To evaluate the usefulness of the apparent diffusion coefficient (ADC) in differentiating between benign and malignant LR-3 lesions classified by Liver Imaging Reporting and Data System 2018 (LI-RADS v2018).Retrospectively analyzed 88 patients with liver nodules confirmed by pathology and classified as LR-3 by LI-RADS. All patients underwent preoperative contrast-enhanced MR examination, and the following patient-related imaging features were collected: tumor size,nonrim APHE, nonperipheral “washout”, enhancing “capsule”, mild-moderate T2 hyperintensity, fat in mass, restricted diffusion, and nodule-in-nodule architecture. We performed ROC analysis and calculated the sensitivity and specificity.3 mm2/s and 1.41 ± 0.31 × 103 mm2/s, respectively. The ADC value of malignant lesions was significantly lower than that of benign lesions, p < 0.0001. Compared with other imaging features, ADC values had the highest AUC (AUC = 0.909), with a sensitivity of 92.6% and a specificity of 74.1% for the differentiation of benign and malignant lesions.A total of 122 lesions were found in 88 patients, with 68 benign and 54 malignant lesions. The mean ADC value for malignant and benign lesions were 1.01 ± 0.15 × 10ADC values are useful for differentiating between benign and malignant liver nodules in LR-3 classification, it improves the sensitivity of LI-RADS in the diagnosis of HCC while maintaining high specificity, and we recommend including ADC values in the standard interpretation of LI-RADSv2018. Early dThe American College of Radiology proposed the 2018 version of the Liver Imaging Reporting and Data System (LI-RADS v2018) as an interpretation and classification of liver observations in patients at high risk for HCC to reflect the risk of benign, malignant tumors, or HCC –6, with Diffusion-weighted imaging (DWI) is a functional technique used to assess cellularity based on motion restriction of water molecules. DWI is currently the standard sequence for liver MR examination and is effective in detecting small liver lesions, including HCC. Compared with the surrounding liver parenchyma, HCC on DWI showed mild-to-moderate hyperintensities, which contributed to the diagnosis of HCC < 1 cm , 16. TheTherefore, this study focuses on whether ADC values can improve the malignant detection rate of LI-RADS v2018 classification as LR-3 nodules.22.1This retrospective study was approved by the institutional review committee and the requirement for written informed consent was waived.From January 2020 to December 2021, a total of 1528 patients who underwent magnetic resonance imaging (MRI) and had high risk factors for HCC were identified, of whom 593 were confirmed by surgical pathology or biopsy. The MRI, clinical and histopathological data of the patients were reviewed.The inclusion criteria were: (1) meeting the LI-RADS diagnostic criteria for the study population, including patients with cirrhosis, chronic hepatitis B infection, and previous HCC; (2) having confirmation by surgical pathology or biopsy; (3) patients underwent liver MRI enhancement and DWI scans within 1 month before surgery; and (4) having focal liver lesions classified as LR-3 lesions according to the 2018 version of the LI-RADS criteria. The exclusion criteria were: (1) previous treatment for intrahepatic lesions before undergoing MRI; (2) poor image quality precluding analysis; and (3) lack of ADC imaging  When the nodule diameter is < 20 mm, no arterial phase enhancement (APHE), and no or only one major features ; (2) When the nodule diameter is ≥ 20 mm, no APHE, and no other major features; (3) When the nodule diameter is < 20 mm, nonrim APHE,and no other major features.(Threshold growth definition was simplified to: ≥ 50% size increase of a mass in ≤ 6 months) (2.32/s), breath-hold axial in-phase and out-of-phase T1-weighted LAVA-Flex sequences. and fat-saturated T1-weighted LAVA-Flex sequences acquired during the postcontrast dynamic  before (noncontrast) and after contrast administration. Contrast-enhanced images were acquired following gadopentetate dimeglumine (Gd-DTPA) administration at a dose of 0.1 mmol/kg body weight. Contrast medium was injected at 2.0 mL/s using a double-headed bolus electric syringe , and arterial, portal, and delayed phase images were collected at 30 s, 60 s, and 180 s after contrast agent injection. Detailed MRI parameters are shown in Liver MRI was performed on a GE Discovery MR 750 3.0T imaging scanner. Patient fasted for 4-6 hours and were instructed to avoid deep breathing during the examination. Conventional liver MRI protocols for all patients included an axial respiratory-triggered fat-saturated T2-weighted fast spin echo sequence, respiratory-triggered diffusion-weighted imaging  in liver nodules. Each lesion was measured three times, and the ADC values were then averaged. The measurements were taken from equal areas of the lesions while excluding adjacent liver parenchyma.In addition, two physicians assessed the main features of imaging diagnosis and other auciliary features of HCC as defined in LI-RADS v2018, Major HCC features: (a) tumor size :Largest outer-edge-to-outer-edge dimension of an observation; (b) nonrim arterial phase enhancement (APHE): Nonrim-like enhancement in arterial phase unequivocally greater in whole or in part than liver. Enhancing part must be higher in attenuation or intensity than liver in arterial phase; (c) nonperipheral “washout”:Nonperipheral visually assessed temporal reduction in enhancement in whole or in part relative to composite liver tissue from earlier to later phase resulting in hypoenhancement in the extracellular phase; (d)enhancing “capsule”:Smooth, uniform, sharp border around most or all of an observation, unequivocally thicker or more conspicuous than fibrotic tissue around background nodules, and visible enhancing rim in PVP, DP, or TP. Ancillary features: (a)mild-moderate T2 hyperintensity:Intensity on T2WI mildly or moderately higher than liver and similar to or less than non-iron-overloaded spleen; (b) restricted diffusion: Intensity on DWI, not attributable solely to T2 shine-through, unequivocally higher than liver and/or ADC unequivocally lower than liver; (c)fat in mass: Excess fat within a mass, in whole or in part, relative to adjacent liver; (d) nodule-in-nodule architecture: Presence of smaller inner nodule within and having different imaging features than larger outer nodule. The definition could be found in 2.5p-value less than 0.05 was considered statistically significant. Delong test verified the difference between ADC values and AUC values of other auxiliary features, and P < 0.05 indicated statistical significance.SPSS 22.0 statistical software was utilized for data analysis. Mean and standard deviation of ADC values were computed and independent samples t-test was used to determine if ADC values could differentiate malignant from benign nodules in the LR-3 classification. ROC curve analysis was used to compare ADC values, Major HCC features, and ancillary features, to determine the area under the ROC curve (AUC), and to analyze sensitivity and specificity for HCC diagnosis in the LR-3 category. A 33.1The results showed that 88 patients were included in the study, including 72 males and 16 females, age 54.70 ± 9.8. Of these patients, 56 had cirrhosis (63.64%), 16 had chronic hepatitis B (18.18%), and 16 had HCC (18.18%). The clinical data of the patients are shown in 3.2There were 135 nodules in 88 patients, according to the 2018 version of LI-RADS criteria, 13 nodules not in the LR-3 category were excluded , and the remaining 122 nodules were in the LR-3 category, which were included in our study. Results analysis showed that these nodules included 54 malignant nodules  and 68 benign nodules . Conscientious lesions and malignant lesions assessed as LI-3 grade are shown in Among them, malignant nodules included 49 hepatocellular carcinomas, including macrotrabecular 30, microtrabecular 11, sclerosing pattern 1, pseudoglandular pattern 1, macrotrabecular-microtrabecular 4, and macrotrabecular massive 2, intrahepatic cholangiocarcinoma 3. In addition, combined hepatocellular -cholangiocarcinoma 2, as shown in 3.3Major HCC features and ancillary features variables were selected to identify independent factors for benign and malignant nodule differentiation in LR-3 classification. ROC analysis showed that the AUC values under the curve were 0.644 [95% CI: 0.546 – 0.743], 0.700 [95% CI: 0.607 – 0.793], and 0.882 [95% CI: 0.814 – 0.949] for nonrim APHE, mild-moderate T2 hyperintensity, and restricted diffusion, respectively. P value is less than 0.05, with statistical significance, and the analysis results are shown in 3.4The consistency analysis of the ADC values of two radiologists shows that the Kappa value is 0.83, which indicates a high level of agreement between them. For our final analysis, we will use the average of the ADC values measured by the two radiologists as the data.−3 mm2/s and benign lesions were 1.41 ± 0.31 × 10−3 mm2/s, and the ADC values of malignant tumors were significantly lower than those of benign tumors, and there was a significant difference in ADC values between benign and malignant nodules, p < 0.0001, which was statistically significant , the highest sensitivity, and the high specificity. The results of our study showed that ADC values had a higher sensitivity in discriminating HCC diagnosis in the observation of LR-3 nodules and had a high diagnostic value. Therefore, the application of ADC values in LI-RADS should be emphasized in clinical practice. Among the main features of HCC and other auciliary features, nonrim APHE, mild-moderate T2 hyperintensity, and restricted diffusion were independent factors for predicting HCC, which tended to be consistent with the results of observers of imaging features in other studies’ LI-RADS classification –27. AmonIn patients at high risk of HCC, it is difficult to characterize some nodules with unclear HCC image characteristics on contrast-enhanced MRI, especially when the lesions are smaller and classified as LR-3 in the LI-RADS classification, DWI/ADC helps us to observe the lesions , 28. In Limitations remain in this study, first, this is a pilot study performed in a single center and further multicenter studies with larger samples are needed to validate its clinical application. Second, some malignant lesions in this study were obtained by puncture and may have errors due to the heterogeneity of the lesions. Therefore, selectivity deviations cannot be excluded. In addition, the application of hepatobiliary specific contrast agents can make LI-RADS classification more accurate for HCC diagnosis , but thi5In summary, ADC values showed a high sensitivity for nodules in LR-3 classification while maintaining a high specificity, and ADC values combined with diagnostic criteria from the 2018 version of the Liver Imaging Reporting and Data System (LI-RADS-v2018) could effectively improve the malignant nodule detection rate in LR-3 classification and reduce invasive examinations such as patient follow-up and needle biopsy.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This study was approved by the Ethics Committee of Eastern Hepatobiliary Surgery Hospital, the Third Affiliated Hospital of Shanghai Naval Military Medical University, China, and waived the requirement of obtaining written informed consent.Conceptualization, NJ and QC; methodology, XC; software, JX; validation, HH, ZL, and KS; formal analysis, XC; investigation, JX; resources, QC; data curation, XC; writing—original draft preparation, XC; writing—review and editing, WL; All authors have read and agreed to the published version of the manuscript.


Genome-wide analyses of maize populations have clarified the genetic basis of crop domestication and improvement. However, limited information is available on how breeding improvement reshaped the genome in the process of the formation of heterotic groups. In this study, we identified a new heterotic group (X group) based on an examination of 512 Chinese maize inbred lines. The X group was clearly distinct from the other non-H&L groups, implying that X × HIL is a new heterotic pattern. We selected the core inbred lines for an analysis of yield-related traits. Almost all yield-related traits were better in the X lines than those in the parental lines, indicating that the primary genetic improvement in the X group during breeding was yield-related traits. We generated whole-genome sequences of these lines with an average coverage of 17.35× to explore genome changes further. We analyzed the identity-by-descent (IBD) segments transferred from the two parents to the X lines and identified 29 and 28 IBD conserved regions (ICRs) from the parents PH4CV and PH6WC, respectively, accounting for 28.8% and 12.8% of the genome. We also identified 103, 89, and 131 selective sweeps (SSWs) using methods that involved the π, Tajima’s D, and CLR values, respectively. Notably, 96.13% of the ICRs co-localized with SSWs, indicating that SSW signals concentrated in ICRs. We identified 171 annotated genes associated with yield-related traits in maize both in ICRs and SSWs. To identify the genetic factors associated with yield improvement, we conducted QTL mapping for 240 lines from a DH population  for ten key yield-related traits and identified a total of 55 QTLs. Furthermore, we detected three QTL clusters both in ICRs and SSWs. Based on the genetic evidence, we finally identified three key genes contributing to yield improvement in breeding the X group. These findings reveal key loci and genes targeted during pedigree breeding and provide new insights for future genomic breeding. On the basis of this pattern, a series of new hybrids has been bred, including Jingke968 (Jing724 × Jing92), Jingnongke728 (JingMC01 × Jing2416), Jingke665 (Jing725 × Jing92), and NK718 (Jing464 × Jing2416). So far, dozens of approved hybrids that are widely cultivated have been bred using X lines  was identified. Seventeen core inbred lines, including 15 elite X lines and two X line parents , Domestic Reid (DR), P group, and X group. The inbred lines in these groups reflect the genetic diversity of the germplasm resources used for maize breeding in China. The DH population was derived from a cross between PH4CV and PH6WC.For all lines, leaf tissue samples were obtained from a pool of at least 30–50 individuals for a DNA extraction according to a CTAB procedure . All lin2.2Resequencing of the genome was conducted on 15 representative X lines and two parental lines. All of the 15 selected X lines have bred many approved varieties , kernel number per ear (KNPE), ear weight (EW), bare top length (BTL), ear length (EL), water content (WC), volume weight (VW), kernel number per row (KNPR), kernel weight per ear (KWPE), and rows per ear (RPE). The quantitative traits were evaluated based on the mean of five independent measurements. Regarding the weight-related traits , we used the WC to correct the data. Specifically, values for all traits were adjusted based on a WC of 13% for the subsequent QTL analyses.2.8Genetic maps for the DH population were constructed using the nnTwoOpt algorithm for ordering and the ripple-SARF algorithm in IciMapping (version 4.2) . The gen33.1). Moreover, the X group was identified as a new and elite subgroup, which included lines that were selected by pedigree breeding from X1132X hybrids  for an analysis of agronomic traits. Substantial improvements were detected for many agronomic traits among the X lines . Most of the yield-related traits were considerably better in the X lines than in the parental lines, including RPE, KNPR, KNPE, KWPE, HGW, and EW. Thus, the primary improvement of the X group during breeding was enhanced yield-related traits Figure 2To clarify the genome structure and identify the artificially selected genome regions in the X lines, we generated whole-genome sequences of 17 representative inbred lines (15 elite X lines and the two parents), with an average sequence coverage of 17.35×  based on π, Tajima’s D, and CLR, respectively Figure 4Interestingly, we identified many selection-related signals concentrated in ICRs. Overall, 96.13% of the ICRs comprising 824.0 Mb overlapped the selection-related signals, including 99.19% of the ICRs from PH4CV and 89.23% of the ICRs from PH6WC. These overlapping regions were probably under artificial selection during the genetic improvement of X lines via breeding.3.4http://www.ricedata.cn/gene/) to determine the annotations of orthologous genes. By integrating multiple annotation methods, we identified 171 genes that control yield-related traits in ICRs and SSWs  system for the functional annotation of genes. This system curated all of the available trait-associated site (TAS) information from almost all association mapping studies involving diverse genetic backgrounds . The TO MN1 gene , which ied yield . The TGAop yield . Many otand FIE2 , have alqknpr1-2, qvw1, qel1-1, qew1-2, and qknpe1-1) with LOD scores ranging from 3.42 to 14.31 and PVE values between 6.48% and 19.27%. Notably, most QTLs controlling yield-related traits overlapped with the SSWs and ICRs. Specifically, 69.09% and 58.18% of the QTLs were located in or near SSWs and ICRs, respectively. These results suggest that maize yield-related QTLs may be enriched and retained in ICRs and SSWs.To identify the genetic factors controlling yield improvement, we assessed multiple agronomic and yield-related characteristics of a DH population derived from a cross between PH4CV and PH6WC. Through QTL mapping experiments , QTL-Cluster 2 (252.9–285.8 Mb on chromosome 1), and QTL-Cluster 3 (18.7–37.2 Mb on chromosome 4). QTL-Cluster 1 contained 13 QTLs with additive effects for yield-related traits, QTL-Cluster 2 contained 4, and QTL-Cluster 3 contained 7. Furthermore, QTL-Cluster 1 included QTLs controlling KWPE, KNPE, VW, EL, BTL, EW, KNPR, and HGW, whereas QTL-Cluster 2 included QTLs controlling KNPE, EL, and KNPR, and QTL-Cluster 3 included QTLs controlling RPE, KWPE, VW, and KNPE. All three QTL clusters overlapped with both the IBD conserved regions and the selective sweeps regions. For example, QTL-Cluster 2 had the highest CLR and Tajima’s D values (34.32 and −1.149). Both QTL-Clusters 1 and 2 resided in the ICRs from PH4CV, whereas QTL-Cluster 3 was located in ICRs from PH6WC.UB2 gene  . Consequently, many elite maize inbred lines, including X lines such as Jing724, Jing725, Jing464, and JingMC01, have been generated. The X lines derived from HIL parents exhibit strong heterosis . The use6 hm2) . Another6 hm2) .). This result was consistent with the primary heterotic pattern non-H&L × H&L , which produced most of the important hybrids , X × HIL was identified as a new heterotic pattern in China.We developed a maize panel comprising 512 inbred lines, which were divided into eight subgroups . The phylogenetic tree and PCA data revealed a consistent relationship among population structures. The HIL, LRC, DR, P, LAN, IDT, and Reid subgroups were identified in previous studies . Because hybrids . On the 4.2Genetic improvements resulting from breeding have left genomic footprints. A pedigree analysis can reveal the genomic changes occurring during maize breeding. The ICRs and SSWs provide insights into artificially selected genomic regions. Elucidating the functions of these regions is a prerequisite for applying them to genetically improve X lines through breeding. Many previous studies identified the important functional genomic blocks. UB2 (INCW5 (CKI7 (MPK7 (FIE2, and MN1 (TGA1 (FIE1, and CADTFR5 (In this study, we identified 103, 89, and 131 SSWs based on π, Tajima’s D, and CLR values, respectively. We also detected 29 and 28 ICRs from the parents PH4CV and PH6WC, respectively. Integrating multiple annotation methods, including TO functional annotations, QTL meta-analyses, and homologous gene functional annotations, indicated many yield-related genes exist in ICRs and SSWs. Of these genes, 113 were in the ICR and SSW overlapping regions in PH4CV, whereas 58 were in the ICR and SSW overlapping regions in PH6WC. For example, UB2 , INCW5 (2 (INCW5 , CKI7 (GW5 (CKI7 , MPK7 (TI7 (MPK7 , FIE2, a and MN1  were detN1 (TGA1 , FIE1, a CADTFR5  were det4.31 generation, results in substantial genomic recombinations and the pyramiding of favorable alleles from the parents into the inbred lines.Meiotic recombination is a crucial driving force for enhancing crop genetic diversity during breeding, and thus, for improving traits . PedigreIn this study, we confirmed the pyramiding of PH4CV and PH6WC genes associated with important traits in the X lines Figure 2The data presented in this study are deposited in the NCBI Sequence Read Archive repository, accession number PRJNA974168.JZ, WS and YW designed the experiments. ZL and CL analyzed the data and wrote the manuscript. RZ, MD, JW, AS, ShuaiW, XS, YZhao, ShuaisW, and YZhan performed to the field work and constructed population. HT, HY, LX, FW, ZS, and XW took part in the part of experiments and the manuscript modification. All authors contributed to the article and approved the submitted version.


Breast cancer (BC) and ovarian cancer (OC) are among the most common and deadly cancers affecting women worldwide. Both are complex diseases with marked heterogeneity. Despite the induction of screening programs that increase the frequency of earlier diagnosis of BC, at a stage when the cancer is more likely to respond to therapy, which does not exist for OC, more than 50% of both cancers are diagnosed at an advanced stage. Initial therapy can put the cancer into remission. However, recurrences occur frequently in both BC and OC, which are highly cancer-subtype dependent. Therapy resistance is mainly attributed to a rare subpopulation of cells, named cancer stem cells (CSC) or tumor-initiating cells, as they are capable of self-renewal, tumor initiation, and regrowth of tumor bulk. In this review, we will discuss the distinctive markers and signaling pathways that characterize CSC, their interactions with the tumor microenvironment, and the strategies they employ to evade immune surveillance. Our focus will be on identifying the common features of breast cancer stem cells (BCSC) and ovarian cancer stem cells (OCSC) and suggesting potential therapeutic approaches. Breast cancer (BC) and ovarian cancer (OC) are the most common and sixth most common cancers, respectively, and the first and fourth leading causes, respectively, of cancer-related deaths among women under the age of 60 ,2. Both BRCA1 and BRCA2) mutations have a higher risk of developing BC and/or OC. The specific factors that determine whether a woman with a BRCA1/2 mutation will develop breast or ovarian cancer are not fully understood. Since BRCA1 and BRCA2 are involved in DNA repair, mutations in these genes can cause genetic errors leading to cancer. Yet, the specific effects of BRCA1/2 mutations on cancer development can vary depending on the type of mutation, its location within the gene, and other genetic and environmental factors [BRCA1/2 mutations comprise about 5–7% of BC and 20–25% of OC cases [BRCA1 and 69% for BRCA2 mutation carriers in BC, whereas for OC it is 44% for BRCA1 and 17% for BRCA2 mutation carriers [BRCA1/2 mutation may also develop BC or OC, risk-reducing surgeries such as bilateral mastectomy, bilateral salpingo-oophorectomy, or a combination of both procedures are suggested to reduce the risk of developing BC or OC. They have been shown to reduce the risk of cancer that arises in the removed tissue by approximately 90%. While salpingo-oophorectomy has also been shown to reduce the risk of BC [BRCA1/2 mutations have a three-fold increased risk of BC if taking hormone replacement therapy after salpingo-oophorectomy [BRCA1/2 mutation to undergo these surgeries should be based on individual factors such as age, family history, personal preferences, and overall health, which requires a patient-oriented approach. Interestingly, although BC and OC are two different cancers that arise in different tissues of the body, women with breast cancer susceptibility gene type 1 and type 2  and OC (~90%) are of epithelial origin, arising from epithelial cells lining the lobules and terminal ducts in the breast or surrounding the ovaries. OC is histopathologically classified into five main types: high-grade serous carcinoma (HGSOC), low-grade serous carcinoma, endometrioid carcinoma, clear-cell carcinoma, and mucinous carcinoma . BC is hCancer recurrence is a major concern for patients with BC and OC, and several factors influence its occurrence, such as age, tumor grade, tumor size, axillary nodal involvement, and hormone receptor status . RecurreIn this review, we will discuss the distinctive markers and signaling pathways that characterize CSC, as well as their interactions with the tumor microenvironment (TME) and the strategies they employ to evade immune surveillance. Our focus will be on identifying the common traits of breast cancer stem cells (BCSC) and ovarian cancer stem cells (OCSC), along with potential therapeutic approaches.TP53), RB transcriptional corepressor 1 (RB1), and phosphatase and tensin homolog PTEN, are necessary for initiating the transformation of ovarian surface epithelium stem cells [Ovarian cancer is characterized by rapid proliferative growth and great metastatic potential. Indeed, epithelial–mesenchymal transition (EMT) is a characteristic of ovarian epithelium cells. During this process, epithelial cells depolarize, disassemble cell–cell contacts, acquire fibroblast-like morphological features, and adopt an invasive, migratory phenotype . It was em cells .If OC is not detected at an early stage (Stage I), before cancer spreads beyond the ovaries, the survival rate of patients decreases significantly. OC can reach stage II—metastasized to pelvic organs , stage III—metastasized across the pelvic cavity to abdominal organs , or stage IV—metastasized beyond the peritoneal cavity to distant parenchymal organs (liver and lung), lymph nodes, bones, and brain ,26. Non-TP53, phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA), and GATA binding protein 3 (GATA3) were common in both sites, EMT-related genes were enriched in or restricted to metastases. This mutational difference contributes to spatial intratumor heterogeneity [Breast cancer typically originates from the epithelial cells within the ducts (85%) or lobules (15%) of the breast glandular tissue . Recent ogeneity .TP53 and BRCA1 with additional PTEN loss, which is an early initiating event in BRCA1-associated basal-like BC [BARD1) mutations contributes to the tumorigenesis of BRCA1-associated BC and OC [BC and OC share approximately 50% of their top mutated genes. Integrated molecular analysis revealed a great difference between BC subtypes and many commonalities between HGSOC and basal-like TNBC, indicating related etiology . The mai-like BC  and a kn-like BC . In addiC and OC , and fouC and OC .BC and OC are highly heterogenous, comprising genetically and molecularly diverse cells. Different theories explain how cancer develops and progresses. According to the stochastic theory, all cancer cells can contribute by accumulating random mutations, while the hierarchy theory suggests that CSC control proliferation and progression . CSC possess the ability to self-renew and undergo symmetrical/asymmetrical division, which contributes to tumor heterogeneity, tumorigenicity, dissemination, and resistance to therapy . While cCD44, CD24, CD133, aldehyde dehydrogenase 1 (ALDH1), CD326 (EpCAM), CD338, and the pluripotency markers NANOG, OCT4, and SOX2 are shared among BCSC and OCSC, although there are others .CD44 is a transmembrane glycoprotein that binds hyaluronic acid and other extracellular ligands, facilitating activation of diverse signaling pathways to regulate cell proliferation, adhesion, migration, survival, invasion, and EMT [CD24 is a cell-surface protein involved in cell-matrix and cell–cell communication [CD24 in SKOV3 cells suppressed OC growth in mice in vivo [In a seminal research study, Al-Hajj et al. identified BCSC by showing that 100 CD44+/CD24−/low-BC cells formed tumors in immune-deficient NOD/SCID mice, while even 100 times more cells of a different phenotype failed to do so. While these BCSC are a minority, they can generate a diverse range of differentiated cells that form the bulk of the tumor . CD44 is and EMT ,47. CD24nication , the expnication ,50. Whilnication , in OC, nication ,53. Diffnication , whereasnication . High exnication . Therefo in vivo . An anti in vivo . Indeed, in vivo . CD44+/CD24−/low phenotype is shown to distinguish both BCSC and OCSC. Meng et al. have demonstrated that the CD44+/CD24− phenotype serves as a marker for OCSC, as these cells exhibit increased differentiation, invasion, and resistance to chemotherapy [IL1α), interleukin-6 (IL6), and interleukin-8 (IL8) [The otherapy . Similarotherapy  and radiotherapy  in BC. Iotherapy ,62,63. Hotherapy . The shiotherapy ,66,67. C-8 (IL8) . Though -8 (IL8) , Sherida-8 (IL8) . Among tALDH1 is an enzyme that oxidizes aldehydes and retinol to retinoic acid (RA). The oxidation of toxic aldehydes protects cell while the activation of RA signaling generally affects cell development, differentiation, and apoptosis, and promotes cancer cell proliferation, drug resistance, and inhibition of apoptosis [poptosis . ALDH1 ipoptosis ,70,71,72CD133 is a transmembrane single-chain glycoprotein also known as prominin, mainly located in cholesterol-rich membrane domains (lipid rafts) [BRCA1-associated BC is correlated with higher tumorigenicity in mouse mammary tumors [d rafts) . In normd rafts) , but expy tumors . Perturby tumors . CD133+ y tumors . CD133 iy tumors ,79.CD326, known as the epithelial cell adhesion molecule (EpCAM), is a transmembrane glycoprotein involved in cell adhesion. The higher expression of CD326 in BC is associated with the stem-like phenotype, increased invasiveness, bone metastasis, and radioresistance [sistance ,81. Simisistance . Thus, Csistance . While asistance , in a rasistance . Catumaxsistance . CD338 is an ABC transporter often overexpressed in OCSC and associated with chemoresistance [BRCA1-mutated cells [sistance ,88,89. Oed cells . Other cBRCA1-mutated BC [A more accurate identification of CSC relies on a combination of various markers, particularly due to their distinct distribution patterns and observed stemness and tumorigenic potential. The percentages of BCSC as well as expression of their markers, such as CD44, CD24, ALDH1, and CD133, are tumor-subtype dependent. Basal-like and HER2+ tumors exhibited a higher frequency of ALDH1+ cells compared to luminal tumors, and a higher percentage of CD44+/CD24− cells is mainly attributed to TNBC and to tated BC ,91. TNBCtated BC . Similartated BC .NANOG, SOX2, and OCT4 are well-known transcription factors essential for maintaining self-renewal and pluripotency in both normal and cancer stem cells, including BCSC and OCSC. Overexpression of NANOG promotes EMT, cell migration, and invasion in OC and is often associated with high-grade cancers, serous histological subtypes, reduced chemosensitivity, and poor overall and disease-free survival [survival . Furthersurvival . SOX2 exsurvival ,97,98. Osurvival ,100. TheAside from common markers, some divergent markers of BCSC and OCSC can be found in A great number of oncogenic signaling pathways has been shown to be implicated in the maintenance of BCSC and OCSC ; therefoWNT signaling is an evolutionary conserved signaling pathway that plays a crucial role in normal embryonic development and adult homeostasis of various organs, including the mammary gland and ovary [nd ovary ,135. WNTnd ovary . Aberrannd ovary ,138. Addnd ovary . The patnd ovary  and can nd ovary , and thend ovary ,142. In nd ovary . Silencind ovary ,145. Hypnd ovary .The PI3K/AKT/mTOR pathway plays a crucial role in regulating cell proliferation, metabolism, angiogenesis, and differentiation. Phosphatidylinositol-3-kinase (PI3K) is activated by the binding of growth factors and cytokines to the receptors on a cellular membrane, such as epidermal growth factor receptor (EGFR), insulin-like growth factor I receptor (IGF-IR), and fibroblast growth factor receptor (FGFR), leading to the autophosphorylation of tyrosine residues in the receptors’ cytoplasmic region. PI3K can then subsequently activate AKT, which further activates downstream effector molecules, mainly mammalian target of rapamycin (mTOR). PTEN antagonizes the action of PI3K [PI3K, AKT, and PTEN can lead to the abnormal activation of this pathway, which is observed in approximately 70% of BC and OC cases. PIK3CA and PTEN mutations are the most common and subtype dependent in both BC and OC. The highest percentage of PIK3CA mutations occurs in hormone receptor-positive (HR+)/HER2− subtypes of BC and endometriosis-associated OC (endometrioid ovarian carcinoma (EnOC) and ovarian clear-cell carcinoma (OCCC)) while the lowest percentage is found in TNBC and HGSOC [PTEN mutations are more frequently associated with more aggressive types of BC and OC [PTEN mutations or inhibition contribute to activation of the EGFR/PI3K/AKT pathway, leading to increased mTOR activation, induction of EMT, enrichment of the stem-like cell fraction, tumorigenicity, and chemoresistance [ of PI3K . Mutationd HGSOC ,149. In C and OC ,150, altC and OC . This abC and OC ,156,157.sistance ,158,159.sistance . The inhsistance , while isistance ,163. Thesistance ,165,166.NOTCH signaling is also associated with stemness maintenance, which is important in adult organisms and pathologies such as cancer. NOTCH1–4 is a family of transmembrane protein receptors that can bind five ligands—Jagged canonical Notch ligands 1 and 2  and Delta-like canonical Notch ligands 1, 3, and 4 . When a ligand interacts with the receptor, it triggers proteolytic cleavages of the receptor by ADAM metallopeptidase domain 10 (ADAM10) and γ-secretase enzymes. This cleavage releases the intracellular portion of the NOTCH receptor, which then initiates the downstream signaling and transcription of target genes [et genes ,168. Hypet genes ,170,171.et genes  and BC, et genes . Hypoxicet genes ,175. RASet genes ,176. NOTet genes ,177. Taret genes ,179. It et genes . For exaet genes ,182.The Hedgehog–GLI (HH-GLI) pathway plays a major role in embryogenesis. Although its activity is reduced in the adult stage, it is highly required for the maintenance of the stem cell population, tissue repair, and regeneration [NANOG, OCT4, SOX2, and BMI1 in gliomas [SHH), Desert hedgehog (DHH), and GLI1, is correlated with a worse prognosis and more advanced stages of BC [GLI2 can decrease ALDH activity and influence mammosphere growth, while its overexpression has a positive effect on mammosphere growth [neration . In cancneration  and contneration . The patneration . In OC, neration . The HH- gliomas , while i gliomas . Ray et  gliomas . The pat gliomas  and vasc gliomas . The pat gliomas ,191. As  gliomas . The HH  gliomas  and chem gliomas , while ies of BC ,193. Thee growth . Inhibite growth . In addie growth  and indue growth .The JAK/STAT pathway regulates cell proliferation, differentiation, apoptosis, and immune response by being stimulated mainly by growth factors  and cytokines  [NANOG and C-MYC in CD24+ OCSC, when inhibited with JAK2, induces cytotoxicity in CD24+ cells, reduces tumor metastasis, and prolongs overall survival [nd IL23) ,199. Thend IL23) . The JAKnd IL23) . Moreovesurvival . Ruan ansurvival . Moreovesurvival . Overexpsurvival . Similarsurvival ,199. STAsurvival . STAT3 isurvival ,207. In survival , which nsurvival . The transforming growth factor-β (TGFβ) signaling pathway plays a crucial role in maintaining normal tissue homeostasis, but its dysregulation is implicated in tumorigenesis, including BC and OC. TGFß binds to the specific receptor complex consisting of the TGF-β type II receptor (TGFβRII) and the TGF-β type I receptor (TGFβRI). Ligand binding with TGFβRII leads to the receptor phosphorylation forming a binding site for TGFβRI, in which phosphorylation triggers the activation of the receptor-activated suppressor of mothers against decapentaplegic (SMAD) proteins that translocate to the nucleus and regulate transcription of targeted genes. TGF-beta signaling can also activate non-SMAD pathways, which contribute to additional cellular responses [TTG2 knockdown decreases the number of cells with a CSC phenotype (CD44+ CD117+) [esponses . Activatesponses ,215,216. CD117+) . Silenci CD117+) . Inhibit CD117+) . In addi CD117+) . In both CD117+) , which c CD117+) . In addi CD117+) . Treatme CD117+) .The NF-κB signaling pathway plays a crucial role in cell functions and processes such as inflammation, angiogenesis, differentiation, stemness, and metastasis in BC and OC [C and OC ,225. TheC and OC . ConstitC and OC , while iC and OC . SimilarC and OC . InhibitC and OC  and specC and OC . TogetheC and OC . MoreoveC and OC ,204,209.C and OC . In BC, C and OC . The Hippo signaling pathway regulates a wide range of biological processes, including cell survival, differentiation, cell proliferation, and tissue homeostasis [eostasis . The Hipeostasis . YAP, theostasis ,238,239.eostasis . In BC, eostasis . Detachmeostasis . RICH1, eostasis . Indeed,eostasis .The nuclear factor erythroid 2-related factor 2 (NRF2) signaling pathway is often associated with the enrichment of BCSC and OCSC, leading to therapy resistance in BC and OC. NRF2 is a transcriptional factor that regulates the expression of more than 250 genes. It is repressed in a complex with Kelch-like ECH-associated protein 1 (KEAP1) and subjected to ubiquitination and proteasomal degradation. However, NRF2 regulation/activation can include other repressors or competitors. Oxidative stress activates this pathway by blocking the binding of NRF2 with KEAP1, which fosters its translocation to the nucleus and activation of target genes with antioxidant-responsive elements (ARE) in their promoter [promoter . Radiorepromoter , but maipromoter . Similarpromoter . Stemnespromoter , regulatpromoter  and CD44promoter . Furtherpromoter . GSK-3β promoter . ML385-mpromoter . These findings highlight the significance of targeting pathways involved in CSC biology as a potential therapeutic strategy to overcome therapy resistance in breast and ovarian cancers.The microenvironment of both BC and OC includes several cell types, including stromal cells, adipocytes, carcinoma-associated mesenchymal stem cells (CA-MSC), and immune cells . All theadipocyte-derived fibroblasts (ADF), which demonstrate CAF-like characteristics. This morphological change is followed by changes in reduced expression of adipose markers and an increase in fibroblast markers, creating a subpopulation of cells at the invasive front of the tumor. These cells can migrate to the tumor center and contribute to tumor invasiveness and migratory capacity [Obesity is a known risk factor for many cancer types, including OC and BC ,254. A rcapacity . Even mocapacity ,264. ADFcapacity ,266. Howcapacity . Adipose-derived stem cells (ADSC) exhibit features of mesenchymal stromal cells, and can differentiate into various cell types: adipocytes, osteoblasts, chondrocytes, or myocytes. ADSC-conditioned medium increases migration and invasion of OC cell lines and xenografts, and promotes EMT through the TGF-β pathway [cancer-associated adipocytes (CAA) can trigger increased expression of pro-inflammatory cytokines IL6 and IL8 in co-cultures with TNBC cells MDA-MB-231 [ pathway ,269. ADS pathway . Convers pathway ,272. To  pathway ,274. WAT pathway ). These  pathway ,275. The pathway . In resp pathway . Yet, in pathway . In OC,  pathway . In addi pathway . TNFα, a pathway . FurtherA-MB-231 . TNFα alA-MB-231 . TNFα prA-MB-231 .The tumor-promoting microenvironment is generated by stimulating angiogenesis (activation of PI3K pathway via VEGF and EGF), regulating adhesion (changes in composition of integrins), and inflammation (pro-inflammatory cytokines IL6 and IL8 and increased neutrophil to lymphocyte ratio). Bioactive lipids such as lysophosphatidic acid (LPA) and arachidonic acid (AA) are elevated in malignant ascites and contribute to immunosuppression . Many imtumor-associated macrophages (TAM) [Classically activated macrophages, also known as M1, are pro-inflammatory, while M2 macrophages are further divided into different subgroups ; furthermore, they have immunosuppressive properties along with tumor-promoting properties, so they are often called es (TAM) . TAM arees (TAM) . TAM alses (TAM) . OCSC caes (TAM) .cytotoxic CD8+ T cells, which are heavily involved in BCSC and OCSC function. Since the function of cytotoxic CD8+ T cells is to kill abnormal cells, they are of great importance in the regulation of cancer growth. At the onset of cancer growth, CD8+ cells are responsible for killing cancer cells, and their presence in cancer tissue correlates positively with better overall survival of BC patients [One of the most important components of the immune system in relation to cancer cells is the population of patients . Howeverpatients ,296. Othpatients ,298. TNBpatients . Furtherpatients . Interacpatients . Even thpatients . This popatients .CAF are generally found in close physical relation to a tumor, and they are characterized by the expression of fibroblast activation protein (FAP) and actin smooth muscle (αSMA) [e (αSMA) . BCSC exe (αSMA) . CAF aree (αSMA) ,306. ECMe (αSMA)  or by MMe (αSMA) . CAF sece (αSMA) . CAF cane (αSMA) . Throughe (αSMA) . These dCA-MSC are another crucial component of the OC TME. They are defined by the expression of CD44, CD73, and CD90 markers, and can differentiate into adipose tissue, cartilage, or bone in vitro [SLUG and SNAIL in BC cells [in vitro . CA-MSC in vitro . Hypoxiain vitro ,312. Hypin vitro . One of in vitro . Anotherin vitro . HypoxiaBC cells . SirtuinBC cells , while SBC cells ,317.The immune system plays a crucial role in shaping the development and progression of cancer, and according to the “cancer immunoediting” hypothesis it comprises three phases: elimination, equilibrium, and escape. During the elimination phase, the immune system (innate and adaptive) detects and eliminates tumor cells that display foreign antigens on their surface. Yet, some tumor cells develop mechanisms to evade or suppress immune responses, leading to the equilibrium phase. In the equilibrium phase, the immune system (mainly T helper type 1 (Th1) cells, cytotoxic T cells, and cytokines of type 1 immunity ) keeps tumor cells dormant or growing slowly. The escape phase occurs when tumor cells develop genetic instability and evade immune detection, resulting in rapid growth and metastasis. It is when the tumor becomes clinically visible. This phase is aided by a proangiogenic microenvironment and the suppression of the immune response. This includes Treg cells, myeloid-derived suppressor cells, type 2 macrophages, IL10, TGF-ß, VEGF, 2,3-dioxygenase (IDO), arginase-1, and cyclooxygenase-2 (COX-2) as well as the overexpression of pro-survival proteins and inefficient presentation of tumor-associated antigens . While BC was firstly perceived as an immunogenically “cold” tumor, OC is considered an immunogenic tumor, as it expresses so-called tumor-associated antigens (TAA) that can be recognized by the immune system. These antigens are produced by the tumor cell, phagocytosed, and processed by the dendritic cells, which then expose them on the major histocompatibility complex (MHC) class molecules on their surface. These are recognized by the T cells and trigger the immune response of the host. TAA identified in OC include HER2/neu, CA125, FR-α, CA153, HE-4, and others . Today, NK cells act cytotoxically on the cells that lose MHC class molecules. In OC, CD24+ cell populations isolated from OC cell lines were more susceptible to NK cell cytotoxicity as they show loss of MHC class I molecules on their surface, and upregulation of NKG2D receptor, which is responsible for initiation of NK killing mechanism. On the other hand, CD24+ population showed increased resistance to cisplatin and doxorubicin compared to CD24− population . In factTNF/CXCR3/P2RX7/CASP1/NLRP3/IL1B/LY96/CD4+/CD8+A/CD8+B/PRF1/IFNG/IL17A/IL17RA) is associated with prolonged overall survival (OS) in BC and OC patients but not in lung cancer patients. Similarly, high expression of the OC-specific ICD-derived metagene signature (CALR/PIK3CA/TNF/IFNA/IFNB1/CXCR3/P2RX7/CASP1/IL1B/TLR4/CD4+/PRF1/IFNG/IL17A/IL17RA) is associated with prolonged OS in OC patients and to some extent with prolonged OS in BC patients, whereas high expression of the lung-cancer-specific ICD-derived metagene signature is associated with prolonged OS only in lung cancer patients. This suggests that immune or inflammatory responses may operate in a more unified manner in BC and OC [In both, OC and BC, noncanonical activation of the TGFβ pathway in CD8+ T cells upregulates CD103 and induces secretion of CXCL13. These CXCL13+CD103+CD8+ TIL subpopulations promote migration of B cells to the tumor and the formation of tertiary lymphoid structures (TLS) and are associated with better prognosis . In addiC and OC . OC tissues express PD-L1 in approximately 50% of cases, and its expression correlates with high CD8 expression and moderate CD4 expression. Interestingly, the expression of PD-L1 colocalizes with the stem cell markers CD44 and LGR5 . In BC, Cancer progression, metastasis, recurrence, and resistance occurs due to the BCSC and OCSC escape from immune surveillance ,344. TheRegulatory T cells CD4+CD25+CD3+ are abundant in the tumor mass and the malignant ascites of OC patients with later stage disease, and they suppress the production of IFN-γ and IL2 and subsequent T cell activation . Aging cOne of the most common problems with studying CSC has been the selection of a method for the isolation and characterization of CSC. Throughout the years, several types of models and methods were used in order to distinguish CSC populations, all with their advantages and limitations. The use of culture models in cancer research provides a valuable tool for investigating various aspects of tumor biology, including drug response, drug resistance, TME, and stem-cell-like properties. While the predominantly used 2D cultures provide a simple and high-throughput method in this field, they lack physiological relevance due to the altered 3D architecture, cell-to-cell interactions, and behavior. Three-dimensional models, by increasing complexity, include spheroid cultures of tumor cells, spheroid co-cultures of two or more cell types, and organoids developed from patient material, as the most complex system. These models more accurately mimic the complex architecture and microenvironment of tumors, cell heterogeneity, and the presence of CSC, but their use can present challenges such as difficult imaging, higher cost, and a lack of standardization. Several reviews already discussed the advantages and disadvantages of using 3D versus 2D cultures in cancer research. They listed different 3D culture models, including spheroids grown on ultra-low attachment plates or in spinner flasks, synthetic or natural hydrogel models and 3D-printed scaffolds, microfluidic organ-on-a-chip models, and cell line or patient-derived xenografts, and discussed their applications and limitations ,359,360.3D models exhibit increased resistance to chemotherapeutics compared to 2D cultures, and they can demonstrate the efficacy of drugs in eradicating CSC populations and reducing spheroid size. An increased resistance to chemotherapeutics was shown on spheroid models [OCT4, SOX2, SOX4, JAG1, and CD49f [OCT3/4, SOX2, SOX4, and CD49f) and increased invasive capability [Studies have shown that d models ,370,371,d models ,379,380,d models ,382,383 nd CD49f . Spheroind CD49f . Cultivand CD49f , an uprepability , and an pability , accompapability . Omentumpability ,390. In pability . Recentlpability .Xenograft models have also been successfully used in BC and OC research, and both BCSC and OCSC were shown to accelerate the tumor growth in mice [ in mice ,394. Pat in mice ,394,395. in mice ,397,398  in mice . PDX mod in mice . patient-derived scaffolds (PDS), which, when recellularized with BC cell lines, led to the development of stem-cell-like properties and a gene-expression profile similar to xenograft cultures [NANOG, POU5F1, and ABCG2, and increased resistance to chemotherapeutics  [Furthermore, decellularizing primary BC tissues led to the development of cultures . In folllitaxel)  and endolitaxel)  in cellslitaxel) . patient material, the models most often used are the paraffin-embedded tissue slides and fresh or fresh frozen tissue samples . They are used for the detection of gene and/or protein expression and mutation detection. For example, immunohistochemical staining and/or CSC-markers-based cell sorting revealed the abundance and CSC distribution between normal and cancer tissue at different stages and clinical outcomes [Regarding the outcomes ,407,408.Fresh tissues can be used to establish organoids/tumoroids in vitro, or for propagation in mice in PDX models . The heterogeneity of OC and BC is largely attributed to the presence of a subset of CSC, which have the ability to differentiate into multiple cancer cell types under various stimuli. Aggressive subtypes typically have a higher proportion of CSC, which can drive tumor development, progression, and resistance to therapy. While primary tumors treated with specific therapy may initially respond well, they often become resistant and relapse when treated again with the same compound. This resistance to therapy is partially mediated by CSC, which can evade initial treatment by persisting in a quiescent, low proliferative state, and then re-activating and repopulating the tumor mass after therapy, often adopting a more resistant phenotype. CSC are intrinsically more resistant due to their active DNA repair, increased expression of ABC transporters, ALDH1, pro-survival BCL-2 protein family, and activation of signaling pathways such as MYC, PI3K/AKT, WNT, NOTCH, HH, NF-κB, and others ,411,412.Therefore, there is a great need for appropriate treatment strategies that are effective against CSC and improve the outcome of cancer therapy. Several approaches have been proposed to target CSC, including the use of small molecules, antibodies, and immune-based therapies. Therapeutic approaches for targeting CSC heavily depend on the identification and isolation of CSC using cell-surface markers. However, targeting these markers poses a challenge due to their overlap with embryonic and adult stem cells, which can potentially affect normal adult stem cells and impair the process of normal tissue regeneration . FurtherSpecific biomarkers of BCSC and OCSC are being utilized in treatment strategies. BRCA1 and BRCA2 genes are sensitive to Poly (ADP-ribose) polymerase (PARP) inhibitors. Although PARP inhibition shows encouraging results even in platinum-resistant patients, resistance to PARP inhibitors can develop [A subset of OC and BC cases caused by mutations in  develop . This re develop . In BC,  develop . The dow develop . ALM201, a 23-residue peptide derived from the N-terminal region of the FK506-binding protein like (FKBPL), is a promising candidate for targeting OCSC, as it specifically binds to the CD44 receptor and exhibits anti-angiogenic and anti-CSC activity. In several OC cell lines, ALM201 reduced tumorsphere-forming efficiency, but its efficacy was not consistent in vivo in a xenograft model due to differences in the microenvironment . AnotherSOX2, NANOG, OCT4, and ALDH1A in vitro and in vivo. Therefore, the authors stress the possibility of treatment failure and/or resistance due to these mechanisms [As the MEK1/2-ERK1/2 pathway is active in the majority of HGSOC cases, inhibition of this pathway was also tested as a potential therapeutic approach. MEK1/2 inhibitor trametinib showed an inhibitory effect on HGSOC proliferation and induction G0/G1 cell cycle arrest in these cells. However, it was also shown to promote stemness, as higher percentages of CD133+ cells were detected after trametinib treatment, as well as an increase in gene expression of stemness markers chanisms . In a preclinical study, the PI3K inhibitor XL147 was used in combination with trastuzumab to treat trastuzumab-resistant BC. The results showed that the combination therapy reduced cancer cell proliferation and increased apoptosis. The treatment also decreased mammosphere formation, inhibited tumor growth, and reduced ALDH activity. This suggests that the addition of a PI3K inhibitor to trastuzumab treatment could potentially improve therapeutic outcomes for trastuzumab-resistant BC patients .+ breast cancer cells, the subpopulation of cancer cells responsible for therapy resistance and cancer recurrence [Repurposing of existing therapeutics has yielded some promising candidates for targeting CSC, including metformin, an antidiabetic drug; salinomycin, an antimicrobial agent commonly used in agriculture; and calcium channel blockers. Metformin has been shown to have the potential to inhibit both OCSC and BCSC, with low concentrations selectively targeting CD44+ CD117+ OCSC while not affecting OC cells, resulting in the inhibition of OCSC growth in vitro and in vivo ,456. In currence .Salinomycin has also been shown to be a selective inhibitor of BCSC and OCSC. It induces apoptosis in OCSC and selectively kills BCSC while reducing tumor growth and EMT ,417,458.Natural products are often explored as potential new therapeutics for cancer treatment. Shikonin (SHK), for example, induced apoptosis and inhibited migration, invasion, and xenograft tumor growth, as well as the expression of CSC-related markers  in OC . A very In recent years, the need for more precise and efficient therapy of CSC has increased—CSC vaccines for OC (targeting CD117+CD44+ OCSC) were able to activate immune responses to autologous tumor antigens, which in turn reduced OCSC, prolonged survival, and reduced tumor growth in mice . This isOverall, a better understanding of CSC biology and their interactions with the TME is needed to develop effective therapies that can improve cancer treatment outcomes.Breast and ovarian cancers are among the most common and deadly cancers affecting women worldwide. BC and OC show marked intertumor heterogeneity, which subdivides them into various subtypes, and even intratumor heterogeneity. Although BC and OC arise from different tissues, they share approximately 50% of the most frequently mutated genes. Integrated molecular analysis revealed major differences between BC subtypes and many similarities between HGSOC and basal-like TNBC, suggesting a related etiology . Even if


Atopic dermatitis represents a complex and multidimensional interaction that represents potential fields of preventive and therapeutic management. In addition to the treatment armamentarium available for atopic dermatitis, novel drugs targeting significant molecular pathways in atopic dermatitis biologics and small molecules are also being developed given the condition’s complex pathophysiology. While most of the patients are expecting better efficacy and long-term control, the response to these drugs would still depend on numerous factors such as complex genotype, diverse environmental triggers and microbiome-derived signals, and, most importantly, dynamic immune responses. This review article highlights the challenges and the recently developed pharmacological agents in atopic dermatitis based on the molecular pathogenesis of this condition, creating a specific therapeutic approach toward a more personalized medicine. Atopic dermatitis (AD) is a common chronic inflammatory skin disorder affecting approximately 11 to 20% of children and 5–8% adults. In a retrospective observational study conducted in South Korea by Lee et al., 944,559 pediatric patients and 1,066,453 adults with AD were identified . T. T77]. TCendakimab (RPC-4046), a recombinant humanized anti-interleukin 13 monoclonal antibody, binds to IL-13 at an epitope that overlaps with the binding site of receptors IL-13Rαl subunit and IL-13Rα2 subunit, thereby preventing its interaction and blocking further signaling b 77]. T. T77]. TLebrikizumab, a humanized monoclonal IgG4 antibody that selectively blocks IL13 and prevents the heterodimerization of the type II IL4R receptor composed of IL4Rα and IL13Rαl subunits b 77], a, a77], aEblasakimab is a fully humanized monoclonal antibody that targets the IL-13Rα1 subunit b, therefInterleukin 5 cytokine binds to interleukin 5-receptor (IL-5R) consisting of IL-5 receptor alpha subunit (IL5Rα) and a common receptor B subunit (BC), as depicted in Mepolizumab, a humanized immunoglobulin G monoclonal antibody that binds to IL-5 b, was geThe investigation of benralizumab, which directly binds to the IL-5Rα chain b to inhiIL-22 cytokine is produced by mast cells, various in vitro and animal studies propose its role in epidermal hyperplasia, and it contributes to skin barrier damage by the inhibition of keratinocyte differentiation. This cytokine is also responsible for the upregulation of pruritogenic peptide gastrin-releasing peptide (GRP), TSLP, and interleukin 33 in epithelial cells, as shown in A phase 2a randomized double-blind trial was conducted to evaluate the effectiveness of fezakinumab, an anti-IL-22 monoclonal antibody b. The trThe phosphodiesterase (PDE) superfamily is composed of 11 isozymes that degrade cyclin nucleotides, particularly cAMP and cGMP a 91]. P. P91]. PCrisaborole, a topical phosphodiesterase-4 inhibitor b, has beSeveral selective phosphodiesterase 4 inhibitors are currently under development. One of these investigational compounds is PF-07038124 ointment, a topical small-molecule PDE4 inhibitor. Currently, a phase 2b randomized, double-blind, vehicle-controlled, parallel-group study is underway to assess the efficacy, safety, tolerability, and pharmacokinetics of multiple dose levels  of PF-07038124 ointment, an oxaborole-based PDE-4 inhibitor b. The stIn a phase 2, multicenter, randomized, blinded, excipient, parallel-group clinical study, topical small-molecule PDE4 inhibitor Hemay-808 ointment  b or a veDifamilast is a selective PDE4 inhibitor b in topiRoflumilast is a highly potent PDE-4 inhibitor b and itsSimpson et al. in their phase II, double-blind, placebo-controlled trial evaluated the efficacy, safety, and pharmacodynamics of apremilast in adults with moderate to severe AD. In their study, patients were randomly assigned or received placebo, apremilast 30 mg twice daily, and apremilast 40 mg twice daily for 12 weeks. During weeks 12 to week 24, all patients would receive either apremilast 30 mg or apremilast 40 mg. Among the 185 randomly assigned intention-to-treat patients at week 12, apremilast 40 mg revealed a statistically significant improvement in EASI (31.6%) as compared with placebo and apremilast 30 mg. Furthermore, apremilast 40 mg was associated with a more unfavorable adverse-event profile, including nausea, diarrhea, headache, and cellulitis, leading to the termination of the study .A phase 2b dose-ranging study is currently underway, examining the effects of orismilast-modified release tablets in adults (18 years and older) with moderate to severe AD. The study follows a randomized, double-blind, placebo-controlled, parallel-group design, involving 210 participants. During the 16-week treatment period, participants are administered with orismilast-modified release tablets at varying doses  or placebo, twice daily (morning and evening). The study is currently in the recruitment phase . The mecHistamines are well-known pruritogens and causes the release of mast cells and basophils via the activation of histamine receptors. There exist four subtypes of antihistamines, those of particular importance of which are H1 and H4 antihistamines, which play roles in pruritic skin diseases like AD and urticaria. Human CD4(+) T cells express a functional H4 receptor, which was upregulated under Th2 conditions in a study by Gutzmer et al. . NumerouThe efficacy and safety of JNJ 39758979, a potent and selective H4R antagonist b, were aAdriforant is a functional antagonist of histamine receptor 4 and is also known as ZPL 3893787, PF 3893787, and ZPL 389. ZPL-3893787 30 mg, an oral selective H4R antagonist b given oA potent and selective H4R antagonist, LEO 152020 tablet b, is curWhile the pathophysiology of pruritus is not limited to H4 receptors, a combined treatment targeting H1 and H4 receptors might be a good strategy in treating patients with AD .CLA+ T cells are produced during the initiation of the AD lesion. These cells require chemo-attractant stimuli to function through their chemokine receptors CCR4 and CCR10. Thymus and activation-regulated chemokine (TARC/CCL17) and macrophage-derived chemokine (MDC/CCL22) are the chemokine ligands specific for CCR4 a, while RPT 193 is a CCR4 antagonist b and a dPro-inflammatory lipid sphingosine 1-phosphate (S1P) is a bioactive lipid mediator released from red blood cells and acts as a second messenger that is involved in several immunological processes like angiogenesis, cytoskeleton organization, trafficking of immune cells, mitogenesis, and apoptosis through acting on either one of the five sphingosine-1-phosphate-specific G-protein coupled receptors (S1PRs) a: sphingTopical S1PR antagonistKRO-105714 b, a dualThe topical application of JTE-013, an S1PR2 antagonist b, was ab2.Oral S1PR modulatorIn a phase 2, randomized, double-blind, placebo-controlled, parallel-group study investigating 140 adult (18 years and older) participants with moderate to severe AD, etrasimod b and oraLC51-0255 (LG Chem) is a potent, selective, and orally available S1P1 receptor modulator b that reUdifitimod (BMS-98166) acts by targeting S1PR1 b. In AugSCD-044, a novel orally bioavailable S1PR1 agonist b, is curNumerous in vivo and in vitro studies have been suggesting the role of the S1P pathway in AD, making it a potential therapeutic agent in humans.Expressed in all hematopoietic cells except T cells, Bruton’s tyrosine kinase (BTK), a member of the TEC kinase family of non-receptor tyrosine kinases, has been a promising target for immunological disorders like AD and psoriasis, as depicted in In a study by Xing et al., topical PRN473, a BTK inhibitor b, effectBranebrutinib is an oral and highly selective BTK inhibitor b that coA phase 2, randomized, double-blind, placebo-controlled, multicenter proof-of-concept study on rilzabrutinib, a BTK inhibitor b, is curLiver x receptor (LXR), a member of the nuclear receptor superfamily, is expressed in keratinocytes a and fibIn a phase II study with a double-blind, placebo-controlled design, involving 104 patients with mild-to-moderate AD, the topical LXR-β agonist VTP-38543 b was admIn a multicenter, randomized, double-blind, bilateral, vehicle-controlled study investigating 209 adult and adolescent subjects with moderate AD, ALX-101 b at diffThe pyschosomatic aspect of the itch–scratch cycle greatly affects the quality of life of patients with AD. This cycle disrupts the epidermal barrier, causes damage to keratinocytes, activates local dendritic cells, and triggers the adaptive response.Coined as the “itchy” cytokine, IL-31 has been associated with acute itch in an article by Oetjen et al.  and has In a post hoc analysis of a Phase III randomized controlled trial conducted in Japan, nemolizumab, a humanized monoclonal antibody that antagonizes IL-31RA b, was evA Phase IIa randomized, double-blind, placebo-controlled study by Sofen et al. investigated the efficacy and safety of vixarelimab, a first-in-class fully human monoclonal antibody that targets the oncostatin M receptor b in 49 pNK1Rs are channels located on mast cells and the dorsal horn of the spinal cord, as pictured in A phase 3 randomized, placebo-controlled, double-blind clinical trial, known as the EPIONE study, investigated the efficacy of oral tradipitant (VLY-686), a novel NK-1 receptor antagonist b, in redIn a large Phase II study called the ATOMIK study, involving 484 participants with pruritus caused by AD, the oral NK1 antagonist selropitant b was admThe inhibition of sensory-neuron-associated neurokinin-1 receptors presents a promising target for drug therapy as the elevated expression of these receptors has been linked to the development of pruritus in AD.Extracellular adenosine 5′-triphosphate (ATP) is released from cells under physiologic or pathologic conditions. These ATPs are mediated by cell-surface receptors called P2R, which are divided into two families: P2XR and P2YR. P2XR has several heterotrimers, among which P2XR3 is particularly important in this review article, which are cationic channels mainly expressed in sensory neurons, as illustrated in In an AD mice model, intradermal treatment with A317491 (selective P2XR3 antagonist) b reducedIn the BLUEPRINT trial, a Phase II multicenter study, the efficacy of BLU-5937—a selective P2XR3 antagonist b—was evaThe TRP channel family is divided into eight subfamilies, including TRPA (ankyrin), TRPC , TRPM (melastatin), TRPML (mucolipin), TRPN (Drosophila NOMPC), TRPP (polycystin), TRPV (vanilloid), and TRPY (yeast) according to their amino acid sequence. These receptors are involved in transmitting sensory inputs such as heat, pain, and taste. These channels are highly expressed in the keratinocytes, mast cells, cutaneous sensory neurons, and T-cells, as showcased in Transient receptor cation ankyrin 1 (TRPA1) is a novel channel that is believed to be responsible for the histamine-independent itch pathway in AD. Aside from the TRPA1 receptor being a cold-sensitive calcium channel in keratinocytes in response to temperatures less than 17 °C, these channels are also activated by various endogenous  and exogenous pruritogens . Once activated, it triggers the different pruritogenic pathways, as seen in Topical TRPA1 antagonist HC-03003 b, applieAnother TRPA1 antagonist, oral GRC17536 b, was abTRPV channels have six members, TRPV1, TRPV2, TRPV3, TRPV4, TRPV5, and TRPV6. Vanillin, vanillic acid, and capsaicin are among the substances that trigger these channels . TRPV 1–Transient receptor potential channel vanilloid 1 (TRPV1)TRP cation channel subfamily V member 1 (TRPV1) is one of the extensively studied channels. TRPV1 and TRPA1 are both expressed on primary afferent sensory neuron a. When TSeveral clinical trials have provided evidence of the safety of topical agents targeting TRPV1. Topical PAC-14028, a TRPV1 channel inhibitor b, has beAnother drug is CT327/SNA-120, a topical TRPV1 pathway inhibitor b that deThe CAPTAIN-AD study, a phase 3 trial, aimed to evaluate the potential of asivatrep, a topical TRPV1 antagonist b, as an By targeting this channel, the release of pruritic and pro-inflammatory mediators can be suppressed, leading to the restoration of the skin barrier.2.Transient receptor potential channel vanilloid 3 (TRPV3)2, and IL-33 from the epidermis, which were attenuated by pharmacologic inhibition of TRPV3 [In the study of Seo et al., the group showed that keratinocytes isolated from patients with AD exhibited enhanced expression and heat sensitivity with a hyperactive channel function of TRPV3 a. This sof TRPV3 .While TRPV1 has been extensively studied, the TRPV3 channel is now gaining recognition as a promising focus for skin regeneration. This is attributed to its impact on epidermal regeneration through EGFR signaling, specifically via the phosphatidylinositol 3 kinase (PI3K)/protein kinase B (AKT) pathway. Numerous investigations are being conducted to explore the potential of TRPV3 in this context .The endocannabinoid system (ECS) is an evolutionary complex intercellular signaling network, which plays roles in the modulation of the immune and nervous systems. The two main receptors for endocannabinoids (ECB) are the cannabinoid type 1 (CB1R) and cannabinoid type 2 (CB2R) receptors, which are G-coupled proteins expressed in epidermal keratinocytes, melanocytes, dermal cells, mast cells, sweat glands, hair follicles, and cutaneous nerve fibers, as shown in A Phase Ib/IIa trial, employing a multiple-dose, double-blind, randomized placebo-controlled design, was conducted to assess the efficacy of oral CBR2 agonist S-777469 b in indiDue to the similar ligand-binding between CBR1 and CBR2, targeting the CBR2 ligands remains to be a therapeutic challenge. Given the neuro-skin physiology pathways as one of the multifactorial factors of AD, future studies developing topical cannabinoids with greater polarity and higher CBR2 selectivity must be taken into consideration .The family of protease-activated receptors (PARs) includes protease-activated receptor-1 (PAR-1), protease-activated receptor-2 (PAR-2), protease-activated receptor-3 (PAR-3), and protease-activated receptor-4 (PAR-4). In vivo and in vitro studies suggest the roles of PARs in the regulation of epidermal permeability and barrier function .Protease-activated receptor-2 (PAR-2), a G-protein coupled receptor expressed in keratinocytes, neurons a, and inTopical methylbenzyl methylbenzimidazole piperidinyl methanone (MMP), a selective PAR-2 inhibitor b, was stGiven their role in the pathogenesis of AD via the Th2 axis immune response, Th17/22 axis immune response, Th1Axis immune response, skin barrier dysfunction, and pruritus in pain, the JAK/STAT pathway has been the target of numerous therapeutic agents for AD . There iAfter demonstrating both safety and efficacy in multiple clinical trials, ruxolitinib 1.5% cream, an inhibitor of JAK1 and JAK2 b, receivIn a phase IIa study conducted by Bisonnette et al., the topical (ointment) form of tofacitinib, an inhibitor of JAK1, JAK2, and JAK3 b, demonsA pan-JAK inhibitor, topical delgocitinib (JTE-052) b, improvBrepocitinib, a selective JAK-1 and TYK-2 inhibitor b, was abIfidacitinib (ATI-502), a topical JAK inhibitor that selectively targets JAK1 and JAK3 b, has emOral tofacitinib b was useThe European Medicines Agency (EMA) has granted approval for the use of baricitinib, an oral selective Janus kinase 1 (JAK1) and Janus kinase 2 (JAK 2) inhibitor b, in aduThe US FDA has granted approval for upadacitinib, an oral reversible JAK inhibitor with higher potency for JAK1 b, availaIn the JADE COMPARE study—a randomized, double-blind, double-dummy, placebo-controlled trial—a total of 837 adult patients (aged ≥18 years) with moderate-to-severe AD were enrolled. The patients were randomly assigned to receive different treatment regimens for a duration of 16 weeks. The treatment options included oral abrocitinib at doses of 200 mg or 100 mg once daily, subcutaneous dupilumab at a dose of 300 mg every other week , or placebo, in addition to medicated topical therapy. The findings of the study revealed that oral abrocitinib at a dosage of 200 mg demonstrated superiority in treating pruritus compared to subcutaneous dupilumab at a dosage of 300 mg by the end of week 16. Moreover, a greater proportion of patients achieved a ≥4-point improvement from baseline in the Peak Pruritus Numeric Rating Scale (PP-NRS4) with abrocitinib 200 mg, starting as early as day 4 of treatment. Abrocitinib 100 mg exhibited a similar trend, with an improvement in PP-NRS4 observed by day 9. Additionally, significant skin clearance was observed in patients treated with abrocitinib at week 12 of the study . Rapid aGusacitinib (ASN002), a dual JAK-SYK inhibitor b, exhibiZhao et al. conducted a phase II randomized controlled trial in China to evaluate the efficacy and safety of oral ivarmacitinib (SHR0302), a highly selective JAK-1 inhibitor with a mild JAK2-inhibiting effect b in patiJaktinib hydrochloride is a pan-JAK inhibitor b that caThe European Medicines Agency recommended the use of JAK inhibitors such as abrocitinib, filgotinib, baricitinib, and tofacitinib in caution in patients with risk of cardiovascular problems, malignancy, venous thromboembolism, and serious infections. In addition, the committee also advises the use only JAK inhibitors if no other suitable treatment is available.Oral JAK inhibitors are a promising group of drugs that may provide a solution to the unmet need for patients who are intolerant or unresponsive to systemic agents or for patients with needle phobia.The family of suppressors of cytokine signaling (SOCS) comprises several members, including SOCS-1, SOCS-2, SOCS-3, SOCS-4, SOCS-5, SOCS-6, SOCS-7, and cytokine-inducible SH2 protein (CIS). As their name suggests, these molecules act as negative feedback stimulators, targeting the downstream components of the JAK-STAT pathway. In the context of AD pathophysiology, the role of SOCS-1, SOCS-3, and SOCS-5 as negative modulators is particularly significant. The modulation of the JAK/STAT/SOCS pathway using natural biomolecules may hold potential as a therapeutic target for future drug development.In vitro, in vivo, and human studies have shown that SOCS-1 inhibits IFN-γ signaling by binding to JAK1 and JAK2. This results in the inhibition of STAT1 phosphorylation of STAT1. Disabled Jak1 and Jak2 cannot mediate STAT1 phosphorylation, which is necessary for the activation of γ-activated sequence (GAS) inflammatory genes . A recenIncreased expression of SOCS-3 was observed in the skin of AD patients than in healthy individuals. In a mouse model, the overexpression of the SOCS-3 protein impaired Th1 differentiation and elevated levels of Th2 responses ,210. SOCWhile little is known about the function of SOCS-5, it has been shown to be involved in a variety of allergic disease states such as AD and asthma. Seki et al. concluded that SOCS-5 inhibits IL-4-dependent signaling toward the control of Th2 differentiation. In the mouse study of Sharma et al., the group was able to demonstrate the role of SOCS-5 in regulating the activation of STAT proteins and the phosphorylation of JAK1/2/3 but not TYK2 . SOCS prReseda luteola or can be taken as a dietary source in various fruits such as carrots, apple skins, peppers, rosemary, and thyme. This flavone was able to demonstrate an increased expression of SOCS-3 and suppressed STAT1/STAT3 phosphorylation in in vitro studies [Herba leunori, increased SOCS-5 expression and decreased the expression of JAK2/STAT3 in the in vitro studies of Liu et al. [Rosa agrestis leaves, showed an elevated SOCS-5 expression, decreased Th2 differentiation, and downregulation of IL-4, IL-5, IL-15, IL-31, and IgE in mouse models [Curcumin from Curcuma longa in various experimental studies demonstrated its ability to upregulate SOCS1 and inhibit phosphorylation of JAK2, STAT3, and STAT6 ,215,216. studies . Further studies . Leunoriu et al. . Astragae models ,224.γ-activated HaCaT cells to detect Th1/Th2/Th17/Treg cell imbalances using flow cytometry. The group found out that a high expression of YAP was found in healthy individuals and mice, suggesting its role in the function and maintenance of Tregs [It is established that the Th1/Th2 imbalance is involved in the pathophysiology of AD. However, recent studies have shown that the Th17 and Treg cells play important roles in AD . Yes-assof Tregs . Their sof Tregs . AD beinof Tregs . In the of Tregs  and it pof Tregs . The dowof Tregs . FurtherIn our review article, we focused on the challenges and the recently developed pharmacological agents in AD based on the specific pathophysiology through modulation of the skin microbiome and improvement of the skin barrier in combination with the selection of appropriate agents that target the innate and adaptive immune system that would significantly make an impact in improving the itch–scratch cycle.A new era in the treatment of AD treatment is approaching, and much more effective therapeutic targets based on molecular and therapeutic phenotype selection will be more readily available and, as a result, every individual patient will have tailored and more personalized treatment options. Recent findings of various clinical trials also showed that we might have opportunities to use a blend or combination of different drugs if there is an insufficient response.Biologic agents will continue to dominate the AD treatment market for years to come. JAK inhibitors offer an important oral option to the AD population. However, more long-term studies are needed on the maintenance of therapeutic efficacy and safety of novel drugs targeting newly discovered cytokines and receptors.More importantly, a multidisciplinary approach is important for achieving a better health-related quality of life in patients with AD. The importance of patient and caregiver education cannot be overly emphasized. A deeper understanding of the complex pathogenesis of AD will lead to the development of newer therapeutic targets and innovative therapeutics.


The purpose of this meta-analysis is to compare the long-term efficacy of transanal local excision (TLE) versus total mesorectal excision (TME) following neoadjuvant therapy for rectal cancer.The Web of Science, Pubmed, Medline, Embase, and the Cochrane Library were systematically searched for correlational research. The Newcastle-Ottawa Scale and the Cochrane risk of bias tool were used to assess the quality of cohort studies (CSs) and randomized controlled trials (RCTs), respectively. Statistically analyzed using RevMan5.4.A total of 13 studies, including 3 randomized controlled trials (RCTs) and 10 cohort studies (CSs), involving 1402 patients, were included in the analysis. Of these, 570 patients (40.66%) underwent TLE, while 832 patients (59.34%) underwent TME. In the meta-analysis of CSs, no significant difference was observed between the TLE group and TME group regarding 5-year overall survival (OS) and 5-year disease-free survival (DFS) (P > 0.05). However, the TLE group had a higher rates of local recurrence (LR)  and a lower rates of 5-years local recurrence-free survival (LRFS)  compared to the TME group. In the meta-analysis of RCTs, there was no significant difference observed between the TLE group and TME group in terms of LR, 5-year OS, 5-year DFS, and 5-year disease-specific survival (P > 0.05).After undergoing neoadjuvant therapy, TLE may provide comparable 5-year OS and DFS to TME for rectal cancer. However, neoadjuvant therapy followed by TLE may has a higher LR and lower 5-year LRFS compared to neoadjuvant therapy followed by TME, so patients should be carefully selected. Neoadjuvant therapy followed by TLE may be a suitable option for patients who prioritize postoperative quality of life. However, the effectiveness of this approach requires further research to draw a definitive conclusion. Since its introduction in 1982 by Heald et al., total mesorectal excision (TME) surgery has become the established standard for the curative treatment of mid-to-low rectal cancer. This surgical approach has markedly reduced the incidence of local recurrence (LR) compared to traditional surgery and has effectively improved the survival rates of patients . DespiteThis paper followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)  and asseAn electronic search was done by two independent researchers (LYH and LL) from the databases of Web of Science, Pubmed, Medline, Embase, and the Cochrane Library to search for the relevant studies which were published from inception of these databases to March 1st, 2023. No restrictions were entered for the search. A literature search was performed using the following index terms: “rectal cancer”, “total mesorectal excision”, “transanal endoscopic microsurgery”, “transanal minimally invasive surgery”, “transanal local excision” and “local transanal excision”.Inclusion criteria:(1) Only published English cohort studies (CSs) or randomized controlled trials (RCTs) will be included. (2) The diagnosis of rectal cancer should include pathological examination, clinical evaluation, colonoscopy, and one or more imaging examinations. (3) No distant metastases. (4) The outcome indicators should include at least one of the following: LR, overall survival (OS), disease-free survival (DFS), local recurrence-free survival (LRFS), and disease-specific survival (DSS). (5) The experimental group underwent TLE, including TEM, TAMIS, and traditional transanal surgery, with complete local excision of the lesion. The control group underwent TME, including laparoscopic, open, and robot-assisted rectal cancer resection surgeries. (6) Both the experimental and control groups received at least one type of neoadjuvant therapy, either radiotherapy or chemotherapy. (7) The total number of cases included in the study should be greater than or equal to 20.(8) Median follow-up time≥ 36 months.Exclusion criteria: (1) Patients with recurrent rectal cancer. (2) Basic research such as animal experiments. (3) Lack of sufficient data which we are interesting or cannot be calculated from the article data; (4) Duplicate data or repeat analysis. (5) The full text is not available. (6) Conference abstract.The data were extracted independently by 2 investigators (LYH and LL) and discrepancies were resolved in consultation with a third author (LGY). In cases where the same study population was reported in multiple research reports, the study with a greater sample size was chosen. If a study performed propensity score matching on two groups of patients, only the data from the propensity-score matched cohort was included. From each study the following information were collected: (1) author; (2) time of publication of the literature; (3) the country of study; (4) number of patients; (5) age of patients; (6) median follow-up time; (7) tumor clinical stage; (8) tumor pathological T staging; (9) histological grade; (10) tumor response after neoadjuvant therapy; (11) preoperative examination method; (12) surgical margin; (13) LR; (14) LRFS; (15) OS; (16) DFS; (17) DSS. Moreover, the HRs and 95% CIs for each endpoint were extracted.Two researchers independently evaluated all included studies. The Newcastle-Ottawa Scale and Review Manager (RevMan) computer program  were used to assess the quality of CSs and RCTs, respectively. The CSs were evaluated based on the selection of study population, comparability between TLE and TME groups, and outcome assessment. The RCTs were evaluated based on several aspects, including random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, other bias. Additionally, funnel plot for LR in CSs was analyzed to evaluate publication bias.2 values. It was considered indicative of low, moderate and high heterogeneity when I2 statistic ≤ 25%, 25% < I2 statistic < 50%, and I2 statistic ≥ 50%, respectively. An I2 statistic ≤ 50% showed no significant heterogeneity, and the fixed-effects model was used. If there was statistical heterogeneity among the results of each study, meta-regression analysis and subgroup analyses were applied to investigate factors for heterogeneity. After excluding the influence of obvious clinical heterogeneity, the random effect model was applied. For meta-analyses that include more than 5 studies, we conducted sensitivity analysis by sequentially removing one study or changing the meta-analysis model to evaluate the stability of the results. Differences were considered statistically significant at a P-value of ≤ 0.05.All statistical analyses were conducted using Revman Manager 5.4, which was provided by the Cochrane Collaboration. Treatment outcomes were expressed as risk ratios (RR) or hazard ratio (HR) and calculated from the raw data extracted from each study. Heterogeneity among the included studies was evaluated using the I.A total of 3653 relevant publications were identified on primary literature search. After removing the duplicates, 2189 articles were identified as eligible, of which 2150 were eliminated after reading of the title and abstract. A total of 39 studies were assessed for eligibility with full-text. Based on the exclusion and inclusion criteria, twenty-six of them were excluded because 9 was conference abstract, 5 reported non-relevant patients, 1 analyzed short-term efficacy, 2 were duplicate data, 8 was quality of life research and 1 has small sample. Lastly, 13 literatures embracing 1402 patients met the inclusion criteria, which were included for extracting needed data (Tables 1 and 2). Of all 13 studies, ten were CSs   , suggesting a correlation between TLE and increased LR. Deleting any single study or converting to a random effects model did not affect the results of this study, indicating that the fixed effects model’s calculated results are stable and reliable.Ten studies reported LR –37. Hete2 = 0%). Therefore, we conducted a meta-analysis using a fixed-effects model. Significant difference was found with respect to 5-year LRFS between the 2 groups  , suggesting a correlation between TLE and lower 5-year LRFS.Four studies reported 5-year LRFS , 36, 37.2 = 32%). Therefore, we conducted a meta-analysis using a fixed-effects model. No significant difference was found with respect to 5-year OS between the 2 groups  . Deleting any single study or converting to a random effects model did not affect the results of this study, indicating that the fixed effects model’s calculated results are stable and reliable.Six studies reported 5-year OS , 34–37. 2 = 0%). Therefore, we conducted a meta-analysis using a fixed-effects model. No significant difference was found with respect to 5-year DFS between the 2 groups  . Deleting any single study or converting to a random effects model did not affect the results of this study, indicating that the fixed effects model’s calculated results are stable and reliable.Six studies reported 5-year DFS , 35–37. 2 = 0%). Therefore, we conducted a meta-analysis using a fixed-effects model. No significant difference was found with respect to LR between the 2 groups  .Three studies reported LR –40. Hete2 = 0%). Therefore, we conducted a meta-analysis using a fixed-effects model. No significant difference was found with respect to 5-year OS between the 2 groups  .Two studies reported 5-year OS , 40. Het2 = 0%). Therefore, we conducted a meta-analysis using a fixed-effects model. No significant difference was found with respect to 5-year DFS between the 2 groups  .Three studies reported 5-year DFS –40. Hete2 = 0%). Therefore, we conducted a meta-analysis using a fixed-effects model. No significant difference was found with respect to 5-year DSS between the 2 groups  .Two studies reported 5-year DSS , 40. HetIn recent years, there has been controversy surrounding the effectiveness of local excision after neoadjuvant chemoradiotherapy for rectal cancer.In 2016, Hallam et al.  reportedThe meta-analysis results of CSs in this paper indicated that while patients with rectal cancer who underwent TLE after neoadjuvant therapy may have provided comparable 5-year OS and 5-year DFS to those who underwent TME surgery, the LR in the TLE group was significantly higher and the 5-year LRFS was significantly lower compared to the TME group. However, the meta-analysis of RCTs showed no significant statistical difference in LR between the TLE and TME groups. In addition to the small sample size in RCTs, the reason for the difference in results may also be related to the composition of TLE group patients in both RCTs and CSs, including the tumor stage before neoadjuvant therapy, tumor stage after neoadjuvant therapy, tumor pathological characteristics, and the proportion of salvage surgery performed due to adverse pathological factors. Apart from surgical methods, patients with stage II/III/IV rectal cancer based on TMN staging have been proven to be a risk factor for LR after surgery , 46. TheThe pathological status after rectal cancer surgery is also related to the LR. Studies showed that rectal cancer patients with lymphovascular invasion, extramural venous invasion, positive margins, serosal involvement, and poorly differentiated tumor cells confirmed by postoperative histopathology had a much higher LR rates than those without , 46. TheIn the CSs included in this article, eight studies reported the probability of ypT0-1 in the TLE group, which were 80.4% (41/51), 71.8% 28/39), 50% (4/8), 100% (42/42), 28.6% (14/49), 100% 35/35), 77.1% 37/48) and 81.9% (45/55) , 35–37. /35, 77.1/48 and 8, 50% Click here for additional data file.