST, which recently has shown promise for glioma grading , 2 and tAlthough patients with non-enhancing gliomas are often included in studies investigating APT-weighted CEST MRI, the main aim is often differentiation of glioma grade based on the classic histological classification of low to high-grade tumours, where high-grade tumours often show enhancement and form the majority of the studied population. The current body of literature indicates that lower grade gliomas are mostly isointense on amide proton transfer (APT)-weighted imaging, with potentially some areas of hyperintensity and that high-grade gliomas, i.e. glioblastomas, show increased APT-weighted CEST signal , 4. HoweAdditionally, although the number of CEST research studies including multi-slice image acquisition schemes is increasing, previous investigations including non-enhancing glioma often use single-slice CEST acquisitions , 8, 9. Basym) and Lorentzian difference (LD) contrasts, CEST metrics widely used in the current literature. The former is commonly applied and is valued for its relative simplicity as it, in its essence, only requires measurement of the CEST effect when applying a B1 saturation pulse at two off resonance frequency shifts (3.5 ppm and − 3.5 ppm) in addition to a separate acquisition of multiple off-sets for B0-correction. The latter requires covering multiple off-resonance frequencies via the acquisiton of a full Z-spectrum to do Lorentzian fitting of the CEST signal. This analysis allows for separate investigation of signal contributions from amide protons at 3.5 ppm and nuclear Overhauser enhancement (NOE) at – 3.5 ppm. Note that in CEST experiments NOE contributes signal between − 1 and − 5 ppm, where aliphatic protons in mobile macromolecules are saturated. Via relayed-NOE this saturation is transferred to amide protons within the same molecule which will exchange with the free water pool [Here we use a 3D pulsed CEST sequence to explore APT-weighted signal in the whole tumour, specifically for non-enhancing glioma. We compare amide-weighted magnetisation transfer ratio asymmetry . All experiments were conducted in compliance with the declaration of Helsinki and under approval of the institutional ethics committee of the Erasmus MC , which is one out of 18 accredited medical research ethics committees in the Netherlands. Image analysis and statistical analysis were done with in-house written Matlab scripts  and the freely available FMRIB Software Library .Eighteen patients with newly diagnosed presumed low-grade glioma were recruited between March 2017 and March 2019. Patients were recruited as part of the Imaging Genomics study and were scanned at maximum 7 days before surgical resection or biopsy. Tumour samples were obtained and histopathologically examined by neuropathologists. Molecular classification of the 1p/19q co-deletion and IDH mutation status was performed as part of the diagnostic routine by molecular biologists with targeted Next-Generation Sequencing (NGS) panels using an Ion Torrent Personal Genome Machine or Ion S5XL (Thermo Fisher Scientific). Patient characteristics can be seen in Table 2, matrix = 128 × 128, acceleration factor = 4, similar to the pulsed CEST sequence used by Jones et al. [1 = 2.3 and 4.0 µT, and each series consisting of 31 frequency off-sets . Note that the saturation powers used are stated as the root mean square B1 across the saturation pulse. Two images were acquired without saturation pulses to obtain the equilibrium magnetisation (M0) for reference, bringing the total to 33 images acquired in 1 map was created by using a multi-slice 2D gradient echo sequence  with voxel size and number of slices  matched to the CEST sequence. T1-weighted  and T2-weighted FLAIR  structural images were additionally acquired. Note that the 3D CEST acquisition was planned to cover the whole tumour, as indicated by the T2-FLAIR hyperintense area.CEST images were acquired with a 3D spoiled gradient echo with TR = 35.4 ms, TE = 6.9 ms, 12 slices, slice thickness = 5 mm, in-plane voxel size = 1.85 × 1.85 mms et al. . Spectras et al.  A Gaussimcflirt, within FSL v5.0.9, Oxford, UK), after which linear registration was used to register the CEST images to the magnitude of the B1-map. Z-spectra were calculated by dividing the images acquired with off-resonance saturation pulses by the average of the two M0 images. A Lorentzian curve was fitted to the Z-spectra using the data points with off-resonance frequency shifts of ± 6 ppm and those from − 1.75 to 1.75 ppm. This fit was first used for B0-correction, by shifting each spectrum by the frequency shift of the minimum value of the Lorentzian fit. Amide-weighted MTRasym was calculated according to the methods described by Zhou et al. [0-corrected Z(3.5 ppm) and Z(− 3.5 ppm). Lorentzian Difference (LD) analysis was used to obtain maps for LDamide at 3.5 ppm and LDNOE at − 3.5 ppm [asym and LD contrasts were calculated for both B1 saturation powers acquired. Contrast-based B1 correction was then carried out according to previously described methods, including the use of an artificial B1 = 0 µT [0- & B1-corrected MTRasym, LDamide, and LDNOE. To avoid extrapolation in voxels with a B1 below the nominal value of B1 = 4.0 µT, in the remainder of the patient data the results are calculated for the images resulting from the B1-correction with B1 values of 2.5 and 3.8 µT.Motion correction of the CEST image series was done by linear registration of each image within a series to the 6 ppm image and a cost function based on mutual information . The contralateral normal-appearing white matter (NAWM) ROI was generated by segmentation of white matter in the T1-weighted images  and a linear registration of this segmentation to the FLAIR image. NAWM was determined by using the white matter contralateral to the tumour in all slices that also included the tumour segmentation. Per patient, average tumour and NAWM MTRasym, LDamide, and LDNOE were calculated.Tumour regions of interest (ROI) were generated semi-automatically by delineating the hyperintense area on the T ITKSnap . Note thTo determine the extent of hyperintense amide-weighted CEST signal within the tumour per contrast and per patient, for each patient a threshold was determined as follows:2-weighted FLAIR hyperintense tumour area, was calculated per slice and for the whole tumour for each patient. asym and LDamide, both calculated for B1 is 2.5 and 3.8 µT.where ROI and B1 on the CEST contrasts generated in the patient data . The ROI factor contained two levels (NAWM and Tumour) and B1 contained two levels (2.5 and 3.8 µT). To compare the different CEST contrasts for differentiating tumour tissue from NAWM effect sizes (Cohen’s d) were calculated for all three contrasts.Mixed effects linear regression models were fitted to determine whether there were significant effects of the fixed effects contrast  or B1  on the volume percentage of the tumour showing hyperintense amide-weighted signal.A mixed effects linear regression model was also used to investigate whether there was a significant effect of asym and LD are plotted in Fig. asym, LDamide, and LDNOE the mixed-effects linear regression showed a significant effect of ROI , indicating significant differences found between NAWM and tumour tissue. Post-hoc paired t-tests illustrate that only for MTRasym and LDamide there are significant increases in tumour tissue versus NAWM . The hyperintense tumour volume percentages found for LDamide,B1=2.5 µT, MTRasym,B1=2.5 µT, and MTRasym,B1=3.8 µT were 17.1% ± 12.4%, 12.7% ± 11.7%, and 13.1 ± 13.0%, respectively . Additionally, no significant effect of B1 power on the hyperintense volume percentage was found .On average, 17.9% ± 13.3% of the tumour volume showed hyperintense LDasym calculations since the largest effect size to differentiate tumour from NAWM was found for LDamide. Another important finding of this study is that, despite the majority of the non-enhancing glioma volume showing isointense signal amide-weighted CEST images, on average approximately 18% of the total volume of the T2-FLAIR hyperintense area showed hyperintensity on LDamide images. The large area of isointense signal within these tumours is as expected, as earlier work in which non-enhancing glioma is included in patient populations has also found largely isointense APT-weighted CEST contrast [We investigated APT-weighted CEST MRI in non-enhancing glioma and showed that Lorentzian difference analyses are preferred in these type of tumours over the use of MTRcontrast . Howeverasym and the Ki-67 labelling index, a histopathological marker of cell proliferation, in patients with low- and high-grade glioma. In a pre-clinical study by Yan et al. both total cytosolic protein content and APT-weighted CEST signal were increased in glioma compared to healthy tissue [In particular in light of the spatial heterogeneity in pathophysiology and molecular signatures in non-enhancing glioma , the regy tissue . These p1 saturation power of 3.8 µT gave a stronger effect size than a B1 of 2.5 µT for separating tumour from NAWM when using LDamide. Note that, based on the theoretical optimal sensitivity of CEST MRI to amide protons when using a lower B1 saturation power  likely to be increased in the tumour compared to NAWM [1 saturation power increases magnetisation transfer effects in NAWM in a stronger manner than in the tumour, (iii) contributions to the CEST signal from fast exchanging amine protons resonating around 2–3 ppm because of the relatively high B1 saturation pulse used here [Note that, in addition to cell proliferation, it is well known that other sources of CEST signal exist that can contribute to differences in signal between tumour and healthy tissue. We find that the use of a B (~ 1 µT ), this f to NAWM , (ii) a  to NAWM , in partsed here .1, high-resolution structural imaging , and a CEST acquisition that allows for separation of CEST signal from amide protons, NOE and MT effects. Such a CEST acquisition could be designed to be as selective to amide protons as possible, for instance as done by Zaiss et al.[1 saturation power and the acquisition of a full Z-spectrum such that multi-pool Lorentzian fitting can be used to separate different CEST signal sources. To assess the extent to which amide protons are contributing to the differences in APT-weighted CEST imaging should be followed by targeted biopsies of tumour tissue for ex vivo analysis of the local environment with proteomics analysis [Although our results indicate that differences in APT-weighted CEST are found in non-enhancing glioma as well, it is thus clear that the origin of increased amide-weighted CEST contrasts in non-enhancing glioma is still to be investigated. This should first be done with an extensive MR imaging protocol, including quantification of Tss et al. at ultraanalysis , 28, ratSecond, if the hyperintensities in amide-weighted CEST MRI are highlighting more aggressive tumour tissue it is important to not miss these regions when imaging non-enhancing glioma, stressing the need for having a CEST acquisition that covers the whole tumour volume. Note that although this may seem to go against the finding of Sakata et al. , who shoamide results in a larger effect size than MTRasym to differentiate non-enhancing glioma tissue from NAWM, which may be caused by finding no significant difference for LDNOE between non-enhancing glioma and NAWM. This latter finding may be as expected, as previous studies on high-grade, enhancing gliomas showing that LDNOE correlated with prognosis [NOE compared to NAWM correlate to worse prognosis/grade in enhancing glioma, with limited changes in LDNOE for tumours with better outcome. Moreover, at 3 T and in 11 high-grade glioma patients, Heo et al.[NOE in tumour tissue. Extrapolating these results to this study in which we only include non-enhancing glioma may suggest that not finding a significant LDNOE effect in the current study is plausible. Note that, as a consequence of finding limited effects of LDNOE, the largest effect size in separating NAWM from non-enhancing glioma was found for LDamide in the current study, with MTRasym being affected by both amide- and NOE-weighted signals within the tumour and hence the noise in MTRasym being affected by CEST signal at both 3.5 and − 3.5 ppm, illustrated by the ratio of the standard deviations compared to the group averaged values being larger for MTRasym  vs IDH-wildtype (N = 6) tumours were performed but resulted in no significant differences for the CEST contrasts as well as the size of the hyperintense volumes (results in Supplementary information). However, note that Paech et al. [The number of included patients is likely too small for thorough investigation of using amide-weighted imaging for classification of non-enhancing glioma. Analyses to investigate differences between the three different tumour types, as well as IDH-mutation  causingA steady-state CEST sequence is used in this work, as at the time of initiating this study it was deemed the most appropriate for rapid acquisition of whole tumour volume at our institute. However, there are alternatives now with long saturation blocks prior to image read-out that may result in higher signal-to-noise ratios for the CEST contrast images . Future amide, which is a step towards the application of APT-weighted CEST MRI for accurate diagnosis and treatment follow-up in light of the new molecular classification of non-enhancing glioma.This study illustrates that 3D pulsed CEST imaging allows for measuring heterogeneity in amide-weighted CEST signal in non-enhancing glioma. Based on the results in this study we recommend to use CEST acquisitions that cover the whole tumour volume for assessment of non-enhancing glioma, to not miss areas of hyperintense APT-weighted signal which may be small within these tumours. Future work includes investigation of the cause for increased LDElectronic supplementary material 1 (DOCX 85 kb)Below is the link to the electronic supplementary material.


Enterobacterales (ENT)—especially Escherichia coli (EC), Klebsiella pneumoniae (KPN), and Proteus mirabilis (PM)—are widely implicated in urinary tract infections (UTIs). Many oral agents are used to manage UTIs, but their usefulness has been compromised by the increased prevalence of extended-spectrum β-lactamases (ESBL) and presence of co-resistance to trimethoprim-sulfamethoxazole (TMP/SMX) and quinolones. Tebipenem (TBP) is an oral carbapenem in clinical development for treating complicated UTIs and acute pyelonephritis. This study assessed the in vitro activity of TBP and comparator agents against ENT responsible for UTIs in the US during 2019-2020. A total of 3,576 ENT recovered from urine samples during the 2019-2020 STEWARD Surveillance Program were included in the study. Isolates were collected from medical centers in all 9 US Census Regions and were centrally tested for susceptibility by reference broth microdilution method. MIC interpretation was performed based on CLSI criteria. 90, 0.015-0.06 mg/L) and ertapenem  showed similar MIC90 results against ENT, EC, and KPN (Table). Ceftazidime  had elevated MIC90 values and suboptimal susceptibility results (86.1-89.3%) against ENT, EC, and KPN. The oral agents, cefuroxime, amoxicillin-clavulanate, TMP-SMX, and levofloxacin showed susceptibility rates ranging from 63.1% to 87.1% against ENT, EC, and KPN. TBP  inhibited all PM at ≤0.25 mg/L. PM isolates were susceptible to ERT (100.0%), CAZ (98.7%), cefuroxime (94.4%), and amoxicillin/clavulanate (96.6%), whereas susceptibility rates of 71.8-76.8% were noted for TMP-SMX and levofloxacin.EC comprised 65.6% of all ENT pathogens, followed by KPN (14.3%), PM (6.6%), and other species (13.7%). TBP AbbVie (formerly Allergan) (Research Grant or Support)Cipla Therapeutics (Research Grant or Support)Cipla USA Inc. (Research Grant or Support)ContraFect Corporation (Research Grant or Support)GlaxoSmithKline, LLC (Research Grant or Support)Melinta Therapeutics, Inc. (Research Grant or Support)Melinta Therapeutics, LLC (Research Grant or Support)Nabriva Therapeutics (Research Grant or Support)Pfizer, Inc. (Research Grant or Support)Shionogi (Research Grant or Support)Spero Therapeutics (Research Grant or Support) Ian A. Critchley, Ph.D., Spero Therapeutics  Nicole Cotroneo, Spero Therapeutics  Jennifer M. Streit, BS, GlaxoSmithKline, LLC (Research Grant or Support)Melinta Therapeutics, LLC (Research Grant or Support)Shionogi (Research Grant or Support)Spero Therapeutics (Research Grant or Support) Helio S. Sader, MD, PhD, FIDSA, AbbVie (formerly Allergan) (Research Grant or Support)Basilea Pharmaceutica International, Ltd. (Research Grant or Support)Cipla Therapeutics (Research Grant or Support)Cipla USA Inc. (Research Grant or Support)Department of Health and Human Services Melinta Therapeutics, LLC (Research Grant or Support)Nabriva Therapeutics (Research Grant or Support)Pfizer, Inc. (Research Grant or Support)Shionogi (Research Grant or Support)Spero Therapeutics (Research Grant or Support) Mariana Castanheira, PhD, AbbVie (formerly Allergan) (Research Grant or Support)Bravos Biosciences (Research Grant or Support)Cidara Therapeutics, Inc. (Research Grant or Support)Cipla Therapeutics (Research Grant or Support)Cipla USA Inc. (Research Grant or Support)GlaxoSmithKline (Research Grant or Support)Melinta Therapeutics, Inc. (Research Grant or Support)Melinta Therapeutics, LLC (Research Grant or Support)Pfizer, Inc. (Research Grant or Support)Qpex Biopharma (Research Grant or Support)Shionogi (Research Grant or Support)Spero Therapeutics (Research Grant or Support) Mariana Castanheira, PhD, Affinity Biosensors  Involved: Self): Research Grant or Support; Allergan  Involved: Self): Research Grant or Support; Amicrobe, Inc  Involved: Self): Research Grant or Support; Amplyx Pharma  Involved: Self): Research Grant or Support; Artugen Therapeutics USA, Inc.  Involved: Self): Research Grant or Support; Astellas  Involved: Self): Research Grant or Support; Basilea  Involved: Self): Research Grant or Support; Beth Israel Deaconess Medical Center  Involved: Self): Research Grant or Support; BIDMC  Involved: Self): Research Grant or Support; bioMerieux Inc.  Involved: Self): Research Grant or Support; BioVersys Ag  Involved: Self): Research Grant or Support; Bugworks  Involved: Self): Research Grant or Support; Cidara  Involved: Self): Research Grant or Support; Cipla  Involved: Self): Research Grant or Support; Contrafect  Involved: Self): Research Grant or Support; Cormedix  Involved: Self): Research Grant or Support; Crestone, Inc.  Involved: Self): Research Grant or Support; Curza  Involved: Self): Research Grant or Support; CXC7  Involved: Self): Research Grant or Support; Entasis  Involved: Self): Research Grant or Support; Fedora Pharmaceutical  Involved: Self): Research Grant or Support; Fimbrion Therapeutics  Involved: Self): Research Grant or Support; Fox Chase  Involved: Self): Research Grant or Support; GlaxoSmithKline  Involved: Self): Research Grant or Support; Guardian Therapeutics  Involved: Self): Research Grant or Support; Hardy Diagnostics  Involved: Self): Research Grant or Support; IHMA  Involved: Self): Research Grant or Support; Janssen Research & Development  Involved: Self): Research Grant or Support; Johnson & Johnson  Involved: Self): Research Grant or Support; Kaleido Biosceinces  Involved: Self): Research Grant or Support; KBP Biosciences  Involved: Self): Research Grant or Support; Luminex  Involved: Self): Research Grant or Support; Matrivax  Involved: Self): Research Grant or Support; Mayo Clinic  Involved: Self): Research Grant or Support; Medpace  Involved: Self): Research Grant or Support; Meiji Seika Pharma Co., Ltd.  Involved: Self): Research Grant or Support; Melinta  Involved: Self): Research Grant or Support; Menarini  Involved: Self): Research Grant or Support; Merck  Involved: Self): Research Grant or Support; Meridian Bioscience Inc.  Involved: Self): Research Grant or Support; Micromyx  Involved: Self): Research Grant or Support; MicuRx  Involved: Self): Research Grant or Support; N8 Medical  Involved: Self): Research Grant or Support; Nabriva  Involved: Self): Research Grant or Support; National Institutes of Health  Involved: Self): Research Grant or Support; National University of Singapore  Involved: Self): Research Grant or Support; North Bristol NHS Trust  Involved: Self): Research Grant or Support; Novome Biotechnologies  Involved: Self): Research Grant or Support; Paratek  Involved: Self): Research Grant or Support; Pfizer  Involved: Self): Research Grant or Support; Prokaryotics Inc.  Involved: Self): Research Grant or Support; QPEX Biopharma  Involved: Self): Research Grant or Support; Rhode Island Hospital  Involved: Self): Research Grant or Support; RIHML  Involved: Self): Research Grant or Support; Roche  Involved: Self): Research Grant or Support; Roivant  Involved: Self): Research Grant or Support; Salvat  Involved: Self): Research Grant or Support; Scynexis  Involved: Self): Research Grant or Support; SeLux Diagnostics  Involved: Self): Research Grant or Support; Shionogi  Involved: Self): Research Grant or Support; Specific Diagnostics  Involved: Self): Research Grant or Support; Spero  Involved: Self): Research Grant or Support; SuperTrans Medical LT  Involved: Self): Research Grant or Support; T2 Biosystems  Involved: Self): Research Grant or Support; The University of Queensland  Involved: Self): Research Grant or Support; Thermo Fisher Scientific  Involved: Self): Research Grant or Support; Tufts Medical Center  Involved: Self): Research Grant or Support; Universite de Sherbrooke  Involved: Self): Research Grant or Support; University of Iowa  Involved: Self): Research Grant or Support; University of Iowa Hospitals and Clinics  Involved: Self): Research Grant or Support; University of Wisconsin  Involved: Self): Research Grant or Support; UNT System College of Pharmacy  Involved: Self): Research Grant or Support; URMC  Involved: Self): Research Grant or Support; UT Southwestern  Involved: Self): Research Grant or Support; VenatoRx  Involved: Self): Research Grant or Support; Viosera Therapeutics  Involved: Self): Research Grant or Support; Wayne State University  Involved: Self): Research Grant or Support


Moreover, high-level stromal HA expression was associated with low ICS (p = 0.017). In conclusion, stromal HA accumulation is associated with poor survival and low immune response in PDAC.Hyaluronan (HA) accumulation has been associated with poor survival in various cancers, but the mechanisms for this phenomenon are still unclear. The aim of this study was to investigate the prognostic significance of stromal HA accumulation and its association with host immune response in pancreatic ductal adenocarcinoma (PDAC). The study material consisted of 101 radically treated patients for PDAC from a single geographical area. HA staining was evaluated using a HA-specific probe, and the patterns of CD3, CD8, CD73 and PD-L1 expression were evaluated using immunohistochemistry. HA staining intensity of tumour stromal areas was assessed digitally using QuPath. CD3- and CD8-based immune cell score (ICS) was determined. High-level stromal HA expression was significantly associated with poor disease-specific survival ( This is partly related to advanced disease stage at the time of diagnosis ruling out curative surgery. Tumour cells are in constant interaction with non-neoplastic cells, and the tumour microenvironment influences cancer progression. PDAC has been shown to develop mechanisms that suppress the host immune response against the tumour3. The first signs of this immune suppression are seen already in the premalignant lesions4. PDAC is characterized by an abundant desmoplastic stroma, which has been suggested to facilitate the escape from the immune surveillance6.Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive solid malignancies with 5-year survival rates of 2–9%7. It also influences immune responses8. A complex regulation system controls HA metabolism, mainly dependent on HA-producing synthases and degrading hyaluronidases. The activation of the cell surface HA receptors such as CD449 and RHAMM10 modulate cell proliferation, aggregation, migration and angiogenesis11 and may also be involved in the HA-induced epithelial–mesenchymal transition12 and stem cell functions13. HA has been shown to be overexpressed in most human malignancies23. Several studies have indicated that hyaluronan accumulation in the tumour cells and/or peritumoral stroma is related to tumour progression and poor survival in many cancer types31. However, the mechanisms underlying the association between accumulation of HA, host immune response and poor survival remain unclear, especially in PDAC.Hyaluronan (HA) is one of the main components of the extracellular matrix. In normal physiological conditions, it is strongly expressed during wound healing and at sites of inflammation, including cancer36. We have previously introduced a T-lymphocyte-based immune cell score (ICS) as a strong favourable prognostic factor in PDAC37. Extensive alterations occur in the complex PDAC microenvironment during the tumorigenesis. Multiple mechanisms, such as overexpression of the immunosuppressive molecules CD73 and PD-L1, may lead to immune suppression41. There is some evidence showing that HA plays a role in immune response regulation43. According to our hypothesis this might be one of the key factors explaining the association between HA accumulation and low survival among cancer patients25.The association between a strong immune response and better survival is well established in various cancersThe aim of the present study was to examine the prognostic role of stromal HA accumulation and its relation to immune cell infiltration and the immune-suppressing molecules CD73 and PD-L1 in PDAC.From 2000 to 2016, a total of 129 patients with PDAC were operated on with curative intent in the Central Hospital of Central Finland, Jyväskylä, Finland. Patients with locally inoperable tumour, peritoneal carcinosis or distant metastases were excluded, resulting in the 101 patients with stage IA-IIB disease. Detailed information on patient and tumour characteristics, surgical treatment and complications, oncological treatment and follow-up were collected prospectively, updated and confirmed by a review of patient records review. None of the included patients received neoadjuvant chemotherapy before surgery.44. The grading was performed according to the WHO classification of tumours 201045.All histopathological tumour specimens were reviewed by an experienced gastrointestinal histopathologist (JB). Tumour staging was done according to the 7th edition of the UICC/AJCC TNM categories37.Tissue microarray (TMA) blocks were constructed as described previously, from formalin-fixed paraffin-embedded primary PDAC patient tumour samples. Two tissue cores 0.6 mm in diameter were taken both from the core of the tumour and the invasive margin from representative tumour blocks. Sections of 2 µm thickness were used for immunohistochemical (IHC) analyses26. Briefly, a complex containing the G1 domain of cartilage aggrecan and link protein was labeled with biotin (bHABC), diluted to 3 µg/ml of 1% bovine serum albumin in phosphate buffer, and incubated overnight at 4 °C on sections pretreated with H2O2 and 1% bovine serum albumin to block endogenous peroxidases and unspecific binding, respectively. After one hour incubation in avidin–biotin–peroxidase  the sections were washed with PBS, and incubated in 0.05% 3,3′-diaminobenzidine  and 0.03% H2O2 in the phosphate buffer, followed by nuclear counterstaining with Mayers hematoxylin , followed by analysis using QuPath v 0.1.2 as described below.37. Briefly, ICS describes the immune response represented by the density of CD3 and CD8 positive immune cells in the tumour centre and at the invasive margin. PD-L1 expression was evaluated by estimating the proportion of PD-L1 positivity on the tumour cell surface as described earlier39. In addition, we analyzed also the proportion of PD-L1 expression in stromal cells using the 5% staining proportion as a cutoff.ICS was determined using the TMA technique as described earlier46. First, the stain vectors and background values were estimated using the Estimate stain vectors command to facilitate stain separation with the color deconvolution method. Simple tissue detection command was used to delineate the tissue area from the white background. This area was manually edited with the brush tool to exclude tumour epithelial regions. SLIC superpixel segmentation was used to divide the area into superpixels (neighboring groups of pixels sharing similar characteristics). DAB intensity was calculated for each superpixel, and the data were exported at individual superpixel level. R statistical programming language version 3.5.2  was used to summarize the mean intensity for each case. The distribution of DAB intensities was similar in different TMAs suggesting that the assay had performed uniformly  curve drawn in relation to disease-specific 3-year mortality.p < 0.05 in univariate analysis were entered into the multivariate analysis despite the a-priori determined confounder, tumour stage (p = 0.117). All statistical tests were two-sided. A p value less than 0.05 was considered significant. The statistical analyses were performed and Fig. https://www.ibm.com/analytics/spss-statistics-software).The chi-square test was used when analysing the associations between HA and clinical and histopathological variables, CD73 positivity and PD-L1 positivity in tumour cells. The estimates for hazard ratios for overall survival (OS) and disease specific survival (DSS) were calculated using univariate and multivariate Cox proportional hazards regression model. Only variables with 48.The use of patient samples and the data inquiry were approved by the Oulu University Hospital Ethics Committee. The need to obtain written or oral consent from patients to use their samples in research was waived by the Finnish National Authority for Medicolegal Affairs . This study was designed and performed according to the reporting recommendations for tumour marker prognostic studies (REMARK) and the Declaration of HelsinkiA total of 101 of PDAC patients were included in this study. The distribution of key clinicopathological variables among these patients is shown in Table p = 0.017). The associations between stromal HA expression and other clinical and histopathological variables, cell-specific CD73 positivity and PD-L1 positivity in tumour cells were also assessed and are shown in Table Stromal HA accumulation appeared to associate with low ICS (p = 0.037) and OS (p = 0.013)  months for those alive at the end of follow-up. The estimated median OS for all patients was 25 months [95% CI: (17.7–32.3)]. Stromal HA accumulation was significantly associated with poor DSS  have been described, including inflammatory CAFs and myofibroblastic CAFs58.As far as we know, the association of HA on T-cell immune response has not been studied earlier in PDAC but the present finding clearly warrants further expansion of the studies to obtain a more detailed view of the interactions between HA and lymphocytes in this disease with such a bleak prognosis. In future studies, information of physical properties (for example molecular mass) of HA molecules is also needed, since there are data indicating that molecular weight affects the biological functions of HA moleculesIn conclusion, our study indicates that stromal HA accumulation may be associated with low T cell densities in the PDAC microenvironment, but still represents an adverse prognostic parameter independent of T cell densities, tumour stage, tumour grade, and CD73 expression. The results warrant further definition of the interactions between T-cell immunity and hyaluronan in the tumour microenvironment.Supplementary Figure.


Nevertheless, besides addressing safety requirements for close physical interaction, which are tackled by approaches like soft robotics and impedance/admittance control . In this context, we understand embodiment as something being “experienced as a part of the body schema due to multisensory integration” , which are denoted as interaction patterns. De Santis takes a more quantitative approach and proposes a general framework for user-machine interaction. The problem is explicitly formulated as a closed-loop block diagram, monitoring the change in the parameters of both the user and a machine to define co-adaptation. Schofield et al.'s perspective argues that embodiment in myoelectrically-controlled prostheses is the key to achieve optimal control and user satisfaction. Tool incorporation, agency and ownership are the three pathways the authors identify to achieve, in the long run, an embodied bionic limb.Embodiment is likely shaped by a process of adaptation and tight interaction between the user and the machine. If the system can also adapt to the user, e.g., as in prosthetics  projects Deep-Hand (grant no.: CA 1389/1-2) and TRAIN (grant no.: BE 5729/16-1), project ROBIN (grant no: 8022-00243A) funded by Independent Research Fund Denmark as well as the Swiss National Science Foundation (grant no.: PP00P1_170511).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Intravenous fluids are often used in the treatment of sepsis. The better strategy regarding fluid volume is debated, but preliminary data in patients with septic shock or sepsis-related hypotension favor restrictive fluid administration. We describe the protocol and statistical analysis plan for the Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis)—a multicenter, randomized clinical proof-of-concept trial. The aim of the REFACED Sepsis trial is to test if a restrictive intravenous fluid protocol in emergency department patients with sepsis without shock is feasible and decreases the intravenous fluid volume administered in comparison to standard care.This is an investigator-initiated, multicenter, randomized, parallel-group, open-labeled, feasibility trial investigating volumes of crystalloid fluid within 24 h in 124 patients with sepsis without shock enrolled at three emergency departments in the Central Denmark Region. Patients are allocated to two different intravenous fluid regimens: a restrictive approach using four trigger criteria for fluid administration vs. standard care.The primary, feasibility outcome is total intravenous, crystalloid fluid volume within 24 h, and key secondary outcomes include protocol violations, total fluids  within 24 h, and serious adverse reactions and suspected unexpected serious adverse reactions.Status: The trial started in November 2021, and the last patient is anticipated to be included in January 2022.Sepsis is very common in emergency department patients and fluid administration is very frequently administered in these patients. However, the evidence to guide fluid administration is very sparse. This feasibility trial will be the foundation for a potential future large-scale trial investigating restrictive vs. standard fluid administration in patients with sepsis.ClinicalTrials.gov number: NCT05076435 (date: 2021 October 13), Committee on Health Research Ethics – Central Denmark Region: 1-10-72-163-21 (date: 2021 June 28).EudraCT number: 2021-000224-35 (date: 2021 May 03), The online version contains supplementary material available at 10.1186/s40814-022-01034-y. Sepsis is common and accounts for approximately a quarter of all admissions from Danish medical emergency departments (ED)  and for The mainstay of sepsis treatment in the initial phase includes intravenous antibiotics and fluids, source control, and supportive care, if necessary . The effRecently, there has been a number of observational studies and interventional trials on fluid volumes in septic shock and several randomized trials are ongoing , 33, 34.The aim of the Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis) trial is to test if a restrictive intravenous fluid protocol in ED patients with sepsis without shock is feasible and if the treatment protocol decreases the volumes of intravenous fluid administered in comparison to standard care. Should the trial prove feasible with separation between the two interventions, a large-scale trial assessing patient important outcomes is warranted.ClinicalTrials.gov (Identifier: NCT05076435 (date: 2021 October 13)). The trial protocol was approved by the Committee on Health Research Ethics—Central Denmark Region (Identifier: 1-10-72-163-21 (date: 2021 June 28)).The full protocol is provided in the The REFACED Sepsis trial is an investigator-initiated, multicenter, randomized, parallel-group, open-labeled, feasibility trial, randomizing 124 sepsis patients without shock to a restrictive approach for fluid administration within the first 24 h or standard care.The trial will be conducted at the EDs at Aarhus University Hospital and the Regional Hospitals in Randers and Viborg, Denmark.not able to provide written consent after being given oral and written trial information before randomization. Since most sepsis patients are not able to provide informed consent, we decided to only include patients who cannot provide written, informed consent at inclusion. This means that all included patients will be either severely in pain, distress, confused, delirious, respiratory, or circulatory acutely affected and/or ill. The inclusion will be approved through legal guardian informed consent from an independent physician. For further details on ethics and consent, see the “Ethical considerations and consent” section.We will include patients fulfilling all of the following inclusion criteria: (1) unplanned emergency department admission, (2) age ≥ 18 years, (3) sepsis defined as (a) suspected infection by the treating clinician AND (b) blood cultures drawn AND (c) intravenous antibiotics administered or planned AND (d) an infection-related increase of SOFA-score ≥ 2 , and (4)Patients are randomized to either standard care or restrictive fluid administration for 24 h by the treating physician or the treating physician in collaboration with research assistants. The intervention protocols in the REFACED Sepsis trial are targeted intravenous crystalloid fluid. Fluid restriction vs. standard care fluid therapy cannot be blinded for investigators, clinical staff, or participants. The two treatment algorithms are shown in Fig. Intravenous fluid will be given as per choice of the treating team. There will be no lower or upper limit for the use of either intravenous or oral/enteral fluids.No intravenous crystalloid fluids should be given unless one of the below mentioned situations occur:Lactate concentration ≥ 4 mmol/l Hypotension (systolic blood pressure < 90 mmHg)Mottling beyond edge of kneecap  Severe oliguria, i.e., diuresis < 0.1 ml/kg/h, during the first 4 h of admissionA fluid bolus of 250 ml isotonic crystalloid  may be given within 15 min if one or more of the following occurs (hypoperfusion criteria):After 30 min, the effect of a fluid bolus may be assessed by re-evaluation of the four hypoperfusion criteria mentioned above by the treating clinician. If one or more of the criteria are still fulfilled, a fluid bolus as defined above may be repeated. This circle of a fluid bolus, 30 min and re-evaluation may be repeated as long as clinically indicated. At any time, the clinician can start vasopressors if deemed necessary.The treating physician may at any time violate the protocol by giving fluid although none of the above-mentioned criteria are fulfilled if found to be in the interest of the patient. The physician must state the reason for violating the protocol.Correct significant electrolyte deficienciesEnsure a total fluid input of 1 L per 24 h (fluids with medications and nutrition count as input)Intravenous fluids may be given as carrier for medications, but the volume should be reduced to the lowest possible volume for the given medication. In case of documented overt fluid losses , intravenous fluid may be given to correct for the loss. In case the oral/enteral route for water or electrolyte solutions is contraindicated or has failed as judged by the clinical team, intravenous fluids may be given to:If a patient undergoes surgery during the 24-h inclusion period, they temporarily pause the protocol, but clinicians will be encouraged to continue restrictive fluid therapy.Research assistants  will be present at all three sites from 14.00-23.30 to ensure enrollment of the patients, information to the involved clinical teams and encourage to complete documentation of all fluids.Eligible patients fulfilling all inclusion criteria and no exclusion criteria will be randomized 1:1 using a centralized web-based system according to a computer-generated allocation sequence list, with varying block sizes, stratified for site. The allocation sequence list and block sizes are only known by the data manager at Trial Partner® at Aarhus University and remains concealed from the investigators until the last patient has completed the study.The primary outcome will be the total volume of all administered intravenous, crystalloid fluids within 24 h of randomization.The secondary outcomes will be as follows: feasibility measures  vs randomized, time from admission to inclusion, number of patients with incomplete data on the primary outcome 24-h fluids ), accumulated serious adverse reactions and events within 7 days in-hospital, and total fluids  at 24 h. We will also report in-hospital mortality and 30- and 90-day mortality, in-hospital length of stay (LOS), mechanical ventilation within 7 days of admission (yes/no), vasopressor use within 7 days of admission (yes/no), and development or worsening of acute kidney failure according to the KDIGO3-criteria within 7 days of admission .t-test, a sample size of 124 patients is required; 62 in each treatment arm.The trial was powered to the primary outcome of 24-h total intravenous fluids. The sample size calculation is based on data from an observational study conducted in the Central Denmark Region in which sepsis patients meeting inclusion criteria for the current trial received 2670 ml intravenous fluids (SD 1695) . We therp-value < 0.05 will be considered statistically significant, and 95% confidence intervals will be presented.The statistical reporting will adhere to the CONSORT guidelines , 46. AllAll analyses will be conducted in a modified intention-to-treat (ITT) population defined as all randomized participants for whom consent to use data was obtained. We will perform the primary analysis adjusted for the stratification variable, trial site. The two groups will be compared regarding baseline characteristics using descriptive statistics.To estimate the mean difference in fluid volume between groups, we will use linear regression with adjustment for the stratification variable to see if it is feasible to reach 1000 ml difference. If the data is severely non-normally distributed, we will consider other appropriate options . Other continuous variables will be analyzed similarly. For binary outcomes, we will use logistic regression adjusted for site and results will be presented as odds ratios.Missing data will be reported. We do not expect any missing data for the primary outcome (except for those discharged or dying within the 24 h) or the key secondary outcomes. Patients discharged within 24 h or who died within 24 h, will be included in the analysis with the volume of fluid they received until discharge/death. We do not expect missing data on mortality or adverse events. Multiple imputation using known risk factors for outcomes in sepsis will be used to impute values for patients with missing data if missing data is substantial (> 10%). There will be no predefined stopping criteria for this feasibility trial. All analyses will be performed using Stata version 17 .The treating team will register limited data during the randomization process, i.e., patient identifier , site, and inclusion/exclusion criteria. A paper case report form (CRF) (a bedside REFACED Sepsis resuscitation chart) for collecting data on fluid management will be placed at the patient’s bedside. The paper CRF will be filled out by the treating team and/or research assistants during the 24 h; timing of fluids administered, indication for fluid bolus, fluid type and volume and time to re-evaluation and protocol violations and reasons for these. Oral and other intravenous fluid administrations will be noted on the CRF. The research assistants are not allowed to administer/prescribe any fluids. Further data will be obtained from the electronic medical record by the research team including vital signs, blood tests, and further clinical data; all data will be based on measurements and assessments made by the clinical team. A trained member of the research team will be responsible for data collection and entry into the eCRF from the electronic medical journal and from the paper-CRF. Data will be entered directly into the REDCap database from the electronic medical journal. Details of the included variables are provided in the full protocol.The clinical management of included patients, other than fluid strategy according to randomization, will be at the complete discretion of the treating clinical team in order to test the interventions in a real-life clinical scenario.A detailed description of the ethical considerations is provided in the protocol in the The trial is monitored according to the standards of Good Clinical Practice . The stuSix months after the publication of the last results, all de-identified individual patient data will be made available for data sharing . ProceduThe current article describes the design of the REFACED Sepsis trial, a feasibility trial investigating if a fluid restrictive protocol reduces 24-h crystalloid fluids in sepsis patients without shock admitted to the emergency department in comparison to standard care.ClinicalTrials.gov Identifier: NCT03668236, just finished enrollment) enrolling septic shock patients in the ICU in primarily Europe [ClinicalTrials.gov Identifier: NCT04569942) enrolling ED patients with sepsis-associated hypotension in Australia and New Zealand [ClinicalTrials.gov Identifier: NCT03434028) is currently randomizing septic shock patients in the ED to either 24 h liberal fluids or restrictive fluids in the USA [The optimal intravenous fluid strategy in adults with sepsis without shock is unknown. In septic shock, trials on restrictive vs. liberal fluid administration have pointed towards benefit with fluid restriction, although the evidence is still uncertain. Three large-scale studies are currently investigating fluids in septic shock and sepsis-associated hypotension. The CLASSIC-trial , general (lactate), peripheral (mottling), and renal (oliguria) circulation and perfusion with inspiration from the CLASSIC trial , 49.The trial design is pragmatic regarding all other aspects of treatments, including fluid type, encouraging the clinical team to follow routine practice to be able to increase external validity as much as possible. The REFACED Sepsis trial intervention cannot be masked for investigators, clinicians, research assistants nor patients, as blinding of the two fluid strategies is not feasible in clinical practice. The non-blinded design increases the risk of bias . We expeThe trial was initiated on November 3, 2021, and is expected to be completed within 2–3 months.Additional file 1.


Sci., 2019, 10, 10958–10962.Correction for ‘Laser cleavable probes for  The authors regret that there is some ambiguity over the origin of the probe molecule and would like to clarify that in the manuscript they presented a multiplexed and sensitive glycan detection approach based on laser cleavable probes.In the article a multiplexed and sensitive glycan detection approach based on laser cleavable probes is developed. In this method, four kinds of glycans at the surface of single cell and tissue were recognized by their specific lectins, and sensitive mass spectrometry detection was achieved by combining the lectins with laser cleavable probes with different mass tags.1–4 were previously synthesized by Moon et al.1  and details of the syntheses are provided in the ESI (Scheme S1 and Fig. S1–S8Regarding the synthesis of the laser cleavable probes, the four laser cleavable probes The Royal Society of Chemistry apologises for these errors and any consequent inconvenience to authors and readers.SC-011-C9SC90270H-s001


The aim of the study was to examine the role of self-esteem in resisting the influence of materialistic goals of four social role models  in adolescents (aged 13–16). Previous studies showed a negative correlation between the psychological health of teens and striving for materialistic goals, one of the main sources is the social modeling of materialism. Two studies were carried out. The first, correlational study, was conducted on target teens and their mothers, fathers, and peers of their choice. It examined if self-esteem is a moderator of the relationship between the materialism of social role models  and the materialism of teens. The second, experimental study, was conducted on target teens only. It examined how boosting the self-esteem of teens and activating materialism of social role models  may affect the materialism of teens. Study 1 showed a significant interaction effect of self-esteem and the materialism of peers on the materialism of teens. The interaction effects of self-esteem and other role models (parents and media) were not significant. Study 2 showed that elevated self-esteem lowered the influence of the materialism of peers on the materialism of teens. The results were not significant when other role models (parents and media) were analyzed. The results obtained in the presented studies indicate that the self-esteem of teens may have an important role in resisting the influence of materialism role models of peers. Practical implications of the studies for the psychological health of teens are also discussed. Self-determination theory holds that the importance attached to the pursuit of intrinsic and extrinsic goals is related to the wellbeing of an individual . IntrinsPsychological research confirms that successive generations of teens are becoming more materialistic . And yetOne of the main sources of the materialism of teens is social modeling, and there are various role models  that can shape the materialism of teens . As a reIn view of the negative health consequences of materialism for adolescents, it is important to identify ways in which the impact of materialism role models can be lessened. One of the possible resources associated with resistance to the influence of materialism role models is high self-esteem. Self-esteem is a positive attitude toward oneself. It is an effective resource, which brings a sense of social support  and workIn this study, we worked toward three goals. First, we analyzed whether elevated teens’ self-esteem can be a moderator of the relationship between the materialism of role models  and the materialism of teens. Second, we checked whether boosting self-esteem can lessen the influence of materialism role models . Third, we examined whether higher self-esteem may help teens to resist the influence of any of the materialism role models in question. Below, we present the theoretical basis of the study and discuss questions posed in our two studies, correlational and experimental.Self-esteem can be analyzed as a one-dimensional global self-evaluation  and as aStudies on teens to date mainly deal with the relationship between self-esteem and materialism. They show that lowered self-esteem is linked to increased materialism . Other sThus, most previous studies show that materialism of teens is negatively linked to high/elevated self-esteem and that materialism may be a compensatory strategy for the decline of self-esteem.Theories of social modeling postulate that certain behaviors and attitudes arise through observation and imitation of role models – mothers, fathers, peers, and those displayed by media . Many stCross-sectional studies indicate that the materialism of teens is positively linked to the materialism of mothers . As far As regards peers, studies show that teens learn materialism from peers and friends , teens wResearch into media and materialism of teens shows that media play a role in increasing the materialism of children and teens . Media mAs described above, the research literature indicates that parents, peers, and media affect the materialism of teens. However, the impact of these role models can be different cf. . In adolThus, previous studies show that although there are links between the materialism of teens and materialism of all role models , peers may play a special role in modeling the materialistic goals and attitudes of teens.Self-esteem is also shaped in the context of social relationships. Parental warmth and commitment, unconditional love, and a sense of security offered by parents lay the foundations for positive self-esteem . It is wFew previous studies analyzed the relations of having or not having social support with materialism and self-esteem as a mediator of such relations. They showed that self-esteem of teens can be a mediator of the relation between perceived acceptance and support of peers or parents and adolescent materialism – acceptance and support elevate self-esteem and, consequently, lower materialism .In conclusion, both parental and peer support can elevate self-esteem and lower materialism. However, the importance of parental support and acceptance for positive self-esteem is crucial, while the importance of peer support and acceptance for positive self-esteem may be susceptible to change. High/elevated self-esteem may give a sense of social support and help deal with being rejected or excluded from the peer group.The aim of the present studies is to fill in the gaps that exist in the literature on teenage materialism (REIVO) and self-esteem. Until now, the role that self-esteem may play in moderating materialistic social influences on adolescents has not been clearly explained in the literature. Based on various findings, we assumed that self-esteem might play a crucial role in resisting the materialistic influence of peers. First, high self-esteem is an emotional resource, which evokes a sense of social support cf.  and elevFurthermore, previous studies have not examined the role that self-esteem may play in reducing materialistic influences on adolescents. Taking into account, once again, theories about the function of self-esteem as a sense of being accepted cf. , and finTo test the hypotheses, we carried out two studies, a cross-sectional one and an experimental one. We analyzed all materialism role models discussed above , to check the assumed effects in both studies.The first, cross-sectional, study tests Hypothesis H1 about self-esteem as a moderator of the relationship between the materialism of peers and materialism of teens. In the study, we checked the moderation effect of self-esteem on the relation between the materialism of teens and materialism of each of the role models examined, i.e., mothers’, fathers’, peers’, and media.Mage = 14.36, SD = 1.07), of whom 53.3% were girls and 46.7% were boys. We also obtained data from 199 of their mothers , 178 of their fathers , and 199 of their peers . None of the mothers and fathers had primary school education, 10.1% of the mothers and 19.6% of the fathers had vocational education, 25.1% of the mothers and 24.1% of the fathers had secondary education, 11.6% of the mothers and 6.5% of the fathers had a Bachelor’s degree, and 52.3% of the mothers and 48.7% of the fathers had a Master’s degree or above. All respondents came from the Pomeranian region of Poland. The families maintained an average standard of living  measured by MacArthur’s Scale of Subjective Social Status . The sets for target teens also included a self-esteem scale and measures of exposure to media and the Internet. The scales and measures were arranged in a random sequence.not at all important and 9 = extremely important) to rate “How important was each goal to you in the past month.” We wanted to find here how important the three primary extrinsic  domains were for the teens, that is a financial success , popularity , and physical appearance , relative to the three primary intrinsic  domains, that is, self-acceptance , affiliation , and community feeling . We calculated the level of materialism assuming, in line with the conclusions of We used an adaptation of the Aspiration Index (AI) for teens AI; , Study 4strongly agree and 4 = strongly disagree). The reliability of the scale was high, Cronbach’s α = 0.86, McDonalds’Ω = 0.87.We assessed self-esteem with the Rosenberg Self-Esteem Scale  consistinot at all important and 7 = very important) for each item. We created a REIVO score , first respondents indicated how often they watch television and use the Internet on weekdays at five specific times of day . Next, using the same 5-point scale, they rated how often they engaged in the same two activities on the weekend at six specific times of day . We summed the ratings of exposure to television, and the Internet, during the weekdays and weekends.We used a method inspired by r = − 0.08) and age (r = − 0.13) were not significant. The materialism of all role models was positively related to the materialism of teens.We examined whether the relationships between the materialism of teens and that of the four role models  were moderated by the self-esteem of teens. Moderation effects were tested with regression analysis using the PROCESS bootstrapping macro procedure .R2 = 0.04, ΔF = 9.69, b = − 0.14, SE = 0.04, t = − 3.11, p = 0.002, lower 95% CI [LLCI] = − 0.222, upper 95% CI [ULCI] = − 0.049). As can be seen in Of the four potential moderation effects of self-esteem, one was significant – self-esteem moderates the relationship between materialism of peers and materialism of teens  = 1.19, b = 0.08, t = 1.09, p = 0.276, LLCI = − 0.061, ULCI = 0.213), father  = 1.32, b = − 0.08, SE = 0.07, t = − 0.1.15, p = 0.251, LLCI = − 0.225, ULCI = 0.059), and media  = 0.735, b = − 0.06, SE = 0.07, t = − 0.857, p = 0.392, LLCI = − 0.201, ULCI = 0.079).The results do not show that self-esteem is a moderator in the case of the other three social materialism role models studied, i.e., mother  together or the materialism of the four role models only. Then we tested if elevating the self-esteem of teens can lessen the impact of the materialism of the role models on the materialism of teens as compared to the neutral group  as a reference group. In our experimental study, we used semantic priming and goal priming to activate both materialisms of social role models and self-esteem. Exposure to specific stimuli, concepts, or clues concerning certain knowledge or goals makes the knowledge and goals more accessible cf. . The depM = 14.47, SD = 0.09), of whom 56.7% were girls and 43.3% were boys. The respondents came from families in which 9.1% of mothers and 4.7% of fathers had only primary school education, 13.6% of mothers and 16.8% of fathers had vocational education, 19.5% of mothers and 22.8% of fathers had secondary education, 10.4% of mothers and 15.4% of fathers had a Bachelor’s degree, and 47.4% of mothers and 40.3% of fathers had a Master’s degree or above. Teenagers came from the Pomeranian region of Poland. Their families maintained an average standard of living  as measured by MacArthur’s Scale of Subjective Social Status (The sample consisted of 164 middle school students aged 13–16 (l Status . All meaThe study was conducted at the schools the teens’ attended. They were seated in classrooms separately so that they could not communicate with each other and were randomly assigned to one of the eight conditions in two (elevated vs. non-elevated self-esteem) × four  experimental design.I am… creative; I am… ambitious; I am… friendly). In the non-elevated condition, teens had to solve a word search puzzle, i.e., 10 nouns referring to everyday life and surroundings, e.g., a cloud, a mountain, a couch. After finding the words, participants had to write them down in a column.The procedure of elevating self-esteem was inspired by a method previously used by n = 4) assessed the content of descriptions of teens in the group with self-esteem manipulation . In assessing the effectiveness of self-esteem manipulation, we took into account the mean and SD of the judges’ ratings and the concordance of the ratings.To check the effect of manipulation, the teens in the experimental group were asked to pick one characteristic and describe a situation within the previous 3 months in which they displayed that characteristic and, thus, were satisfied with themselves . After the survey, competent judges (psychology experts) . The provided answers in all four conditions included materialistic goals only, e.g., fame, celebritydom, and very high salary, studying at a world-famous/prestigious university.The procedure of activation of materialism role models  was inspired by a method successfully employed in previous studies by Next, respondents in all four conditions were shown visual materials of 36 material goods  with high price tags and logos of prestigious brands. A preliminary study had confirmed that teens were familiar with the goods/brands used in the visual materials and considered them luxurious. In mother, father, and peer conditions, teens were asked to “indicate at least three things that their mother/father/peer would choose to make herself/himself happy”; the products were customized depending on who the questions referred to. In the media condition, teens indicated “at least three things that would bring the biggest happiness to everybody according to media advertisements and commercials”.working in a room with paintings on the walls; (b) working in a room with flowers; and (c) working in a room with colorful walls”; “Which of the following things would you choose to make yourself happy, when you grow up: (a) more green places in the place where I live; (b) more cycle lanes in the place where I live; and (c) more playgrounds in the place where I live.” Next, teens were asked to choose at least three most preferred figures out of 36 colorful figures: i.e., (a) squares, (b) rectangles, (c) ellipses, and (d) triangles (e) polygons.In the neutral condition, teens answered three neutral questions about preferences for colors and places, choosing one out of three suggested neutral responses, e.g., “Which of the following things would you choose to make yourself happy with your job in the future, when you grow up: (a) To assess the materialism of teens, we used the AI adapted for teens AI; , Study 4M = 4,21, SD = 0.53 (Max = 5). Kendall’s W of concordance analysis of competent judges was W = 0.68. Thus, the judges agreed that the descriptions of teens in the experimental group do express pride and self-satisfaction, which means that the manipulation of self-esteem – self-esteem elevation was successful.The mean of competent judges’ ratings was To check hypothesis 2, regression analyses with categorical variables were performed for each of the tested materialistic models . In accordance with the analysis requirements, the nominal variables  were counted into instrumental variables by binary coding (zero-one) before entering the model. The first variable represented the group primed with both elevated self-esteem and materialism role model . The second variable represented the group primed with materialism role model only. The control group was a reference group. The dependent variable was the materialism of teens (REIVO score).R = 0.39, R2 = 0.15, F = 4.83, p = 0.012]. Regression analysis coefficients indicated that the peer condition differed significantly from the control condition on the level of materialism of teens  whereas the self-esteem and peer condition did not differ significantly from the control group . Regression analyses of the tested models for the other conditions were not significant .The aim of the study was to check whether the self-esteem of teens can help resist the social modeling of materialism. The research conducted so far has focused on the relationship between materialism and self-esteem , on selfThe findings of the first study, that confirm a moderation effect of high self-esteem for peer influence on materialism of teens, may be explained by the fact that this superior strength of this specific influence results from the need to be accepted and the fear of ostracism  since peThe absence of a moderation effect for parental models may result from differences between the developmentally based nature of parental influence and that of the peers. In teens, parental influence is diminished in favor of peer influence . ParentaThe absence of a moderation effect in the case of media may be due to the fact that the relationship between the media and advertisement exposure and teens’ materialism is weaker than the relationship between other materialistic influences and teens’ materialism. Previous studies also show that the relationship between materialistic media and teens’ materialism does occur but is rather weak cf. . AdoptinIt is worth mentioning in this study that Study 1 did not confirm the conclusions from the research of predecessors on American teens that indicate a significant negative relationship between self-esteem and materialism of teens . As statOur experimental study also confirmed that elevating the self-esteem of teens reduces the impact of the materialism of peers but not that of the other materialistic models. In this respect, the experimental study results echo the results of the cross-sectional one. Based on these results, it can be assumed that peers’ materialistic influence is less stable than that of parents and can be changed by boosting the teen’s self-esteem. Boosting self-esteem is not related to lessening the materialistic influence of parents because parental influence is more stable since parents are the first social models and self-esteem is largely determined by the relationship with parents and the upbringing of the child in the period prior to adolescence cf. .The presented research also has its limitations. First, following our predecessors the measurement of media materialism used in the cross-sectional study (1) focuses on media use frequency. Considering the conclusions from studies on adults, it would be a good idea to extend the next study to include additional variables such as active processing during viewing or materialistic purposes of using media cf. , which mDespite the limitations indicated above, the research presented here clearly demonstrated that self-esteem may allow predicting the effect of materialistic peer influences on materialism if teens and that elevating self-esteem can work as a resource helping teens, i.e., 13–16-year olds from families with average SES resist the materialistic influence of peers.Conclusions from the research on the role and function of self-esteem in healthy functioning carried out so far are not obvious. In the present study, it was shown that good self-esteem can be an effective way to be less prone to being influenced by peers, for example, overpaying attention to materialistic goals that have negative consequences for health cf. . Some reThus, the obtained results may contribute to the development of intervention programs promoting boosting self-esteem on both cognitive (perception of self-worth) and social (perception of oneself in relationships with others) levels  to make Contrary to previous studies on self-esteem interventions that did not indicate that self-esteem interventions can enhance the wellbeing of the individual , the resThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee Department of Psychology, University of Gdańsk. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.AZ: project administration, supervision, conceptualization, methodology, formal analysis, and writing the original draft. JB: methodology, investgation, and writing the original draft and data curation. MI and AL-W: methodology, investigation, and writing the original draft. All authors read and approved the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Because diagnostic tools for discriminating between hepatocellular carcinoma (HCC) and advanced cirrhosis are poor, HCC is often detected in a stage where transarterial chemoembolization (TACE) is the best treatment option, even though it provides a poor survival gain. Despite having been used worldwide for several decades, TACE still has many limitations. First, there is a vast heterogeneity in the cellular composition and metabolism of HCCs as well as in the patient population, which renders it difficult to identify patients who would benefit from TACE. Often the delivered drug does not penetrate sufficiently selectively and deeply into the tumour and the drug delivery system is not releasing the drug at an optimal clinical rate. In addition, therapeutic effectiveness is limited by the crosstalk between the tumour cells and components of the cirrhotic tumour microenvironment. To improve this widely used treatment of one of our most common and deadly cancers, we need to better understand the complex interactions between drug delivery, local pharmacology, tumour targeting mechanisms, liver pathophysiology, patient and tumour heterogeneity, and resistance mechanisms. This review provides a novel and important overview of clinical data and discusses the role of the tumour microenvironment and lymphatic system in the cirrhotic liver, its potential response to TACE, and current and possible novel DDSs for locoregional treatment. Hepatocellular carcinoma (HCC) is a primary liver cancer that usually develops in patients with an underlying liver disease and sustained liver damage. It is one of the most common and deadly cancers worldwide, currently ranking fifth and third in terms of global incidence and mortality of all cancers ,2. With HCC develops after a period of prolonged hepatic damage, leading to inflammation, fibrosis and eventually cirrhosis, the end-stage of chronic liver disease. The occurrence of fatty liver disease is one of its most common risk factors, and it evolves from intrahepatic fat accumulation through steatohepatitis to cirrhosis . CirrhosTACE is a locoregional chemotherapy performed though a percutaneously inserted intravascular catheter, which has been advanced using image-guidance and positioned in the hepatic artery as close as possible to the liver tumour region to create a local hot spot with the active drug . There a® Ultra-Fluide, Guerbet, Paris NORD 2, France), and is often followed by embolization of the blood vessel with gelatine sponge or solid embolic agents. This vascular occlusion reduces local blood flow, thereby depriving the tumour from its oxygen and nutrient supply and increasing the local transit time of the formulation that should enhance the tumour’s chemotherapeutic exposure. However, clinical evidence on an enhanced anti-tumour effect caused by the addition of vascular occlusion remains uncertain [The rationale for cTACE is that the intra-arterial injection of a viscous emulsion in tumour feeding vessels will result in a strong cytotoxic effect. The emulsion-based product is made from a chemotherapeutic drug  mixed with iodized oil  is loaded into microspheres from which it is released slowly. However, the microspheres cannot cross the peribiliary capillary plexus and enter the tumour, and thus, the drug is released in the distal arterioles and distributed from there via diffusion, convection, or both ,22. The Several randomized control trials (RCTs) and observational studies report no difference in tumour response and overall survival (OS) between cTACE and DEM-TACE, thereby suggesting that both treatments have a similar effectiveness ,31,32. HIf the delivered drug(s) do not sufficiently penetrate both selectively and deeply into the tumour and the drug delivery system is not releasing the drug(s) at an optimal clinical rate, it may contribute to an overall modest antitumour effect. Furthermore, the effectiveness of TACE is confounded by variations in the HCC genotype and phenotype, and the highly heterogeneous population of patients with intermediate-stage HCC . In addiIn this review, we have provided a novel and important overview of clinical data, as well as a deeper understanding of the underlying biological mechanisms that could contribute to the response to TACE. In addition, we also highlight the importance of the tumour microenvironment and lymphatic system in this complex interplay. Therefore, the objective of this review is to discuss three key features: (i) the role of the tumour microenvironment and lymphatic system in the cirrhotic liver and its potential response to TACE; (ii) some of the most frequently clinically applied parenteral products for locoregional drug treatment, and finally; (iii) possible novel drug-delivery systems (DDS).® accumulation is sometimes seen in such unexpected sites during or after TACE, or both , which is a growth factor highly involved in stellate cell activation, have been tested in clinical trials (NCT01246986 and NCT02178358). Another important contributor to the microenvironment is the deposition of ECM, which includes heparan sulfate proteoglycans. PI-88 is a heparin sulfate mimic that specifically targets heparanase in cancer, thus preventing the release of growth factors that otherwise would contribute to tumour growth, angiogenesis, and metastasis. The safety and efficiency of PI-88 as an adjuvant therapy for post-operative HCC has been shown in a phase II trial, and a recent follow up study revealed significant clinical benefits for patients with HCC (PMID: 1930316), which has been further studied in a phase III trial (NCT01402908). However, none of these compounds have been tested in combination with TACE, yet it could be speculated that reducing the dense network of activated stellate cells and deposition of ECM, would positively influence the response to TACE in patients. More studies are needed to confirm this.Significant progress on the treatment of advanced HCC has been made possible by sorafenib, which in itself targets the tumour microenvironment by blocking angiogenesis. While TACE and sorafenib have both been shown to prolong survival in patients with unresectable hepatocellular carcinoma, previous trials assessing the combination of TACE and sorafenib have been unable to show clinical benefits compared with TACE alone. A recent study from Kudo et al. reports the results from a randomized, multi-centre prospective trial of this combination treatment in patients with unresectable HCC. Median progression-free survival was significantly longer in the combination group (25.2 months) than in the TACE without sorafenib group (13.5 months), thus showing promising results in tackling both the tumour cells and the microenvironment in the context of TACE.The tumour microenvironment contains non-malignant cells that are assisting tumour cells to proliferate, invade, and metastasize. Furthermore, immunosuppression, associated with chronic inflammatory factors, such as growth factors, cytokines, and chemokines is generated by both stromal and tumour cells ,44. MultThe cirrhotic liver is characterized by a severe inflammatory reaction and an excessive deposition of extracellular matrix, which actively contributes to the progression of HCC ,46. SeveThe hepatic immune population is highly heterogeneous. It is comprised of myeloid-derived suppressor cells, regulatory T cells, and tumour-associated macrophages, which are responsible for the building of an immunosuppressive pro-tumoral environment. The intrinsic immunosuppressive nature of the hepatic microenvironment plays a major limiting role in the effectiveness of chemotherapeutic agents. In addition, chemotherapeutic agents themselves alter the composition of the hepatic inflammatory populations.The most dominant immune cells of the tumour microenvironment are tumour-associated macrophages, which have been established as key mediators of drug resistance in several solid tumour types ,48. It hStudies have shown that immunogenic cell death involves the release of calreticulin and other endoplasmic reticulum proteins, as well as the secretion of ATP, and apoptosis-associated release of the non-histone chromatin protein high-mobility group box 1 . This stThe well-established contribution of the immune-cell population in the pathogenesis of HCC has led to several clinical trials assessing the potential of immunotherapy in HCC patients ,55. StudOverall, these observed alterations in inflammatory populations and inhibitory immune checkpoints after TACE treatment warrant further research on whether a combination of TACE with chemotherapeutics and immune-checkpoint inhibitors could increase drug-response.In addition to the cellular interactions, the cirrhotic microenvironment forms a physical barrier that prevents the drugs to reach their target(s) within the tumour parenchyma, which reduces drug availability . The tumHowever, vascular leakiness can increase the perfusion of chemotherapeutic drugs at the local tumour site. A key process for a successful tumour targeting formulation is an enhanced permeability and retention (EPR) effect. This effect has been extensively investigated as a unique phenomenon of solid tumours related to their anatomical and pathophysiological differences from normal tissues, and it is fundamental for the development of macromolecular and nanoparticle based anticancer therapy. Unfortunately, progress in developing effective pharmaceutical formulations, especially particles in the nano-size range, has been hampered by a heterogeneity in the EPR effect and a lack of information on factors that influence this process in the liver ,61.The tortuous and disorganized nature of the tumour vasculature complicates an even drug distribution. In addition, HCC is severely affected by the hypoxia induced by the intra-arterial formulation applied in TACE, which may induce angiogenesis and/or alter the complex cellular metabolism and thereby reduce the treatment effect. This mechanism of increased resistance to treatment might be reduced by combining chemotherapeutic drugs with anti-angiogenic and anti-proliferation treatments, such as the multiple kinase inhibitor sorafenib .The abundant ECM and the substantial stromal cells, such as activated hepatic stellate cells and tumour-associated macrophages, are considered a binding-site barrier that may reduce the penetration of drug formulations within solid tumours . This leDrug mass transport and availability at the core of a solid tumour is significantly influenced by the elevated interstitial fluid pressure and poor vascularization . Both cTThus, diffusion remains the main driving force for drug transport in these heterogenous tumours, and the diffusion process needs to be better understood to develop new drug molecules, nano particles, and other advanced DDS.The liver is the largest lymph-producing organ in the human body, generating about 50% of the body’s total lymphatic fluid, and it is the most important part of the lymphatic system from a functional point of view . The maiIt has been reported that the volume of the lymphatic fluid produced in a cirrhotic liver is up to 30 times larger than in a non-cirrhotic liver . ResistaApart from bland embolization, aiming to starve the tumour by inducing ischemia with particles, or degradable starch microspheres (DSM), there are two main types of parenteral drug delivery systems (DDS) for TACE, which provide a transient or permanent vascular occlusion-mediated ischemic reaction, in combination with drug-mediated cytotoxicity: cTACE and DEM-TACE.®  and a wide variety of chemotherapeutic drugs. Both single-drug and fixed-dose drug combinations are used, where doxorubicin is the most common [®-based emulsions can be administered in lobular, segmental, or subsegmental arteries, and all administration sites are used in a clinical context. Selective or super-selective drug administration has been recommended to optimize tumour necrosis and reduce adverse effects to the non-tumour liver parenchyma [The viscous emulsion used for cTACE is composed of Lipiodolt common . The Liprenchyma .® is an iodinated poppy seed oil, with 73% line-olic, 14% oleic, 9% palmitic, and 3% stearic acid, which makes it suitable as a contrast agent. It was clinically introduced in radiology in the 1920s as an X-ray marker, and in the 1980s it was reported to accumulate in rabbit tumour tissue [® appears in the portal venules, and passes through to the sinusoids. This causes a temporary and partial stasis of blood flow [®-based drug formulation, it is also feasible to administer embolic particles that can be biodegradable  or permanent  to further enhance the ischemic effect [Lipiodolr tissue . When thood flow . These tood flow . After ic effect .® may also function as an imaging biomarker for tumour response because the necrosis has been proved proportional to the fraction of tumour volume opacified by Lipiodol® on computer tomography (CT) [Besides being the vehicle for drug delivery, Lipiodolphy (CT) . The prophy (CT) ,80, or a® can also be used as an imaging biomarker for survival, because clinical trials have demonstrated improved survival in patients with more complete Lipiodol® retention in the tumour [® enhancement (PPLE) is seen during cTACE have longer survival and better tumour response than patients without PPLE [Lipiodole tumour ,82. Furtout PPLE . An inteout PPLE  and a loout PPLE ,86. Presout PPLE . Howeverout PPLE . Progresout PPLE , which hout PPLE .®-based emulsions have been used clinically, and the full composition of the formulation is often not described in reports [®-based emulsions constitutes a source of variation. For instance, the final emulsion ex tempore preparation is often performed in the IR suite at ambient temperatures. The emulsion is then prepared by using a simple pumping technique, which has been identified as a critical formulation step, affecting the properties and performance of the final DDS [Visible uptake and retention during the cTACE procedure varies greatly between studies . A varie reports , therebyinal DDS ,78,92. Hinal DDS . All theinal DDS  and can ® part (1:2–1:4) enhances the emulsion stability and reduces the drug release rate from the formulation both in vitro and in vivo [For example, it has been suggested that the addition of a contrast agent to the aqueous phase increases emulsion stability and decreases drug release rates . The pro in vivo ,95. A re in vivo . In addiThese variations, along with the lack of information on emulsion composition in clinical reports, makes comparisons of tumour response between clinical studies highly difficult. This probably contributes to the fact that there is still no consensus regarding the optimal chemotherapeutic drug for TACE. Despite more than six decades of experience in the clinical use of anthracyclines, their mechanism(s) remain mainly empirical .® dose that is retained in the tumour is related to the tumour size, tumour physiology, and biochemical condition of different liver compartments. However, it is unclear which dose of the active drug in these formulations provides the best benefit-to-safety ratio. Besides doxorubicin, the most used chemotherapeutic drugs for cTACE are epirubicin, cisplatin, miriplatin, and idarubicin.The dose of the active drug and its concentration-time profile in local liver tissue, tumour tissue, and plasma has not been well characterized for either of the drugs used in the treatment of HCC. It is clear that the fraction of the Lipiodol®, entailing a higher effective permeability across biological membranes [® - idarubicin based emulsion has been reported to be very limited (5% aqueous solution and 95% persisting emulsion); fluorescent electronic microscopy has revealed idarubicin to be located inside and at the interface of the emulsion because of drug-lipid ionic interactions. This enhanced emulsion stability is expected to be beneficial as it increases the contact time of the drug with the cancer cells [® and membrane barriers or transport proteins [® emulsion. Because Lipiodol® is known to be retained by HCC cells for at least several weeks, a more stable formulation could provide a slow-releasing, tumour-targeting vector. Thus, idarubicin, which forms a more stable emulsion with Lipiodol®, could be a suitable alternative.As idarubicin is more lipophilic and has a smaller polar molecular surface area than doxorubicin, a higher idarubicin concentration can be achieved in Lipiodolembranes . The phaer cells . Based oproteins . Doxorubproteins ,99. ThisFurthermore, in vitro studies on three HCC cell lines have demonstrated idarubicin to be the most effective among 11 tested chemotherapeutic drugs, including doxorubicin, cisplatin, and epirubicin . The supLiposome based nano-formulations have been widely investigated as carriers for potent chemotherapeutic drugs with the objective to increase efficacy and reduce toxicity. An example is the encapsulation of doxorubicin within PEGylated liposomes. The intra-particle drug load of doxorubicin is more than 90% in the nano-liposome, which has a size range of 80–100 nm in diameter. The proposed non-specific target mechanism for nano-sized formulations in solid tumours is mediated by the EPR effect.While nano-formulations have been reported to exhibit improved anti-tumour effects in a variety of animal models, the translational and clinical relevance of the EPR effect of nano-formulations has been challenged. In patients, treatment with doxorubicin in nano-sized PEGylated liposomes produced a prolonged total plasma exposure and improved safety properties but did not improve efficacy compared to systemic intravenous treatment with doxorubicin. In patients with advanced HCC, treatment with PEGylated liposomal doxorubicin after intravenous administration of gemcitabine has been demonstrated to be active and safe . Thus, s® is a liposomal nano-formulation, which penetrates much less into ECM, resulting in a lower exposure of doxorubicin intracellularly, which reduces the frequency of its most severe adverse effects in the heart and intestine. The maintained anti-tumour effect and lower frequency of these side-effects are consequences of a longer terminal half-life due to the poor vascular penetration and encapsulation of doxorubicin, which is the most significant clinical gain of this PEGylated liposomal product (Doxil®). There are experimental strategies that utilize a reversible vasodilatation effect mediated by nitric oxide and an ultrasound responsive liposome able to cross both rate-limiting steps at the same time [It is well-established that liposomal nano-formulations with doxorubicin have a strong effect on the total plasma and blood concentration-time profile and tissue distribution. The tissue distribution of encapsulated and free doxorubicin reflects the direct deposition of doxorubicin-based nano-liposomes. Tumour vascular endothelium and ECM are considered as major barriers for tissue distribution of therapeutic nanoparticles and can, consequently, limit the anticancer effect. There are few strategies available to overcome this rate-limiting step. Doxilame time .Hydrogel microparticles are used as a DDS for chemotherapeutic drugs, proteins, and peptides, as they protect these drugs from degradation and also protect the environment from the drug itself, thus decreasing side-effects ,106.®, Tandem™, DCB, and HepaSphere™ are approved globally, and there are reports on experimental and clinical investigations of more DEMs [Several types of DDSs can be used for DEM-TACE, where DCBead™, HepaSphere™, LifePearlore DEMs ,107. DEMWhile doxorubicin remains the most common used anthracycline in DEM-TACE, worldwide doxorubicin shortages challenge the current treatment regime for intermediate stage HCC patients, and finding new alternatives to doxorubicin is essential. DEMs loaded with idarubicin have been demonstrated to have a good safety profile, a promising objective response rate (ORR) and time to progression (TTP) in retrospective , as well®-based emulsion. Furthermore, ischemia is known to stimulate angiogenesis and might even fuel tumour growth [As the DEMs are non-biodegradable, they generate a permanent embolization in the treated arteries, which is considered to contribute to the anti-tumour effect, but may also further worsen the liver toxicity . If the r growth .®-based emulsions, the DEMs have been described to generate reproducible and predictable results in blood vessel blockage, and a prolonged drug release. However, the DEMs have not been proved to release the entire drug dose nor to enter the tumour, but they seem to release only parts of the drug [Compared to the variability of the Lipiodolthe drug ,24 in arthe drug ,22. Thusthe drug ,27,28.Thus, this DDS needs further investigation and development. For instance, the size of the DEMs and the loading dose of the chemotherapeutic drug are expected to affect the treatment response, survival outcomes, and side-effect panorama. Several clinical trials have reported that smaller DEMs (100–300 μm) are associated with a better treatment response and survival, and a reduced number of adverse events than larger DEMs (300–700 μm) ,113. A pMost of our understanding of carcinogenesis and drug response in HCC has been derived from mouse models ,117. MurCurrently, three animal models are used to investigate the effects of interventional oncology tools. Firstly, the rabbit VX2 model, which has been widely used for intra-arterial drug delivery to hepatic tumours.  This modIn addition, two other commonly used animal models are the rat, where HCC is induced by injections with diethylnitrosamine , and the® and tested on the rabbit VX2 model [To overcome the limitations of current TACE formulations, an aqueous phase of ultrasound-triggered, doxorubicin-loaded, nanoparticle-conjugated microbubble complexes has been emulsified in LipiodolX2 model . This seAs described above, the EPR effect is one of the tumour specific pathophysiological processes that is fundamental for the development of macromolecular and nanoparticles anticancer therapies. Yet the heterogeneity in the EPR effect and lack of mechanistic understanding of this process have hampered the development of effective pharmaceutical formulations that would benefit from this tumour-specific condition ,61. An aDespite more than six decades of experience from clinical use of anthracyclines, their mechanism is still mainly empirical and there is no consensus regarding the optimal chemotherapeutic drug of TACE in the treatment of HCC . It is iFor instance, it has been demonstrated that both idarubicin and doxorubicin increase the levels of polyunsaturated fatty acids (PUFAs) and alkylacylglycerophosphoethanolamines (etherPEs) in different HCC-cell lines with markedly different drug-responses . The facModulating the different lipid metabolic pathways could also form a new treatment strategy and contribute to generalized and personalized metabo-chemotherapies. In addition, it has been demonstrated that doxorubicin in itself induces the unfolded protein response pathways in different tumour cell lines . ActivatSeveral attempts have been made to combine TACE with systemic agents, mainly those using multi-kinase inhibitors targeting angiogenic pathways. The SPACE and TACE 2 trials compared TACE combined with Sorafenib to TACE alone ,130 and In April 2021, a four-year-long clinical trial has started that directly compares Atezolizumab and Bevacizumab to TACE in patients with intermediate-stage HCC . The priIt is also considered that in the future the combination of TACE and immunotherapy might be very useful clinically. The two main immune checkpoints are the PD-1/PD-L1 and the cytotoxic T lymphocyte-associated protein 4 (CTLA-4). Based on two phase II clinical trials, CheckMate040 and Keynote-224, in which the PD1-inhibitors nivolumab and pembrolizumab yielded promising results as second line agents after sorafenib-treatment, these drugs have become approved as second-line therapies for HCC . HoweverDespite its shortcomings, TACE has been the standard of care for intermediate stage HCC for several decades ,12,13. N® presents several advantages as a DDS in TACE treatment: in addition to being a vehicle for the chemotherapeutic drug, it also acts as an embolic agent, and as a marker for tumour response. The fact that there is no consensus regarding the optimal chemotherapeutic drug for TACE is probably of less importance than the unreliable properties of the emulsions. The great variations in preparation technique, aqueous-to-lipid phase ratio, aqueous phase composition, and injectability properties of the emulsions [Lipiodolmulsions ,93 all aDuring the last decade, realization of doxorubicin-TACE in patients with intermediate HCC has become complex due to discontinuation of production of lyophilized doxorubicin by many pharmaceutical groups. The use of the lyophilized form is essential to obtain a mix with sufficient viscosity to induce the embolizing effect in cTACE. Currently, only Pfizer continues to produce lyophilized doxorubicin, which has led to recurring shortage periods and a vast need to find treatment alternatives. Idarubicin has exhibited several pharmaceutical formulation and pharmacological advantages and future clinical trials will investigate the clinical response and outcome.Ideally, the active drug(s) in cTACE or DEM-TACE should, after release in the vicinity of the tumour, have an effective target mass transport into the effect compartment. In addition, an optimal drug for TACE should have a high total body clearance and a large component of clearance outside the target compartment in the liver, to reduce systemic exposure and risk for serious adverse effects. To develop and improve DDSs for TACE, the diffusion process needs to be better understood because it is the main driving force for drug transport. In addition, the effects of an increased lymphatic vascular flow on the effectiveness of locoregional drug therapies is an area for future investigation.The unsatisfactory effect of TACE can be improved by combining TACE with other locoregional or systemic therapies, which is sometimes performed in the clinical setting. It remains to be seen if a future TACE strategy will include several active components enhancing the anti-tumour effect in different ways. The chemotherapeutic effect might be augmented by drugs modifying the inflammatory and cirrhotic microenvironment, such as immune-checkpoint inhibitors, anti-fibrotic or anti-angiogenic drugs, or by inhibitors of the unfolded protein response or endoplasmatic reticulum stress pathways.Although there is a constant development and improvement of imaging techniques, early detection of HCC is still challenging. Thus, TACE remains an important treatment tool despite its limitations. The absence of an overall benefit, together with the generally poor prognosis of this common cancer, highlight the need for further research and development, to increase our understanding of how the different tumour and stromal factors contribute to drug response, and to optimize the treatment.