Evolution Of Metastases In Space And Time Under Immune Selection Pdf

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evolution of metastases in space and time under immune selection pdf

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Swarm intelligence SI is the collective behavior of decentralized , self-organized systems, natural or artificial.

How to look after your mental health using exercise

Treatment of solid tumors by ablation techniques has gained momentum in the recent years due to their technical simplicity and reduced morbidity as juxtaposed to surgery. Cryoablation is one of such techniques, known for its uniqueness to destroy the tumors by freezing to lethal temperatures. Freezing the tumor locally and allowing it to remain in situ unleashes an array of tumor antigens to be exposed to the immune system, paving the way for the generation of anti-tumor immune responses.

However, the immune responses triggered in most cases are insufficient to eradicate the tumors with systemic spread. Therefore, combination of cryoablation and immunotherapy is a new treatment strategy currently being evaluated for its efficacy, notably in patients with metastatic disease.

This article examines the mechanistic fabric of cryoablation for the generation of an effective immune response against the tumors, and various possibilities of its combination with different immunotherapies that are capable of inducing exceptional therapeutic responses.

The combinatorial treatment avenues discussed in this article if explored in sufficient profundity, could reach the pinnacle of future cancer medicine. Percutaneous image-guided ablation techniques are playing an increasing role in the management of patients with solid cancers. The minimally invasive nature of percutaneous ablations together with their proven antitumor efficacy have gained a wide acceptance in the medical community. In fact, percutaneous ablations have demonstrated to be analogous to surgery in achieving total eradication of small tumors with the added advantage of decreased morbidity 1 , 2.

While surgical resection extirpates the tumor, ablative therapies yield tumor cell death in situ. This unique feature offers a therapeutic opportunity as it uncovers to the immune system previously shielded tumor antigens.

Indeed, the immunomodulatory abilities of percutaneous ablation therapies could be used as in vivo vaccination tools, and combinatorial approaches with immunotherapy could be beneficial for patients with widespread disease. Commonly employed ablation therapies in the clinical setting are radiofrequency ablation RFA , microwave ablation, high-intensity focused ultrasound and cryoablation.

All these treatments operate on the principle of hyperthermia with the exception of cryoablation, which is a hypothermic modality that induces tissue damage by a freeze-thaw process. Of all the ablation techniques, cryoablation demonstrated the highest potential to elicit post-ablative immunogenic response. Chapman et al. In contrast, these lesions were not observed in the rats subjected to hepatic RFA.

In a subsequent clinical study on tumors treated with cryoablation or RFA or microwave ablation, patients treated with cryoablation exhibited significantly elevated plasma IL-6 levels as compared to patients that received RFA or microwave ablation 5.

This could be explained by the fact that heat-based therapies can cause protein denaturation, reducing the availability of intact immunogenic antigens, which can be circumvented by cryoablation, as demonstrated by a recent study employing Fourier-transform infrared spectroscopy 6.

Cryoablation refers to the technique of ablating the tissue by freezing to lethal temperatures followed by thawing, causing extensive tissue destruction.

This technique is widely used to treat benign and malignant primary tumors 7 , 8. Although the use of cold temperatures to treat wounds dates back to B. He successfully attempted the usage of cold temperatures by salt and ice solutions for the generation of local numbness prior surgical operations, as a replacement for chloroform inhalation. He reported that the freezing temperatures not only acted as a local anesthetic, but also impaired cancer cell viability that translated into patient's extended survival, and suggested cryoablation as an attractive therapeutic option for treating local tumors 9 , In s, William Pusey started using liquid CO 2 under high pressure, which upon release and expansion at the atmospheric pressure resulted in cooling effect and the subsequent formation of ice crystals This is famously known as the Joule-Thomson effect, the principle underlying all the modern techniques of cryoablation.

Around the same time, Irvine and Turnacliffe utilized liquid air and liquid oxygen to achieve the same effect. These three liquid gases were mostly employed to treat skin conditions like lesions, warts and keratosis In , Allington replaced the above gases with liquid N 2 for the treatment of various skin diseases Rowbotham et al.

The major disadvantage with this technique is the non-insulation of the cannula, and therefore, passing a freezing agent through the inserted cannula not only caused a temperature drop in the targeted tumor, but also along the inserted tissue path. Later, Irving Cooper and Arnold Lee published landmark studies in the early s that laid the foundation for current cryoablation technologies. Later, many others used this technology to treat benign and malignant tumors successfully in patients.

Gage et al. Intriguingly, none of the patients treated with cryoablation showed local tumor recurrence. Modern cryoablation devices have replaced liquid N 2 by an inert argon gas that produces the same effect 14 — 16 , due to its associated technical advantages of easier handling and operation 9. This review article summarizes the key cellular events and factors influencing the effectiveness of cryoablation, and discusses the potential combinatorial approaches of cryoablation with different forms of immunotherapy.

Freezing rate is one of the most important factors that determines the kinetics and scope of tissue damage. At low freezing rates, solvents in extracellular spaces form ice crystals, leading to intracellular fluid loss as a compensatory mechanism for the osmotic imbalance across the cell membrane This eventually leads to cell shrinkage, followed by damage to cell membranes and organelles due to the increased intracellular solute concentrations Figure 1 At high freezing rates, intracellular ice formation ensues the formation of extracellular crystals, because the cell does not have enough time to lose the solvent like above This results in severe physical damage to cell membranes and intracellular organelles leading to cell death Therefore, the faster the freezing the higher the level of intracellular ice formation, and the greater is the causation of cryolesion and tissue damage 7 , 15 , 17 , 19 , The cells in close proximity to the cryoprobe undergo rapid freezing rates, whereas the cells in the periphery of the ablation zone are likely to undergo moderate or low freezing rates 7.

Figure 1. Mechanisms of cell death and immunologic responses induced by cryoablation. A Cells in the core of the ablation zone are subjected to lethal temperatures at rapid freezing rates, resulting in the generation of extra and intracellular ice crystals. Cells adjacent to the core zone undergo moderate or low freezing rates. This permits the cells to lose intracellular water by exosmosis in response to the formation of extracellular ice crystals resulting in cellular dehydration and shrinkage.

In contrast, cells in the core zone cannot undergo exosmosis due to rapid freezing rates and thus, form intracellular crystals. Both intra and extracellular ice crystals cause mechanical damage to the cells.

B During the thawing phase, the small intracellular ice crystals, due to their thermodynamic instability, fuse to form larger intracellular crystals re-crystallization that enhances the mechanical damage to the cell membranes and intracellular organelles. C Post-thawing, mechanically damaged cells die by necrosis and release their contents into the surrounding milieu.

Cells that have undergone exosmosis swell and burst due to osmotic shock. Cells in the utmost periphery of the ablation zone exposed to sub-lethal temperatures undergo apoptosis, releasing apoptotic bodies.

Antigens released from necrotic cells upon uptake by antigen presenting cells like DCs, induce co-stimulatory signals that would result in the generation of anti-tumoral T-cell responses. In contrast, antigen uptake by DCs in the form of apoptotic bodies imprints immune tolerance or anergy on T-cells due to the non-induction of co-stimulatory signals on DCs. DC, Dendritic cell. Different cell types undergo freezing at different temperatures, due to the variations in their intracellular solute compositions.

The ideal duration of freezing is not defined, as the requirements vary based on the tissue type, vascularization, and the volume of the tissue to be frozen 7 , Duration of freeze should be evaluated in a manner that ensures the maximal freezing of the tumor tissue while sparring the surrounding normal tissue.

Upon thawing, the extracellular ice melts and causes local hypotonicity in relation to the dehydrated hypertonic intracellular environment. This leads to a high influx of solvent into the intracellular space, causing the previously dehydrated cells to swell and burst, releasing their intracellular contents into the surrounding milieu. At rapid cooling rates, the ice crystals formed are small and thermodynamically unstable; upon thawing, these small ice crystals fuse to form large crystals, a process known as re-crystallization Figure 1.

Large intra- and extracellular crystals thus formed cause severe mechanical damage to the lipid cell membranes. The slower the thawing, the higher the time for re-crystallization, and thus, greater the cellular damage by necrosis 7 , The volume of tissue necrosis is directly proportional to the number of freeze-thaw cycles The tissue that is already damaged in the first cycle of freeze-thaw goes through a faster cooling rate in the second cycle.

In addition, there is also an increased formation of intracellular ice crystals in the additional cycle, all contributing to the severity of cell damage.

Most studies employ two or more freeze-thaw cycles 7 , 22 , 24 , However, an increase in the number of freeze-thaw cycles and the proportional increase in tissue damage does not always translate into improved survival The cells in the core of ablation zone that die by osmotic shock or physical damage by ice crystals die by necrosis, releasing their intracellular contents into the extracellular space, triggering an active immune response. In contrast, cells in the periphery of ablation zone subjected to sub-lethal temperatures die by a mitochondrial mediated apoptosis pathway 27 , The balance between immunogenic necrosis and immune tolerant apoptosis is one of the key factors that decides the course of an immune response induced by cryoablation Figure 1.

Freeze-thaw process also causes damage to the endothelial cells of the vasculature, leading to platelet activation, aggregation, thrombosis, and ischemia. This damage also causes edema, vasodilation, and hyperemia 7 , 18 , 27 , There were reports in the s of isolated cases having spontaneous regression of metastases upon cryoablation of primary prostate tumors.

Results suggested that the regression could be immune mediated 29 — Experiments with preclinical models bearing tumors treated by cryoablation exhibited an impressive resistance to tumor re-challenge 33 — This enhanced protection was tumor-specific, as the survived mice were completely susceptible to re-challenge with an unrelated tumor cell line. These results provided a substantial evidence of immune-mediated protective responses evoked by cryoablation of tumors.

Den Brok et al. This suggests that the ablated tumor tissue needs to remain in situ , where the tumor antigens will be available for the generation of an anti-tumor immune response A study report of patients that underwent cryoablation for hepatic tumors exhibited increased levels of serum IL-6, serum amyloid A and C-reactive protein.

Interestingly, the latter group had increased levels of systemic IL, indicative of a Th2 response Taken together, above data point out to the fact that tumor cryoablation can trigger a tumor-specific protective immune response.

However, the magnitude and sustainability of this immune response may not be adequate to protect from tumor re-challenge or exert an abscopal regression of distant metastases. In addition, tumors have developed sophisticated immune suppressive mechanisms to evade the host's immune attack 40 — Therefore, synergy of cryoablation and immunotherapy to modulate and revert immunosuppressive responses presents a fascinating opportunity to treat cancer, in particular, for advanced metastatic cancer patients.

TLRs are primarily expressed on innate immune cells like neutrophils, macrophages and dendritic cells DCs , although expression on other cells has also been detected.

These receptors recognize microbial-associated molecular patterns derived from microbiota and pathogens, and danger-associated molecular patterns derived from damaged and necrotic cells 43 , Each TLR has its own specific set of ligands; cell surface TLRs recognize lipids, proteins and lipoproteins, whereas intracellular TLRs recognize nucleic acid material.

The resultant of these signaling pathways is the production of type-1 interferons or other inflammatory mediators, initiating an immune response TLR agonist treatment with cryoablation in experimental tumor models has shown substantial improvements in survival and anti-tumor immune responses. Mice bearing less immunogenic BF10 tumors treated with cryoablation failed to survive tumor re-challenge.

Thus, TLR agonists can be employed as powerful adjuvants along with cryoablation in order to generate an effective antitumor immunity. Pro and anti-tumorigenic effects of each TLR on the specific cancer type targeted should also be taken into consideration for the selection of TLR agonists DCs are scattered across the body and act as a bridge between innate and adaptive immune responses.

Looking backward in time to define the chronology of metastasis

Clinical indications for epidural anesthesia and analgesia have expanded significantly over the past several decades. In addition, epidural techniques are used increasingly for diagnostic procedures, acute pain therapy, and management of chronic pain. Epidural blockade may also reduce the surgical stress response, the risk of cancer recurrence, the incidence of perioperative thromboembolic events, and, possibly, the morbidity and mortality associated with major surgery. This chapter covers the essentials of epidural anesthesia and analgesia. After a brief history of the transformation from single-shot to continuous epidural catheter techniques, it reviews 1 indications for and contraindications to epidural blockade; 2 basic anatomic considerations for epidural placement; 3 physiologic effects of epidural blockade; 4 pharmacology of drugs used for epidural anesthesia and analgesia; 5 techniques for successful epidural placement; and 6 major and minor complications associated with epidural blockade. This chapter also addresses several areas of controversy concerning epidural techniques.

Graeme Eisenhofer, David S. Brouwers, Edwin W. Lai, Karen T. Measurements of plasma-free normetanephrine and metanephrine provide a sensitive test for diagnosis of pheochromocytoma but may fail to detect tumors that produce predominantly dopamine. Such tumors are extremely rare, usually found as extraadrenal paragangliomas. This report describes measurements of plasma concentrations of free methoxytyramine, the O-methylated metabolite of dopamine, in patients with catecholamine-producing tumors, including nine with extraadrenal paragangliomas secreting predominantly dopamine. In seven of these nine patients, tumors were found incidentally or secondary to the space-occupying complications of the lesions.

Thank you for visiting nature. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser or turn off compatibility mode in Internet Explorer. In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript. The timing of cancer metastasis has implications for treatment and prevention.

Cryoablation and Immunotherapy: An Enthralling Synergy to Confront the Tumors

Treatment of solid tumors by ablation techniques has gained momentum in the recent years due to their technical simplicity and reduced morbidity as juxtaposed to surgery. Cryoablation is one of such techniques, known for its uniqueness to destroy the tumors by freezing to lethal temperatures. Freezing the tumor locally and allowing it to remain in situ unleashes an array of tumor antigens to be exposed to the immune system, paving the way for the generation of anti-tumor immune responses.

Roles of the immune system in cancer: from tumor initiation to metastatic progression

The presence of inflammatory immune cells in human tumors raises a fundamental question in oncology: How do cancer cells avoid the destruction by immune attack? In principle, tumor development can be controlled by cytotoxic innate and adaptive immune cells; however, as the tumor develops from neoplastic tissue to clinically detectable tumors, cancer cells evolve different mechanisms that mimic peripheral immune tolerance in order to avoid tumoricidal attack.


Иначе Танкадо не отдал бы ключ. Какой идиот станет делать на кольце надпись из произвольных букв. Фонтейн свирепым взглядом заставил его замолчать. - Вы меня слышите? - вмешался Беккер, чувствуя себя неловко.  - Вы все время говорите о произвольном наборе букв. Мне кажется, я должен вам сказать… что это не случайный набор букв.

Epidural Anesthesia and Analgesia

ГЛАВА 126 - Одна минута. Джабба посмотрел на ВР. Стремительно исчезал уровень авторизации файлов - последняя линия обороны.


  1. Tecla V. 15.04.2021 at 23:49

    Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

  2. Ethel B. 18.04.2021 at 15:50

    We examined how the immune microenvironment molds tumor evolution at different metastatic organs in a longitudinal dataset of colorectal.