Patients with MetS or SIRS experience higher rates of mortality and morbidity, across both cardiac and noncardiac surgery. Frailty assessment has acquired increasing importance in recent years as it predisposes elderly patients to a worse outcome. The aim of our study was to investigate the influence of MetS, SIRS, and with or without frailty on elderly patients undergoing emergency surgical procedures.We analyzed data of all patients with nonmalignant diseases requiring an emergency surgical procedure from January 2017 to December 2020. The occurrence of MetS was identified using modified definition criteria used by the NCEP-ATP III Expert Panel: obesity, hypertension, diabetes, or if medication for high triglycerides or for low HDL cholesterol was taken. Systemic inflammatory response syndrome (SIRS) was evaluated according to the original consensus study (Sepsis-1). The frailty profile was investigated by the 5-modified Frailty Index (5-mFI) and the Emergency Surgery Frailty Index (EmSFI). Postoperative complications have been reported and categorized according to the Clavien–Dindo (C–D) classification system. Morbidity and mortality have been mainly considered as the 30-day standard period definition.n-MetSG 10.5 ± 10.2 days, p = 0.046). MetSG has a significantly higher rate of morbidity (353 (35.%) vs. 385 (29.4%), p = 0.005). The mortality rate in patients with MetS  was similar to that in patients without it . Considering patients with MetS who developed SIRS and those who had frailty or both, the occurrence of these conditions was associated with a higher rate of morbidity and mortality.Of the 2,318 patients included in this study, 1,010 (43.6%) fulfilled the criteria for MetS (MetsG group). Both 5-Items score and EmsFI showed greater fragility in patients with MetS. All patients with MetS showed more frequently a CACI index greater than 6. The occurrence of SIRS was higher in MetSG. LOS was longer in patients with MetS (MetSG 11.4 ± 12 days vs. Impact of MetS and SIRS on elderly surgical patient outcomes has yet to be fully elucidated. The present study showed a 43.6% incidence of MetS in the elderly population. In conclusion, age per se should be not considered anymore as the main variable to estimate patient outcomes, while MetS and Frailty should have always a pivotal role. Although advances in surgical techniques, anaesthetic procedures, and postoperative care have all made surgery less hazardous, surgeons are generally more reluctant to operate on elderly patients because they are perceived to be frail, to have less physiological reserve, and to have more underlying medical conditions –3. SeverThis research originates from a previous well-consolidated experience (the ERASO collaborative study group) which has led to the FRAILESEL project and related reports . FollowiExclusion criteria were the following: age <65 years; lack of informed consent for the study participation, if requested; patients participating in other randomized or interventional clinical trial; with regard to emergency surgery, patients were excluded if already hospitalized and scheduled for the same procedure. Sole emergency endoscopic procedures or reoperations after elective surgery were excluded. Submissions made by unconfirmed participants, duplicate submissions, records with more than 5% of missing data, and data submitted by residents from dual or more residency programs were excluded. Although demographic information was collected on the patients, all data were anonymized before analysis even for center identification.For the aim of the present study, we analyzed data of all patients with nonmalignant diseases requiring an emergency surgical procedure from January 2017 to December 2020. Cancer patients were excluded because of the possible concomitant role of the neoplasm in determining an inflammatory response and/or an adverse outcome. Data collected included patient demographic characteristics , medical and surgical history (comorbidities), common preoperative biochemical blood examination , pathological features, and operative details. Comorbidity was recorded if the condition was being medically treated at the time of admission, or if previous treatment for the condition was described in the admission report. The age-adjusted Charlson comorbidity index (age-CACI) was calculated and a score ≥6 was used to categorize patients having a severe comorbid condition , 27. Theχ2 test, with or without Yates correction, was used to compare differences in frequencies. The role of MetS stratified for the BMI class, and the presence of SIRS and/or frailty was also assessed using the estimated adjusted odds ratio. All tests were two-tailed, and a p-value ≤0.05 was considered statistically significant.Statistical analysis was carried out using IBM Corp. Released 2019, IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp. Dichotomous data and counts were presented in frequencies, whereas continuous data were presented as mean values ± standard deviations (SD) and/or median with 25–75 Interquartile Range (IQR), or minimum-maximum range. Differences between means were compared using the independent sample Student’s t-test or the Mann–Whitney U test when indicated. Fisher’s exact test or n = 1,175 (50.7%) were male. The overall BMI was 25.7 ± 4.5 . Of the total patients included in this study, n = 1,010 (43.6%) fulfilled the criteria for MetS (MetS Group). Of these, n = 414 (38.1%) were under weight, n = 22 (2.0%) were normal weight, n = 376 (34.6%) over weight, and n = 275 (25.3%) obese. A 5-mFI ≥0.4 was observed in n = 1,203 (52.0%) patients and an EmsFI ≥4 in n = 887 (38.0%). A CACI >6 was observed in n = 870 (37.5%) patients (n = 738 pts) and a Clavien–Dindo ≥2 was present in 505 (22%) patients. ] vs. the n-MetS Group [n = 459 pts (35.1%)] (p < 0.001); an EmSFI ≥ 4 was detected more frequently in MetS Group [n = 437 pts (43.2%)] vs. n-MetS Group [n = 446 pts (34.1%)] (p < 0.001). Similarly, all patients with MetS showed more frequently a CACI index ≥6 (MetS Group n = 451 pts (44.6%) vs n-MetS Group n = 419 (32.0%) p < 0.001). The occurrence of SIRS was higher in the MetS Group [n = 349 (34.5%) vs n = 371 (28.4%)] with a statistically significant difference (p = 0.001). We then evaluated the surgical outcomes according to the presence or absence of MetS (n-MetS Group 10.5 ± 10.2 days p = 0.046).No difference in terms of age and sex were identified between the two groups. Regarding frailty, both 5-mFI score and EmsFI showed greater fragility in patients with MetS. A 5-mFI score ≥0.4 was more frequent in the MetS Group [ of MetS . LOS wasn = 353 (35.0%) vs. n = 385 (29.4%), p = 0.005). In particular, CD ≥2 was detected in n = 245 (24.3%) patients with MetS and in n = 260 (20.0%) patients without it, being the difference statistically significant (p = 0.011). We then conducted a sub-analysis considering separately the morbidity risk according to the Clavien–Dindo grading classification showing no association with the presence of MetS, SIRS, or frailty (n = 227 patients). The mortality rate in patients with MetS was similar to the mortality rate in patients without it . Regarding the overall morbidity (CD I-IV), patients with MetS and normal weight or overweight were at increased risk . Again, patients with MetS in which SIRS occurred and with frailty were at increased risk of overall morbidity .Patients with MetS have a significantly higher rate of morbidity , and decreased high-density lipoprotein concentrations . The preThis study has several potential limitations. First, although the FRAILSESL is a rich clinical registry, we had to adapt the NCEP-ATP III definition of MetS to the data recorded in the FRAILESEL database. In the light of this, our definition of Mets is rather deficient due to the data collection which concerns emergency conditions whose often not all data are recorded, this may have led to an uncorrected estimation of the actual incidence of Mets. Some patients with the MetS may have been “missed” because we did not include the lipid profile in our definition—and because central obesity is not always captured by a high BMI, while others could have arbitrarily included. However, our results report an incidence of MetS comparable to the literature. Furthermore, the results of this study empirically demonstrate that this syndrome, as defined here, is associated with significant morbidity. A further limitation is the design of the study with a mixed perspective and retrospective component as well as the inclusion of all diseases except malignancy; in our opinion, further studies would be useful to specifically analyze certain diseases. However, one of the primary strengths of this study is that the number of elderly patients with MetS was sufficiently large to explore the impact of this syndrome on 30-day mortality and on individual postoperative complications. Another important strength of this study is the richness of the database on which it is based. Because of the large number of clinical variables collected on the patients in the FRAILESEL database, we were able to control for many important confounders and to evaluate the impact of Mets when it is associated with both SIRS and frailty. This feature is particularly important given the fact that patients with the MetS have many comorbidities.Metabolic syndrome at admission portends a higher rate of morbidity, mortality, and longer LOS. Regarding the fact that most metabolic syndrome components can be either prevented or improved through lifestyle changes and/or pharmacological agents, a question is raised whether this can also prevent the occurrence of acute surgical conditions. Moreover, this situation demands the undertaking of a systematic review of surgical patients with MetS to articulate risks as well as the development of a care pathway to better manage these risks. Further knowledge about the nature and prevalence of complications from surgery related to MetS is needed to help formulate targeted interventional research studies aimed at improving surgical outcomes among patients with this condition. In conclusion, age per se should be not considered anymore as the main variable to estimate patient outcomes, while MetS and Frailty should have always a pivotal role.


There is a paucity of knowledge regarding the association of alcohol use with overall survival (OS) of patients with head and neck squamous cell carcinoma (HNSCC).All 1033 patients treated for new HNSCC in Southwest Finland regional referral center of Turku University Hospital in 2005–2015. Cox regression analysis was used. Tumor TNM classification, age at baseline and tobacco smoking status were assessed as potential confounders.p = 0.017) as well as current use of at least 10 units per week  were associated with OS.A history of severe harmful alcohol use with major somatic complications (HR: 1.41; 95%CI: 1.06–1.87; Alcohol consumption of 10–20 units/week, often regarded as moderate use, was found to increase risk of mortality independent of other prognostic variables. Systematic screening of risk level alcohol use and prognostic evaluation of alcohol brief intervention strategies is highly recommended. Extensive information on alcohol and tobacco use as well as other potential confounders allows for assessment of prognostic issues in a robust analytical framework. As the regional referral center is responsible for treatment of all HNSCC cases in Southwest Finland per national treatment guidelines, the study is void of inclusion bias induced by socioeconomic or insurance status‐related issues.22.1The study protocol is shown in Figure 2.2Information on alcohol use was collected from the patient records. Alcohol use was estimated at the time of diagnosis by clinical interview to determine alcohol intake in units per week, and repeatedly at each visit. This is an established practice in the TUH clinic responsible for treating HNSCC cases. Current use was categorized into three groups of consuming less than 10 units per week, 10–20 per week or more than 20 units per week. On the first visit, the patients were asked to consider alcohol use in the last 6 months prior to diagnosis of HNSCC. A unit is defined as 12 g of pure alcohol.Cumulative alcohol exposure was ascertained dichotomously as presenting with a history of problem level alcohol use (yes/no) defined as previous alcohol consumption more than 10 units/week. In addition, a history of severe alcohol‐related somatic complications was defined as the presence of alcohol‐related ICD‐10 diagnoses F10.31, F10.4, F10.40, F10.41, F10.6, F10.73, F10.01, F10.02, F10.06, F10.74, F10.6, G31.2, G40.51, G62.1, G72.1, K70*, I42.6, K85.2, K86.00, K86.01, K86.08, T510, T510* X45 or T510*X69, which include pancreatitis, alcohol hepatitis, alcohol polyneuropathy, or alcohol encephalopathy, in the medical records of the TUH.2.3Overall survival was defined from end‐of‐treatment to end‐of‐follow‐up or death. Five‐year survival was preferentially used, and cause of death determined by chart review. Survivalship status was recorded from medical records of the TUH which have linkage to the Finnish National Population Information System database. Patients lost to follow‐up were censored at the last data in the hospital records.2.4Tumors were staged according to TNM criteria applicable at the time of diagnosis. Treatment protocols followed decisions by the multidisciplinary Tumor Board for head and neck cancer.Information on tobacco use was collected from the patient records. Tobacco history was determined at the time of diagnosis by clinical questions to determine tobacco use duration in years and the number of daily cigarette equivalents. On further visits, tobacco use was repeatedly inquired. Subjects were categorized by tobacco use status into four group: patients with no tobacco use for at least 5 years, patients who quitted tobacco use within 5 years, patients who quitted tobacco use at diagnosis, and patients with continued tobacco use after diagnosis of HNSCC. Cumulative tobacco use was estimated as pack‐years (PY), the product of the number of packs of cigarette equivalents smoked per day and the number of years of tobacco use. When other tobacco products than cigarettes were used, established conversion criteria were applied. In this study, subjects were categorized by PY years categories of never, PY < 10, PY < 20, PY < 30, PY < 40, and PY ≥ 40.2.5p‐value of 0.10. All covariates presented in Table Statistical analyses were performed using SPSS statistical software . First, we applied multivariable Cox proportional hazards method to identify a preliminary prognostic model using backward stepwise regression using 5‐year OS, the likelihood ratio method, and exclusion Next, the association of current and former alcohol use with OS was studied using Model 2 . The alcohol use history variables  were included in Model 3, while the final prognostic Model 4 included current alcohol consumption as a variable .p‐values are reported.For all reported models, the proportionality of hazards was confirmed using log‐minus‐log plotting and plotting Schoenfeld residuals against survival time, when appropriate. For all Cox models, hazard ratios (HR) with 95% confidence intervals (CI), and 33.1A total of 1033 individuals with new primary HNSCC during the years 2005–2015 were identified and included in the cohort, the characteristics of which are shown in Table 3.2p = 0.004). Using different PY cut‐offs, both exposure history of at least 20 PY  as well as exposure history of at least 40 PY  associated with OS . However, quitting tobacco use at diagnosis did not result in an unequivocal improvement in prognosis. Thus, tobacco use at the time of diagnosis was revealed to be the strongest predictor of OS  and was accordingly included in the final prognostic model.However, in prognostic models adjusting for current tobacco use, the cumulative tobacco exposure variables were found to lose their OS impact. Thus, the impact of current tobacco use was carefully evaluated Table . ContinuS Figure  (HR: 1.63.3p = 0.036). Even more strongly, however, history of severe alcohol‐related somatic complications such as pancreatitis, alcohol hepatitis, or alcohol encephalopathy (cf. section p = 0.002).Cohort characteristics in terms of current and former alcohol exposure are presented in Table p = 0.004). The survival impact of severe alcohol history remained significant in the final model. No significant interactions were found between current alcohol use, current tobacco use, cumulative tobacco use history, and history of alcohol use.The survival impact of current alcohol use was investigated in a multivariable model, where patient age, high T classification, nodal positivity, primary tumor site, tobacco use at the time of diagnosis, and history of severe alcohol‐related somatic complications were entered as covariates. Current problem level alcohol use was associated with a poor prognosis Figure  (HR: 1.43.4p < 0.001).Finally, the confounder bias introduced by differences in the treatment protocols was evaluated Table . When th4This large population‐based regional cohort study of patients with HNSCC reports a strong association between current problem level alcohol use, history of severe alcohol‐related somatic complications and 5‐year OS. Importantly, current alcohol use retained its prognostic worth despite adjustment for history of severe alcohol‐related somatic complications and previously identified clinical prognostic variables.The previously published cohort studies reporting a significant positive finding in unstratified analysesIn our sample, history of problem level alcohol use was also associated with impaired survival. The association was even stronger for a history of severe alcohol‐related somatic complications, possibly due to an independent adverse prognostic influence of alcohol‐related somatic diseases. The lack of linearity between survival impacts of current exposure levels is most likely due to bias introduced by the adjustment for complicated alcohol use history as well as the greater likelihood of interventions when severe alcohol use is reported. Most importantly, moderately heavy consumption (10–20 units/week) was associated with OS. This is of special clinical significance as this group includes patients with problem level alcohol use but not necessarily meeting criteria for an alcohol use disorder (AUD).Concerns have been raised regarding underscreening and non‐treatment of problem level alcohol use in patients with HNSCC.The strengths of this study are as follows: The main strength of this study is the large sample size, which included all patients with HNSCC within a 10‐year period treated at our regional referral center. As all diagnosed cases of HNSCC are referred to our tertiary referral center from the complete Southwestern Finland region per national treatment guidelines, the study is void of bias inflicted by socioeconomic or insurance status. Moreover, although Finnish alcohol consumption levels per capita do not markedly differ from those other European countries,However, there are also limitations. Underreporting of alcohol use is a concern5After receiving diagnosis of HNSCC, continuation of alcohol use, even at moderate level, that is, 10–20 units/week, associates with increased mortality risk, independent of age at diagnosis, tumor stage, and tobacco use status. HNSCC patients with moderate alcohol use would most probably benefit from alcohol brief interventions. Thus, implementing non‐labor‐intensive systematic screening of alcohol use and alcohol brief interventions in treatment and follow‐up of patients with HNSCC is of paramount importance.Concept and design: Alexander Denissoff, Solja Niemelä, and Johannes Routila. Acquisition, analysis, or interpretation of data: Alexander Denissoff, Teemu Huusko, and Johannes Routila. Drafting of the manuscript: Alexander Denissoff. Critical revision of the manuscript for important intellectual content: Teemu Huusko, Sami Ventelä, Solja Niemelä, and Johannes Routila. Statistical analysis: Alexander Denissoff and Johannes Routila. Obtained funding: Alexander Denissoff and Johannes Routila. Administrative, technical, or material support: Solja Niemelä, Sami Ventelä, and Johannes Routila. Supervision: Johannes Routila.Johannes Routila had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.Figure S1 The relationship between tobacco use and overall survival (OS). Both tobacco history exceeding (A) 20 pack years, and (B) 40 pack years had a significant association with OS. However, a more significant prognostic role was associated with (C) continued tobacco use after cancer diagnosis, and especially (D) smoking at the time of diagnosis. CI: confidence interval; HR, hazard ratio.Click here for additional data file.Table S1 The survival effects of treatment protocols assessed in the final Model 4.Click here for additional data file.


The present study was intended to analyze the characteristics of myelinated nerve fibers density (MFD) of transthyretin amyloid polyneuropathy (ATTR‐PN) and other similar neuropathies.A total of 41 patients with ATTR‐PN, 58 patients of other common peripheral neuropathies, and 17 age‐and gender‐matched controls who visited the First Hospital of Peking University and performed sural nerve biopsy between June 2007 and August 2021 were included for analysis of MFD.Except the vasculitic neuropathy group, the total and small MFD of patients in the ATTR‐PN group were significantly lower than those of other disease groups. There was an obvious negative correlation between the total MFD and the disease course in the ATTR‐PN group. The disease course of early‐onset and late‐onset symptoms was similar, but the loss of large myelinated nerve fibers (MF) was more severe for the latter. In addition, all late‐onset and most early‐onset patients had severely reduced MFD after a 2 years' disease course. The MFD in ATTR‐PN patients was negatively correlated with Neuropathy Impairment Score (NIS) and Norfolk Quality of life‐diabetic neuropathy (Norfolk QOL‐DN) score.MF is lost differently in ATTR‐PN and in other common peripheral neuropathies. The late‐onset and early‐onset ATTR‐PN patients have different patterns of loss of large and small MF. TTR gene mutation with an autosomal dominant inheritance pattern. The disease is characterized by transthyretin (TTR) amyloid fibrils deposition in multiple organs, mostly leading to sensory‐motor neuropathy, autonomic dysfunction, and cardiomyopathy, accompanied by involvement of other organs.TTR gene testing. So far, more than 150 mutations have been described in the TTR gene.TTR Val30Met mutation is the most common pathogenic variant overall.Transthyretin amyloid polyneuropathy (ATTR‐PN) is a progressive and life‐threatening disease caused by Late‐onset and sporadic ATTR‐PN cases, which were found to be common in mainland China in our previous study, are prone to misdiagnosis.Sural nerve biopsy is preferred when clinicians are confused about the diagnosis that is based on clinical and electrophysiological findings alone.Between June 2007 and August 2021, we retrospectively analyzed the sural nerve pathology of 41 patients  with ATTR‐PN, 10 patients  with CIDP, 14 patients  with CIAP, 6 patients  with LO‐CMT2, 8 patients  with POEMS syndrome, 13 patients  with definite vasculitic neuropathies, 7 patients  with toxic neuropathy, and 17 controls , who were diagnosed in Peking University First Hospital. All ATTR‐PN patients were diagnosed according to the diagnostic criteria.For the diagnosis of definite CIDP, the diagnostic criteria proposed by the Joint Task Force of the European Federation of Neurological Societies and the Peripheral Nerve Society (EFNS/PNS) were adopted.TTR gene screening.The diagnosis of CIAP was based on previously described criteria.MFN2 in three patients, and MPZ (relating to CMT2J subtype), NEFL, and GDAP1 in one patient, respectively. All these variations had been reported and were considered to be likely pathogenic or pathogenic variations according to the criteria by the American College of Medical Genetics and Genomics (ACMG).All LO‐CMT2 patients were diagnosed by Next Generation Sequencing (NGS) with All POEMS syndrome patients were diagnosed according to the latest criteria of 2019.All vasculitic neuropathy patients were diagnosed based on sural nerve biopsies, and compatible with diagnostic criteria of pathologically definite vasculitic neuropathy proposed by Peripheral Nerve Society Guideline.All toxic neuropathy patients had a definite history of toxic exposure. Meanwhile, other common causes of peripheral neuropathy were excluded, such as diabetic neuropathy, alcoholic neuropathy, and paraneoplastic neuropathy. The peripheral neuropathy‐related substances included chemotherapeutic drugs  in four patients, thalidomide in two patients, and organophosphorous pesticide, telbivudine, and acrylamide in one patient, respectively. All these chemotherapies or toxicants related neuropathies had been reported previously.Seventeen sural nerve tissues from subjects who had no definite pathological abnormalities, which were judged by a group of experienced neuropathologists, were selected as pathomorphological normal controls.All the subjects associated with this study underwent sural nerve biopsies and signed informed consent, and this study was approved by the Ethics Committee of First Hospital of Peking University.TTR gene mutation, with Val30Met in thirteen, Val30Leu in four, Ala97Ser in three, Lys35Asn in three, Ala36Pro, Phe33Leu, Phe33Val, Gly47Arg, Val30Ala, Gly83Arg, and Glu61Lys in two, Glu42Gly, Ser77Phe, Thr59Lys, and Val28Ser in one patient, respectively.The mean age at which all the ATTR‐PN subjects underwent biopsies was 50.3 ± 13.3 years, with 21 early‐onset patients and 20 late‐onset patients. All patients had All the ATTR‐PN patients were inquired about their disease history and had a focused neurological examination of measurement scales performed, including Coutinho stages, Neuropathy Impairment Score (NIS), Norfolk Quality of life‐diabetic neuropathy (Norfolk QOL‐DN) score, and Composite Autonomic Symptom Score 31 (COMPASS‐31). The onset of disease was defined as the progressive sensory‐motor neuropathy or/and autonomic neuropathy. A disease course of more than 2 years was considered as a long course.2 was considered as severe MF loss.Sural nerve biopsies were performed as described previously.p values were calculated for all analyses, and p values <0.05 were considered statistically significant. Spearman's correlation analysis was used to test the correlations between MFD and data of clinical scores.For statistical analysis, IBM SPSS Statistics, version 26, was used. As most of the disease and control groups showed a non‐normal distribution , Pearson's chi‐square test or Fisher's exact test, Mann–Whitney test and Kruskal–Wallis test were used to study the differences between the ATTR‐PN group, non‐ATTR‐PN groups, and the control group. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the use of MF loss per year in differentiating ATTR‐PN from CIDP and CIAP groups. The area under the curve (AUC) was calculated. The value of the Youden index at its maximum was taken as the cut point for the diagnosis of ATTR‐PN, and the sensitivity and specificity were calculated. Two‐sided p < 0.05), as was shown in Figure p > 0.05). The large MFD of ATTR‐PN, LO‐CMT2, vasculitic neuropathy, and toxic neuropathy groups were all significantly reduced, but there was no statistically significant difference between ATTR‐PN and LO‐CMT2, vasculitic neuropathy or toxic neuropathy group . As for small MFD, severe reduction was observed in both the ATTR‐PN and vasculitic neuropathy groups, but without significant difference (p > 0.05). More significant loss occurred in the ATTR‐PN group than in other disease groups . Furthermore, the correlations between MFD and the disease course were analyzed. Just as Figure p < 0.0001). It seemd that there was a more severe loss of the MF but a shorter course in the vasculitic neuropathy group than in other groups. However, the correlations between MFD and the disease courses in these groups were not statistically significant  except the ATTR‐PN group.The clinical features and MFD of all groups were shown in Table 2, 1695.1/mm2, and 1494.4/mm2 for small, large and total MFD, respectively. The AUCs of the above MFD were 0.9042, 0.7456, and 0.8624, with a high sensitivity  and specificity , respectively. For ATTR‐PN and CIDP, the cutoff values of the MFD reduction per year were 670.1/mm2, 1659.0/mm2, and 1112.0/mm2 for small, large, and total MFD, respectively. The AUCs of the related MFD were 0.7774, 0.6646, and 0.7652, the sensitivities were 1.0, 0.875, and 0.5, respectively, and the specificities were 0.5, 0.537, and 1.0, respectively . Compared with the patients with a short disease duration (≤2 years), the proportion of positive Congo red staining was higher in patients with a long disease duration (>2 years) (61.1% vs. 26.0%), with significant difference (p = 0.0308). Considering both the disease duration and age of onset, late‐onset patients with a short disease duration had a lower positive Congo red proportion than early‐onset patients with a long disease duration(16.6% vs. 70.0%), with significant difference(p = 0.0274) (Table The Congo red positive proportion of nerve biopsies was 17/41 (41.4%) in all ATTR‐PN patients. The early‐onset patients had a higher Congo red positive proportion than  late‐onset ones (52.3% vs. 30.0%), but without significant difference (p < 0.05). . Table .p <0.05). But patients in the Val30Met group had older age of onset and a higher proportion of positive family history . Furthermore, the proportion of cases, whose total MFD were lower than 1000/mm2, was higher in the long disease course group than in the short disease course group, whether the cases were early‐onset (p = 0.0300) or late‐onset (p = 0.0409). However, MFD were lower than 1000/mm2 among more late‐onset cases than early‐onset ones, especially in the early disease stage (50.0% vs. 27.3%), but without statistical difference (p > 0.05). For the long course group (longer than 2 years), all the late‐onset patients and most of the early‐onset patients had severe MFD reductions, which were lower than 1000/mm2 , as well as negative correlations between NIS, Norfolk QOL‐DN, and duration (p < 0.05). Correlations between COMPASS‐31 and MFD, duration of disease were not observed in this study (p > 0.05) (Table For clinical measurement scales, negative correlations between MFD and NIS, Norfolk QOL‐DN score were observed with significant difference (2, with a disease duration of 18.7 months.2 with an average disease duration of 41 months in Vrancken AF et al's study.The most common misdiagnosed disease of ATTR‐PN is CIDP, due to the similar sensory‐motor symptoms, decreased tendon reflex, electrophysiological demyelination, and cerebrospinal fluid cytoalbuminologic dissociation.In general, both ATTR‐PN patients and vasculitic neuropathy patients had the most severe MF loss, and the former was relatively insidious. Interestingly, our study also proved that only in the ATTR‐PN group was the MFD negatively correlated with the course of disease, indicating ATTR‐PN was a relatively severe chronic progressive disease that was similar to neurodegenerative disorders, such as Alzheimer's disease, Parkinson's disease, and Amyotrophic lateral sclerosis, with abnormal protein aggregation and no relapse or remission in the course of disease.Previous studies revealed that the longer the course of disease was, the higher positive propotion the nerve Congo red staining had. There were mild or no amyloid deposits in the early disease stage despite the severe loss of MF.2, offering more evidence that ATTR‐PN was a malignant and progressive disease. So, for late‐onset patients with polyneuropathies of more than 2 years disease courses, the diagnosis of ATTR‐PN should be cautious, if no severe MFD reduction have not been observed. The pathological findings can also help improve the efficiency of TTR gene detection.In our study, large MF was impaired more severely in late‐onset patients than in early‐onset ones. In another ATTR‐PN study of Val30Met mutation, sural nerve biopsy specimens showed predominantly small‐fiber loss in early‐onset cases.In this study, we found that the MFD were positively correlated with the NIS, Norfolk QOL‐DN scores of ATTR‐PN, which was more pronounced in large MFD, but there was no significant correlation between MFD and the COMPASS 31. These findings suggested that the loss of sensory MF morphologically, especially large sensory MF, was consistent with the severity of neuropathy and functional impairment in ATTR‐PN patients. However, small MF, not including unmyelinated nerve fibers, could not reflect autonomic nerve impairment, which was why COMPASS 31 was not correlated with the small MFD.This study had several limitations. First, the sample size was relatively small. Second, classification of subtypes was lacking in disease groups, such as CIDP, vasculitic neuropathy, and toxic neuropathy groups, which made it difficult to gain keen insights into the disease duration‐dependent loss of MF.In conclusion, the MFD observation of nerve tissues is useful for differentiation between ATTR‐PN and other common peripheral neuropathies, especially in Congo red negative cases. It was found that the loss of the sural nerve fibers density in patients with ATTR‐PN was significantly related to the course of peripheral neuropathy, and the loss of nerve fibers was more serious than in most of other common peripheral neuropathies. The pattern of large and small MF loss is different in early‐onset and late‐onset cases. Loss of sensory nerve fibers is consistent with the severity of neuropathy and functional scores.KD: acquisition of data, completion of statistical analysis, and drafting of the initial manuscript and writing of the final manuscript. XC: acquisition of data, study concept and design, and critical revision of the manuscript. YT, MY, YZ, JD, HL, WZ, and ZW: study concept and design, and critical revision of the manuscript. YY and LM: data review, interpretation of results, and revision of the initial draft.The authors declare no conflict of interest.


Accessibility of pre‐exposure prophylaxis (PrEP) in Canada remains complex as publicly funded coverage and delivery differs by province. In January 2018, PrEP became publicly funded and free of charge in British Columbia (BC), whereas PrEP coverage in Ontario and Montreal is more limited and may require out‐of‐pocket costs. We examined differences over time in PrEP uptake and assessed factors associated with PrEP awareness and use.Gay, bisexual and other men who have sex with men (GBM) were recruited through respondent‐driven sampling (RDS) in Toronto, Vancouver and Montreal, Canada, in a prospective biobehavioural cohort study. We applied generalized estimating equations with hierarchical data  to examine temporal trends of PrEP use and correlates of PrEP awareness and use from 2017 to 2020 among self‐reported HIV‐negative/unknown GBM.p<0.001): Montreal 14.2% during the first time period to 39.3% during the last time period (p<0.001), Toronto 21.4–31.4% (p<0.001) and Vancouver 21.7–59.5% (p<0.001). Across the study period, more Vancouver GBM used PrEP than Montreal GBM , with no significant difference between Toronto and Montreal GBM .Of 2008 self‐identified HIV‐negative/unknown GBM at baseline, 5093 study visits were completed from February 2017 to March 2020. At baseline, overall PrEP awareness was 88% and overall PrEP use was 22.5%. During our study period, we found PrEP use increased in all cities (all Full free‐of‐charge public funding for PrEP in BC likely contributed to differences in PrEP awareness and use. Increasing public funding for PrEP will improve accessibility and uptake among GBM most at risk of HIV. Ontario≤24 and the Ontario Drug Benefit for those ≥65 qualifying with Ontario Disability Support Programme or Ontario Works. Partial coverage is available for those qualifying under Trillium (a programme for Ontario residents who spend 4% or more of after‐tax household income on prescription‐drug cost), with annual deductibles up to $3100 scaled to household income, for those with no insurance, PrEP can cost $250 per month [Considering healthcare in Canada is distributed provincially, coverage of PrEP remains complex with different policies between provinces . Nationaer month . Althouger month .Prior to PrEP approval, a 2015 online cross‐sectional survey of Canadian GBM found that 54.7% were aware of PrEP and 47.7% were interested in using PrEP, but use was not reported . After aGiven the evolutions in PrEP policy and access, we sought to explore how PrEP use has changed over time among self‐reported HIV‐negative/unknown GBM in Canada's three largest cities: Toronto, Montreal and Vancouver. We examined within and between city trends from 2017 to 2020 and we assessed factors associated with PrEP awareness and use among a pooled sample of these urban GBM.22.1Data come from the Engage Study, a longitudinal biobehavioural cohort study of GBM in Toronto, Montreal and Vancouver , 19. Bas2.2PrEP awareness was assessed (after giving the definition of PrEP), “Before today, had you ever heard of PrEP?” Responses were either Yes or No. Lifetime PrEP use  was assessed by asking, “Have you ever taken PrEP yourself?” Responses were either Yes or No.2.3Explanatory measures included healthcare access, sexual risk factors, sexually transmitted infections (STI) diagnoses and socio‐demographics. Relationship questions included open relationship status and whether participants knew the HIV status of their main partner. We asked participants if they had a primary healthcare provider (PCP), if they were out about their sexuality with their PCP and if they had insurance coverage for prescription medication. We included the HIRI‐MSM scale, a clinical tool used to measure HIV risk, with dichotomized scores of ≥10 indicating high HIV risk and good candidates for PrEP , 22. We 2.4p‐values. Variables that were statistically significant at p<0.2 and theoretically relevant to our analysis were included for consideration in our final model using a backward stepwise selection approach and we used Quasi Information Criterion (QIC) to compare model fit [p<0.05. We used three‐level hierarchical data  for all regression analyses and included the city as a covariate. All analyses were performed using SAS version 9.4 . A planned post‐hoc sensitivity analysis was undertaken to assess if results would differ for PrEP‐eligible GBM, defined as reporting CAS and ANY of the following  [We applied the Wald chi‐square test to examine differences in descriptive results, including city‐specific counts and percentages, and RDS‐II adjusted percentages . RDS‐II odel fit . The finore ≥10) . Using b3n = 1768) of participants had ever heard of PrEP, with RDS‐adjusted estimates indicating significant differences in awareness between Montreal (71.7%), Toronto (82.4%) and Vancouver (92.9%) (p<0.001). Overall, 22.5% (n = 398) of participants reported lifetime PrEP use at enrolment; RDS‐adjusted estimates from between city analysis indicated significant differences in lifetime PrEP use between Montreal (13.1%), Toronto (14.1%) and Vancouver (20.3%) (p = 0.002). PrEP eligibility varied between Montreal (45.8%), Toronto (43.9%) and Vancouver (57.1%) (p<0.001). Full descriptive results are in Table Our analysis included 2008 self‐reported HIV‐negative/unknown participants, 968 (48.2%) in Montreal, 418 (20.8%) in Toronto and 622 (31.0%) in Vancouver recruited from February 2017 to August 2019. At enrolment, we found that overall 88%  participants completed at least one follow‐up visit. The median number of follow‐up visits was 2 (Q1–Q3: 1–3) and the median follow‐up time was 1.7 years (Q1–Q3: 1.1–2.1). Overall, lifetime PrEP use increased during our study period . Further, we found PrEP use increased in all three cities. From first time period to last, Montreal increased from 14.2% to 39.3% (p<0.001), Toronto 21.4% to 31.4% (p<0.001) and Vancouver 21.7% to 59.5% (p<0.001). Full results are in Figure Of 3.2Participants in Vancouver  were more aware of PrEP than those in Montreal, we found no significant difference between Toronto  and Montreal. Furthermore, participants who reported being in a  open relationship versus closed/monogamous relationship , had a HIRI‐MSM score ≥10 , had ever been diagnosed with an STI  and reported any CAS with an HIV‐positive or unknown status partner in the past 6 months  were more likely to be aware of PrEP. Having prescription medication insurance was positively associated with PrEP awareness . Full univariable and multivariable results are in Table Lifetime PrEP use was more likely among participants in Vancouver  than in Montreal, with no significant difference between Toronto and Montreal GBM . Lifetime PrEP use was more likely among those who were certain or thought their main partner was HIV positive , compared to those who did not know the HIV status of their main partner. GBM were more likely to have ever used PrEP if they had a HIRI‐MSM score ≥10 , reported any CAS with an HIV‐positive or unknown status partner in the past 6 months  and had ever been diagnosed with an STI . Moreover, PrEP use was positively associated with insurance coverage for prescription medication  and use of chemsex drugs in the past 6 months . GBM who self‐reported being “somewhat likely” to acquire HIV  or as “(very) likely”/“I think already have HIV”  were less likely to have ever taken PrEP in comparison with those who self‐reported they were “(very) unlikely” to acquire HIV. Full univariable and multivariable results are in Table 3.3PrEP‐eligible participants from Vancouver had greater odds of PrEP use compared with GBM from Montreal , while GBM from Toronto had lower odds of PrEP use compared with Montreal . Among socio‐demographic variables, GBM aged 30–44 versus <30 , and aged >45 versus <30 , GBM with an annual income $30,000–$59,999 versus <$30,000 , an annual income >$60,000 versus <$30,000  and participants who identified as Asian versus Canadian  were more likely to report PrEP use. Additionally, GBM who had  open relationships  and GBM who were single  had greater odds of PrEP use compared to GBM who had a closed/monogamous relationship with a main partner. GBM who indicated they were out about their sexual orientation to their PCP  also had greater odds of PrEP use compared with GBM who were not out. Reporting a greater number of male sexual partners in the past 6 months was associated with greater odds of PrEP use .p = 0.728).Lastly, we conducted a PrEP‐to‐need ratio for each city. In Montreal, 504 participants met PrEP eligibility at baseline, with 25% indicating they had ever taken PrEP. In Toronto, 245 participants met PrEP eligibility at baseline, with 33.47% ever using PrEP. In Vancouver, 403 participants met PrEP eligibility at baseline, with 34.99% ever reporting PrEP. Our lost‐to‐follow‐up analysis did not find significant differences in HIRI scores between participants with at least one follow‐up visit and those without  to the end of our study (early 2020: 45%). In 2019, the World Health Organization reported that PrEP use has increased over time with over 600,000 people across 76 countries receiving PrEP at least once, a 70% increase from 2018 . In contApart from Canada, countries including Norway, Scotland and South Africa have demonstrated the success of free‐of‐charge PrEP programmes . In 2016Implementing a free‐of‐charge publicly funded PrEP programme has a multitude of beneficial implications that can also address larger barriers to care. First, PrEP programmes reduce barriers for those most marginalized, including GBM, those with financial barriers, youths and gender‐diverse individuals. Second, although PrEP does not directly protect against STIs, a protocol for PrEP disbursement is regular HIV and STI testing, which can lead to earlier diagnosis, treatment and engaging individuals in regular care . Third, This study was subject to a number of strengths and limitations. First, data from each city are not proportional to the underlying populations within each city. Second, descriptive results found that GBM in Vancouver were more likely to report behaviours that met eligibility criteria for PrEP. However, when limiting our analysis to those who were PrEP eligible in each city, participants in Vancouver were still significantly more likely to report lifetime PrEP use and GBM from Toronto were less likely to have ever used PrEP compared to GBM in Montreal. Third, PrEP measures were based on self‐reported data where misreporting and social desirability bias are possible. Fourth, RDS recruitment is based on social networks and GBM who are not connected with other gay, bisexual, transgender, two‐spirit and queer communities or are isolated may be underrepresented. Fifth, Vancouver had more follow‐up visits than Montreal and Toronto. Despite this difference, Engage had the same baseline and number of follow‐up months. However, a strength of RDS is the ability to recruit a more probabilistic community‐based sample and longitudinal data allowing us to estimate population‐level coverage over time.5Awareness and uptake of PrEP were much higher in Vancouver, likely indicating how free‐of‐charge public funding of PrEP in BC led to greater PrEP uptake compared with Ontario and Quebec, where PrEP is not fully free of charge. Future policies should consider providing full public funding for PrEP.None of the authors has any competing interests to declare.DMM, NJL, JC, GL, JJ, RSH and TAH designed the study. HA, AP and AL supervised data collection and study implementation. JB was responsible for managing the study database and developed the analytic dataset. SWN and SSS provided consultation on the analysis plan. LW conducted the analyses. JMS and KM developed the first draft of the manuscript and all authors provided input on updated versions. All authors have read and approved the final manuscript.Engage has been/is funded by the Canadian Institutes for Health Research , the CIHR Canadian HIV/AIDS Trials Network (#CTN300), the Canadian Association for HIV/AIDS Research , the Ontario HIV Treatment Network  and the Public Health Agency of Canada (#4500370314). TAH is supported by an Endgame Leader Chair Award in Gay and Bisexual Men's Health from the Ontario HIV Treatment Network. DMM and NJL are supported by Scholar Awards from the Michael Smith Foundation for Health Research . SSS is supported by a CIHR postdoctoral fellowship award. DG is supported by a Canada Research Chair in Sexual and Gender Minority Health. JMS is supported by a Michael Smith Foundation for Health Research Trainee award and a CTN CIHR Canadian HIV/AIDS Trials Network postdoctoral fellowship award.


Sarcopenia is prevalent in patients with chronic kidney disease (CKD), which is defined as a low estimated glomerular filtration rate (eGFR). It has been reported that oral hypofunction characterized by decreased tongue pressure is related to sarcopenia. Although there are several previous reports regarding the association of renal dysfunction with oral hypofunction characterized by low tongue pressure, the association between tongue pressure and renal function is not fully understood.This cross‐sectional study included 68 men aged 79.0 ± 4.8 years and 145 women aged 77.3 ± 5.4 years from a rural area in Hyogo Prefecture, Japan. We examined the relationships between cystatin C‐based CKD (CKDcys), creatinine‐based CKD (CKDcre), ratio of cystatin C‐based GFR (eGFRcys) divided by creatinine‐based GFR (eGFRcre): eGFRcys/eGFRcre, and tongue pressure in community‐dwelling older adults.Tongue pressure was significantly lower in participants with CKDcys than in those without CKDcys in men and women. However, there were no significant differences in tongue pressure with or without CKDcre. Tongue pressure was significantly lower in participants with eGFRcys/eGFRcre <1.0, than in those with eGFRcys/eGFRcre ≧ 1.0 in men. According to the receiver operating characteristic analysis, the optimal cut‐off value of tongue pressure for the presence of CKDcys was 36.6kPa, area under the curve (AUC) 0.74  in men and 31.8kPa, AUC 0.65  in women.CKDcys but not CKDcre is associated with low tongue pressure. In addition, a lower eGFRcys/eGFRcre ratio is a useful screening marker of low tongue pressure in community‐dwelling older adults. In the Kashiwa study, Tanaka et al.  reportedPrevious studies have suggested that low masticatory ability is associated with weaker physical performance, sarcopenia, and mortality, whereas low tongue pressure is significantly associated with frailty in elderly individuals and reflects dysphagia  and a significant association between frailty and motor skills, affecting swallowing in patients with CKD  strengthens the association between the eGFR and the risk of death and end‐stage renal disease (ESRD). CysC‐based eGFR values (eGFRcys) are more reliable than creatinine‐based eGFR values (eGFRcre) for determining long‐term prognosis . Handgrip strength was evaluated as described previously  study. The study population comprised individuals aged ≥65 years. Healthy community‐dwelling elderly individuals from the Sasayama Tamba area, a rural area in Hyogo Prefecture, Japan, were recruited between 2015 and 2019. Measurement of body composition and blood sample analysis were performed as described previously  and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.2.2For the assessment of gait speed, we asked participants to cover a 12 m walkway at their usual speed, during which the time to walk 10 m was assessed. We measured maximum grip strength using a grip strength tester   and evaluated the sum of the two.For tongue pressure, we measured the maximum tongue pressure twice using a JMS Tongue Pressure Measuring Device  and took the highest value  as an eGFR <60 ml/min/1.73 m2. The SMI was calculated as SMM/height‐squared (kg/m2).CKD was defined and classified according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria , renal function parameters, muscle volume and strength parameters, usual and maximal gait speed, number of teeth, and occlusal force.The results are expressed as the mean±standard deviation (SD) or percentages. For intergroup comparisons, a Student's n) and relative frequency (%) and were analyzed using Fisher's exact test. Univariate and multivariate logistic regression analyses were performed to calculate the odds ratio and 95% confidence interval (CI). A receiver operating characteristic curve (ROC) analysis was performed to confirm the diagnostic efficacy of tongue pressure for CKDcre and CKDcys. The area under the curve (AUC) was then calculated. JMP 13.1 software was used for data analysis. Statistical significance was set at p < .05.Categorical variables are expressed as absolute (3p < .001)  had low tongue pressure. In total, 67  participants had low eGFRcre (CKDcre), and 64  had low eGFRcys (CKDcys). In total, 78 participants  had a low eGFRcys/eGFRcre ratio (<1.0).Table Consistent with previous reports, age, SMI, SMM, grip power, and knee extension muscle strength were significantly correlated with tongue pressure in men and women. Interestingly, eGFRcys, but not eGFRcre, were positively correlated with tongue pressure. Cre/CysC and eGFRcys/eGFRcre were positively correlated with tongue pressure in men but not in women. Maximal gait speed was positively correlated with tongue pressure in men and women. Usual gait speed was positively correlated with tongue pressure in women but not in men. The number of teeth was not correlated with tongue pressure. However, the occlusal force was positively correlated with tongue pressure only in men.p < .05). Moreover, eGFRcys/eGFRcre < 1.0 was associated with low tongue pressure in men and women (Tables p < .05)  Table .Figure 4The current study shows the relationships between cystatin C and creatinine‐based eGFR in Japanese rural community‐dwelling older adults with oral dysfunction characterized by low tongue pressure. Consistent with previous reports, the current study shows that tongue pressure is negatively correlated with age and positively correlated with indices of sarcopenia diagnosis, such as muscle volume and grip strength  both in men and women.　In our previous study, multivariate logistic regression analysis showed that an eGFRcys/eGFRcre ratio < 1.0 was associated with sarcopenia in men but not in women  and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.


Matsumurasca onukii . Oyo‐Kontyu Tokyo, 8(1): 19–21), one of the dominant pests in major tea production areas in Asia, currently is known to occur in Japan, Vietnam, and China, and severely threatens tea production, quality, and international trade. To elucidate the population genetic structure of this species, 1633 single nucleotide polymorphisms (SNPs) and 18 microsatellite markers (SSRs) were used to genotype samples from 27 sites representing 18 geographical populations distributed throughout the known range of the species in East Asia. Analyses of both SNPs and SSRs showed that M. onukii populations in Yunnan exhibit high‐genetic differentiation and structure compared with the other populations. The Kagoshima (JJ) and Shizuoka (JS) populations from Japan were separated from populations from China by SNPs, but clustered with populations from Jinhua (JH), Yingde (YD), Guilin (GL), Fuzhou (FZ), Hainan (HQ), Leshan (CT), Chongqing (CY), and Zunyi (ZY) tea plantations in China and the Vietnamese Vinh Phuc (VN) population based on the SSR data. In contrast, CT, CY, ZY, and Shaanxi (SX) populations clustered together based on SNPs, but were separated by SSRs. Both marker datasets identified significant geographic differentiation among the 18 populations. Various environmental and anthropogenic factors, including geographical barriers to migration, human transport of hosts (Camellia sinesis [L.] O. Kuntze) and adaptation of M. onukii to various local climatic zones possibly account for the rapid spread of this pest in Asia. The results demonstrate that SNPs from high‐throughput genotyping data can be used to reveal subtle genetic substructure at broad scales in r‐strategist insects. Matsumurasca onukii, one of the dominant pests in major tea production areas in Asia. General migration route showed that there are two diffusion sources including Yunnan and the other tea plantations of China, respectively, from where introduced to Japan tea plantations. Our findings indicate that the host plants and geographical distances are significant involved to the genetic variation of M. onukii between different Clusters and that SNPs from high‐throughput genotyping data can be used to reveal subtle genetic substructure at broad scales in r‐strategist insects.In this study, SNPs and microsatellite markers were used to capture multiscale patterns of genetic structure of  Kuntze in Japan, Vietnam, and China that are grown under a variety of ecological conditions  have become widely used in population genetic analyses, particularly genotyping‐by‐sequencing (GBS) and restriction‐associated DNA sequencing (RAD‐seq)  to compare population relationships and levels of geographic differentiation among populations from the performances of SNPs and microsatellite markers and determine if patterns reflect morphological variation among populations; and (iii) to estimated historical migration between genetic clusters for inferring the evolutionary history of M. onukii populations in East Asia. This study will reveal correlated patterns of morphological variation and hierarchical genetic structure in East Asian M. onukii population, which will be useful in monitoring species distribution and future population dynamics. This will be enable better prediction, regulation, and management of M. onukii populations in different tea producing regions of East Asia.In the present study, microsatellite markers were coupled with high‐throughput sequencing approaches to obtain three goals: (i) to assess the spatial distribution of genetic variation of 22.12) near the center of each site, spaced 100 m or more apart. Specimens from all collecting sites within a location were pooled to represent one population. All these specimens were preserved in 100% ethanol and stored in the Entomological Museum, Northwest A & F University, Yangling, China (NWAFU).Tea green leafhopper specimens of 27 representative populations, including 24 Chinese localities, two populations from Japan (Kagoshima and Shizuoka), and one population from Vietnam (Vinh Phuc), were collected during the seasons of tea green leafhopper occurrence from 2013 to 2020 Table . The samSpecies identifications were confirmed by examining the morphological characters of all specimens from each representative population by dissection under an OLYMPUS SZX‐10 Stereoscopic Zoom Microscope. Male genitalia of each specimen was separately preserved in a small tube prefilled with glycerin and diagnostic characters  among populations were checked and compared to confirm the species identification and check for intraspecific variation.2.2Thirty male adults in each population, except for the dissected male genitalia used for species identification, were used for extracting DNA using either the CTAB method or DNeasy blood and tissue kits (Qiagen). The quality of DNA was detected and quantified with a Nanodrop One (Thermo Scientific).2.32.3.1Individuals of seven populations  were genotyped using 18 previously developed microsatellite markers Table . Genotyp2.3.2E), observed heterozygosity (HO), and expected heterozygosity, (HE) were determined using GenALEx v. 6.5.The frequency and signs of null alleles were investigated using FreeNA  repetitions. The range of possible clusters was set from 1 to 27 or to 18, with 20 independent runs for each K ) and the ad hoc statistic (ΔK) using the Web server Clumpak was used to align results from replicate analyses and visualize population structure  was constructed using POPTREE v. 2.0  based on population clustering from Structure v. 2.3.4 and FST was calculated using Arlequin v. 3.11  among the 2.42.4.1Based on the SSR population genetic analysis results, one to six populations  with significant genetic differentiation were selected from four genetic clusters. The GBS libraries were constructed and sequenced following the protocol of Elshire et al.  and OnyaApeKI and 300–600 bp fragments were determined by detecting genome size and its restriction sites. DNA (more than 500 ng) extracted from one sample of M. onukii from each of the 18 populations was added to 96‐well plates with 3 μl 10 × NEB buffer and 2 μl ApeKI (5 U/μl) (reagents from New England Biolabs) to a final volume of 30 μl and heated in water for 2 h. Following ligation, samples in PCR‐96‐well plates in 40 μl with 60 picomoles barcode DNA (5′‐ACACTCTTTCCCTACACGACGCTCTTCCGATCTxxxx and 5′‐CWG yyyyA GATCGGAAGAGCGTCGTGTAGGGAAAGAGTGT) and universal adaptor (5′‐CWGAGATCGGAAGAGCGGTTCAGCAGGAATGCCGAG and 5′‐CTCGGC ATTCCTGCTGAACCGCTCTTCCGATCT), 1 mM dNTPs, 5 units T4 DNA Ligase and 4 μl10 × T4 DNA Ligation Buffer. The reaction system was incubated for 1 h and inactivated for 30 min at 65°C. The Barcode DNA provided special identification tags for each sample, and the included universal adaptor that also provided binding sites for sequencing primers. All the DNA fragments (300–600 bp) were pooled in a sequencing library after purification and recovery. Following amplification with sequencing primers, purification, and recovery, the quality of the library was assessed using an Aglient 2100 Bioanalyzer, KAPA Library Quantification Kit and Qubit 2.0. The libraries were then sequenced on an lllumina HiSeq 2500 platform using a 150 bp Paired End protocol at Allwegene Technologies.2.4.2Raw reads were obtained by Base calling, assessed for quality, and filtered by length of fragment, Q‐value, and sequence alignment in databases. The identification of SNPs in Raw reads was accomplished using the Universal Network Enabled Analysis Kit (UNEAK) in TASSEL 3.0 , expected heterozygosity (HE), and nucletide diversity (π) were determined by VCFtool v.4.0  in random mating populations was estimated by FASTStructure with a Bayesian assignment test, and the optimal K was chosen based on analyses with K from 1 to 20 replicates for cross‐validation, with clustering pattern generated by the online software Structure Plot v. 2.0. We also implemented the best model (determined by JMODELTest v. 2.1.7) to reconstruct population relationships using maximum‐likelihood (ML) with 100 bootstrap replicates in MEGA v. 7.0.14  vitis as the outgroup. The final tree was visualized and beautified using iTOL v. 4.0 ; PCoA was performed using SNPRelate in R  and the logarithm of geographic distance matrix (Log km) were estimated using a Mantel test with 999 permutations in GenALEx v. 6.5. The geographic distance between each pair of populations was estimated by Geographic Distance Matrix Generator v. 1.2.3  analyses were conducted to test whether genetic differentiation increased with geographic distance. The correlation between the linearized pairwise 3 Ersts, .2.6M) per generation and the mutation‐scaled population size (θ) were analyzed using the Bayesian inference with full model in MIGRATE v. 3.7.2  of each population was calculated with θ = 4Neμ   was calculated as Nem = θM/4. The first run was estimated from FST, and the other three runs were started with θ and M from the previous run. During the Bayesian search, one long chain with four independent replicates was used for each run with 10,000,000 generations after an initial burn in of 100,000 interactions. Heated chain was set to: 1.0, 1.5, 3.0, and 1000,000.Given high polymorphism and mutation rates, microsatellite markers were used to estimate population size and migration parameters among clusters obtained from the results of population structure analysis. The immigration rate  of t Figure ; in cont3.2M. onukii showed high‐genetic diversity in all tea production areas, as measured by the number of effective alleles (4.11–5.93), expected heterozygosity (0.665–0.778) and AR (7.244–10.060). Higher genetic diversity was found across M. onukii populations in China than in Japan   Table .M. onukii formed four main genetic clusters: Cluster 4–1 includes four populations from Central and East China, viz. Xinyang (XY), Rizhao (RZ), Taian (TA), and Hanzhong (SX) populations; Cluster 4–2 consists of 14 populations from South China, Japan, and Vietnam, viz. Jinhua (JH), Hangzhou (HZ), Huangshan (HS), Nanchang (NC), Yichun (YT), Chengde (CD), Yingde (YD), Guilin (GL), Baise (BS), Fuzhou (FZ), Hainan (HQ), Kagoshima (JJ), Shizuoka (JS), and Vinh Phuc (VN) populations; Cluster 4–3 includes three populations from Southwest China, viz. Leshan (CT), Chongqing (CY), and Zunyi (ZY) populations; Cluster 4–4 includes six populations from Southwest China, viz. Chuxiong (CX), Pu′er (PE), Mojiang (MJ), Menghai (MH), Lincang (LX), and Jingdong (JD) populations. The six populations of M. onukii from the Southwest tea production area in China  were also clustered ; although a significant fraction of the total variation was also due to variation between clusters  and between populations  (Table M. onukii throughout the tea plantations in East Asia (FST > 0.050)  Figure .3.3M. onukii in East Asia using microsatellite data, 18 populations were chosen for GBS analyses. After quality control, a final GBS dataset of 1633 SNPs representing 180 genotypes of M. onukii was obtained for further genetic analysis. On an average, the sequence depth of populations ranged from 5.85 to 10.84. The observed heterozygosity (range 0.231–0.364), the expected heterozygosity (range 0.210–0.291) and nucleotide diversity (range 0.198–0.275) indicated that higher genetic diversity is present in populations of M. onukii from the Southwest tea production areas in China . Among all 18 populations, the genetic diversity of populations of M. onukii in China was higher than those in Japan  and Vietnam   Table .3.4amova, revealed that populations were genetically more differentiated across the three clusters  than between populations   , but not significant based on microsatellite markers . IBD tests revealed no significant geographic differentiation in genetic clusters  with weak genetic differentiation and small distribution  Figure . The IBDn Figure .3.6θ, ranged from 563 to 2053. Frequent exchange of migrants per generation was inferred to occur among clusters . Asymmetric migration was found among clusters in China and between clusters in China, Japan, and Vietnam, with effective number of migrants per generation (Nem) from Cluster 3–1 and Cluster 3–2 to SX (34.29 and 11.37) higher than numbers of migrants in the opposite direction (11.16 and 6.33). CT/CY/ZY populations displayed asymmetric migration from Cluster 3–1 (65.13), Cluster 3–2 (20.06) and SX populations (13.02); Nem from Cluster 3–1 and Cluster 3–2 to Cluster 3–3 were 32.73 and 15.83; and immigrants to the VN population were mainly from Cluster 3–1 (19.10). When SX population or CT/CY/ZY populations were included in Cluster 3–1 based on the results by SNP dataset, obvious asymmetric migration was also detected  and identify population structure between populations with similar levels of genetic diversity, which is consistent to many prior studies . The “introduction from south to north” mainly occurred in recent decades, during which major tea planting areas were established in North China   Figure .4.2M. onukii populations from the Southwest tea areas, especially among the populations from Yunnan tea plantations that also exhibit morphological variation in the aedeagus. Such correlation between genetic and morphological variation contrasts with a previous study of Asymmetrasca decedens, in which no genetic differentiation was found between individuals of two morphotypes based on differences in the shape of the aedeagus,  and Shizuoka (JS) populations from Japan and the Vinh Phuc (VN) population from Vietnam are closely related to  Figures  and 4a. 4.3M. onukii populations in Yunnan (Cluster 3–2), Japan (Cluster 3–3) and the other tea plantations of China and Vietnam. Significant asymmetrical historical migration from Cluster 3–1 and Cluster 3–2 to Cluster 3–3 is supported by non‐overlapping 95% confidence intervals  in M. onukii. Instead, our results suggest that natural or human‐assisted dispersal occurs among major tea growing areas of China but not frequently enough to prevent maintenance of population‐level differences between major tea areas and high levels of genetic variability within some populations.Analyses of population structure and phylogeography based on the SNPs reveal significant genetic differentiation between s Figure . Previous Figure , and thes Figure . AccordiM. onukii populations throughout East Asia was further elucidated in this study by SNPs, and high levels of genetic differentiation were observed between populations in different clusters. But our analyses failed to reveal fine‐scale dispersal routes between populations. Incorporation of additional SNPs into future studies by more efficient genotyping with the M. onukii reference genome (ASM1883171v1) in Genome Warehouse may allow for finer‐scale analysis of gene flow among populations  and nature geographical condition  may be significant involved to the genetic variation of M. onukii between different Clusters.Recent advances in sequencing technologies can provide genomic data for accurately identifying patterns of genetic structure with effective samples. The accurate genetic structure will be obtained when the gene markers and samples are chosen reasonably. In this study, representative populations of M. onukii, further study should encompass more SNPs and additional samples from various host plants within Camellia spp. at fine scales (such as within the southwest tea planting area). Higher‐resolution study of gene flow and its relation to geography/host associations will help elucidate the microevolution of adaptability in M. onukii populations in the East Asia.Therefore, to illuminate fine‐scale dispersal routes of Li Zhang: Conceptualization ; formal analysis (lead); investigation (lead); resources ; software ; writing – original draft (lead); writing – review and editing . Christopher H. Dietrich: Conceptualization (supporting); writing – original draft (supporting); writing – review and editing . Ye Xu: Investigation (supporting); writing – original draft (supporting); writing – review and editing . Zhaofu Yang: Software ; writing – review and editing . Maohua Chen: Conceptualization (supporting); methodology (lead); writing – review and editing . Thái H. Pham: Funding acquisition (supporting); resources (supporting); writing – review and editing (supporting). Cuong C. V. Le: Resources (supporting); writing – review and editing (supporting). Li Qiao: Resources (supporting); writing – review and editing (supporting). Masaya Matsumura: Resources (supporting); writing – review and editing (supporting). Daozheng Qin: Conceptualization ; funding acquisition (lead); investigation (supporting); resources (lead); writing – original draft (supporting); writing – review and editing .The authors declare that there are no conflicts of interest.M. onukii, is an agricultural pest, not an endangered or protected species. All the samples were collected in open tea plantations and not from any national parks or protected areas.Benefits from this research accrue from the sharing of our data and results on public databases as described earlier. No specific permits were required for this study. Tea green leafhopper, Appendix S1Click here for additional data file.


KDM6A as the susceptibility gene and LEPR as the driver gene by Sanger sequencing in case 2 of LELC of the renal pelvis. Three mutation sites of the existing targeted drugs were screened: CA9, a therapeutic target for zonisamide; ARVCF, a therapeutic target for bupropion; and PLOD3, a therapeutic target for vitamin C. In a population‐based study, patients with primary LELC of the upper urinary tract had clinical outcomes similar to those of patients with primary upper urinary tract urothelial carcinoma (UUT‐UC) before and after propensity score matching at 1 : 5. Focal subtype was an independent prognostic factor for the overall survival of patients with LELC of the upper urinary tract. The carcinogenesis of primary LELC may be due to different genetic variations, including single‐nucleotide variants, insertion and deletions, structural variations, and repeat regions, which may provide the basis for clinical diagnosis and treatment. The prognosis of LELC in the upper urinary tract is similar to that of UUT‐UC. We suggest that the focal subtype can serve as a prognostic factor for LELC of the upper urinary tract; however, further studies are required to confirm this.The genetic features of primary lymphoepithelioma‐like carcinoma (LELC) of the upper urinary tract have not been systematically explored. In this study, tumor mutation profiling was performed using whole‐genome sequencing in two patients with LELC of the renal pelvis. Novel candidate variants relevant to known disease genes were selected using rare‐variant burden analysis. Subsequently, a population‐based study was performed using the Surveillance, Epidemiology, and End Results (SEER), PubMed, MEDLINE, Embase, and Scopus databases to explore clinical features and prognostic risk factors. Immunohistochemical analysis revealed seven positive cytokeratin‐associated markers in tumor cells and five positive lymphocyte‐associated markers in and around the tumor area. Sub‐sequently, we identified  LEPR and susceptibility gene KDM6A might be associated with LELC of the renal pelvis. The prognosis of LELC of the upper urinary tract is similar to that of UUT‐UC.Here, the genetic, pathological and prognostic features of primary lymphoepithelioma‐like carcinoma (LELC) of the renal pelvis are explored. Mutations in the driver gene  AAamino acidAltalternativeBAMbinary alignment mapBWABurrows‐Wheeler AlignerCCFcancer cell fractionCDcluster of differentiationCDScoding sequenceChrchromosomeCIsconfidence intervalsCKcytokeratinCNVcopy number variationCOSMICthe Catalogue of Somatic Mutations in Cancer DatabaseCTcomputed tomographyCTXchromosomal translocationsDAB3,3′‐diaminobenzidineDELdeletionFDAFood and Drug AdministrationFFPEformalin‐fixed and paraffin‐embeddedFPGfusion partner geneGATA3GATA binding protein 3HCVhepatitis C virusHRshazard ratiosICDInternational Classification of DiseasesINDELsinsertions and deletionsLELClymphoepithelioma‐like carcinomaN/Anot applicablencRNAnoncoding ribonucleic acidNGSsecond‐generation sequencingNMFnon‐negative matrix factorizationp63protein‐63PCRpolymerase chain reactionPharmGKBthe Pharmacogenomics Knowledge Base DatabasePSMpropensity score matchingqPCRquantitative polymerase chain reactionRefreferenceRNradical nephrectomyRNUradical nephroureterectomySEERSurveillance, Epidemiology, and End ResultsSMGsignificantly mutated geneSNPssingle‐nucleotide polymorphismsSNVssingle‐nucleotide variantsSVsstructural variationsTNMtumor, node and metastasisTrftransformationTS : TVtransformation/transmutation ratioUCurothelial bladder carcinomaUCSC hgthe University of California, Santa Cruz human reference genomeUTRuntranslated regionUUT‐UCupper urinary tract urothelial carcinomaWGSwhole‐genome sequencing1Lymphoepithelioma, characterized by syncytial nests of malignant epithelial cells with a prominent reactive lymphoid infiltrate, is an undifferentiated epithelial tumor primarily found in the nasopharynx and is especially common in young Asian populations , 2, 3. TIn the current study, two cases of LELC of the primary renal pelvis are presented. A comprehensive genetic analysis of the two cases was performed using whole‐genome sequencing (WGS). Given the lack of data on the prognosis and characteristics of LELC in the upper urinary tract, LELC and upper urinary tract urothelial carcinoma (UUT‐UC) cases were added from the Surveillance, Epidemiology, and End Results (SEER), PubMed, MEDLINE, Cochrane, Web of Science, Embase, and Scopus databases. From reviewing related literature and public databases, combined with data from our two cases, clinicopathologic features, therapeutic strategies, and prognosis were evaluated.22.1The relevant clinical characteristics of case 1  were obtained from the First Affiliated Hospital of Dalian Medical University, whereas the related clinical characteristics of case 2  were obtained from the Second Affiliated Hospital of Dalian Medical University. This project was approved by the Ethics Committee of the First Affiliated Hospital of Dalian Medical University (No. LCKY2015‐08) and the Second Affiliated Hospital of Dalian Medical University (No. DYEY‐2022‐018). The study methodologies conformed to the standards set by the Declaration of Helsinki. Written informed consents to participate in the study were obtained from the patients for use of their samples. Patient consent for publication by using samples.2.2Formalin‐fixed tissues were paraffin‐embedded and cut into 5‐μm sections. After dewaxing in xylene and hydration in ethanol, sections were placed in sodium citrate buffer for antigen repair and heated at 95 °C for 20 min. The sections were incubated with 0.5% hydrogen peroxide for 20 min to block endogenous peroxidase activity and blocked with goat serum for 1 h, followed by overnight incubation with primary antibodies at 4 °C. Antibody information is shown in Table 2.32.3.1Genomic DNA was extracted from two formalin‐fixed and paraffin‐embedded (FFPE) LELC tissues and two matched normal renal cortical tissues using the GeneRead DNA FFPE Kit , following the manufacturer's instructions. The quantity and purity of genomic DNA were assessed using 1% agarose gel electrophoresis to analyze DNA degradation and impurities, and using a Qubit® 2.0 Fluorometer  to quantify DNA concentration.2.3.2Whole‐genome sequencing libraries were captured using the Agilent SureSelect Human All Exon Kit , according to the manufacturer's recommendations. Genomic DNA was randomly fragmented into 350 bp fragments using a Covaris instrument . The products were purified using an AMPure XP system . Quality control was performed using a Qubit® 2.0 Fluorometer (Invitrogen), Agilent Bioanalyzer 2100, and a quantitative polymerase chain reaction (qPCR) approach to quantify library concentration and evaluate library quality. Sequencing libraries were sequenced on an Illumina HiSeq platform  using the Novogene sequencing facility . Sanger sequencing of the susceptibility and driver genes was performed by Sangon Biotech Co., Ltd. .2.3.3The filtration of raw data containing adapter reads, undetected nucleotides, and low‐quality nucleotides is essential for obtaining clean reads for quality analysis. After removing the following reads: adapter reads, reads with the proportion of unconfirmed base information greater than 10%, and paired reads with the proportion of low‐quality  bases greater than 50%, subsequent analysis was based on the obtained high‐quality clean reads.2.3.4bwa, 0.1.22) software with binary alignment map (bam) file generation [picard (http://broadinstitute.github.io/picard/) and sambamba software (v0.4.7) [bam file sorting. The sequence coverage and depth were calculated by sequence alignment.Sequencing reads were aligned to the University of California, Santa Cruz human reference genome UCSC hg19) using Burrows‐Wheeler Aligner ( using Buneration . picard (v0.4.7)  were use2.3.5samtools software (1.0) was used to test for single‐nucleotide polymorphisms (SNPs) and insertions and deletions (INDELs) [mutect (1.1.4) [strelka (v1.0.13) [crest (v0.0.1) [control‐freec (v6.7) softwares [annovar (2013 Aug 23) software [The (INDELs) . INDELs, (1.1.4) , strelkav1.0.13) , crest ((v0.0.1) , and conoftwares . Finallysoftware . We classoftware  to expla2.3.6http://cancer/sanger.ac.uk/cancergenome/projects/census) databases to identify potential driver genes for LELC in the renal pelvis. SIFT, Polyphen‐2, and Mutation‐Taster scores were used to assess whether the mutations were pathogenic. Moreover, after detecting germline mutations (SNVs and INDELs) in the normal tissue of matched patients using samtools software, potential susceptibility genes could be identified by detecting germline mutations and comparing them with those in the Cancer Gene Census database and two susceptibility gene databases [Sample mutations were compared with known driver mutations in the Bert Vogelstein , signifiatabases , 23 usin2.3.7absolute [pyclone [absolute software calculates the purity and ploidy of tumor samples based on copy number and somatic mutation frequency. To analyze tumor evolution, pyclone software was used to analyze tumor clonal structure by using somatic mutation frequency of the samples combined with tumor purity, copy number, and other information to calculate CCF. Cluster analysis was performed on the tumor cells to determine the clonal structure of the tumor samples. Based on the detection of somatic mutations in tumor samples, the detected mutation sites were compared with the NovoDR drug‐resistant gene databases [We used absolute  and pycl[pyclone  for puriatabases  to scree2.42.4.1n = 39) [n = 5). Finally, combined with the two cases in this study, 46 cases with LELC of the upper urinary tract were included. The flow diagram of the LELC cases is shown in Fig. The clinicopathologic features and survival data of UUT‐UC and LELC of upper urinary tract patients were obtained from the SEER database, which contains official clinicopathologic and follow‐up reports from 18 population‐based tumor registries that mainly embody the U.S. patient population . The foln = 39) , 54, 55.2.4.2Baseline patient characteristics and outcome data included sex, age, race, tumor location, tumor focality, tumor side, pathological classification, surgery type, lymphadenectomy, and application of chemotherapy and radiation therapy. Eligible patients who were not clearly stated were classified using version 7 of the tumor, node, metastasis (TNM) classification system of malignant tumors, according to the full‐text description. The main endpoint was overall survival, which was defined as the time from the initial diagnosis of cancer to death from any cause or the last follow‐up, according to the literature and the SEER database. Patients who were still alive at the last follow‐up were censored.2.5spss version 13.0  was used for all statistical analyses. To eliminate potential confounding factors in the clinicopathological baseline characteristics, propensity score matching (PSM) was conducted using r software version 3.6.0 (http://www.R‐project.org/). One LELC patient was matched with five UUT‐UC patients by using the predetermined clinicopathological factors described above. Statistical significance was defined as a two‐sided P‐value < 0.05.Clinicopathological characteristics were assessed to determine the significant differences between upper urinary tract LELC and UUT‐UC. Fisher's exact probability and Pearson's chi‐square tests were used for categorical and continuous variables, respectively. Hazard ratios (HRs) and 95% confidence intervals (CIs) for different survival‐related variables were calculated using the Cox proportional hazards model. The two histological types were compared using Kaplan–Meier plots and log‐rank tests. 33.1Case 1 was a 61‐year‐old man who presented with swelling and pain on the left side of his waist for 2 months. Enhanced computed tomography (CT) images of the urinary system revealed a tumor in the left renal pelvis, tumor invasion into the upper section of the left ureter, swelling and uronephrosis in the left renal pelvis, and multiple lymph node metastases in the left renal hilus and peritoneum Fig. . UltrasoCase 2 involved a 76‐year‐old woman with left hydronephrosis and ureteral stricture that persisted for 3 months. Ultrasonography revealed enlargement of the left kidney with an anechoic renal cortical cyst and severe dissociation of the left renal collecting system with a width of 36 mm, suggesting severe left uronephrosis and a renal pelvic ureteral transitional lesion. Abdominal computed tomography revealed a stricture between the renal pelvis and the ureter Fig. . Dynamic3.23.2.1Hematoxylin–eosin staining was performed on pathological sections of tumor tissues from the two patients. In case 1, the tumor cells were arranged in lamellar nests with high atypia, a high nucleolus ratio, prominent nucleoli, and eosinophilic nuclei. Lymphocytes infiltrated the stroma and were scattered around the nests of tumor cells Fig. . In case3.2.2Immunohistochemical analysis revealed histopathological manifestations of a primary lymphoepithelioma‐like carcinoma of the renal pelvis. The Ki‐67 staining was strongly positive. The tumor cells were positive for cluster of differentiation (CD) 10, cytokeratin (CK) AE1/AE3, cytokeratin 7, cytokeratin 20, cytokeratin 34βE12, GATA binding protein 3 (GATA3), and protein‐63 (p63), which are markers of lymphoepithelioma‐like carcinomas  and 267 512 090 (case 2) read pairs in the primary tumor and 635 040 964 (case 1) and 397 049 253 (case 2) read pairs in normal tissue specimens. A total of 3 268 638 SNPs in case 1 and 1 754 424 in case 2 were identified in the LELC specimen: 2 821 722 and 2 708 028 in the adjacent normal specimen of cases 1 and 2, respectively. The transformation/transmutation ratio (TS : TV) was employed for the exactness of the SNP dataset, which was approximately 2.2 in the whole genome and approximately 3.2 in the coding region. An individual has approximately 350 000 INDELs in its genome. A total of 523 417 in case 1 and 267 005 in case 2 were detected in the LELC specimen; 414 198 in case 1 and 412 892 in case 2 were found in the adjacent normal specimens. Most of the identified SNPs and INDELs were located in intergenic and intronic regions  intronic regions . The results were filtered using the database mentioned in Section KDM6A  and ploidy (the average copy number of the sample) of tumor samples were calculated to ensure the quality of analysis. 3.3.6CA9, PLOD3, and ARVCF in two cases, for which detailed information is available in Table CA9, two drugs (bupropion and risperidone) for ARVCF and vitamin C for PLOD3.After comparing the identified somatic mutations and the Novo Drug database, including the Pharmacogenomics Knowledge Base Database (PharmGKB), My Cancer Genome, and the Food and Drug Administration (FDA) databases, we screened three mutation sites of the existing targeted drugs 3.43.4.13.4.1.1P < 0.001) and the proportion of sex  between LELC patients and UUT‐UC patients, as well as statistical differences across the three races (P < 0.001). For gross and histological features, the LELC group, which was relative to the UUT‐UC group, tended to be unifocal (P = 0.002) and had significant differences in tumor sides (P < 0.001). Compared with the UUT‐UC group, the LELC group had a higher stage , higher lymph node involvement , and lower incidence of distant metastasis . Regarding the treatment modality, patients with LELC of the upper urinary tract were more likely to undergo surgery, especially radical nephroureterectomy and nephrectomy , whereas no significant differences were detected in chemotherapy or radiation. The overall clinical and pathological data of the two groups after propensity score matching are shown in Table P = 0.035) and pathological stage (P = 0.016).Until March 2022, 46 patients with LELC of the upper urinary tract identified in the public database and 18 183 patients with UUT‐UC extracted from the SEER database were included in our study. Table 3.4.1.2The survival outcomes of patients with LELC and UUT‐UC are compared according to the Kaplan–Meier plots in Fig. 3.4.2P = 0.014), pure pathological classification (P < 0.001), low pathologic stage (P = 0.003), and surgical treatment (P = 0.001) demonstrated higher overall cumulative survival rates  and one driver gene (LEPR) were validated in LELC using Sanger sequencing.The identification of susceptibility and driver genes through mutation analysis plays an integral role in the identification of clinically relevant genetic variations in patients with cancer. In the present study, one susceptibility gene . We found that KDM6A, an X chromosome‐linked histone lysine demethylase, was frequently mutated in bladder cancer not only in European and American populations [KDM6A may be clinically actionable and related to the malignant progression of bladder cancer. Compelling biological evidence supports that tazemetostat may be effective in bladder cancer patients with KDM6A mutation. These evidences suggest that abnormalities and mutations in the susceptibility gene KDM6A and/or driver gene LEPR may be associated with case 2 of LELC of the renal pelvis. Our findings need to be validated by molecular biology and genetic studies based on primary cell culture in future. Meanwhile, the heterogeneity between different cases of LELC needs to be taken into account when applying the conclusions of hypothesis.For clinically actionable, we had checked targeted mutations by reviewing the OncoKB website , sex (P < 0.001), and race (P < 0.001). In terms of clinical and pathological features, statistical differences were also detected in tumor focality (P = 0.002), tumor side (P < 0.001), pathological stage (P < 0.001), lymph node status (P < 0.001), distant metastasis (P < 0.001), and type of surgery (P < 0.001). According to the Kaplan–Meier survival curves, LELC did not indicate poorer overall survival than that for UUT‐UC. Nevertheless, we supposed that the differences mentioned above were not reliable owing to the marked impact of uneven baseline characteristics. Therefore, we performed propensity score matching in a proportion of 1 : 5, and 34 LELC cases were successfully matched with 166 UUT‐UC patients. After matching, the remaining significant differences included tumor side (P = 0.035) and pathological stage (P = 0.016). In addition, the overall survival was not significantly different between patients with LELC and UUT‐UC. The results indicate that patients with upper urinary tract urothelial carcinoma did not have a significantly shortened survival compared with patients with lymphoepithelioma‐like carcinoma of the upper urinary tract.After analyzing the genetic characteristics of primary LELC of the upper urinary tract, 44 reported cases were collected of LELC of the upper urinary tract based on a comprehensive search of the SEER, PubMed, Medline, Cochrane, Web of Science, Embase, and Scopus databases, as well as combined with our two cases to comprise the LELC group. Meanwhile, 18 183 UUT‐UC data entries from the SEER database were used to compare patients with LELC in terms of prognostic risk factors and survival outcomes. The results demonstrated significant differences between the LELC and UUT‐UC groups in terms of baseline characteristics, including age (P = 0.002).Lymphoepithelioma‐like carcinoma morphologically appears as nests, flakes, and strips with undifferentiated cell morphology, such as a large polymorphic nucleus, significant nucleolus, and ill‐defined intracellular boundary. As LELC of the upper urinary tract is rarely seen in clinical practice, it should be differentiated from tumor invasion into the upper urinary tract and from chronic inflammation of the upper urinary tract. Although invasive tumors contain neoplastic lymphocytes, the nuclei and cytoplasm of the epithelial cells are clearly defined. In contrast, in chronic inflammation, infiltrating cells in the mucosal layer and lamina propria are considered inflammatory cells , 85, 86.Our study also has limitations. As LELC of the renal pelvis is very rare, the number of cases to date is insufficient to provide a reliable evidence and statistical conclusion. Furthermore, the limited samples for WGS made it difficult to completely avoid the false discovery rate associated with multiple testing effects, indicating that the proposed hypothesis in our study required further exploration of molecular mechanisms by biological or genetic validation. However, the isolation of primary cells from fresh tissues may be limited by the rarity or low incidence of LELC. In addition, immortalized human urothelial cells T24, 5637 or RT4 may not simulate the real malignant biological behavior of primary LELC cell. Meanwhile, single‐component cell line could not construct a real‐world tumor microenvironment. In the long run, the development of organ‐on‐a‐chip by microfluidic device or organoid technology may bring certain possibilities to solve the dilemma.5LEPR and susceptibility gene KDM6A may be associated with case 2 of LELC of the renal pelvis. These two genes may be involved in the metastasis and recurrence of tumors and provide a basis for clinical diagnosis and treatment. Our findings need to be validated by molecular biology and genetic studies based on primary cell culture in future. Meanwhile, the heterogeneity between different cases of LELC needs to be taken into account when applying the conclusions of hypothesis. Additionally, the prognosis of LELC of the upper urinary tract is similar to that of UUT‐UC. We suggest that the focal subtype can serve as a prognostic factor for LELC of the upper urinary tract, which warrants further studies.Lymphoepithelioma‐like carcinoma of the renal pelvis is a rare subtype of upper urinary tract carcinomas. This study presented patient‐specific characteristics, tumor‐specific features, potential mechanisms of pathogenesis, classification of LELC subtypes, possible prognoses, and therapeutic strategies. Awareness of this disease can help promote its early detection and diagnosis, prompt and effective treatment, and improve disease outcomes. Therefore, in cases of LELC of the renal pelvis, clinicians should ideally ascertain the biological behavior of the disease and arrive at a consensus on the best treatment options that would improve prognosis. To our knowledge, this is the first report to identify genetic information for LELC of the renal pelvis using WGS. Finally, it was found that mutations in the driver gene The authors declare no conflict of interest.BF, YH, HSZ, and XL conceived and designed this study. BF and XL undertook project leadership and guaranteed this work. ZL reviewed and guaranteed the ethical accuracy and feasibility of our study. BF, YH, HSZ, and TC performed the sequencing experiments. SW, HW, and TL carried out the immunohistochemical staining. BF, YH, HSZ, ST, XW, HXZ, and TH searched and collected the data from public databases. BF, YH, and TC analyzed and interpreted the data. BF, YH, HSZ, TC, and ZL wrote, reviewed, and revised the manuscript. All authors have read and approved the final version of this manuscript for publication.Fig. S1. Workflow diagram of the selection process for patients with lymphoepithelioma‐like carcinoma of the upper urinary tract.Fig. S2. Somatic mutation heatmap of case 1 and 2.Fig. S3. Frequency of mutated cancer cells.Table S1. Antibodies used for immunohistochemistry.Table S2. Number of SNPs in different regions of the genome and in coding regions.Table S3. Number of SNP in different regions of the genome.Table S4. Number of INDELs in different regions of the genome and in coding regions.Table S5. Number of INDELs in different regions of the genome.Table S6. Number of Somatic SNVs in different regions of the genome.Table S7. Number of Somatic INDELs in different regions of the genome.Table S8. Gene‐related structure variations discovered by whole‐genome sequencing in two cases.Table S9. Detailed information regarding the tandem repeat regions identified in the primary lymphoepithelioma‐like carcinoma of the renal pelvis tissue in two cases.Table S10. Analysis results of susceptibility genes in two cases.Table S11. Analysis results of driving genes in two cases.Table S12. Baseline demographic and clinicopathological characteristics of 46 patients with lymphoepithelioma‐like carcinoma of the upper urinary tract.Table S13. Univariate regression analysis of pathologic classification associated with overall survival of patients with lymphoepithelioma‐like carcinoma of the upper urinary tract.Click here for additional data file.