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Synchronous triple primary gastrointestinal malignant tumors treated with laparoscopic surgery: A case report

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Published/Copyright: July 3, 2023

Abstract

Synchronous gastrointestinal multiple primary tumors including gastric, colonic, and rectal cancers are rare. Moreover, it was a challenge to find an appropriate procedure without negatively impacting the overall outcome. We described the case of a 63-year-old woman who presented with a 4 month history of upper abdominal pain, acid regurgitation, and anemia. Gastroscopy with biopsy suggested early cancer of gastric antrum. Abdominal contrast-enhanced computerized tomography and colonoscopy revealed ascending colon and rectum tumors. She had no family history of malignancy. Endoscopic submucosal dissection was performed for gastric cancer, and the pathological result presented that it was poorly differentiated and invaded into deep submucosa. The laparoscopy-assisted radical surgery combined with distal gastrectomy, right hemicolectomy, and anterior resection of rectum was performed for these three tumors via eight ports and a 7 cm midline upper-abdominal incision. No other perioperative complications were encountered except postoperative ileus. The patient was discharged on the 12th postoperative day. The pathological results revealed gastric cancer (T1N0M0), right colonic cancer (T3N1M0), and rectal cancer (T2N0M0), indicating complete surgical resection. We reported that our laparoscopic approach for synchronous triple primary gastrointestinal malignant tumors was feasible and minimally invasive.

1 Introduction

Multiple primary tumors (MPT) are defined as more than one tumor diagnosed in the same patient. The incidence of multiple primaries in cancer patients is reported in the range of 2–17% [1]. Depending on different definitions, synchronous MPT is defined as tumors diagnosed within 2 or 6 months of the initial diagnosis of a primary tumor [2,3]. Synchronous triple primary malignant tumors are a very rare finding [4] with uncertain incidence. Extensive surgery might lead to worse postoperative outcomes. The challenge was to find an appropriate procedure without a negative impact on the overall outcome when synchronous malignancies were diagnosed [1,5]. Laparoscopic surgery had been widely used for gastrointestinal cancer with many advantages over traditional open surgery [6]. However, there were few reports about laparoscopic procedures used in MPT [7]. And in terms of triple primary malignancies, there were no such reports yet. Here we reported a case of laparoscopic resection of triple gastrointestinal tumors via our procedure successfully.

2 Case presentation

A 63-year-old woman visited the Department of Gastroenterology because of upper abdominal pain with acid regurgitation and anemia for 4 months. Her past medical history included a hysterectomy for benign disease and lumbar disc prolapse. Her body mass index was 27.8 kg/m2. A gastroscopy was performed and suggested an early-stage gastric cancer lesion located at the antrum with shallow ulcer formation, about 1.5 cm in diameter. The pathology confirmed gastric adenocarcinoma. Abdominal contrast-enhanced computerized tomography (CT) showed a space-occupying lesion of the ascending colon and thickening of the rectal wall with no metastatic lesions. Furthermore, colonoscopy with biopsy revealed ascending colonic cancer with stenosis as well as rectal cancer of 2.5 cm in diameter located 12 cm proximal to the anal verge. Laboratory tests showed elevated serum carbohydrate antigen (CA-199) (30.39 U/mL). Additionally, preoperative chest CT found no lung metastasis.

Given the possible diagnosis of early-stage gastric cancer, endoscopic submucosal dissection was performed. However, the pathological result presented that it was poorly differentiated and invaded into deep submucosa. Therefore, it was required to manage three tumors with minimal adverse effects; and laparoscopic surgery was considered.

Laparoscopic surgery was performed under general anesthesia, and the patient was placed in the lithotomy position. Pneumoperitoneum was established through a Veress needle which was inserted just above the umbilicus. The intra-abdominal pressure was maintained at the level of 12 mmHg. Then a 10 mm port (Port 1) was introduced at the point about 5 cm under the umbilicus for a 30 degree laparoscopic camera. After abdominal exploration, the patient was turned into lithotomy-anti-Trendelenburg position. The first 12 mm port (Port 2) and the first 5 mm port (Port 3) were introduced below the costal margin at the left and right anterior axillary lines, respectively. The position of Port 3 was a little closer to the foot side than Port 2. Then, another 5 mm port (Port 4) was introduced above umbilicus level at left midclavicular lines. Moreover, one more 5 mm port (Port 5) was introduced under the umbilicus level at the left midclavicular line. These five ports were used to perform the right-side approach laparoscopic distal gastrectomy with D2 lymphadenectomy (Figure 1a). After the separation and dissection of the distal gastrectomy, another 5 mm port (Port 6) was introduced under the umbilicus level at the right midclavicular line. Ports 1, 3, 4, 5, and 6 were used to perform the separation and dissection of right hemicolectomy with D3 lymphadenectomy (Figure 1b). Then a 7 cm midline upper abdominal incision, just above the umbilicus, was made for anastomosis of distal gastrectomy and right hemicolectomy. A disposable wound retractor was used for incision protection. Billroth II reconstruction with 29 mm circular stapler was chosen as the type of gastrointestinal reconstruction, while end-to-side anastomosis with 29 mm circular stapler was the reconstruction type of right hemicolectomy.

Figure 1 
               The steps of laparoscopic surgery for synchronous multiple gastrointestinal cancer. The patient was placed in the lithotomy position. The surgeons’ position and the trocar ports were introduced as shown. (a) The positions for distal gastrectomy; (b) the positions for right hemicolectomy; and (c) the positions for anterior resection of rectum. (d) The position of the incision and ports.
Figure 1

The steps of laparoscopic surgery for synchronous multiple gastrointestinal cancer. The patient was placed in the lithotomy position. The surgeons’ position and the trocar ports were introduced as shown. (a) The positions for distal gastrectomy; (b) the positions for right hemicolectomy; and (c) the positions for anterior resection of rectum. (d) The position of the incision and ports.

Then, the sac wrist of a glove was used to snare the disposable wound retractor. The glove’s thumb was cut off, and a 10 mm port (Port 7) was inserted into the thumb stump (Figure 2). After that, the thumb stump was ligatured by a 1-0 suture. This unit, just like the single port laparoscopy device, was used for the laparoscopic camera inserting and the pneumoperitoneum reestablishing. The patient was turned into lithotomy-trendelenburg position. Another 12 mm port (Port 8) was introduced at McBurney’s point. Thus, Ports 4, 5, 6, 7, and 8 were used to perform the separation and dissection of the anterior resection of rectum (tumor-specific mesorectal excision) (Figure 1c). After stopping the inflation and removing the glove, the incision could be used to perform the anastomosis of the rectum and colon with a 29 mm circular stapler. The gross specimens and microscopic morphologic pictures of three tumors are shown in Figure 3.

Figure 2 
               The unit for the pneumoperitoneum reestablishing and the laparoscopic camera inserting. The sac wrist of a glove was used to snare the disposable wound retractor. The thumb of the glove was cut off, and a 10 mm port was inserted into the thumb stump. Then, the thumb stump was ligatured by a 1-0 suture.
Figure 2

The unit for the pneumoperitoneum reestablishing and the laparoscopic camera inserting. The sac wrist of a glove was used to snare the disposable wound retractor. The thumb of the glove was cut off, and a 10 mm port was inserted into the thumb stump. Then, the thumb stump was ligatured by a 1-0 suture.

Figure 3 
               Gross specimens and microscopic morphologic pictures of three tumors. (a) distal gastrectomy; (b) right hemicolectomy; and (c) anterior resection of rectum.
Figure 3 
               Gross specimens and microscopic morphologic pictures of three tumors. (a) distal gastrectomy; (b) right hemicolectomy; and (c) anterior resection of rectum.
Figure 3

Gross specimens and microscopic morphologic pictures of three tumors. (a) distal gastrectomy; (b) right hemicolectomy; and (c) anterior resection of rectum.

The duration of surgery was 330 min with a blood loss of 200 mL. The only postoperative complication was postoperative ileus. The patient’s first flatus and stool time were on day 4 and 6 after surgery, respectively. Because of distension, enteral feeding remained a low amount before day 7 and increased to about 80% of target needs on day 10 after surgery. Supplement parental nutrition support was started on day 5 and stopped on day 11 after surgery. The patient was discharged and returned home on day 12 with no other complications.

The pathological results revealed stage T1N0M0 gastric adenocarcinoma, stage T3N1M0 adenocarcinoma of the ascending colon, and stage T2N0M0 adenocarcinoma of rectum. And deficient mismatch repair (dMMR) was not found on immunohistochemistry (IHC) testing, which indicated microsatellite stability. The patient received capecitabine and oxaliplatin as postoperative adjuvant chemotherapy. By the time of submission of this manuscript, 1 year after surgery, follow-up CT showed no recurrence, and the patient was capable of general housework.

  1. Ethics approval and consent to participate: This study was approved by the Ethics Committee of Tongji Hospital. Consent for this presentation is obtained from the patient in writing.

  2. Consent for publication: The patient provided written consent for publication of his case details and medical images.

3 Discussion and conclusion

In general, MPT was considered rare and described in case reports [4,8]. The improvement in screening and diagnostic procedures had led to the increasing frequency of MPT [1,9]. Synchronous gastrointestinal MPT was relatively rare. The incidence varied between 1.1 and 3.5% in the population with primary gastrointestinal cancer [7,10,11]. In this report, we presented a patient with synchronous gastric, colonic, and rectal cancer, which was even rare.

For patients with resectable gastric, colonic cancer, as well as stage I and II rectal cancer, the surgical procedure was the first recommendation in clinical guidelines [12,13,14,15,16]. However, a wide incision would be needed if traditional open surgery was performed. And it might lead to a poor prognosis because of severe trauma and postoperative complications. In this report, the patient was overweight, which increased the difficulty of the surgery and the possibility of poor outcomes [17,18]. Now, laparoscopic surgery had been widely used for gastrointestinal cancer. The benefits of minimally invasive surgery in gastrointestinal surgery had been well established. And in many experienced medical centers, similar oncology and safety outcomes are achieved compared to traditional open surgery [19,20,21,22]. The observational study [5] concluded that the most likely reason for unfavorable outcomes was extensive surgery, in which the synchronous colorectal tumors were less often treated by laparoscopy. Therefore, we chose laparoscopic surgery, which was more likely tolerated by the patient.

For three tumors to resect, the steps of the whole surgery should be carefully planned. The gastrectomy and colectomy were relatively clean operations. And during these two operations, the monitor was positioned on the head side of the patient. Additionally, one single incision could be used for reconstruction for both the operations. Therefore, these two operations were performed first. In this case, the unit combined the wound retractor, glove, and the port, which was used for the laparoscopic camera and the pneumoperitoneum reestablishing in proctectomy. This simple unit could be applied in many other conditions in our center, like laparoscopic examination before the abdomen closes. In addition, the reconstruction of rectectomy was more accessible with a circular stapler. The upper abdomen incision could be used to excise the tumor and insert the anvil shaft when about 5 cm more proximal descending colon was dissociated. Hence, rectectomy was performed as the second step. For the reason of longer operative time, we did not choose the total laparoscopic approach. The laparoscopic-assisted approach for resection of three tumors would reduce operative time, leading to less complication and better prognosis [23]. Eventually, with some compromise on the placement of trocar ports and the position of incision, this complex surgery was performed successfully.

In this case, the patient had postoperative ileus as the only complication after the surgery. It might be associated with extensive surgical trauma and postoperative inflammation [24]. The postoperative hospital stay was similar to the time reported in previous studies about gastrointestinal MPT, in which the patients were diagnosed with gastrointestinal synchronous double MPT [7,25]. And the patient received postoperative adjuvant chemotherapy successfully as planned, which also indicated the safety of this surgery.

Lynch syndrome was the common cause of multiple primaries in patients with colon cancer [1,26]. However, it was excluded for the reason that dMMR was not found on IHC testing in this case. It was a limitation that the genetic testing was not performed.

We reported a single case of gastrointestinal triple primary tumors treated by laparoscopic surgery. As long as the surgical procedure details are properly planned and the indications are carefully selected, laparoscopic surgery is safe and feasible as an MPT treatment even in synchronous triple primary gastrointestinal malignant tumors.

Abbreviations

MPT

multiple primary tumors

CT

computerized tomography

dMMR

deficient mismatch repair

IHC

immunohistochemistry

Acknowledgements

Thanks to the members and patient involved in this article.

  1. Funding information: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

  2. Author contributions: The authors that contributed to the study conception and design were W.J. and Z.C. Data acquisition was performed by W.J. and G.Z. The operation was performed by W.J., H.L., X.L., and Z.C. W.J. drafted the manuscript. X.X. and L.J. participated in the correction of the manuscript. All authors read and approved the final manuscript.

  3. Conflict of interest: The authors declare that they have no conflict of interest.

  4. Data availability statement: Data related to this case report will be available upon request if needed.

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Received: 2022-03-23
Revised: 2023-06-06
Accepted: 2023-06-11
Published Online: 2023-07-03

© 2023 the author(s), published by De Gruyter

This work is licensed under the Creative Commons Attribution 4.0 International License.

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  100. Knockdown of circ_0113656 assuages oxidized low-density lipoprotein-induced vascular smooth muscle cell injury through the miR-188-3p/IGF2 pathway
  101. Low Ang-(1–7) and high des-Arg9 bradykinin serum levels are correlated with cardiovascular risk factors in patients with COVID-19
  102. Effect of maternal age and body mass index on induction of labor with oral misoprostol for premature rupture of membrane at term: A retrospective cross-sectional study
  103. Potential protective effects of Huanglian Jiedu Decoction against COVID-19-associated acute kidney injury: A network-based pharmacological and molecular docking study
  104. Clinical significance of serum MBD3 detection in girls with central precocious puberty
  105. Clinical features of varicella-zoster virus caused neurological diseases detected by metagenomic next-generation sequencing
  106. Collagen treatment of complex anorectal fistula: 3 years follow-up
  107. LncRNA CASC15 inhibition relieves renal fibrosis in diabetic nephropathy through down-regulating SP-A by sponging to miR-424
  108. Efficacy analysis of empirical bismuth quadruple therapy, high-dose dual therapy, and resistance gene-based triple therapy as a first-line Helicobacter pylori eradication regimen – An open-label, randomized trial
  109. SMOC2 plays a role in heart failure via regulating TGF-β1/Smad3 pathway-mediated autophagy
  110. A prospective cohort study of the impact of chronic disease on fall injuries in middle-aged and older adults
  111. circRNA THBS1 silencing inhibits the malignant biological behavior of cervical cancer cells via the regulation of miR-543/HMGB2 axis
  112. hsa_circ_0000285 sponging miR-582-3p promotes neuroblastoma progression by regulating the Wnt/β-catenin signaling pathway
  113. Long non-coding RNA GNAS-AS1 knockdown inhibits proliferation and epithelial–mesenchymal transition of lung adenocarcinoma cells via the microRNA-433-3p/Rab3A axis
  114. lncRNA UCA1 regulates miR-132/Lrrfip1 axis to promote vascular smooth muscle cell proliferation
  115. Twenty-four-color full spectrum flow cytometry panel for minimal residual disease detection in acute myeloid leukemia
  116. Hsa-miR-223-3p participates in the process of anthracycline-induced cardiomyocyte damage by regulating NFIA gene
  117. Anti-inflammatory effect of ApoE23 on Salmonella typhimurium-induced sepsis in mice
  118. Analysis of somatic mutations and key driving factors of cervical cancer progression
  119. Hsa_circ_0028007 regulates the progression of nasopharyngeal carcinoma through the miR-1179/SQLE axis
  120. Variations in sexual function after laparoendoscopic single-site hysterectomy in women with benign gynecologic diseases
  121. Effects of pharmacological delay with roxadustat on multi-territory perforator flap survival in rats
  122. Analysis of heroin effects on calcium channels in rat cardiomyocytes based on transcriptomics and metabolomics
  123. Risk factors of recurrent bacterial vaginosis among women of reproductive age: A cross-sectional study
  124. Alkbh5 plays indispensable roles in maintaining self-renewal of hematopoietic stem cells
  125. Study to compare the effect of casirivimab and imdevimab, remdesivir, and favipiravir on progression and multi-organ function of hospitalized COVID-19 patients
  126. Correlation between microvessel maturity and ISUP grades assessed using contrast-enhanced transrectal ultrasonography in prostate cancer
  127. The protective effect of caffeic acid phenethyl ester in the nephrotoxicity induced by α-cypermethrin
  128. Norepinephrine alleviates cyclosporin A-induced nephrotoxicity by enhancing the expression of SFRP1
  129. Effect of RUNX1/FOXP3 axis on apoptosis of T and B lymphocytes and immunosuppression in sepsis
  130. The function of Foxp1 represses β-adrenergic receptor transcription in the occurrence and development of bladder cancer through STAT3 activity
  131. Risk model and validation of carbapenem-resistant Klebsiella pneumoniae infection in patients with cerebrovascular disease in the ICU
  132. Calycosin protects against chronic prostatitis in rats via inhibition of the p38MAPK/NF-κB pathway
  133. Pan-cancer analysis of the PDE4DIP gene with potential prognostic and immunotherapeutic values in multiple cancers including acute myeloid leukemia
  134. The safety and immunogenicity to inactivated COVID-19 vaccine in patients with hyperlipemia
  135. Circ-UBR4 regulates the proliferation, migration, inflammation, and apoptosis in ox-LDL-induced vascular smooth muscle cells via miR-515-5p/IGF2 axis
  136. Clinical characteristics of current COVID-19 rehabilitation outpatients in China
  137. Luteolin alleviates ulcerative colitis in rats via regulating immune response, oxidative stress, and metabolic profiling
  138. miR-199a-5p inhibits aortic valve calcification by targeting ATF6 and GRP78 in valve interstitial cells
  139. The application of iliac fascia space block combined with esketamine intravenous general anesthesia in PFNA surgery of the elderly: A prospective, single-center, controlled trial
  140. Elevated blood acetoacetate levels reduce major adverse cardiac and cerebrovascular events risk in acute myocardial infarction
  141. The effects of progesterone on the healing of obstetric anal sphincter damage in female rats
  142. Identification of cuproptosis-related genes for predicting the development of prostate cancer
  143. Lumican silencing ameliorates β-glycerophosphate-mediated vascular smooth muscle cell calcification by attenuating the inhibition of APOB on KIF2C activity
  144. Targeting PTBP1 blocks glutamine metabolism to improve the cisplatin sensitivity of hepatocarcinoma cells through modulating the mRNA stability of glutaminase
  145. A single center prospective study: Influences of different hip flexion angles on the measurement of lumbar spine bone mineral density by dual energy X-ray absorptiometry
  146. Clinical analysis of AN69ST membrane continuous venous hemofiltration in the treatment of severe sepsis
  147. Antibiotics therapy combined with probiotics administered intravaginally for the treatment of bacterial vaginosis: A systematic review and meta-analysis
  148. Construction of a ceRNA network to reveal a vascular invasion associated prognostic model in hepatocellular carcinoma
  149. A pan-cancer analysis of STAT3 expression and genetic alterations in human tumors
  150. A prognostic signature based on seven T-cell-related cell clustering genes in bladder urothelial carcinoma
  151. Pepsin concentration in oral lavage fluid of rabbit reflux model constructed by dilating the lower esophageal sphincter
  152. The antihypertensive felodipine shows synergistic activity with immune checkpoint blockade and inhibits tumor growth via NFAT1 in LUSC
  153. Tanshinone IIA attenuates valvular interstitial cells’ calcification induced by oxidized low density lipoprotein via reducing endoplasmic reticulum stress
  154. AS-IV enhances the antitumor effects of propofol in NSCLC cells by inhibiting autophagy
  155. Establishment of two oxaliplatin-resistant gallbladder cancer cell lines and comprehensive analysis of dysregulated genes
  156. Trial protocol: Feasibility of neuromodulation with connectivity-guided intermittent theta-burst stimulation for improving cognition in multiple sclerosis
  157. LncRNA LINC00592 mediates the promoter methylation of WIF1 to promote the development of bladder cancer
  158. Factors associated with gastrointestinal dysmotility in critically ill patients
  159. Mechanisms by which spinal cord stimulation intervenes in atrial fibrillation: The involvement of the endothelin-1 and nerve growth factor/p75NTR pathways
  160. Analysis of two-gene signatures and related drugs in small-cell lung cancer by bioinformatics
  161. Silencing USP19 alleviates cigarette smoke extract-induced mitochondrial dysfunction in BEAS-2B cells by targeting FUNDC1
  162. Menstrual irregularities associated with COVID-19 vaccines among women in Saudi Arabia: A survey during 2022
  163. Ferroptosis involves in Schwann cell death in diabetic peripheral neuropathy
  164. The effect of AQP4 on tau protein aggregation in neurodegeneration and persistent neuroinflammation after cerebral microinfarcts
  165. Activation of UBEC2 by transcription factor MYBL2 affects DNA damage and promotes gastric cancer progression and cisplatin resistance
  166. Analysis of clinical characteristics in proximal and distal reflux monitoring among patients with gastroesophageal reflux disease
  167. Exosomal circ-0020887 and circ-0009590 as novel biomarkers for the diagnosis and prediction of short-term adverse cardiovascular outcomes in STEMI patients
  168. Upregulated microRNA-429 confers endometrial stromal cell dysfunction by targeting HIF1AN and regulating the HIF1A/VEGF pathway
  169. Bibliometrics and knowledge map analysis of ultrasound-guided regional anesthesia
  170. Knockdown of NUPR1 inhibits angiogenesis in lung cancer through IRE1/XBP1 and PERK/eIF2α/ATF4 signaling pathways
  171. D-dimer trends predict COVID-19 patient’s prognosis: A retrospective chart review study
  172. WTAP affects intracranial aneurysm progression by regulating m6A methylation modification
  173. Using of endoscopic polypectomy in patients with diagnosed malignant colorectal polyp – The cross-sectional clinical study
  174. Anti-S100A4 antibody administration alleviates bronchial epithelial–mesenchymal transition in asthmatic mice
  175. Prognostic evaluation of system immune-inflammatory index and prognostic nutritional index in double expressor diffuse large B-cell lymphoma
  176. Prevalence and antibiogram of bacteria causing urinary tract infection among patients with chronic kidney disease
  177. Reactive oxygen species within the vaginal space: An additional promoter of cervical intraepithelial neoplasia and uterine cervical cancer development?
  178. Identification of disulfidptosis-related genes and immune infiltration in lower-grade glioma
  179. A new technique for uterine-preserving pelvic organ prolapse surgery: Laparoscopic rectus abdominis hysteropexy for uterine prolapse by comparing with traditional techniques
  180. Self-isolation of an Italian long-term care facility during COVID-19 pandemic: A comparison study on care-related infectious episodes
  181. A comparative study on the overlapping effects of clinically applicable therapeutic interventions in patients with central nervous system damage
  182. Low intensity extracorporeal shockwave therapy for chronic pelvic pain syndrome: Long-term follow-up
  183. The diagnostic accuracy of touch imprint cytology for sentinel lymph node metastases of breast cancer: An up-to-date meta-analysis of 4,073 patients
  184. Mortality associated with Sjögren’s syndrome in the United States in the 1999–2020 period: A multiple cause-of-death study
  185. CircMMP11 as a prognostic biomarker mediates miR-361-3p/HMGB1 axis to accelerate malignant progression of hepatocellular carcinoma
  186. Analysis of the clinical characteristics and prognosis of adult de novo acute myeloid leukemia (none APL) with PTPN11 mutations
  187. KMT2A maintains stemness of gastric cancer cells through regulating Wnt/β-catenin signaling-activated transcriptional factor KLF11
  188. Evaluation of placental oxygenation by near-infrared spectroscopy in relation to ultrasound maturation grade in physiological term pregnancies
  189. The role of ultrasonographic findings for PIK3CA-mutated, hormone receptor-positive, human epidermal growth factor receptor-2-negative breast cancer
  190. Construction of immunogenic cell death-related molecular subtypes and prognostic signature in colorectal cancer
  191. Long-term prognostic value of high-sensitivity cardiac troponin-I in patients with idiopathic dilated cardiomyopathy
  192. Establishing a novel Fanconi anemia signaling pathway-associated prognostic model and tumor clustering for pediatric acute myeloid leukemia patients
  193. Integrative bioinformatics analysis reveals STAT2 as a novel biomarker of inflammation-related cardiac dysfunction in atrial fibrillation
  194. Adipose-derived stem cells repair radiation-induced chronic lung injury via inhibiting TGF-β1/Smad 3 signaling pathway
  195. Real-world practice of idiopathic pulmonary fibrosis: Results from a 2000–2016 cohort
  196. lncRNA LENGA sponges miR-378 to promote myocardial fibrosis in atrial fibrillation
  197. Diagnostic value of urinary Tamm-Horsfall protein and 24 h urine osmolality for recurrent calcium oxalate stones of the upper urinary tract: Cross-sectional study
  198. The value of color Doppler ultrasonography combined with serum tumor markers in differential diagnosis of gastric stromal tumor and gastric cancer
  199. The spike protein of SARS-CoV-2 induces inflammation and EMT of lung epithelial cells and fibroblasts through the upregulation of GADD45A
  200. Mycophenolate mofetil versus cyclophosphamide plus in patients with connective tissue disease-associated interstitial lung disease: Efficacy and safety analysis
  201. MiR-1278 targets CALD1 and suppresses the progression of gastric cancer via the MAPK pathway
  202. Metabolomic analysis of serum short-chain fatty acid concentrations in a mouse of MPTP-induced Parkinson’s disease after dietary supplementation with branched-chain amino acids
  203. Cimifugin inhibits adipogenesis and TNF-α-induced insulin resistance in 3T3-L1 cells
  204. Predictors of gastrointestinal complaints in patients on metformin therapy
  205. Prescribing patterns in patients with chronic obstructive pulmonary disease and atrial fibrillation
  206. A retrospective analysis of the effect of latent tuberculosis infection on clinical pregnancy outcomes of in vitro fertilization–fresh embryo transferred in infertile women
  207. Appropriateness and clinical outcomes of short sustained low-efficiency dialysis: A national experience
  208. miR-29 regulates metabolism by inhibiting JNK-1 expression in non-obese patients with type 2 diabetes mellitus and NAFLD
  209. Clinical features and management of lymphoepithelial cyst
  210. Serum VEGF, high-sensitivity CRP, and cystatin-C assist in the diagnosis of type 2 diabetic retinopathy complicated with hyperuricemia
  211. ENPP1 ameliorates vascular calcification via inhibiting the osteogenic transformation of VSMCs and generating PPi
  212. Significance of monitoring the levels of thyroid hormone antibodies and glucose and lipid metabolism antibodies in patients suffer from type 2 diabetes
  213. The causal relationship between immune cells and different kidney diseases: A Mendelian randomization study
  214. Interleukin 33, soluble suppression of tumorigenicity 2, interleukin 27, and galectin 3 as predictors for outcome in patients admitted to intensive care units
  215. Identification of diagnostic immune-related gene biomarkers for predicting heart failure after acute myocardial infarction
  216. Long-term administration of probiotics prevents gastrointestinal mucosal barrier dysfunction in septic mice partly by upregulating the 5-HT degradation pathway
  217. miR-192 inhibits the activation of hepatic stellate cells by targeting Rictor
  218. Diagnostic and prognostic value of MR-pro ADM, procalcitonin, and copeptin in sepsis
  219. Review Articles
  220. Prenatal diagnosis of fetal defects and its implications on the delivery mode
  221. Electromagnetic fields exposure on fetal and childhood abnormalities: Systematic review and meta-analysis
  222. Characteristics of antibiotic resistance mechanisms and genes of Klebsiella pneumoniae
  223. Saddle pulmonary embolism in the setting of COVID-19 infection: A systematic review of case reports and case series
  224. Vitamin C and epigenetics: A short physiological overview
  225. Ebselen: A promising therapy protecting cardiomyocytes from excess iron in iron-overloaded thalassemia patients
  226. Aspirin versus LMWH for VTE prophylaxis after orthopedic surgery
  227. Mechanism of rhubarb in the treatment of hyperlipidemia: A recent review
  228. Surgical management and outcomes of traumatic global brachial plexus injury: A concise review and our center approach
  229. The progress of autoimmune hepatitis research and future challenges
  230. METTL16 in human diseases: What should we do next?
  231. New insights into the prevention of ureteral stents encrustation
  232. VISTA as a prospective immune checkpoint in gynecological malignant tumors: A review of the literature
  233. Case Reports
  234. Mycobacterium xenopi infection of the kidney and lymph nodes: A case report
  235. Genetic mutation of SLC6A20 (c.1072T > C) in a family with nephrolithiasis: A case report
  236. Chronic hepatitis B complicated with secondary hemochromatosis was cured clinically: A case report
  237. Liver abscess complicated with multiple organ invasive infection caused by hematogenous disseminated hypervirulent Klebsiella pneumoniae: A case report
  238. Urokinase-based lock solutions for catheter salvage: A case of an upcoming kidney transplant recipient
  239. Two case reports of maturity-onset diabetes of the young type 3 caused by the hepatocyte nuclear factor 1α gene mutation
  240. Immune checkpoint inhibitor-related pancreatitis: What is known and what is not
  241. Does total hip arthroplasty result in intercostal nerve injury? A case report and literature review
  242. Clinicopathological characteristics and diagnosis of hepatic sinusoidal obstruction syndrome caused by Tusanqi – Case report and literature review
  243. Synchronous triple primary gastrointestinal malignant tumors treated with laparoscopic surgery: A case report
  244. CT-guided percutaneous microwave ablation combined with bone cement injection for the treatment of transverse metastases: A case report
  245. Malignant hyperthermia: Report on a successful rescue of a case with the highest temperature of 44.2°C
  246. Anesthetic management of fetal pulmonary valvuloplasty: A case report
  247. Rapid Communication
  248. Impact of COVID-19 lockdown on glycemic levels during pregnancy: A retrospective analysis
  249. Erratum
  250. Erratum to “Inhibition of miR-21 improves pulmonary vascular responses in bronchopulmonary dysplasia by targeting the DDAH1/ADMA/NO pathway”
  251. Erratum to: “Fer exacerbates renal fibrosis and can be targeted by miR-29c-3p”
  252. Retraction
  253. Retraction of “Study to compare the effect of casirivimab and imdevimab, remdesivir, and favipiravir on progression and multi-organ function of hospitalized COVID-19 patients”
  254. Retraction of “circ_0062491 alleviates periodontitis via the miR-142-5p/IGF1 axis”
  255. Retraction of “miR-223-3p alleviates TGF-β-induced epithelial-mesenchymal transition and extracellular matrix deposition by targeting SP3 in endometrial epithelial cells”
  256. Retraction of “SLCO4A1-AS1 mediates pancreatic cancer development via miR-4673/KIF21B axis”
  257. Retraction of “circRNA_0001679/miR-338-3p/DUSP16 axis aggravates acute lung injury”
  258. Retraction of “lncRNA ACTA2-AS1 inhibits malignant phenotypes of gastric cancer cells”
  259. Special issue Linking Pathobiological Mechanisms to Clinical Application for cardiovascular diseases
  260. Effect of cardiac rehabilitation therapy on depressed patients with cardiac insufficiency after cardiac surgery
  261. Special issue The evolving saga of RNAs from bench to bedside - Part I
  262. FBLIM1 mRNA is a novel prognostic biomarker and is associated with immune infiltrates in glioma
  263. Special Issue Computational Intelligence Methodologies Meets Recurrent Cancers - Part III
  264. Development of a machine learning-based signature utilizing inflammatory response genes for predicting prognosis and immune microenvironment in ovarian cancer
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