Post-hepatectomy liver failure (PHLF) is a serious complication of hepatectomy. The current criteria for PHLF diagnosis (ISGLS consensus) require laboratory data on or after postoperative day (POD) 5, which may delay treatment for patients at risk. The present study aimed to determine the associations between early postoperative (POD1) serum aminotransferase levels and PHLF.The medical records of patients who underwent hepatectomy at Ramathibodi Hospital from January 2008 to December 2019 were retrospectively examined. Patients were classified into PHLF and non-PHLF groups. Preoperative characteristics, intraoperative findings, and early postoperative laboratory data  on POD0 to POD5) were analyzed.A total of 890 patients were included, of whom 31 (3.4%) had PHLF. Cut-off points for AST of 260 U/L and ALT of 270 U/L on POD1 were predictive of PHLF. In multivariate analysis, AST > 260 U/L on POD1, ICG-R15, major hepatectomy, blood loss, and INR were independently associated with PHLF.Early warning from elevated serum AST on POD1, before a definitive diagnosis of PHLF is made on POD5, can help alert physicians that a patient is at risk, meaning that active management and vigilant monitoring can be initiated as soon as possible. Post-hepatectomy liver failure (PHLF) is the most serious complication and a common cause of mortality following hepatic resection Russell, . The curPredictors of PHLF can be categorized into three main groups with regards to the timing the predictor may be present: preoperative, intraoperative and postoperative predictors. Many studies have tried to identify preoperative risk factors for the development of PHLF  5 were excluded from the study. A further 21 patients were excluded  resulting in the final sample size of 890 patients. The study protocol was approved by the Institutional Ethical Committee at Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Thailand . At Ramathibodi Hospital, candidates for surgery were routinely evaluated by a multidisciplinary team comprising surgeons, gastroenterologists, medical oncologists, radiologists, and interventionists. All patients underwent preoperative cross-sectional dynamic imaging using triple-phase computed tomography (CT) or magnetic resonance imaging (MRI). Routine blood examinations were performed, including complete blood count (CBC), coagulogram, liver function tests (LFT), kidney function tests, and preoperative serum alpha-fetoprotein level. Preoperative characteristics including the American Society of Anesthesiologists class, evidence of viral hepatitis B or C infection, and smoking status were recorded. A preoperative indocyanine green retention test at 15 min (ICG-R15) was also performed. Preoperative biliary intervention was defined as history of percutaneous or endoscopic biliary drainage or any previous operative procedures involving the biliary tract. In our center, the extent of liver resection was based on the liver functional reserve, determined mainly in accordance with the Makuuchi’s criteria , aspartate aminotransferase (AST), alkaline phosphatase (ALP), serum albumin (Alb), INR, platelet, and serum phosphate (PO4) were collected.The occurrence of PHLF was determined in accordance with the criteria in the ISGLS consensus  and blood tests. Recurrent disease was defined as the presence of new tumors found on imaging (CT or MRI) during the follow-up period. For benign lesions, patients were followed up at an outpatient clinic at intervals deemed appropriate by the attending physician.t test, and categorical variables were analyzed using the chi-square or Fisher’s exact test. A p value of < 0.05 was considered statistically significant. The potential risk factors were analyzed by univariate and multivariate analyses using a Binary logistic regression model with stepwise and best subset approach for variable selection . The cut-off value of AST, ALT, and INR post-hepatectomy were determined by receiver operating characteristic (ROC) curve analysis. The values that provide the most accuracy for PHLF prediction were selected as cut-off values. Post-hoc power analysis for two-sample comparison of proportions to detect a statistical alpha of 5% significant level (two-sided) revealed a power of 0.83.For the patient characteristics, continuous variables were analyzed using the Student’s n Zhang, . Odds rap = 0.032) and more smokers than nonsmokers . The PHLF group had significantly worse ALBI score compared to the non-PHLF group . The PHLF group had significantly higher levels of certain preoperative laboratory data than the non-PHLF group, namely serum AST , ALT , and ALP . The PHLF group had higher incidence rate of cholangiocarcinoma than non-PHLF group . The ICG R15 value was higher in the PHLF group compared with the non-PHLF group . Most patients in the PHLF group received hepatic lobectomy, while most patients in the non-PHLF group underwent minor hepatectomy . The operative time was longer in the PHLF group compared with the non-PHLF group . The PHLF group also experienced greater intraoperative blood loss and longer clamp time than the non-PHLF group .Of the 890 patients who underwent hepatectomy from January 2008 to December 2019, 31 patients (3.4%) had PHLF. Of the 31 patients with PHLF, 17 (54.8%), 9 (29.0%), and 5 (16.3%) patients had PHLF grade A, B and C respectively. The clinicopathological characteristics of the cohort are summarized in Table p = 0.011), POD1 , POD2  and POD3 . The PHLF group also had significantly higher serum ALT on POD0 , POD1 , POD2 , and POD3 . Consistently, the PHLF group had significantly higher serum TB on POD0 , POD1 , POD2 , and POD3  as well as significantly higher INR on POD0 , POD1 , POD2 , and POD3 .Comparisons of postoperative biochemical data by day between the PHLF group and the non-PHLF group are shown in Table The kinetics of postoperative serum transaminase levels, TB, INR, Alb, and ALP in the PHLF group and non-PHLF group are shown in Fig. p = 0.037), DLP , smoking , ICG-R15 , major hepatectomy , operative time , blood loss , clamp time , POD1 ALT > 270 U/L , POD1 AST > 260 U/L , POD1 TB , POD1 ALP , and POD1 INR . Multivariate analysis identified the following independent factors associated with PHLF: ICG R15 , major hepatectomy , blood loss , POD1 INR , and POD1 AST > 260 U/L .The results of the univariate and multivariate analyses of potential early postoperative biochemical risk factors of PHLF are shown in Table Inadequate functional liver remnant after hepatectomy is the underlying pathophysiology for PHLF  or the transfer to an ICU can be started earlier.


The receptor for advanced glycation end products (RAGE) is a member of the immunoglobulin family that is overexpressed in several cancers. RAGE is highly expressed in the lung, and its expression increases proportionally at the site of inflammation. This receptor can bind a variety of ligands, including advanced glycation end products, high mobility group box 1, S100 proteins, adhesion molecules, complement components, advanced lipoxidation end products, lipopolysaccharides, and other molecules that mediate cellular responses related to acute and chronic inflammation. RAGE serves as an important node for the initiation and stimulation of cell stress and growth signaling mechanisms that promote carcinogenesis, tumor propagation, and metastatic potential. In this review, we discuss different aspects of RAGE and its prominent ligands implicated in cancer pathogenesis and describe current findings that provide insights into the significant role played by RAGE in cancer. Cancer development can be hindered by inhibiting the interaction of RAGE with its ligands, and this could provide an effective strategy for cancer treatment. Cancer is a leading cause of mortality globally—it is estimated to have accounted for 10 million deaths in 2020, which is approximately one-sixth of all deaths worldwide. In 2020, the most prevalent cancers were lung, breast, colorectal, prostate, skin (nonmelanoma), and stomach cancers, with 2.21, 2.26, 1.93, 1.41, 1.2, and 1.09 million cases, respectively. The most prevalent causes of cancer-related deaths were lung, colorectal, stomach, liver, and breast cancers, which accounted for 1.80, 0.935, 0.769, 0.83, and 0.685 million deaths, respectively [Receptor for advanced glycation end products (RAGE) is a 45 kDa multiligand transmembrane receptor in the immunoglobulin (Ig) superfamily that plays an important role in pathophysiological activities and has attracted considerable attention for therapeutic applications ,3. RAGE In identical tumor types, increased RAGE expression has been associated with increased tumor histological progression ,20,21,222O molecule connects to the amide nitrogen of Ile120 via the backbone atoms of Glu119 and Arg29 in the V domain. As hydrophobic interactions occur between the backbone atoms of Pro215 via the C1 F-G loop and Tyr118 via the C1 B-C loop and Ile91, the V and C1 domains of RAGE are consistently conserved and the VC1 domains have the same components [Full-length RAGE comprises a signal peptide (residues 1–22), an extracellular domain (residues 23–342) flanked by V, C1, and C2 domains, a transmembrane domain (residues 343–363), and a cytoplasmic domain (residues 364–404) as shown in mponents ,36. The mponents ,36,37,38mponents . Becausemponents ,40,41.Different isoforms of RAGE, including full-length RAGE, dominant-negative RAGE, N-truncated RAGE, and C-truncated secretory/soluble RAGE, have been reported. Excessive accumulation of RAGE on the cell membrane leads to multiple stimulatory and immunological responses ,43,44. RCalgranulins are small cell signaling proteins with Ca-binding sites and EF-hand motifs. These S100 family members act as stimulatory ligands that ensure interaction between two or more monomers for intracellular and extracellular processes and are responsible for cell growth, differentiation, and mobility ,54,55. The shortage of oxygen in tumors necessitates the glycolytic metabolism of glucose to fulfill the energy needs and is associated with the increased formation of advanced glycation end products (AGEs). Carboxymethyllysine (CML) is a lysine glycation end product that has been identified as one of the most prominent AGEs of tissue proteins. RAGE is a receptor for AGEs in various human malignancies; nonetheless, the presence of AGEs in human malignancies has largely been unexplored ,45,56,57Amphoterin (HMGB1) is an electrically neutral non-histone protein involved in transcription, DNA repair, differentiation, neural development, and extracellular signaling, and has a plausible connection with cancer. HMGB1 is a cytokine released by monocytes and macrophages or other cells, except for apoptotic cells. It is responsible for the pathogenesis of various inflammatory diseases and is involved in the secretion of inflammatory cytokines ,22,58,59In the present review, we discussed various aspects of RAGE and its prominent ligands, which are implicated in cancer pathogenesis, and summarized the recent findings that will provide novel insights into the significant role of RAGE and its ligands in cancer.Immunotherapy, in which immune cells are stimulated to destroy cancer cells, has gained significant attention among researchers and physicians as a valuable therapeutic option besides chemotherapy and targeted therapy. Exciting clinical remissions have been reported in incurably ill cancer patients with no other treatment options, which have laid the framework for many innovative cancer immunotherapies that are presently being investigated in clinical trials. However, the treatment outcomes of this remarkable approach are only relevant in 20–30% of all cancers ,65,66. IAGEs are products of nonenzymatic glycation, in which the bases of DNA react with reducing sugars, such as glucose, fructose, or deoxyribose, to form a Schiff’s base, which can lead to the formation of an Amadori product through an enamine intermediate. Furthermore, AGEs can also be formed through a variety of different processes, such as the oxidation of sugars, lipids, and amino acids, which produce active aldehydes that eventually become AGEs. The Amadori product undergoes dehydration, cyclization, condensation, and isomerization, culminating in the production of AGEs . The forAccumulating evidence implicates AGEs in aging, diabetes, and cancer. The interaction of RAGE with AGEs causes oxidative stress, which in turn promotes the production of AGEs and increases their interaction with RAGE . RAGE–AGHMGB1 is made up of an N-terminal A segment (residues 1–83), a B segment (residues 88–164), and a C-terminal acidic tail . ReceptoIn vitro and in vivo studies revealed that HMBG-1 promotes PGDF activity and expression of the vascular endothelial factor. The expression of HMGB1 involves various autocrine/paracrine factors, which are responsible for the positive feedback mechanism to its receptors. HMGB1 stimulates and promotes the expression of proangiogenic genes in endothelial cells. It may bind various receptors, including RAGE, TLRs, and syndecan-1 (CD138), which activate NF-κB and ERK1/2 C. It canExtracellular HMGB1 interacts with RAGE to increase the release of proinflammatory cytokines via NF-κB activation, which is responsible for harmful inflammatory responses ,90,91,92The binding of HMGB1 with RAGE through its carboxyl-terminal tail can stimulate RAGE, a criterion for cell motility; its binding to RAGE has a synergistic effect with a dominant inhibitor in stopping the progression of cancer . HMGB1 i2+ is a second messenger that regulates nerve conduction, muscle contraction, cell motility, gene expression, cell mortality, and necrosis. Ca2+ signaling is controlled by calcium-binding proteins, which regulate Ca2+ concentration in the cytoplasm [2+. S100 proteins, such as S100B, S100A6, S100A7, S100A8, S100A9, S100A10, and S100A12, are EF-hand calcium-binding proteins that form homo- and heterodimers. Cysteine and histidine are major constituent amino acids in these proteins. These proteins undergo a structural change upon calcium-binding, which is responsible for protein–protein interaction. The protein–protein interaction site of S100B contains hydrophobic and polar residues required for high binding affinity. S100B functions extracellularly in a cytokine-like manner and shows unique interaction with RAGE [Caytoplasm ,115,116.ytoplasm . In addiith RAGE ,119,120.S100A4, also known as calvasculin/metastatin/placental calcium-binding protein/protein Mts1, is abundantly expressed in various cancers. Its expression is associated with malignant growth. It affects various cellular processes, such as angiogenesis, metastasis, and cell growth, and also increases the expression of matrix metalloproteinases ,123,124.2+ is coordinated via the backbone carboxyl group at Ser20, Glu23, Asp25, Lys28, the side-chain carbonyl of Glu33, and an H2O molecule. The two binding sites are contiguous in space and involve hydrophobic interactions between Lys28 from site 1 and Glu69 from site 2 [S100A4 has a 12-amino acid calcium-binding domain at the C-terminus and an N-terminal pseudo-EF-hand with 14 residues ,138. It m site 2 ,141,142.2+. S100A6 belongs to the calgranulin family and is involved in the propagation of calcium signals. It is conspicuously located in the cytoplasm although it has also been detected in the extracellular matrix and various body fluids. It is highly expressed in the muscles, lungs, kidneys, and brain. The signaling pathway is aided by the extracellular binding of S100A6 with RAGE. Calcium binding induces a conformational change in S100A6, which increases its hydrophobicity and allows for interaction with target proteins. Elevated levels of S100A6 have been observed in epithelial cells, fibroblasts, and several types of tumor cells. The function of S100A6 is unknown; however, it is thought to be involved in cell propagation, cytoskeletal dynamics, and tumorigenesis [Homodimeric S100A6 (10–11 kDa) is a calcium-binding protein that is believed to also interact with Znigenesis ,145,146.2+ per monomer, each through an EF-hand structure composed of two helices connected by a short loop region. S100A6 can also bind two Zn2+ per monomer and can serve as a Zn2+ chelator mostly in the cytoplasm, but also outside the cell. Under conditions of increased Ca2+ concentration, S100A6 can associate with the nuclear envelope and plasma membrane [S100A6 functions as a homodimer formed by noncovalent interactions and binds two Camembrane ,148. Themembrane ,149,150.membrane ,152. S10membrane ,157,158.2+ EF-hand motifs and two Zn2+ ions at the binding site that span the dimer interface. S100A7 has been postulated to be involved in cell propagation, relocation, invasion, and tumor metastasis. Its expression is higher in cervical cancer compared with that in normal cervical tissues. The binding of S100A7 with RAGE activates the ERK signaling cascade, promotes cell mesenchymal competence, and induces epithelial–mesenchymal transition. Human S100A7 induces IL-1α expression in keratinocytes through RAGE-p38 MAPK-calpain-1 signaling  and S100A9/MRP14 (13.2 kDa) are calcium-binding proteins expressed by neutrophils and activated monocytes. At basal concentrations, S100A8 and S100A9 display growth-promoting effects upon binding RAGE. Their binding to RAGE is implicated in breast cancer metastasis and stimulates the phosphorylation of LIN-11, IsL-1, and MEC-3 protein domain kinase, as well as cofilin. The binding of S100A8 and S100A9 with RAGE stabilizes Snail via NF-κB, enhances lung metastasis, and improves mesenchymal properties ,172,173.2+ binds to the EF-hand I, which exhibits additional varied sequences correspondingly, as in the crystal structures with specific ligands. In the homodimers of S100A8 and S100A9 with calcium-binding sites at the N terminus occupied, each monomer is held together by a hydrophobic core of conserved sequences. Homodimers are stabilized by interactions of hydrophobic sidechains among these helices. S100A8 homodimer interaction takes place at the surface of each monomer between Leu72 and Ile76, whereas S100A9 interaction takes place on S100A8 at the site of Ile76 in a single chain that connects two helices. S100A9/S100A8 connection provides extra balance to the S100A9 subunit and promotes transition for a stretch of 6–14 amino acid residues at the C-terminal end, α-helix customs a disorganized state to α-helical configuration through increased electron compactness. S100A8 and S100A9 heterodimers have disulfide bridges between S100A9 at Asp30, and in S100A8 at His83 and His87, these amino acids participate in the binding of two Zn+ ions [Carboxylated N-glycans are expressed on RAGE, for example, on immune and tumor cells, which mediate S100A8/A9 and RAGE binding, promoting receptor-mediated signaling and pathogenesis. In colon cancer, S100A8 and S100A9 induce RAGE- and carboxylated glycan-dependent phosphorylation of ERK1/2 and SAPK/JNK, but in prostate and breast cancer, they promote p38 phosphorylation. The binding of S100A8/S100A9 on RAGE and carboxylated glycan in colon cancer activates the NF-κB pathways, resulting in a life-threatening link between inflammation and cancer. S100A8 and S100A9 are recognized as novel target genes in hepatic carcinoma cells during inflammation-mediated liver carcinogenesis ,184,185.Zn+ ions ,188,189.2+ entry by limiting the FAK signaling pathway and MMP expression. In vivo and in vitro data demonstrate that S10014 inhibits NPC cellular motility via the NF-κB signaling pathway; moreover, it has been discovered that overexpression of S100A14 lowers the risk of NPC resistance to cisplatin [S100A14 is an 11.6 kDa protein belonging to the S100 family. It has an N-glycosylation site, a protein kinase phosphorylation site, and an N-myristoylation motif . S100A14isplatin ,199,200.0 and helix IV0, and the various connection link residues in helices IV and IV0 become constant. The association between two monomers was intended to be enhanced by residues 53–57 in the hinge loop, which was recognized by residues at the N-terminal of helix I0 and the C-terminal segment of helix IV. As a result, it is said that S100A14 takes a conformation distinguished from that of the canonical apo arrangement, and that the Ca2+ loaded from helices II and III are almost antiparallel, employing the canonical apo arrangement of S100 proteins. However, the superimposition of the current structure of S100A13 with the structures of the apo and holo forms of S100A13 reveals a well-structured fold that used the last N-terminal of S100A14 with 13 residues for the Ca2+-binding loop, and another Ca2+-binding loop reported at the end C-terminal of S100A14 [On other hand, a higher amount of S100A14, can cause apoptosis and increase the generation of reactive oxygen species. Exogenous S100A14 stimulates cell proliferation or promotes apoptosis at different doses based on in vitro findings ,205,206. S100A14 ,211,212.2+ binding motif significantly regulated in lung, ovarian, prostate, and breast cancers [2+ stimulation, implying that it may perform a role in ribonucleoprotein complex processing, gene silencing, or cell cycle development. The identified nuclear localization signal is absent in S100A16, as it is in other members of the S100 family. Phosphorylated S100A16 protein has been discovered in the nucleoli of HeLa cells, indicating that phosphorylation of S100A16 may play a role in nuclear translocation. S100A16 binds a single Ca2+ monomer at each atom, and it also binds Zn2+. However, the Ca2+ and Zn2+ binding sites are at distinct sites [S100A16/S100F is a 10–12 kDa protein with the EF-hand Ca cancers ,213,214.ct sites ,217,218.ct sites ,221,222.ct sites ,224. Conct sites .+ binding, one at the EF-hand C-terminal and the other at the S100 short N-terminal. S100 family proteins have highly conserved Ca+ ligand amino acids at 1, 3, 5, 7, and 12 locations, which generate an enhanced attraction for metals. The backbone oxygen atoms of the residues at the positions of 1, 4, 6, and 9, as well as two side-chain oxygen atoms of the residues at the 14 locations, which is generally glutamate, are placed at the position of the 14th residue. However, due to the absence of glutamate at the comparable location S100A16, the Ca+ binding affinity is reduced by the S100A16 shortage of glutamate by the side of this site. In addition, the N-terminal has 15 amino acids rather than 14, which is unique to S100A16. Dimerization of Apo S100A16 with Ca+-loaded S100A16 generally occurs across communications between helices I, I0, IV, and IV0, which is responsible for forming an X-type helix package. Trp80 and Ile83, two hydrophobic amino acids in helix IV0, form many contacts with Leu8, Val12, and Leu15 in helix I0, as well as Trp80 and Ile83 in helix IV0 of the other subunit. Amino acids at positions Glu45, Leu46, His48, and Met49, in the hinge loop between helices II and III, form connections with amino acids towards the N-terminus of the subsequent subunit of helix I0. The connections in a dimeric arrangement of S100A16 align helices I and IV in opposing orders to helices I0 and IV0, respectively [Interestingly, the S100 family proteins have two sites for Caectively .+-dependent progression; nevertheless, S100B ligation with Ca+ causes conformational rearrangement, causing several hydrophobic amino acids to become solvent-exposed. As a result, an interaction flanked by two associate proteins has been identified in rat S100B in multipart, using the C-terminal negative regulating domain, which comprises the amino acids in helices III and IV, and the S100B hinge loop [2+ binding reveals a significant hydrophobic grove near helix III on S100B. Homodimeric S100B binds two Ca2+, one at the position of the hinge-connected C-terminal and another at the site of the N-terminal EF-hand, indicating that many ligands result in RAGE-mediated signal transduction [2+, Cu2+, and Ca2+; therefore, Zn2+ interaction with S100B increases the attraction, as mentioned above, to Ca2+, particularly in the peptide and protein function [2+ organization at Asp61 on the X-axis, Asp65 on the Y-axis, and Glu72 on the Z-axis, which has many homologous sequences in the S100 family Ca2+ binding EF-hand ligand. Helix III, which closely follows in the loop in human S100B, causes a conformational change in the C-terminal loop with Ca2+ binding, resulting in a redirection of helix III involving helices II and IV, as seen in rat apo S100B [S100B is a 10.7 kDa protein, and its expression has been reported in many disorders, including neurological diseases and cancer. High S100B absorptions continue to be used as a biomarker for malignant melanoma, with the increasing amount of S100B indicating cancer progression. High expression of S100B is still linked to unfavorable liver metastases and early deterioration in colorectal cancer. On other hand, high expression of S100B reveals ovarian malignancy-associated utilizing primary cancers. By activating NK-кB, S100B ligation with RAGE improves cell survival. S100B, a RAGE ligand that promotes tumorigenesis by promoting IL-6 expression and STAT-3 activation, is abundantly expressed in gliomas ,234,235.nge loop ,245. Ca2sduction ,246,247.function ,249. S10function ,250,251.po S100B ,211,252.2+-binding loop I, on the other hand, attaches to helices I, one at Glu3 to Ser19 and the other at Lys30 to Glu40, forming the N-terminal EF-hand, whereas helices III at Ala53 to Ala63 and helices IV at Phe71 to His86 are linked via the Ca2+-binding loop II, forming the C-terminal EF-hand. The Ca2+-binding loop forms the N-terminal EF-Hand I attaching to helices I, one at Glu3 to Ser19 and the other at Lys30 to Glu40, whereas the C-terminal EF-hand is formed by the Ca2+-binding loop II connecting helices III at Ala53 to Ala63 and helices IV at Phe71 to His86. There appears to be no change in preceding Ca2+ binding in the S100 family, but there is a change in the relative position of loop I to helices I and II. Phe44 to Gly48 participate in a short α-helix that connects with two Ca2+ binding domains at Leu41 to Asp52 [S100P, a RAGE ligand, has been found in prostate, pancreatic, lung, breast, and colon cancers ,256,257.to Asp52 ,262. Theto Asp52 ,264.Cell adhesion molecules are life-threatening in tumor growth and are classified into several functions and classifications. Cell adhesion molecules of various classes and roles can collaborate and temper the signaling purpose of receptor tyrosine kinases and soluble proteins in the extracellular matrix, accompanied by cadherins, integrins, immunoglobulin family CAMs, and CD44 . They plSimilarly, IgSF associates such as L1CAM, NCAM, PECAM-1, ALCAM, and ICAM-1 are associated with metastatic development in melanoma, glioma, breast, ovarian, endometrial, prostate, and colon cancer ,275,276.The complement component is a danger-sensing organization for external pathogens and endogenous modified characters. Although there is no conclusive proof, the complement component has a function in tumor resistance, according to available studies. The complement component, on the other hand, appears to be more effectively induced in tumor cells and their non-malignant specimens . Even thAdvanced lipoxidation end products (ALEs) are a collection of adducts and cross-links formed by the nonenzymatic response of reactive carbonyl species (RCS) produced by lipid peroxidation, lipid breakdown by nucleophilic sites of proteins , amino phospholipids, and DNA . LipoxidLipoxidation is a well-known process between electrophilic carbonyl species and certain proteins, which is characterized by the oxidation of lipids and, in some situations, the alteration of protein characteristics. Studies on lipoxidation have revealed the impact of cancer growth on tumor cells, the change of immune elements, and subsequent immune response stress. Protein adducts disrupt a variety of proteins in cancer that can activate various types of machinery, such as cell division, differentiation, and death. In in vivo findings on the human colon, adenocarcinoma showws a reduced appearance of TGFb-1 and a scarcity of 4-HNE protein adducts, implying that neoplastic evolution is healthier under these conditions. Meanwhile, TGFb-1 and 4-HNE collaborate to promote colon cell apoptosis by activating the JNK pathway ,292. At Lipopolysaccharide is a bacterial antigen that plays a vital role in cancer progression by encouraging the release of IL-8 and TGF-1, which promotes the growth and invasion of liver cancer cells, colorectal cancer cells, and leukemia cells ,296,297.RAGE–AGE interaction enhances the activation of the PI3K, oncogenic Ras, PKC, and Rho/GTPase partners (Cdc-42 and Rac-1) signaling pathways, which is mandatory for cell survival, stress responses, apoptosis, the release of growth factors, proinflammatory cytokines, and motility  21,207,,302. A pIn vitro and in vivo findings of S100A8/9 interaction with RAGE can cause human breast cancer, human prostate cancer, colon tumor, and oral and esophageal tumors ,310,311.In vitro experiments with S100 proteins and HMGB-1 in mutual ligation with RAGE stimulate HMGB-1 ligation on RAGE. Likewise, via S100P, the first 40 amino acids of HMGB-1, the HMGB-1 derivative peptide, can prevent the ligation and activation of RAGE. RAGE inhibitor peptide sequences occur at residues 32–42 on S100P in the same region as many other S100 family members. RAGE inhibitor peptides can disrupt the connection between S100P, HMGB-1, and S100A4 on RAGE as shown in RAGE has been identified as an oncogenic protein that promotes the development and spread of various malignancies. However, the migratory and invasive abilities of NSCLC cells are reduced when siRNA inhibits RAGE. RAGE is also involved in EMT, reducing RAGE and initiating transmutation from mesenchymal to epithelial signals in cell lines. Moreover, we found RAGE to be a factor in epithelial–mesenchymal transition (EMT), with RAGE deficiency resulting in the transmutation of mesenchymal to epithelial markers in cell lines. According to in vivo data, siRNA can decrease RAGE and tumor growth and proliferation ,321,322.RAGE accumulation is associated with increased microvessel efficiency in colorectal tissue samples, and the familiar method can reduce VEGF expression by silencing RAGE expression, implying that RAGE plays a role in VEGF expression and blood vessel formation in colorectal cancer. Furthermore, the VEGF gene promoter’s convenient domain has significant GC-rich motifs that may be modulated by transcriptional factor explicitness (SP1) ,324. AccIn contrast to RAGE, RGBO1 is a monoclonal antibody. KLH (keyhole limpet hemocyanin) linked RAGE was injected into mice, and the KLH coupled peptides corresponding to amino acid residues 198–217 or 327–344 of the RAGE protein. Replicas were selected based on a positive ELISA screen utilizing BSA  linked peptides. RGBO1 is a clone of the full-length RAGE protein . In vivoFurthermore, RBGO1 ADC is effective in vivo at a 7.4 µg/ml concentration. The RAGE importance on RBGO1 ADC was significantly more potent than the same ADC focus on HER2. RAGE-directed efficacy of ADCs is based on V-domain binding, and RGBO1 ADC is 200-fold more effective than cytotoxic drug therapy alone . These fSorafenib, a kinase inhibitor, has been approved to treat early-stage kidney cancer, advanced liver cancer, and thyroid carcinoma. RAGE is overexpressed in both tumor and stromal cells; however, RAGE accumulation is more prominent in tumors, and RAGE targets in HCC cell lines can enhance autophagy . RAGE acDuloxetine, commonly known as serotonin/noradrenaline, is a reuptake inhibitor (RI) used to treat depression and neuropathic pain. It has also been employed for the treatment of chemotherapy-induced acentric neuropathy ,325. GaoIn various studies, an anti-thrombotic medicine, achieving the perfect anti-coagulant, was critically employed for modern hematology and oncology with the affected patient, who was at the greatest risk of bleeding and circulatory thromboembolism through RAGE of an NF-κB dependent on luciferase reporter assay and the human fibrosarcoma cell line (HT1080); heparin decreased the HMGB1 level and encouraged the activation of NF-κB . HeparinThe HMGB-1 antagonist peptide sequence was compared to the S100P sequence and a resemblance was found in amino acid sequence and pattern between the first 40 residues of S100P and the 33 residues of RAGE-obligatory peptide derived from HMGB-1. The discovery of this likeness resulted in the modeling of three peptides from the S100P sequence, each of which was 95% pure. The peptides were designed with the amino terminus by amidation, and the carboxyl terminus by acetylation to improve their consistency. A RAGE inhibitor derived from S100P can prevent the adherence of various RAGE ligands involved in inflammation and cancer. In vivo data revealed that the S100P-derived inhibitor may have therapeutic potential against glioma and pancreatic cancer and may inhibit a variety of RAGE ligands, implying that it could be useful in additional RAGE-related diseases .RAGE overexpression stimulates cervical cancer cell proliferation and increases the appearance of proliferating cell nuclear antigens. Meanwhile, RAGE overexpression inhibited cells, resulting in apoptosis suppression, a reduction in Bax/Bcl-2 levels, and activation of PI3K/AKT. SiHa cell capability and PCNA appearance were decreased by FPS-ZM1, a RAGE inhibitor, which also increased cell death and Bax/Bcl-2 levels. The PI3K inhibitor LY294002 decreased PI3K and AKT activation and RAGE accumulation, promoting cell proliferation and death [HMGB1 has a key function in autophagy stimulation in vital carcinogenesis, and it is mostly found in the cytoplasm of human gastric cancer cells with cell death and survival supervisory body. Gefitinib is an EGFR inhibitor, and HMGB1 release from tumor cells treated with gefitinib promotes autophagy, interacts with RAGE, and induces ERK1/2 signaling in gastric cancer cells. HMGB1 inhibitors, such as gefitinib, and RAGE inhibitors might play an essential role in preventing cancer regrowth, as suggested by HMGB1-related autophagy in chemotherapy .Metformin use has been linked to duction in the occurrence and mortality of breast cancer in diabetics patient. AGEs appear to have accelerated MCF-7 cell proliferation, which was inhibited by 0.01mM or 0.1mM metformin or anti-RAGE antibodies. Metformin, at a dosage of 0.01 mM, also suppressed the AGE-induced upregulation of RAGE and VEGF mRNA levels in MCF-7 cells. In AGEs-exposed MCF-7 cells, compound C, an AMP-triggered protein, appeared to block the growth inhibition of metformin, RAGE, and VEGF effects. As reported, metformin may limit AGE-induced growth and VEGF expression in MCF-7 breast cancer cells by RAGE expression via the AMP-triggered protein kinase pathway. As a result, metformin may protect diabetic individuals against breast cancer expansion by inhibiting the AGEs–RAGE axis ,332,333.In vivo and in vitro research reveals that RAP inhibitor inhibits the ligation of S100A4, S100P, and HMGB-1 with RAGE at micromolar concentrations. The efficiency of the ligands to promote RAGE activation of NF-κB in cancer cells is hampered by the presence of a RAP inhibitor. Systemic in vivo study of RAP significantly reduced the growth and spread of pancreatic and glioma tumors. The RAP has the potential to explore RAGE issues and cure RAGE-related disorders in vivo [ in vivo .Cromolyn is an antiallergen, and its study revealed that it inhibits S100P. Cromolyn is a RAGE inhibitor that reduces cancer growth, endurance, and invasiveness in vitro by inhibiting RAGE interaction with S100P. Cromolyn inhibited the NF-κB pathway in pancreatic cancer with endogenic S100P in vitro and in vivo. In mouse models, studies show that the processes clarify the pragmatic suppression of tumor development and cromolyn’s capacity to increase gemcitabine’s efficacy in eradicating pancreatic cancer cells .An ethyl ester of pyruvic acid effectively inhibits HMGB1 in treating inflammatory diseases and malignancies ,335,336.Papaver somniferum. Contrary to multiple tumor cells, papaverine demonstrated discriminating anticancer effects [A non-narcotic opium alkaloid derived from the plant  effects ,339. An Phellinus linteus that can be used as a major medication due to its biological applicability as an antioxidant and anticancer. Hispidin may be a novel gemcitabine chemosensitizer and a cooperative representative that can shift the gemcitabine therapeutic indication to pancreatic cancer treatment. Furthermore, hispidin induces apoptosis in colon cancer cells via a class of reactive oxygen species. Fungi and bacteria make ergothioneine, a thiol molecule. A mixture of 2 µM ergothioneine and hispidin reduces the development of AGEs, RAGE expression, and the activation of NF-κB in a PC12 cell line from rat pheochromocytomata (Hispidin is a polyphenol derived from the fungus cytomata  [340,341We reviewed RAGE and its ligands, as well as various inhibitors that can provide a platform for researchers and clinicians to develop a novel strategy for tackling numerous types of cancers, considering that RAGE is a cell surface receptor known to interact with a wide range of ligands. Multiple small RAGE inhibitors were explored in this review for their ability to inhibit RAGE in various malignancies. The current research shows that RAGE and its interaction with ligands increase the efficiency of antiapoptotic proteins while diminishing the effectiveness of proapoptotic proteins in promoting cancer cell proliferation, invasion, and angiogenesis. In the initial sections of this review, we described the role of RAGE ligands in cancer progression, particularly AGEs, HMGB1, S100 proteins, adhesion molecules, complement components, ALEs, and lipopolysaccharides, which play important roles in cancer biology in conjunction with RAGE. In the later sections, we focused on various anti-RAGE therapeutics, particularly mAbs, peptides, and small molecules, for managing cancer metastasis. The utilization of existing and newly discovered RAGE inhibitors for cancer prognosis might reduce the burden of cancer. Additionally, several existing RAGE inhibitors, acting as anticancer drugs, which could be beneficial in integrated treatment strategies, were also presented.


Background: Low grade glioma is one of the most common lethal cancers in the human nervous system. Emerging evidence has demonstrated that homeobox A cluster (HOXA) gene family plays a critical role in the transcriptional regulation as well as cancer initiation and progression. However, the expression, biological functions and upstream regulatory mechanism of 11 HOXAs in low grade glioma are not yet clear.Methods: In this study, we utilized various public databases and bioinformatics analyzed, including TCGA, CGGA, Rembrandt, HPA, LinkedOmics, cBioPortal, TISDIB, single-sample GSEA (ssGSEA), TIMER, LnCeVar, LASSO regression, Cox regression, Kaplan-Meier plot, and receiver operating, characteristic (ROC) analyses, GDSC and CTRP databases to analyzed the mRNA and protein expression profiles, gene mutation, clinical features, diagnosis, prognosis, signaling pathway, TMB, immune subtype, immune cell infiltration, immune modulator, ceRNA network and drug sensitivity of 11 HOXAs. Growth curve and transwell assays were utilized to study the biological characteristics of HOXA6 in LGG progression.Results: In the present study, we found that 11 HOXAs  were consistently up-regulated in LGG tissues and GBM tissues. Up-regulated of the HOXAs expression were significantly correlated with higher tumor stage, IDH mutation status, 1p/19q co-deletion, histological type and primary therapy outcome. Survival analyses showed that higher expression of HOXA1, HOXA2, HOXA3, HOXA4, HOXA5, HOXA7, HOXA9, HOXA10, HOXA11 and HOXA13 were correlated with shorter overall survival (OS), disease-specific survival (DSS) and progression-free survival (PFS) in LGG patients. Univariate and multivariate analyses revealed that HOXA1, HOXA6 expression and tumor grade, age, primary therapy outcome and age were independent factors affecting the prognosis of LGG patients. ROC curve analysis of HOXAs showed that HOXAs had a high accuracy (AUC > 0.80) in predicting LGG. Furthermore, gene functional enrichment analysis indicated that HOXAs mainly involved in the inflammatory response and immune regulation signaling pathway. CNV and DNA methylation significantly affect the expression of HOXAs. Finally, we uncover that HOXAs expression are highly correlated with immune cells infiltrate, immune modulator and drug sensitivity. We also uncover that the HOXAs related ceRNA network in LGG. More importantly, we found that HOXA6 was highly expressed in LGG cells lines and significantly affected their proliferation and migration abilities.Conclusions: In conclusion, our data demonstrated that HOXA was correlated with progression and immune infiltration, and could serve as a prognostic biomarker for LGG. Low grade glioma (LGG) is a relatively common tumor in the central nervous system that mainly includes World Health Organization (WHO) grade 2 and 3 gliomas . EmerginAs a member of homeobox genes, the HOXA cluster genes family including the HOXA1 to HOXA7, HOXA9, HOXA10, HOXA11 and HOXA13 . Zheng ein vitro assay to explore the function of HOXAs in LGG progression.In this study, we conducted a comprehensive bioinformatics analysis of the expression profiles, genetic alterations, clinicopathological parameters, diagnosis values, prognostic values and immune functions of HOXA family in LGG. Furthermore, we perform CNV, DNA methylation, KEGG analysis for the HOXA family. Finally, we examined the correlation between HOXAs expression and immune cells infiltration, immune modulator and drug sensitivity. We also perform the https://www.cancer.gov/) and CGGA (http://www.cgga.org.cn/) [https://www.proteinatlas.org/) database utilized to examine the protein of HOXAs in LGG [We utilized TCGA database (org.cn/) –10 to exs in LGG .http://www.linkedomics.org/login.php) obtained the co-expression genes of HOXAs in LGG. We were using clusterProfiler package to examine the function of HOXAS in LGG [http://genemania.org/) used to constructed gene-gene interaction network of HOXAs [In the present research, we utilized the LinkedOmics database  [http://cis.hku.hk/TISIDB/) database utilized analysis the expression of HOXAs in different immune subtype of LGG [TIMER (/timer/) , an inte/timer/) . The TISe of LGG .http://www.cancerRxgene.org) is the largest public resource for information on drug sensitivity in cancer cells and molecular markers of drug response. Data are freely available without restriction. GDSC currently contains drug sensitivity data for almost 75 000 experiments, describing response to 138 anticancer drugs across almost 700 cancer cell lines. In this study, we utilized the Genomics of Drug Sensitivity in Cancer (GDSC) (http://www.cancerRxgene.org) and the Cancer Therapeutics Response Portal (http://www.broadinstitute.org/ctrp) databases to analysis the correlation between HOXAs expression and drug sensitivity [The Genomics of Drug Sensitivity in Cancer (GDSC) database  and GSCA (http://bioinfo.life.hust.edu.cn/web/GSCALite/) used to analysis the gene mutation, DNA methylation of HOXAs in LGG [The cBioPortal database constructed a competing endogenous RNA (ceRNA) network [To explore the potential upstream regulatory of HOXAs in LGG, we used the LnCeVar database  were purchased from cell bank of Kunming Institute of Zoology, and cultured in DMEM medium (Corning) supplemented with 10% fetal bovine serum (FBS) and 1% penicillin/streptomycin at 37° C in atmosphere containing 95% air and 5% CO2.−ΔΔCt method.The qRT-PCR assay was performed as documented . The pri4, the cell numbers were subsequently counted each day using an automatic cell analyzer Countstar . .Cell proliferation was performed as previously documented . BrieflyCell migration assays was performed as previously documented . BrieflyCorrelation analysis was performed using Pearson correlation test. Kaplan-Meier survival curves were plotted to exhibit the overall survival for LGG patients. Univariate and multivariate Cox regression analyses were used to examine the independent prognostic significance of each variable enrolled in this finding. The significance of the data between two experimental groups was determined by Student’s t-test and multiple group comparisons were analyzed by one-way ANOVA. P < 0.05 (*), P < 0.01 (**) and P < 0.001 (***), were considered significant.We used TCGA and GTEx databases explored the expression of 11 HOXAs in GBM and LGG, the results showed that 11 HOXAs were significantly higher in lower-grade glioma (LGG) and glioblastoma multiforme (GBM) than those in normal samples , 1B. FurWe further explored the correlation between HOXAs and clinical characteristics of LGG. The results showed that up-regulated 11 HOXAs were significantly associated with a higher tumor stage, IDH mutation status, 1p/19q chromosome co-deletion, histological type, primary therapy outcome, and age based on TCGA dataset . This reGiven that HOXAs were significantly up-regulated in LGG and its higher expression was associated with adverse clinical features and adverse clinical outcomes. Therefore, we decided explored the diagnosis values of HOXAs in LGG. ROC curve analysis of HOXAs showed that HOXAs had a high accuracy (AUC > 0.80) in predicting LGG . These rIn order to provide clinicians with predicted prognosis of LGG patients quantitatively, we constructed the nomogram combining HOXA1, HOXA6 expression and independent clinical risk factors . Higher total points on the nomogram for overall survival (OS), disease-specific survival (DSS) and progression-free survival (PFS), respectively, indicated a worse prognosis . In summWe utilized cBioPortal analysis the genetic alteration of differentially expressed HOXAs family. Results confirmed that HOXA1, HOXA2, HOXA3, HOXA4, HOXA5, HOXA6, HOXA7, HOXA9, HOXA10, HOXA11 and HOXA13 were all altered, with 1.2, 0.8, 1, 0.6, 0.8, 0.8, 1, 1, 0.6, 1 and 0.6alterations in the LGG samples, respectively . We alsoTo explore the potential functions of HOXAs in LGG progression, we were using the GeneMANIA database constructed the gene-gene interaction network for HOXAs and the altered neighboring genes . FurtherFor determine the expression of HOXAs in diverse immune subtypes of LGG, we utilized the TISIDB database analysis and found that HOXAs mainly highly expressed in C3 and C4 subtype .Given that HOXAs was significantly correlated with immune regulation related signaling pathway. Therefore, we decide to examine the correlation between HOXAs expression and immune cell infiltration. In this finding, we used TIMER database analysis and found that somatic copy number alterations of HOXAs were significantly correlated with diverse immune cell infiltration levels in LGG , 7. FurtFinally, ssGSEA with Spearman’s rank correlation was employed to measure the correlation between HOXAs expression and infiltration levels of 24 immune cell types in glioma. The results showed that HOXA1 expression was correlated with the immune infiltration of macrophages and eosinophils, negatively correlated with the immune infiltration of NK CD56bright cells and pDC. HOXA2 positively correlated with the immune infiltration of Macrophages, Eosinophils and T cells, negatively correlated with the immune infiltration of Tcm and pDC. HOXA3 positively correlated with the immune infiltration of NK cells, Th2 cells and T cells, negatively correlated with the immune infiltration of NK CD56bright cells and pDC. HOXA4 positively correlated with the immune infiltration of macrophages, eosinophils and neutrophils, negatively correlated with the immune infiltration of pDC and NK CD56bright cells. HOXA5 positively correlated with the immune infiltration of Macrophages, Eosinophils, NK cells and Neutrophils, negatively correlated with the immune infiltration of NK CD56bright cells and pDC. HOXA6 positively correlated with the immune infiltration of Eosinophils, Th2 cells and Macrophages, negatively correlated with the immune infiltration of CD8 T cells and pDC. HOXA7 positively correlated with the immune infiltration of Th2 cells, neutrophils and NK cells, negatively correlated with the immune infiltration of NK CD56bright cells and pDC. HOXA9 positively correlated with the immune infiltration of Neutrophils and Eosinophils, negatively correlated with the immune infiltration of NK CD56bright cells and TReg. Furthermore, HOXA10 expression associated with the immune infiltration of several subsets of myeloid cells, including macrophages, Eosinophils and Neutrophils, HOXA10 expression negatively correlated with the immune infiltration of TReg and NK CD56bright cells. There are positive correlations between HOXA11 expression and the immune infiltration of Macrophages, T helper cells and Neutrophils, negatively correlated with the immune infiltration of TRegNK CD56bright cells. There is also a strong positive correlation between HOXA13 expression and immune infiltration of Tgd, T helper cells and Macrophages, negatively correlated with the immune infiltration of TReg and NK CD56bright cells . Taken tConsidering immune modulator plays a crucial role in the immune response and development and progression of LGG. We explored the correlation between HOXAs and the immune checkpoint-related genes by using Pearson correlation analysis in LGG, including CD274, CTLA4, HAVCR2, LAG3, PDCD1, PDCD1LG12, TIGIT, SIGLEC15. The result showed that HOXAs expression was significantly positively correlated with CD274, CTLA4, HAVCR2, LAG3, PDCD1, PDCD1LG12 and SIGLEC15 . These rWe downloaded the IC50 values of anti-cancer drugs and gene expression profiles in the relative cell lines from the GDSC and CTRP database. To explore the influence of HOXAs expression on the sensitivity of anti-cancer drugs, we divided the tumor cells into high- and low- HOXAs groups and compared their IC50 values. For example, we found that the IC50 values of several anti-cancer drugs decreased in the high- HOXA3 group, including abiraterone, Trametinib, VAF-347, BRD-K09344309, BRD-K34099515 and erlotinib , indicatEmerging reports have revealed that lncRNA /miRNA regulatory axis play a vital role in the gene expression . To uncoGiven that HOXA1 expression was independent factors affecting the prognosis of LGG patients and previous no study reported the function of HOXA6 in LGG. Therefore, we decide explored function of HOXA6 in LGG. We first examined the expression of HOXA6 in LGG cells lines by qRT-PCR assay. The results confirmed that HOXA6 was up-regulated in LGG cells lines, especially in SF295 and A172 cells . Next, wGrades I and II are grouped together as low-grade gliomas and grades III and IV as high-grade gliomas, low-grade gliomas have a 10- to 15-year survival. Although earlier diagnosis and newer therapies have increased overall survival, disparities in access and outcomes of care for low-grade gliomas persist . TherefoPrevious studies reported that HOXA genes differentially expressed in various cancers. For instance, it was found that HOXA7 and HOXA9 mRNAs were elevated in esophageal squamous cell carcinoma tissues . On the It has been showed that higher level of HOXA9 and HOXA10 were found to be predictors of poor outcome in patients with NSCLC and GBM . AdditioWe also analysis the landscape of genetic variation of HOXAs in LGG, the results confirmed that HOXA1, HOXA2, HOXA3, HOXA4, HOXA5, HOXA6, HOXA7, HOXA9, HOXA10, HOXA11 and HOXA13 were all altered, with 1.2, 0.8, 1, 0.6, 0.8, 0.8, 1, 1, 0.6, 1 and 0.6alterations in the LGG samples, respectively. We also uncover that missense mutation was the most common variant classification, SNPs were the most common variant type and C > T ranked as the top SNV class. The results also showed HOXA1 as the gene with the highest mutation frequency, followed by HOXA11 and HOXA6, among the 11 HOXAs. CNV analysis results confirmed that copy number variations of HOXAs was significantly positive correlated with its expression in LGG. Furthermore, HOXAs CNV affect the overall survival (OS), disease-specific survival (DSS) and progression-free survival (PFS) in LGG patients. Finally, we uncover that the DNA methylation level of HOXA13 negatively associated with its expression. More importantly, lower DNA methylation level of HOXA1, HOXA3, HOXA9 and HOXA10 were correlated with poor DSS, OS and PFS.Past studies revealed that HOXAs played a key role in the regulating cell differentiation, proliferation, migration and cell death. For example, it has been found that HOXA10 was highly expressed in hepatocellular carcinoma. Depletion of HOXA10 induced cell cycle arrest at the G0/G1 phase and apoptosis by decreased the expression of CCND1 and survivin . On the Previous studies showed that the immune infiltration of CD4+ T cells and CD8+ T cells were significantly affected the prognosis of LGG . In thisFinally, we also constructed HOXAs related mRNA–miRNA–lncRNA network in LGG. The results confirmed that ZHF337-AS1 or SNHG12/miR-210-3p / regulatory axis may regulate the expression of HOXA1. LINC00174/miR-26a-5p regulatory axis may regulate the expression of HOXA5. HCG18 or G18 or TRG-AS1/miR-196a-5p regulatory axis may regulate he expression of HOXA7. LNC00665/miR-320a regulatory axis may regulate he expression of HOXA10. KDM4A-AS1/ miR-27a-5p regulatory axis may regulate he expression of HOXA13. Previous study found that lncRNA SNHG12 promotes the cell proliferation, invasion and epithelial-mesenchymal transition of pancreatic cancer cells by absorbing miRNA-320b . Li et aJiang et al. found that HOXA6 was over-expressed in in CRC tumor tissue than that in adjacent normal tissue. Depletion of HOXA6 inhibits the cell proliferation, migration and invasion, but inhibited apoptosis . Xin et HOXAs participated in the progression of LGG and were differentially expressed in LGG tissues. HOXA6 may be potential biomarker for the diagnosis of LGG.Supplementary FiguresSupplementary Table 1


Diabetes has been shown to accelerate vascular senescence, which is associated with chronic inflammation and oxidative stress, both implicated in the development of endothelial dysfunction. This condition represents the initial alteration linking diabetes to related cardiovascular (CV) complications. Recently, it has been hypothesised that the acetyltransferase, p300, may contribute to establishing an early vascular senescent phenotype, playing a relevant role in diabetes-associated inflammation and oxidative stress, which drive endothelial dysfunction. Specifically, p300 can modulate vascular inflammation through epigenetic mechanisms and transcription factors acetylation. Indeed, it regulates the inflammatory pathway by interacting with nuclear factor kappa-light-chain-enhancer of activated B cells p65 subunit (NF-κB p65) or by inducing its acetylation, suggesting a crucial role of p300 as a bridge between NF-κB p65 and the transcriptional machinery. Additionally, p300-mediated epigenetic modifications could be upstream of the activation of inflammatory cytokines, and they may induce oxidative stress by affecting the production of reactive oxygen species (ROS). Because several in vitro and in vivo studies shed light on the potential use of acetyltransferase inhibitors, a better understanding of the mechanisms underlying the role of p300 in diabetic vascular dysfunction could help in finding new strategies for the clinical management of CV diseases related to diabetes. Cardiovascular diseases (CVDs) are the main causes of death and disability among patients with diabetes. This was confirmed by a meta-analysis of 102 prospective studies, showing that diabetes confers a two-fold excess risk in adverse vascular outcomes, independently of other risk factors. CV complications associated with diabetes can be classified as microvascular, such as nephropathy and retinopathy, which are major causes of kidney disease and blindness, respectively, or macrovascular complications, including ischaemic heart disease, heart failure, stroke, coronary artery disease and peripheral artery disease . SpecifiDiabetes-associated endothelial dysfunction is one of the most critical initiating triggers of vascular complications and, therefore, an important predictor of the onset of CVD.This is a very complex process orchestrated by several factors, such as hyperglycaemia, dyslipidaemia, free fatty acids and insulin resistance, which impair the normal functionality of the endothelium by promoting inflammation, oxidative stress, thrombosis, arterial stiffness and the impaired regulation of arterial tone and flow . All theIn addition to impaired vasodilation, diabetes is also associated with increased circulating levels of endothelium-derived adhesion molecules, plasminogen activator inhibitor-1 and high triglyceride levels, which denote a proinflammatory endothelial phenotype. Inflammation is also driven by the increase in advanced glycation end products (AGEs), which result from the overproduction of mitochondrial superoxide anion. Diabetes is also characterised by high circulating levels of free fatty acids, which may compromise endothelial function through the activation of protein kinase C and the dysregulation of insulin pathway transduction.All these processes exacerbate vascular inflammation and are characterised by the increased expression of several cytokines, such as Vascular cell adhesion molecule 1 (VCAM-1), E-selectin, Intercellular adhesion molecule-1 (ICAM-1), Interleukin-6 (IL-6), IL-1 and IL-8 and Monocyte chemoattractant protein-1 (MCP-1), facilitating the adhesion of monocytes, neutrophils and macrophages to the endothelium and, consequently, the formation of atherosclerotic plaque ,12,13,14Although diabetes management has improved, the prevention and control of cardiovascular complications represent the main target of diabetes therapy , and theDiabetic patients present dysfunction of multiple organ systems similar to that observed in chronological ageing, suggesting that this metabolic disease might induce an early ageing state associated with early vascular senescence, implicated in the development of endothelial dysfunction ,21,22,23Cellular senescence is an irreversible arrest of the cell cycle, which has the purpose of repairing or eliminating damaged cells by restoring tissue homeostasis ,25,26. HAge increases the susceptibility to a wide variety of diseases, which can be considered as degenerative pathologies because they lead to the tissues’ normal functionality loss. Examples include neurodegenerative diseases, such as Alzheimer’s disease, Parkinson’s disease, Huntington’s disease, cardiovascular disease, musculoskeletal decrements and cancer ,31. FurtSenescence has also been shown to be key in the pathophysiology of CVDs, such as atherosclerosis, myocardial infarction and cardiac fibrosis. Indeed, it was found that cardiac cells exhibit a SASP, which induces the release of soluble signalling factors, proteases and extracellular matrix (ECM) components in the surrounding environment that contribute to cardiovascular damage initiation and progression ,35.Numerous studies have shown that cardiovascular ageing is largely characterised by cardiomyocyte hypertrophy, increased senescence, cardiac fibroblast and endothelial dysfunction and decreased cardiac function. In particular, senescent cardiomyocytes show augmented cellular stressors, such as inflammation, ROS levels, DNA damage, endoplasmic reticulum stress, mitochondrial dysfunction, telomere shortening and SASP. All these factors determine contractile dysfunction loss and hypertrophic growth, which negatively affect myocardial function ,37,38,39In addition, an ageing heart may undergo fibrotic remodelling with senescent fibroblasts showing changes in the expression of genes regulating inflammation, extracellular matrix organization and angiogenesis. This leads to a higher proinflammatory response, autophagy and contractile dysfunction ,43.Senescence could also alter myofibroblast functionality: several studies have shown that senescent myofibroblasts, positive to senescence-associated beta-galactosidase , accumulate in the perivascular fibrotic areas of transverse aortic constriction-treated mice ,45 and iThe dysregulation of p53 also appears to be involved in other age-related pathologies, such as hypertrophy cardiopathy. Specifically, it was found that p53 upregulation in pathological hypertrophy leads to the ubiquitylation and proteasomal degradation of Hypoxia-inducible factor 1α (HIF1α) through the E3 ubiquitin-protein ligase, MDM2, promoting heart failure ,47,48.Several pieces of evidence have demonstrated that senescence plays a key role in promoting vascular EC dysfunction through the dysregulation of the cell cycle, oxidative stress, altered calcium signalling and vascular inflammation . SenesceDiabetes, which is strictly associated with inflammation, oxidative stress and impaired endothelial function, has also been shown to accelerate vascular senescence and, consequently, favour the occurrence of CVD ,21,22,58Several in vitro studies demonstrated that high-glucose-induced senescence in EC is accompanied by a reduction in NO synthesis ,60, and Of note, animal models, such as Zucker diabetic rats and streptozotocin diabetic mice, show vascular cell senescence associated with an increase in SA β-Gal activity and p16INK4a and p53 expression ,68,69,70In addition, several in vitro studies have highlighted the key role of the deacetylase Sirtuin 1 (SIRT1) in p53 activation through the regulation of acetylation. Indeed, SIRT1 leads to the inactivation of p53-driven DNA damage responses, which plays a major role in contributing to endothelial senescence ,72,73,74The findings of the Diabetes Control and Complications Trial (DCCT), the follow-up observational Epidemiology of Diabetes Interventions and Complications (EDIC) and 10-year UKPDS follow-up studies in patients with type 1 (T1D) or type 2 (T2D) diabetes mellitus suggest that early exposure to hyperglycaemia prompts individuals to the development of diabetic complications—a phenomenon referred to as glycaemic memory ,76,77. ANotably, post-translational modification, such as the acetylation of p53, has been demonstrated to be involved in the “glycaemic memory” correlated with endothelial senescence. In detail, a study conducted by Zhang and colleagues showed that transient hyperglycaemic stress induces a persistent premature cellular senescence in EC, despite the subsequent restoration of normoglycaemia. This phenomenon was mediated by the deacetylase, SIRT1, and the acetyltransferase, p300, which modulate p53 activity. Specifically, three days of high-glucose incubation followed by three days of normal glucose induced a persistent downregulation of SIRT1 and the upregulation of acetyltransferase p300, which in turn drives the hyperacetylation and activation of p53, contributing to the maintenance of p53/p21-mediated senescent “memory” .In this regard, our recent study contributed to strengthening the concept of the glycaemic memory of endothelial senescence. Thoroughly, we observed that EC isolated from the umbilical cords of gestational diabetic (GD-HUVECs) women compared to EC isolated from control women revealed an impaired antioxidant enzymatic defence, as well as increased basal and stimulated ROS levels associated with decreased nuclear localization of nuclear factor erythroid 2–related factor 2 (Nrf2)—an essential transcriptional factor regulating the antioxidant defence gene expression . FurtherFurthermore, several studies highlighted the role of p300 in establishing glycaemic memory also through epigenetic modifications, such as histone acetylation ,84,85,86Therefore, we believe that a deep discernment of p300 function in inflammation and oxidative stress, the two main drivers of diabetes-related endothelial dysfunction, is urgently needed to support new pre-clinical and clinical studies.Several studies have pointed out the key role of acetylation in diabetes , which i+-dependent SIRT family is the most common type of HDAC [Acetylation is mainly controlled by histone acetyltransferases (HATs) and histone deacetylases (HDACs). HATs are classified into the following families: general control non-depressible 5 (GCN5), CREB-binding protein (CBP)/p300 and Moz, Ybf2/Sas3, Sas2 and Tip60 (MYST families). While the NAD of HDAC .The acetyltransferase, p300, regulates several cellular processes, including proliferation, migration, differentiation, senescence and apoptosis ,99,100. Importantly, p300 is involved in regulating numerous transcription factors, including NF-κB . The N- Numerous studies have documented the physiological role of p300 in development and heart diseases, such as accelerated cardiac hypertrophy, cardiomyopathy, matrix remodelling or fibrogenesis and heart failure . The invRecently, lysine acetylation has emerged as a major mechanism underlying diabetic vascular complications ,119,120.Additionally, p300 was significantly elevated in myofibroblast-like cells derived from the primary culture of mouse cardiac EC in response to profibrogenic cytokine TGF-β. On the contrary, the dissociation of p300 from the transcription initiation complex at the collagen gene promoter blunts profibrogenic signalling-induced type I collagen synthesis . InteresGusterson and colleagues demonstrated that inhibition of p300 activity arrests cardiomyocyte hypertrophy induced by phenylephrine. On the other hand, p300 overexpression promotes this adverse cardiac phenotype ,125. It Notably, p300 levels are significantly elevated also in angiotensin (Ang) II-induced hypertensive myocardial tissues and are associated with increased H3K9ac and cardiac hypertrophy and fibrogenesis . MoreoveIn vascular smooth muscle cells (VSMCs), it was also observed that p300 modulates the pro-atherogenic effect of 12(S)-Hydroxyeicosatetraenoic acid (12(S)-HETE) by mediating IL-6 and MCP-1 expression through p300-driven H3K9/14ac .Recently, several studies pointed out the importance of p300 as a regulator of diabetes-associated CVD ,132,133.As mentioned above, the tight interconnection between p300 and SIRT1 may regulate accelerated vascular ageing associated with hyperglycaemia. In this regard, EC exposed to high glucose and tissues from diabetic animals showed downregulation of SIRT1, which, in turn, leads to the reduction in mitochondrial antioxidant enzymes in a p300- and Forkhead box O1 (FOXO1)-mediated pathway .The essential role of p300 and SIRT1 in high-glucose-induced vascular senescence was further confirmed in a cellular model of hyperglycaemia, evidencing the direct role of p300 in the activation of p53 and, consequently, p21 ,80. AddiDiabetes is associated with augmented inflammation, which has been proven by a consistent body of evidence as one of the main drivers of atherosclerotic CVD ,139 and The role of p300 appears to be crucial in the regulation of NF-κB—one of the main mediators of the inflammatory pathway . Lan andSeveral in vitro studies supported the key role of p300 in vascular inflammation associated with hyperglycaemia. Chen and colleagues demonstrated that glucose exposure increased p300 expression, histone acetylation and p300 binding to ET-1 and to fibronectin promoters in EC. This suggests that glucose-induced p300 upregulation regulates the gene expression of vasoactive factors and ECM proteins in EC through epigenetic mechanisms .Moreover, in vitro studies have shown that the p300-driven acetylation of H3K9 recruits NF-κB to the promoters of proinflammatory genes, such as IL-6, IL-8 and cyclooxygenase-2 (COX-2) ,146.It was also found that high glucose increases the p300-driven acetylation of histones H3K14, H3K18, H3K23, H4K5 and H4K16 in retinal glial cells. These changes are positively correlated with the induction of the proinflammatory molecules ICAM-1, Inducible Nitric Oxide Synthase (iNOS) and Vascular Endothelial Growth Factor (VEGF). Of note, both the acetylation and expression of the inflammatory proteins can be inhibited by modifying HAT/HDAC activity .The regulating Forkhead box O3a (FOXO3a) acetylation by p300 is another mechanism involved in diabetes-induced inflammation: diabetes-induced FOXO3a acetylation prevents its binding to gene target promoters, increasing NOD-, LRR- and pyrin domain-containing protein 3 (NLRP3) inflammasome activation. This mechanism was then reverted by C646, a p300 inhibitor .Diabetes enhances oxidative stress and compromises antioxidant defences, as evidenced by increased superoxide generation and reduced Superoxide dismutase (SOD) activity catalase (CAT) and glutathione (GLT) . ChronicIt is well known that eNOS plays a central role in vascular homeostasis by regulating the synthesis of NO and that the impairment of enzyme activity is involved in the pathogenesis of diabetic endothelial damage . In thisIn support of these results, the involvement of p300 in the regulation of eNOS was demonstrated. In detail, Chen and colleagues have shown that the acute stimulation of endothelial eNOS mRNA transcription by laminar shear stress is dependent on the NF-kB subunits, p50 and p65, which in turn bind to a shear stress response element (SSRE) in the human eNOS promoter. This is mediated by the activation of p300, which acetylates p65 and the histones, H3 and H4, in proximity to the human eNOS SSRE, promoting an opened chromatin structure and allowing gene transcription .A recent study indicated a key role of histone acetyltransferase p300 in diabetes-accelerated renal damage. Interestingly, the authors observed that kidneys of diabetic C57BL/6J mice treated with C646, a pharmacological inhibitor of p300, showed significant downregulation of H3K27ac and diabetes-induced expression of NADPH oxidase (NOX), known to be the main trigger of ROS production .SIRT1, antagonizing p300, has been shown to inhibit transcriptional factors, such as NF-κB, MAPK, Matrix metallopeptidase 9(MMP-9), FOXO3a and p53. On the other hand, it increases Cardiac sarcoplasmic reticulum Ca2+-ATPase2a (SERCA2a), extracellular signal-regulated protein kinase (ERK1/2), eNOS activity, proliferator-activated receptor-gamma coactivator α (PGC-1α) and AMP-activated protein Kinase (AMPK) . The oveIn VSMCs, HDAC1/2 and p300 proteins were found to bind the promoter’s sites of active NOX1/4/5 genes. H3K27 acetylation was increased at the promoters of NOX genes in high-glucose-exposed VSMCs . Considering the possibility of interfering with epigenetic modifications , HistoneSome compounds, such as metformin, already used in clinical practice and established as a first-line drug in the treatment of T2D patients, have shown some epigenetic effects . MetformInterestingly, the activity of some pharmacological inhibitors targeting epigenetic modifiers for the treatment of cancer, such as JQ1 , has alsTo date, studies on the potential effect of drugs with proven cardio-renal benefits in diabetes, such as glucagon-like peptide 1 agonists (GLP1-as) and sodium-glucose co-transporter-2 inhibitors (SGLT2is), on p300 regulation are lacking. However, a recent study showed that liraglutide, a GLP1-a that has been reported to exert protective effects against myocardial ischaemia–reperfusion injury, displays a beneficial effect on renal ischaemia–reperfusion injury by decreasing histone acetyltransferase activity .Regarding SGLT2i, the new drugs, β-hydroxybutyrate and dapagliflozin, have shown some effects on oxidative stress and cardioprotection, respectively, through epigenetic mechanisms ,165. TheAmong natural compounds, there is garcinol—a potent p300 inhibitor—that was able to mitigate high-glucose-induced inflammation in retinal cells, suggesting its potential use in the prevention of diabetic retinopathy ,166.A recent study demonstrated that epigallocatechin gallate (EGCG), the major bioactive polyphenol present in green tea, attenuates vascular inflammation via a repressive epigenetic effect on the NF-κB signalling pathway. In detail, this compound was able to block the recruitment of p65, p300 and HDAC1-3 in the promoters of IL-6, C-reactive Protein (CRP), ICAM-1, vascular cell adhesion molecule 1 (VCAM-1), IL-1α and IL-1β .Curcumin has been considered a potential epidrug for diabetes because of its hypoglycaemic, hypolipidaemic and epigenetic effects in various rodent models . InteresUnfortunately, important evidence gaps remain before implementing the use of these substances in a clinical setting. These are mainly due to the lack of specificity in chromatin modifiers, implicating the unspecific and undesirable modulation of transcriptional programs with wide effects on cellular pathways. In addition, the safety of these approaches remains to be proven.In summary, the evidence analysed and reported in this review supports the idea that p300 may be a relevant actor in diabetes-induced vascular inflammation and oxidative stress, which promote endothelial senescence, driving atherosclerotic cardiovascular disease.As shown in Lastly, several in vitro and in vivo pre-clinical studies shed light on the potential use of acetyltransferase inhibitors, which, following further clinical validation, could be promising in the treatment of diabetes complications. Therefore, it would be very interesting to further study p300 as a potential therapeutic target that may contribute to the clinical management of diabetic vascular complications.


Research suggests that colorectal cancer (CRC) is associated with mental health disorders, primarily anxiety and depression. To synthesize this evidence, we conducted a systematic review and meta-analysis of studies evaluating the onset of anxiety and depression among patients with CRC. We searched EMBASE and Medline from inception to June 2022. We included original, peer-reviewed studies that: used an epidemiologic design; included patients with CRC and a comparator group of individuals without cancer; and evaluated anxiety and depression as outcomes. We used random effects models to obtain pooled measures of associations. Quality assessment was completed using the Newcastle-Ottawa scale. Of 7326 articles identified, 8 were eligible; of which 6 assessed anxiety and depression and 2 assessed depression only. Meta-analyses showed a non-significant association between CRC and anxiety  and a significant association between CRC and depression . Predictors of anxiety and depression among patients with CRC included clinical characteristics , cancer treatment , and sociodemographic characteristics . The impacts of anxiety and depression in patients with CRC included increased mortality and decreased quality of life. Altogether, our systematic review and meta-analysis quantified the risks and impacts of CRC on anxiety and depression, particularly an increased risk of depression after CRC diagnosis. Findings provide support for oncologic care that encompasses mental health supports for patients with CRC. Colorectal cancer (CRC) is the third most common malignancy in both males and females and the second most common cause of cancer-related death in the world . In 2020Altogether, the physical and functional impacts of CRC may further result in detrimental psychological impacts on a patients’ overall health and quality of life . In 2019To our knowledge, this growing literature on mental health disorders following diagnosis of CRC has not been synthesized to date. Information across multiple studies (versus a single study) will provide better understanding on the relationship between CRC diagnosis and the onset of mental health disorders, including quantifying the association and identifying determinants of these outcomes as well as impacts on downstream patient outcomes. Furthermore, as awareness for the psycho-oncologic impacts of CRC continues to expand, comprehensive evidence on mental health outcomes will have implications for mental health care  and advocacy for supports for patients. As such, we conducted a systematic review and meta-analysis to (1) synthesize the association; (2) identify predictors; and (3) examine impacts of anxiety and depression among patients with CRC.Our systematic review was guided by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2020 guidelines, and completed with the PRISMA checklist  9]. The. The9]. Search results were uploaded onto Covidence , where dGeneral information extracted from the included studies were: study characteristics  and CRC information . Studies that reported mean ages with standard deviation were pooled using StataSE 17 . We primWe also extracted information on predictors of anxiety and depression, which we define as factors reported to be associated with these outcomes in multivariable regression models. A priori, we anticipated potential predictors to include sociodemographic characteristics, particularly sex, based on previously reported relationships with mental health ,13. We aWe assessed the quality of included articles using the Newcastle-Ottawa Scale (NOS) . For coh2 test as a measure of heterogeneity, with (1) 0–40% indicating little to no heterogeneity; (2) 30–60% representing moderate heterogeneity; (3) 50–90% indicative of substantial heterogeneity; and (4) ≥75% describing considerable heterogeneity [We conducted a narrative synthesis of findings of included studies. We used random effect models (DerSimonian and Laird) to conduct a meta-analysis and pooled reported  measures of association for anxiety and depression among patients with CRC. Further, we used the Iogeneity . Forest n = 80); study designs that did not match inclusion criteria (n = 35); and outcomes that did not match inclusion criteria (n = 27). Altogether, we included a total of eight studies in the systematic review.As shown in n = 3) [n = 2) [n = 1) [n = 1) [n = 1) [n = 2) [n = 7) [The characteristics of the studies included are summarized in n = 3) ,17,21, T [n = 2) ,20, Neth [n = 1) , Denmark [n = 1) . All stu [n = 7) ,19,20,21 [n = 7) ,20 did n [n = 7) ,7,19 inc [n = 7) ,17 inclu [n = 7) ,18,20,21n = 7) [Among included studies, six ,18,19,20n = 7) ,18,20,21n = 7)  assessedn = 7) ,18. Specn = 7)  and Sun n = 7)  further 2 = 99.72%). Sensitivity analysis by removing Zhang et al.’s [2 of 99.72%, still indicating the presence of heterogeneity   to 3.50 et al.’s  study reogeneity B.2 = 98.89%). A sensitivity analysis was also performed by removing the study of Zhang et al. [2 = 98.58%.Among studies that evaluated depression, point estimates for reported measures of association also consistently suggested increased risk, ranging from 1.12 (95% CI 1.09 to 1.15)  to 5.46 g et al. , which sAlso of interest are predictors of mental health disorders, with four studies ,8,18,19 Three studies ,19,21 adIn our systematic review and meta-analysis, we aimed to synthesize current evidence on the association, predictors, and impacts of anxiety and depression among patients with CRC. Altogether, we included eight studies that evaluated anxiety and depression among 228,069 patients with CRC. Our meta-analyses suggested that individuals with CRC have a 51% increased risk  of experiencing depression after diagnosis. Findings for anxiety suggested no association as the pooled estimate of 1.43 was not statistically significant, suggesting the need for further studies. Importantly, several predictors of anxiety and depression in patients with CRC were identified including clinical characteristics , cancer treatments , and sociodemographic characteristics . Additionally, we identified the impacts ,21 of ann = 5) [Previous research has shown the concern of patients experiencing anxiety and/or depression symptoms following a cancer diagnosis ,25; thusn = 5) ,7,17,18 n = 5) . Differen = 5) . As highn = 5) . These bn = 5) ,28. Moren = 5) ,4,29.n = 6 studies) [n = 8 studies) [2 values . In terms of depression, although we found a statistically significant association between depression and CRC patients, there is also a considerably high heterogeneity in the pooled HRs . As the results of our meta-analyses suggested heterogeneity between studies, it is plausible that the high heterogeneity may be due the variation between the countries  where our included studies were conducted. In 2020, Krendl et al. published a cross-national epidemiologic survey, revealing higher levels of stigma around mental illness among individuals in Eastern countries compared to those from Western countries [It is important to contextualize findings with respect to anxiety and depression outcomes. Among patients with CRC, anxiety was often less evaluated n =  studies studies) ,18,19,20studies) , as is eountries . The finountries . Correspountries  and Sun ountries ,32. Thusn = 5) [Beyond quantifying the association of mental health disorders with a CRC diagnosis, it was also imperative to identify predictors of anxiety and depression among CRC patients to inform practical recommendations. Thus, another important contribution of our synthesis was extracting information on different predictors as these may represent potential targets for intervention or means for identifying high-risk patients. Most studies (n = 5) ,8,18,19 n = 5) ,7, diagnn = 5) ,7, and wn = 5) ,7,33. Fin = 5)  reportedn = 5) . The incn = 5) . As a ren = 5) . With ren = 5) ,38. Althn = 5) , sex alsn = 5) ,40. Furtn = 5) . Individn = 5) ,42. Addin = 5) ,43,44. Tn = 5) . FollowiLastly, an important consideration of our review is the observation of mental health disorders on the impact on overall patient health outcomes. Observation of these in three studies ,19,21 inThe strength and limitations of a systematic review deserve discussion. Our systematic review describing the risk of anxiety and depression in patients with CRC identified articles using a thorough search strategy. An original and updated search further ensured the comprehensive and timely capture of relevant studies to date. To our knowledge, this is the first study aiming to synthesize and critically appraise evidence from observational studies analyzing the association of anxiety and depression following a diagnosis of CRC. As in any other systematic review, the inclusion of relevant studies may have been limited by publication bias, as shown by funnel plots in Altogether, our systematic review and meta-analysis provide a comprehensive synthesis of mental health outcomes among CRC patients. Further synthesizing the predictors and impacts of anxiety and depression provides practical information for the identification of at-risk CRC patients, as well as integrating psychological and mental health care interventions early on in CRC patients’ journeys. Our findings prompt future research to further expand on the scope of anxiety and depression in individuals with a CRC diagnosis. Furthermore, our results have implications to support the need for mental health care support before, during, and after a CRC diagnosis, as well as informing future research to substantiate the risk of anxiety in CRC patients. As mental health disorders may go unnoticed in CRC clinical care, our findings further provide significance for clinical practice health care providers , as they should be aware of anxiety and depression when treating patients diagnosed with CRC.


The UFM1 conjugation system(UFMylation)is a novel type of ubiquitin-like system that plays an indispensable role in maintaining cell homeostasis under various cellular stress. Similar to ubiquitination, UFMylation consists of a three-step enzymatic reaction with E1-like enzymes ubiquitin-like modifier activating enzyme5 (UBA5), E2-like enzymes ubiquitin-fold modifier-conjugating enzyme 1(UFC1), and E3-like ligase UFM1-specific ligase 1 (UFL1). As the only identified E3 ligase, UFL1 is responsible for specific binding and modification of the substrates to mediate numerous hormone signaling pathways and endocrine regulation under different physiological or pathological stress, such as ER stress, genotoxic stress, oncogenic stress, and inflammation. Further elucidation of the UFL1 working mechanism in multiple cellular stress responses is essential for revealing the disease pathogenesis and providing novel potential therapeutic targets. In this short review, we summarize the recent advances in novel UFL1 functions and shed light on the potential challenges ahead, thus hopefully providing a better understanding of UFMylation-mediated cellular stress. As one 1.1The ubiquitin-fold modifier 1 (UFM1) conjugation is a newly-identified ubiquitin-like system . Similar1.2Thus far, UFL1 is the only identified E3 ligase reported with the UFM1 conjugated function . At the 1.3According to previous research, under the ufymlation system, UFL1 performs its biological functions mainly by modifying UFM1 to the substrates. The biological processes involved include hematopoiesis, liver development, kidney development, DNA damage repair, autophagy, and intestinal homeostasis Table 1.1.3.1DDRGK1, also known as UFBP1, c20orfll6, and Dashurin, was the first identified UFMylation substrate . The DDR1.3.2Activating signal cointegrator 1 (ASC1), also named thyroid hormone receptor interactor 4 (TRIP4), was previously identified as a transcriptional co-activator of estrogen receptor α (ERα). By forming a dimeric complex with 17β-estradiol, ERα translocates to the nucleus and recruits transcriptional coactivators, binding to ER-responsive elements (EREs) and activating gene expression downstream. Thus, ERα is a prominent growth factor in breast cancer. Yoo et al. reported that ASC1 can be ufmylated at the sites of Lys69, Lys324, Lys 325, Lys334, and Lys367, and ufmylated ASC1 enhances the ability of ERα recruited transcription co-factors, increasing the target genes expression, thereby affecting the intracellular homeostasis and ultimately tumor formation .1.3.3via a proteasome-independent way , a component of the large ribosomal subunit responsible for the synthesis of proteins in the cell, was identified as a primary target of UFM1 conjugation . In the dent way . In meta1.3.4Histone H4 is a core component of the nucleosome, which tightly wraps DNA and achieves the nucleosome’s compact chromatin structure. However, histone H4 has tails that project from the nucleosome. By post-translational modifications to the tails, histone H4 influences all DNA-based processes, such as transcription, chromatin compaction, DNA replication, and reparation. For instance, Histone H4 acetylation is essential for opening chromatin during replication, and histone H4 methylation regulates DNA replication by compacting chromatin. Recently, Qin et al. reported that the site of Lys31 on histone H4 was ufmylated by UFL1 following DNA damage. Ufmylated histone H4 is vital for amplifying ataxia-telangiectasia mutated (ATM) kinase activation, which orchestrates the DNA reparation and maintenance of genomic integrity .1.3.5Meiotic recombination 11 (MRE11) encodes a nuclear protein, which is one of the vital response proteins in DNA damage, functions in DNA double-strand break repair (DSBR) and other DNA damage response (DDR). MRE11 protein is the core of the MRE11-RAD50-NBS1 (MRN) complex, which acts as the early sensor and responder for locating DSBs. In the presence of the MRN complex, ATM is activated and recruited to the DSB site and triggers the downstream DDR pathway, tethering and resecting damaged chromosomes . Similar1.3.6Cdk5 activator p35-binding protein C53  was initially identified as the binding protein of Cdk5 activator p35, CBP, and ARF. Previous studies show that Cdk5rap3, as a substrate adaptor for UFMylation, is essential for the growth, proliferation, and functional maturation of hepatocytes, loss of Cdk5rap3 in mice suffering liver hypoplasia, and prenatal lethality. The hepatocyte-specific Cdk5rap3 knockout mice displayed impaired lipid metabolism and hypoglycemia, leading to death after weaning . Additio1.3.7TP53 is a tumor suppressor gene, which encodes a protein with a molecular weight of 53kDa, so the coding protein is named p53. As the most intensively studied tumor suppressor transcription factor , P53 fun2In order to further clarify the function of UFL1 in multiple stress, we summarized the substrates and regulatory pathways of UFL1 in cellular stress response, including ER stress, Genotoxic stress, Oncogenic stress and Inflammation Figure 22.1The endoplasmic reticulum (ER) is the central organelle responsible for the biosynthesis of cholesterol, steroids, and calcium homeostasis, regulating second messenger signaling , 32. HowBased on the findings that the UFMylation system is highly enriched in the ER, it is a close relationship between UFMylation and ER stress. On the clinical side, ER stress induced by the dysfunction of UFMylation causes a series of diseases, including hematopoietic disease , 41, 42,UFMylation also functions in other ER stress susceptive secretory cells, for instance, pancreatic cells. The deficiency of UFL1 in pancreatic cells caused decreased Bip expression, which disrupted ER homeostasis. It led to trypsin activation and pancreatic acini death, indicating that the UFL1/BiP pathway is essential for the synthesis and secretion of pancreatic enzymes correctly . AnotherIn heart disease, UFL1 cardiac-specific knockout mouse display increased expression of fetal cardiac genes, elevated fibrosis, and impaired cardiac contractility, ultimately developing into cardiomyopathy and heart failure. Mechanistically, UFL1 protects against cell death induced by ER stress by regulating ATF6 signaling and calcium cycling in cardiomyocytes, which is proven to be crucial for cardiomyocyte contractility and potentially impaired by depletion of UFMylation, indicating the essential role of UFL1 for cardiac homeostasis by regulating the function of ER .In summary, the dysfunction of the UFL1 impairs the quality control system in the endoplasmic reticulum, induces ER stress and UPR, breaks cellular homeostasis, and disrupts the autophagic pathway, ultimately inducing cell apoptosis. By forming a UFL1/DDRGK1/UFM1/C53 tripartite receptor complex with the ER lumen, UFMylation regulates the degradation of proteins and senses proteotoxic stress, eventually evolving into an ancient quality control pathway that bridges lysosomes autophagy with ribosome translocation-arrested protein quality control in the ER , 42.2.2Stable genomic DNA is necessary for the accurate transmission of genetic information. However, genotoxic stress includes DNA single-strand breaks, double-strand breaks, base damage, and the numerous alterations that block DNA replication, impairing genome stability and cell viability. To ensure genome integrity and prevent tumorigenesis, cells have evolved to derive a set of DNA damage response (DDR) collaborative networks, such as cell cycle checkpoint system, DNA repair system, chromatin recombination, gene expression regulation, and other signal pathways –55. The Up to now, only two UFMylation substrates (MRE11 and histone H4) have been identified under genotoxic stress, and both function in ATM activation , 23. WanIn general, UFL1 functions as an ATM signaling regulator, playing a vital role in DDR signaling under genotoxic stress2.3The molecular epidemiological datasets show that the UFMylation pathway may have dual effects under oncogenic stress. Specifically, genetic variation of the UFMylation components  has been identified in various tumors in The Cancer Genome Atlas (TCGA) database, such as breast carcinoma, hepatocellular liver carcinoma, ovarian serous cystadenocarcinoma, lung adenocarcinoma, esophageal carcinoma, lung squamous cell carcinoma, uterine corpus endometrioid carcinoma, bladder urothelial carcinoma, and sarcoma . In addiBased on the present findings, two substrates were identified explicitly involved in cancer development. ASC1 is the first substrate identified in breast cancer development . MechaniCollectively, the research results of substrate demonstrate the multiple effects of UFMylation in tumorigenesis depending on different cellular contexts.2.4Inflammation is a central feature of an effective immune response, which prevents the invasion of pathogenic microorganisms and other foreign material. The activation of immune response depends on pattern recognition receptors (PPRs), including Toll-like receptors (TLR), nucleotide-binding oligomerization domain-like receptors (NLR), and RIG-I-like receptor (RLR), to discern pathogen-associated molecular and activate downstream signal-pathways , 63. AmoIn addition, both UFL1 and UFM1 were found to be up-regulated in inflammation induced by LPS , 46. EleTaken together, these results provided unambiguous evidence for the essential role of UFMylation maintenance of congenital immunity and gut inflammation.3Overall, this review discussed the roles of UFL1 in multiple cellular stress responses and provided some examples that illustrate how the UFMylation acts as a dynamic post-translational modification system for maintaining homeostasis. It is proved that the UFMylation system components (UFM1/UFL1/DDRGK1/CDK5RAP3) are part of different regulatory modules that coordinate the fine-tuning of important homeostatic processes in multiple cellular stress.However, with limited knowledge, elucidating the underlying molecular mechanism of UFMylation remains challenging. Here we list some examples of questions that need to proceed for future research.1) how can UFL1 be manipulated to enable appropriate stress responses and restore homeostasis? To explain this, we surmised that UFL1 functions by recruiting adaptor and signaling proteins, especially the transcription factors, to assemble the signaling platforms perceived stress sensors, therefore modulating the amplitude and kinetics of downstream responses.2) Is any other stress responses that UFL1 involved in? The stress response is the protective mechanism of cells against changes in the external environment. UFL1 has been proven activated in including but not limited to ER stress, genotoxic stress, oncogenic stress, and inflammation. However, how UFL1 performed in other environmental conditions, such as heat stress, oxidative stress, variable pH, calcium deficiency, and viral infection, is still mysterious. Therefore, exploring UFL1 function in different physiological or pathological stress responses is an important direction for future research.-/- and UFL1-/- mice, which raises the question of whether there is an unknown regulatory mechanism among the UFMylation components.3) For UFMylation progress itself, still needs to be better understood. Although recent studies have identified the components involved in the UFMylation system, the regulatory relationship between them is puzzling. For instance, CDK5RAP3, a substrate adaptor that can form an integrated complex with UFL1, restricts UFL1/DDRGK1 E3 ligase activity. However, some phenotypes are similar between CDK5RAP3Taken together, UFMylation is a newfound and attractive modification system. Appreciation of the UFMylation molecular mechanism of maintaining homeostasis under multiple cellular stress, as well as its feedback regulation, sheds light on stress-induced disease pathogenesis and provides novel therapeutic targets for treating relevant diseases.QJ: writing original draft and editing. YW: writing-original draft. MX: investigation. JinH: investigation. TZ: Data sorting. XL: Data sorting. FC: review and editing. JinH: editing and supervision and funding acquisition. YC: editing and supervision and funding acquisition. All authors contributed to the article and approved the submitted version.