In the evolving immune-oncology landscape, numerous patients with cancer are constantly treated with immune checkpoint inhibitors (ICPIs) but among them, only sporadic cases with pre-existing hepatitis B virus (HBV) and hepatitis C virus (HCV) are recorded. Despite the global dissemination of HBV and HCV infections, viral hepatitis-infected patients with cancer were traditionally excluded from ICPIs containing trials and current evidence is particularly limited in case reports, retrospective cohort studies and in few clinical trials on advanced hepatocellular carcinoma. Thus, many concerns still remain about the overall oncological management of this special subpopulation, including questions about the efficacy, toxicity and reactivation risks induced by ICPIs. Here, we examine the natural course of both HBV and HCV in cancer environment, review the latest antiviral guidelines for patients undergoing systematic cancer therapies, estimating treatment-related immunosuppression and relocate immunotherapy in this therapeutic panel. Among the ICPIs-treated cases with prior viral hepatitis, we focus further on those experienced HBV or HCV reactivation and discuss their host, tumor and serological risk factors, their antiviral and immunological management as well as their hepatitis and tumor outcome. Based on a low level of evidence, immunotherapy in these specific cancer cases seems to be associated with no inferior efficacy and with a relevantly low reactivation rate. However, hepatitis reactivation and subsequent irreversible complications appeared to have poor response to deferred antiviral treatment. While, the prophylactic use of modern antiviral drugs could eliminate or diminish up front the viral load in most cases, leading to cure or long-term hepatitis control. Taking together the clinical significance of preventive therapy, the low but existing reactivation risk and the potential immune-related hepatotoxicity, a comprehensive baseline assessment of liver status, including viral hepatitis screening, before the onset of immunotherapy should be suggested as a reasonable and maybe cost-effective strategy but the decision to administer ICPIs and the necessity of prophylaxis should always be weighed at a multidisciplinary level and be individualized in each case, up to be established by future clinical trials. Immune checkpoint inhibitors (ICPIs) have drastically transformed clinical cancer care and continue to expand further their therapeutic indications.2 13–15In support, some recent studies showed that unbalancing the immune system and releasing the T cell-mediated cytotoxicity via checkpoint inhibition could cause reactivation of HBV, HCV or other pre-existing chronic infections such as tuberculosis.18Based on the current evidence, we examine here the hepatitis behavior in cancer environment, estimate the level of immunosuppression of administered cancer therapies and evaluate the oncological implications of both HBV and HCV on treatment and tumor outcome. Among the identified ICPIs-treated cases with HBV or HCV infections, this review focuses further on those patients experiencing hepatitis reactivation, and tries to evaluate the rate of viral exacerbation and to recognize any potential risk factors, therapy-related or not. In relation to estimated efficacy and safety of ICPIs in this non-trial population, the guidelines for screening, monitoring, immunological management as well as the recommendations for antiviral prophylaxis and on-demand treatment are thoroughly discussed and reconsidered.The biological course of HBV or HCV infections is determined by the interplay between viral replication and host’s immune response. Both HBV and HCV are small, enveloped viruses containing circular double-stranded DNA and single-stranded RNA, respectively, that are transmitted by blood or bodily fluids and cause mainly hepatocellular injury. Once hepatocytes are infected, innate and adaptive immune systems are activated secondary to viral immunotropism. More specifically, secreted interferons by natural killer cells emerge the T cell-mediated response; CD4+ T cells are involved in the production of neutralizing antibodies by B cells, whereas CD8+ T cells eliminate virus-infected hepatocytes via cytotoxicity, inducing liver immunopathology. Many hypothetic mechanisms of hepatitis reactivation during checkpoint inhibition have been suggested but none of them has undoubtedly been established. The blockade of programmed cell death-1/programmed cell death 1 ligand (PD-1/PD-L1) axis may restore HBV-specific CD8+ T cells that overexpressed PD-1 due to chronic viremia,In immunocompetent individuals, most primary infections are self-limited and spontaneously resolved after their acute phase, establishing protective antibodies. However, in 60%–85% of exposed patients, a chronic setting of hepatitis is developed due to weaker innate and adaptive immune responses. The viral load is not sustainably cleared and may persist in hepatocytes for >6 months, even after serological recovery. The chronicity of hepatitis places these patients at later risks of cirrhosis and hepatocarcinogenesis. Chronic HBV causes approximately 60% of HCC worldwide, whereas 20% and 50% of cases with HCC in Asia and in the USA, respectively, are associated with chronic HCV.25 27 28In chronic hepatitis setting, any additional reconstitution of immune control after immunosuppressive medications could trigger viral reactivation. Similarly to acute infection, hepatitis reactivation could be presented with a variety of non-specific clinical manifestations, ranging from asymptomatic flare mainly of alanine aminotransferase (ALT) or aspartate aminotransferase (AST) to fatal liver damage.9 persons have been previously infected with HBV and clinically resolved their infection, HBsAg(−)/anti-HBc(+)6 developed chronic infection, HBsAg(+)/anti-HBc(+).2The global numbers of viral hepatitis are growing with threatening pattern. Approximately 2×10According to Loomba and Liang, the main risk factors for HBVr can be categorized as virus-related, host-related, and medication-related factors.47et al concluded that pre-emptive antiviral treatment could reduce the adverse effects of HBVr and prevent chemotherapy interruption.et al noticed that the lack of antiviral prophylaxis was the only significant risk factor for HBVr .In cancer setting, HBVr can spontaneously occur as a complication during progression,Nevertheless, type of malignancy may also play a role in HBVr. In a retrospective study of patients with HBsAg(+) with solid tumors or hematological malignancies who underwent chemotherapy without antiviral therapy, the incidence of severe acute HBV exacerbation was higher in patients with hematologic malignancies than in those with solid tumors  and in cases receiving rituximab-based chemotherapy than in those receiving non-rituximab-based chemotherapy .57In an effort to determine the incidence and prognosis of HCVr during anticancer treatment, an observational study from MD Anderson Cancer Center estimated an overall reactivation rate of 23%, ranging from 36% in patients with hematologic malignancies to 10% in patients with solid tumors.3 IU/mL , based on the available data. Eight of 10 patients were diagnosed with HBV-related flare with a median peak ALT of 289.6 U/L  and a median peak of AST 485.5 U/L . One patient exhibited an increase in HBV DNA level without ALT elevation. Two patients were receiving prophylactic entecavir before the initiation of immunotherapy; one was receiving abacavir due to HBV/HIV coinfection and had recently been vaccinated twice for HBV while the remaining seven were not under antiviral pre-emptive therapy. In the HBV/HIV coinfected case, abacavir switched to tenofovir disoproxil fumarate (TDF) respecting the patient’s decision to avoid adding a third medication into his antiretroviral therapy. After the occurrence of HBVr, four of seven patients without antiviral prophylaxis were treated with entecavir, one patient was treated with tenofovir and administration of steroids for potential autoimmune hepatitis, one patient was treated with TDF concurrently with nivolumab since aminotransferases were already elevated from prior treatment with ipilimumab; while the patient without ALT elevation did not receive any antiviral treatment but the HBV DNA spontaneously turned to undetectable 5 weeks later. For the one case with prophylactic entecavir, antiviral treatment was intensified with the addition of TDF at the time of reactivation. Due to HBVr, six patients disrupted their immunotherapy, including one discontinuation and five treatment delays. Three cases continued uninterruptedly their treatment with ICPIs and for the last one no information was available about her immunological management. For the entire cohort, HBVr has resolved and all the 10 patients achieved undetectable or diminished HBV DNA levels after a median of 6.5 weeks (range 1–40 weeks). No HBV-related fatal events occurred up to publication of these case reports. Kothapalli and KhattakFrom the beginning of immunotherapy era up to now, 10 isolated incidents of HBVr after treatment with ICPIs have been described in four case reportset alJust two case studies describe the outcomes of nine patients with HCV infection treating with ICPIs. Davar et alIn the clinical trials of advanced HCC where HBV-infected or HCV-infected patients were included, no hepatitis-related flares were reported. In the CheckMate-040 trial, 51 HBV-infected cases  and 50 HCV-infected patients  with advanced HCC were treated with nivolumab, none of these patients experienced hepatitis reactivation.So far, universal screening of patients with newly diagnosed cancer for HBV and HCV is not a routine in oncology practice. Initially, the majority of experts’ societies including AASLD,57 64 65In cases with HBsAg(+)/anti-HBc(+) , antiviral pre-emptive therapy should be started as soon as possible before  or, at the latest, simultaneously with the onset of immunosuppressive therapy using anti-HBV drugs with a high resistance barrier, such as entecavir, TDF, or tenofovir alafenamide (TAF) and should be continued during therapy and for at least 6 months (or for at least 12 months in patients receiving anti-CD20 antibodies and up to 18 months according to EASL) after its completion.In patients with HBsAg(−)/anti-HBc(+) , the risk of HBVr varies widely according to their virological profile, their underlying disease and their immunosuppressive schema . Moreover, the strategy is depending on their clinical situation and feasibility of close monitoring  with the intent of on-demand antivirals at the first sign of HBVr (pre-emptive therapy), except for patients receiving anti-CD20 treatment or undergoing SCT, for whom prophylaxis is recommended.63In response to previously reported data, we agree that immunotherapy should be included in this universal screening strategy and antiviral prophylaxis should be recommended in patients with viremia with detectable serum HBV DNA at baseline. Putting cost-effectiveness parameters in our considerations for universal screening, local HBV prevalence should also be taken into account, particularly in countries with too low HBV rates. In these countries, screening should be followed only for patients at high risk for HBV infection  or for patients anticipating high-risk treatments for HBVr (SCT or chimeric antigen receptor T cells (CAR-T) or (non)-myeloablative chemotherapy). However, the optimal management of patients with HBsAg(−)/anti-HBc(+), the threshold of HBV DNA levels to start prophylaxis, the most appropriate nucleotide analogs (NAs) in terms of efficacy and cost trade-off, and the recommended duration of preventive treatment need to be determined. Given the durable effect of immunotherapy beyond its administration period and the general late event of HBVr, antiviral therapy should be continued for at least 6 months after the last dose of ICPI and not be stopped even after HBV DNA negativity.For HCV, current guidelines support universal screening in patients with hematologic malignancies and hematopoietic SCT recipients,25When HBV DNA monitoring at-risk patients without prophylaxis demonstrates reactivation, the preferred antivirals for deferred (‘on-demand’) treatment are NAs.In a direct comparison between NAs, entecavir has been found to be more effective (and more expensive) than lamivudine.Regarding the management of chronic HCV infection in patients with cancer, the updated guidelines by AASLD and Infectious Diseases Society of America (IDSA) without robust evidence from RCTs supported that the overall benefits of DAAs in terms of virologic, hepatic, and oncologic outcomes far outweigh the risks of not treating.86In HCV-infected patients with cancer, the administration of newer DAAs, such as of glecaprevir/pibrentasvir for 8 weeks or sofosbuvir/velpatasvir for 12 weeks is proposed as a feasible and effective strategy as suggested to patients without cancer.79 81Current data regarding efficacy and safety of ICPIs in patients with HBV and HCV are derived from case reports, case series, retrospective cohort studies and few clinical trials on advanced HCC, leading to a very low evidence level. Immunotherapy seems to be associated with no inferior efficacy in cases with previous or chronic HBV/HCV infections, nor with major safety issues regarding antiviral or immunologic response. Despite the well-tolerated profile of ICPIs in these patients, the behavior of viral hepatitis under ICPI is scarcely investigated and probably underestimated in the literature. The existing evidence on hepatitis–PD1 interface could not estimate the exact reactivation risk induced by ICPIs and thus, could suggest but not sufficiently support a universal hepatitis screening. However, the management of immune-related hepatotoxicity is coming to agree with a comprehensive baseline assessment of liver status, including screening for prior HBV/HCV infections.Even if baseline viral hepatitis screening could be modeled as a cost-effective strategy in patients with cancer, as already demonstrated in the general population,Navigating into uncharted water, we should notice that further prospective immunotherapy trials including hepatitis-infected patients with cancer are required in order to strengthen the suggested management. There is still a lot to learn about the way that ICPIs affect the immune vigilance of underlying HBV and HCV infections, while numerous parameters are under consideration in the final therapeutic decision for both cancer and viral diseases, including the viral course, the nature of metastatic cancer, the immune-mediated mechanisms of administered treatments, the expected patient response and prognosis, as well as the financial costs of selected therapies. Treating this special patient population represents a clinical challenge in everyday oncological practice and still, a shift is needed in the design of modern trials to reflect more representatively real-world scenarios and to enable more precise extrapolation of research findings.


It also highlighted microenvironment-centered mechanisms dictating indolence or aggressiveness of early lesions and how spatial geography impacts stromal attributes and function. The prognostic and therapeutic implications as well as potential vulnerabilities within the heterogeneous tumor microenvironment were also discussed. These broad topics were included in this workshop as an effort to identify current challenges and knowledge gaps in the field.Significant advances have been made towards understanding the role of immune cell-tumor interplay in either suppressing or promoting tumor growth, progression, and recurrence, however, the roles of additional stromal elements, cell types and/or cell states remain ill-defined. The overarching goal of this NCI-sponsored workshop was to highlight and integrate the critical functions of non-immune stromal components in regulating tumor heterogeneity and its impact on tumor initiation, progression, and resistance to therapy. The workshop explored the opposing roles of tumor supportive  The last two decades have seen significant gains in unveiling the crosstalk between cancer cells and the stroma within which they reside. This complex mixture of interacting cells can be considered as a dynamic multidimensional ecosystem that regulates tumor growth, inherent and acquired plasticity/heterogeneity, invasion, and metastasis. The expansion of cancer research beyond a cell autonomous-based model has enabled the identification and characterization of a wide range of cell types including fibroblasts, immune, endothelial, neuronal, and specialized mesenchymal cells that regulate the formation of a tumor-permissive and therapy-resistant environment. In addition, a deeper appreciation for the role that the extracellular matrix (ECM) plays in this ecosystem has emerged. Despite these advances, much of the scientific focus has remained primarily centered on the tumor cells and on driver mutations that dictate stromal reprogramming to support tumor growth. These include oncogene-mediated tumor cell proliferation, reactive oxygen species (ROS)/hypoxia-induced regulation of the endothelium, inflammation-associated angiogenesis and immune-suppression, and metabolic reprogramming of stromal fibroblasts and adipocytes to offset tumor cell nutrient deprivation –5. StudiThe traditional view of driver mutations within incipient tumor cells instructing each step of tumorigenesis has influenced basic cancer researchers and drug developers alike to focus on genetically and molecularly profiling tumor cell autonomous mechanisms for targetable vulnerabilities. The foundational principle of “a tumor cell as an organizer”  also gavThe delivery of durable remission induced by anti-programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) immune checkpoint inhibitors in a subset of cancer types and patients has motivated many basic and translational investigators to focus their attention and resources towards studying the role of the immune cell-tumor interplay in cancer growth, progression, and recurrence –11. HoweLimited, yet pivotal studies demonstrating the importance of non-immune stromal components in shaping the fate of tumors exist, but remain poorly understood and underpowered. Examples of work that must be expanded include understanding the role of non-immune stroma in regulating immune cell recruitment to tumor sites, driving chronic inflammation-induced DNA damage in preneoplasia, characterizing and tracing different carcinoma-associated fibroblasts (CAF) functional subtypes and their roles in different states as both promoters and suppressors of tumor progression, and the direct causal relationship between acellular stroma, ECM remodeling and/or age-related senescence-associated secretory phenotype (SASP) in inducing a field-effect conducive to malignant conversion.An ongoing challenge in studying these non-immune stromal programs is that the models are still limited. Appropriate and highly specific Cre-drivers that allow for dynamic fate mapping of these cells are often lacking. Limited studies have genetically manipulated these stromal cell types in an unbiased manner using shRNA and/or CRISPR approaches. This is essential for discovering new functional aspects of stroma-tumor crosstalk to move it from correlation to causality. Current models that will enable these discoveries include more rapid mouse transgenic models, complex organoid models, as well as zebrafish and flies, the latter of which are particularly amenable to screens of this sort.Expanding the notion that stroma, along with the tumor cells, co-organizes all stages of tumorigenesis will lay the foundation for a broad spatial and temporal understanding of the complete TME from initiation through metastasis. In order to assess the challenges associated with this goal, the NCI’s Division of Cancer Biology sponsored a workshop that built upon the advances in the immune-oncology realm and emphasized non-immune stromal components. The workshop highlighted the critical functions of the non-immune stromal cell types and ECM in regulating heterogeneity and tumor cell fate throughout initiation, progression, and therapy resistance. The workshop not only explored the multifaceted role of stroma in suppressing and/or supporting tumorigenesis in early and advanced stage cancers, but also considered emerging themes of stromal plasticity and position-dependent functions of stromal subtypes in driving disease progression, resistance to therapy, and as possible clinical targets of vulnerability. These workshop topics were consolidated within five themes that addressed key scientific and technical challenges related to 1) stromal-centric arbiters of tumor progression and suppression; 2) the unique biology of early lesions in regulating indolence versus aggressiveness; 3) stromal plasticity and its role in regulating the fate of the tumor mass; 4) the significance of stromal cell geography and architecture in cancer; and 5) clinical implications of microenvironmental heterogeneity.Stroma contributes to both suppressing and promoting tumor progression, yet what cell subtypes, ECM components, and underlying mechanisms regulate tumor fate in varying contexts, including aging, genetic background, and systemic comorbidities, remain ill-defined. Studies conducted on fibroblasts and CAFs as a major stromal element have contributed significantly in the recent past to characterizing the heterogeneity of the microenvironment and important leads are beginning to emerge that elucidate distinct functions of different subtypes in these diametrically opposing functions. In the first talk of the session, Raghu Kalluri highlighted the functional diversity of tumor-restraining (αSMA+) and tumor-promoting (FAP+) CAF subtypes in a mouse model of pancreatic ductal adenocarcinoma (PDAC). αSMA+ CAFs predominantly modulate ECM production, facilitate cell-ECM adhesion, and regulate adaptive immunity .Simon Hayward shifted the focus to human prostate cancer models and provided evidence of CAF subtypes with distinct expression signatures revealed by single cell RNA-seq analysis. CAF clusters differ in their chemokine/cytokine profiles, leading to cluster-specific effects on the microenvironment – such as macrophage recruitment via high CCL2 expressing CAFs or modulation of inflammatory cells by high CXCL12-expressing CAFs. Specific populations of recruited populations (depending on the CAF subtype) can produce distinct factors that will shape the tumor and/or microenvironment in distinct ways – e.g., macrophage-derived pro-tumorigenic factors, recruitment of other immune cell types that promote the M2-macrophage phenotype .In her presentation, Ellen Puré focused on reactive CAFs expressing fibroblast activation protein positive (FAP+) in mouse PDAC. In contrast to normal stromal cells that maintain epithelial integrity and confer tumor resistance, FAP+ fibroblasts have immunosuppressive and tumor promoting properties. Indeed, both the Puré and Kalluri laboratories have provided evidence that human PDAC patients with FAP+ fibroblasts have decreased survival compared to αSMA+ fibroblasts , 15. FAPDavid Tuveson discussed findings from his team involving the identification of additional CAF subtypes classified as either myogenic myCAFs, inflammatory iCAFs, or the most recently isolated and characterized antigen presenting apCAFs that express MHC class II and CD74 and are capable of activating CD4+ T cells, but lack other immune related genes including classical co-stimulatory molecules , 20. StuThe topic of cellular plasticity was expanded further by Ashani Weeraratna in her discussions of the aging stroma in a mouse model of melanoma. She summarized data that suggest age-associated events contribute to altering the function of CAFs in a tissue-specific manner and with important implications to not just tumorigenesis and metastasis but also therapeutic outcomes. For instance, aged lung fibroblasts (but not aged skin fibroblasts from human donors) drive proliferation via induction of canonical Wnt signaling . In contFibroblasts and other stromal cell types in the tumor microenvironment acquire pro- and/or anti-tumorigenic phenotypes that impact carcinoma growth. Research in this area has identified heterogeneity in CAF marker expression and function, altered functions of fibroblasts based on tissue source, and plasticity of fibroblasts among cell states. A greater understanding of this functional heterogeneity and determining the degree of plasticity in other stromal cell types will elucidate novel mechanisms of tumor promotion and/or suppression, which may have therapeutic potential.It has become increasingly clear that the TME changes throughout disease progression, but the involvement of stromal cells is primarily studied with regard to established and more advanced stages of cancer . The contribution of stromal cells and the ECM to tumor initiation has not been widely studied, but some research in this area using diverse approaches has opened exciting avenues for further investigation.Drosophila model. He described that, upon knockdown of a tumor suppressor gene scrib, specific regions within developing fly tissues would reject tumor growth while other regions would allow tumor growth. This identified “tumor hotspots” in which JAK/STAT signaling was determined to be elevated [Wu-Min Deng actively investigates tissue environments which are susceptible or resistant to tumor formation using a elevated , 24. FurPhilip Beachy highlighted work from his group demonstrating stromal suppression of growth in tumors of endodermal origin. In bladder cancer, tumors are almost completely clonal in origin, and using a mouse bladder cancer model his group determined that sonic hedgehog (Shh)-expressing cells act as long-term stem cells that regenerate the bladder epithelium via Wnt signaling , 26. PreAnother approach to investigating stromal involvement in early cancer lesions was described by Mara Sherman, who studies stromal evolution with pancreatic stellate cells (PSCs). Work by her group is focused on understanding the origins of fibroblasts within the TME in mouse PDAC. PSCs give rise to the PDAC CAF phenotype, but other non-PSC-derived CAFs exist as well. Using known markers of fibroblasts, such as desmin and podoplanin (PDPN), she indicated that some PDAC CAFs were PSC-derived while other CAFs were PDPN-positive, non-PSC-derived CAFs . She proThe discussion of this session was expanded further by Ken Lau, who uses computational modeling in colon cancer to identify CAF-cancer cell interactions that drive tumor progression . His stuComplete knowledge of the TME requires an understanding of the many cell types and interactions within it. Unfortunately, the complexity of these interactions makes this work technically and conceptually difficult. Some of these interactions cannot be adequately studied because appropriate tools have not yet been developed. Thus, one of the objectives of this meeting was to discuss interactions between all cell types within the TME, including fibroblasts, adipocytes, immune cells, endothelial cells, nerves, normal epithelial cells, and cancer cells, as well as to discuss current limitations associated with researching intercellular communication.Throughout the last decade, our understanding of cancer-immune cell interactions has been significantly advanced and has even led to successful new therapeutic strategies. PD-L1 targeting is one example of recently discovered therapeutic options, but clinical applications of PD-1/PD-L1 therapies have identified limitations, specifically by driving resistance mechanisms in tumors . CurrentWhile the role of some immune cell populations, notably T cells and tumor-associated macrophages, have been widely studied in the context of the TME, this is an active area of research in which novel findings continue to evolve our understanding of immune cell-tumor cell dynamics and their potential implications in shaping tumor evolution. Melissa Wong and her group have recently characterized a cell fusion of macrophages with cancer cells . These cin vitro [Significant efforts are currently in progress to target immune cells, so discussions at this meeting put greater emphasis on other cell types in the microenvironment that have not been so widely studied. Adipose tissue, for instance, is very dynamic and may serve as a nutrient source for cancer cells. Ernst Lengyel works to understand the microenvironmental contributions to human ovarian cancer metastasis and the metabolic co-dependencies between cancer and stromal cells. Metastasis to the omentum, the common site in this disease, leads to the localized disappearance of adipose tissue in the affected area. Dr. Lengyel’s group has provided evidence that this loss is likely due to the contributions of adipose tissue lipids and FABP4 to the tumor cells . Ovarianin vitro , 36. Conin vitro . HoweverTo further elucidate the role of lipids and adipose tissue in the TME, James Granneman’s laboratory investigates adipogenic niches and the stromal/immune cells that are key to adipose tissue maintenance, remodeling, and may play a role in tumor progression. scRNA-seq of mouse adipose tissue by his group identified two major adipocyte stem cell (ASC) subpopulations, ASC1 and ASC2, in epididymal and inguinal white adipose tissue that express different collagens and trophic factors, such as neurotrophin 3 and bone morphogen 7 . The ASCcasper strain, which allows for powerful in vivo imaging [in vivo imaging, the White lab found that tumor cells export a variety of extracellular vesicles such as melanosomes and exosomes into the seemingly normal keratinocytes. The recipient keratinocytes then undergo reprogramming and switch from a tumor suppressive to tumor promoting role. These reprogrammed keratinocytes exhibit an N-myc pluripotency signature and dramatic alterations in chromatin structure. Although the absolute number of keratinocytes that undergo such reprogramming is small, their importance in promoting melanoma progression highlights the need for a detailed understanding of the “geography” of tumor-stroma interactions [Richard White further expanded the discussion of stromal-cancer cell interactions by discussing his work using zebrafish melanoma models. The zebrafish is ideal for this given the optical transparency of the  imaging . Melanom imaging , which i imaging . What is imaging  and realractions .In other cancer models, such as renal cell carcinoma, the environmental context of cancer epithelial cells drastically influences the invasion potential of epithelial tumor cells. David Beebe’s models that incorporate compartmentalized epithelial and endothelial duct-based organotypic platforms, indicate that incubation of tumor epithelium with normal endothelium promotes invasion of the endothelial cells. However, incubation of tumor epithelium with cancer associated endothelium only yields cancer cell invasion without endothelial invasion. The Beebe lab continues to lead the development of cell-cell interaction and microfluidic models for the study of unanswered biological questions , 44. UseThe late Dr. Patricia Keely revolutionized the TME field by demonstrating that architectural organization of the ECM  is fundamental to tumor cell-stromal cell interactions, metastasis, and response to therapy –48. A stDespite recent technological advances, such as imaging mass cytometry and co-detection by indexing (CODEX) , histoloNext, Kristian Pietras showed that breast cancer CAFs from a mouse model are characterized by three distinct transcriptional programs, potentially reflecting unique spatial origins within the TME . The larRuth Scherz-Shouval discussed transcriptomic data from a murine breast cancer model obtained using single-cell RNA-seq at different time points along tumor progression and metastasis. Her group identified two distinct CAF populations, each of which could be further dissected into subsets that change as tumors progress. These CAF subtypes, sCAF and pCAF, were characterized by high expression of S100A4 and PDPN, respectively, and found in both mouse and human breast tumors. Interestingly, a higher sCAF/pCAF ratio was indicative of better overall survival in human patients, suggesting that the sCAF population may play a protective role against tumor progression . IdentifKaterina Politi shifted the focus to discuss how tumor intrinsic-targeted therapies are impacted by the organs affected by metastases. As mentioned above, these approaches have limited benefits, since tumors may, in part, undergo clonal selection upon targeted-therapy eventually culminating in a more aggressive tumor. For example, in EGFR-mutant lung tumors, resistance to first and second generation tyrosine kinase inhibitors (TKIs) is mostly driven by the emergence of a secondary T790M mutation in EGFR. To overcome this resistance, a third generation TKI, osimertinib, is currently used clinically, but patients can still develop resistance and many of the resistance mechanisms are poorly understood. To unravel the underlying mechanism, Politi and colleagues are investigating therapeutic responses in different metastatic sites. Early data support the idea that the TME location can impact sensitivity to TKIs. It is well known that different tumor sites can differentially impact tumor progression. Hence, the field needs to advance towards a better characterization of the molecular and cellular mechanisms that drive increased tumor progression in an organ and location-specific manner. Concomitantly, improved comprehension of the specific sites in the body that more potently restrict tumor cell proliferation could also provide valuable knowledge about stromal/tumor interactions that drive tumor progression.The meeting also tackled the question of endothelial heterogeneity. Ying Zheng discussed the dynamic nature of the tumor microvasculature and how it changes during tumor progression. Zheng noted that many ongoing studies still work with specific cell lines that do not recapitulate the heterogeneity found in endothelial cells of different tissues. It is also important to consider the interactions of endothelial cells with their surroundings, which contain diverse cell types, ECM, and geometric complexities. Taking this into consideration, Zheng engineered a device that allows endothelial cells to reconstruct 3D vessel structures using fetal endothelial cells from different tissues. This technology aided in determining that endothelial cells with distinct tissue origins do indeed form vessels with diverse architecture and unique transcription profiles . Studiesex vivo setting. Another looming challenge is to define cell states versus subtypes, particularly in CAFs. Also, work toward identifying triggers of cellular plasticity versus a more permanent epigenetic state is needed. This work will lay the groundwork for the field to move more deeply into the mechanisms that drive changes in the TME and impact tumorigenesis.The present level of characterization of CAFs, adipocytes and endothelial cells has brought valuable, but less than comprehensive information about their function within the TME. Nevertheless, it will help develop a necessary expansion in the field to identify new opportunities for targeted therapies. Better understanding the role of the non-immune stroma in shaping the microenvironment prior to the appearance of a tumor is also pivotal to unravelling the mechanisms driving tumorigenesis. A key issue is the high degree of stromal cell plasticity driven by multiple environmental vectors, creating a challenge to working with them in an During the final session, discussions were focused on the implications of current cancer therapy in the TME. Despite recent advances in targeted and immunotherapies, the core of cancer treatment is based on genotoxic agents, such as ionizing radiation and chemotherapy. Those agents exert systemic and local damage in non-tumor cells that consequently impact therapy-associated comorbidities and cancer recurrence. In this context, Sheila Stewart discussed her findings related to the impact of senescence in chemotherapy-induced bone loss, a common comorbidity in cancer patients. Using a genetic mouse model, her team found that elimination of senescent cells that arise after chemotherapy prevented bone loss . In addiin vivo when expressed in the prostate TME [in vitro and in vivo. These data support ongoing clinical trials to assess whether rapamycin-induced inhibition of DDSP in prostate cancer patients under chemotherapy treatment can improve response. Other druggable DDSP pathways, including PARP inhibition to attenuate the DDSP and the NKG2D-MIC-MMP axis to eliminate damaged cells with immune-suppressive phenotypes, are also under consideration for future studies to identify new opportunities for stroma-targeted therapies [Besides SASP, chemotherapy-induced genotoxic stress can trigger a DNA damage secretory program (DDSP) – very similar to SASP but not associated with cell cycle arrest and/or p16 signaling– releasing numerous inflammatory (IL-6/8), angiogenic , mitogenic (amphiregulin), pro-EMT (HGF) and chemo-preventative factors. Focusing on the potential effects of genotoxic stress in the TME, Peter Nelson showed that human prostate fibroblasts upregulate numerous pro-tumorigenic factors upon a variety of genotoxic stimuli. Among the released factors, WNT ligands attenuate a cytotoxic chemotherapy effect tate TME . He highherapies .Neil Bhowmick expanded on the stromal considerations for prostate cancer therapy by presenting findings that demonstrated chemotherapy-triggered crosstalk between CAFs and tumor cells. His team found that docetaxel induces mitophagy and ER stress in prostate tumor cells, leading to secretion of mitochondrial DNA (mtDNA) . This reFinally, Edna Cukierman discussed the stromal heterogeneity found in the desmoplastic environment of pancreatic tumors. Her group found that fibroblastic cell function depends on the fibroblastic ECM. She showed that the desmoplastic ECM sustains the expression of Netrin G1 in PDAC CAFs while tumor adjacent fibroblasts cultured in “normal” ECM do not express this protein. Netrin G1 is a glycosylphosphatidylinositol-anchored protein known for its glutamatergic pre-synaptic function. Interestingly, the Netrin G1 binding partner, NGL1, is overexpressed in pancreatic cancer cells, suggesting a possible crosstalk between CAFs and tumor cells through Netrin G1/NGL1 signaling axis . FurtherThis meeting fostered discussions of the needs and limitations of research currently focused on the components of the TME. Participating individuals are leading research programs to identify novel cell types, pathways of cellular interactions, model systems suitable for TME research questions, and to unravel heterogeneous cell populations. However, investigation of the TME components – and how they evolve throughout tumor progression, their role as drivers or suppressors of tumorigenesis, malignancy and/or partner with the tumor mass as co-organizers in tumor growth and respond to current therapeutics – remains limited. While progress has been made by several research programs in identifying novel CAF subpopulations, and initial traction is beginning to emerge with endothelial cells and adipocytes, standardized functional and molecular definitions for fibroblast subtypes (and other non-immune cells) do not yet exist. Tools to capture stromal heterogeneity are limited due to variable isolation techniques and the loss of cellular and microenvironmental context. Even with scRNA-seq data acquired to-date, lack of uniform analysis pipelines makes full utilization of the biological implications of this data difficult.It would also be beneficial to create an accessible catalog of all cell types, spatial context, mechanical properties, and events that regulate them such that the field may begin to interpret what constitutes a supportive or resistant tumor stroma – or even sub-stromal compartments such as the perivascular niche that may uniquely protect tumor cells relative to other stromal regions. Similarly, it is not yet understood when a stroma becomes supportive of the tumorigenic process, when a suppressive stroma is lost or reprogrammed, and what determines this “stromagenic switch.” This includes the contribution of lifestyle factors, aging, and drug treatments that are likely to not only impact traditionally (and narrowly) defined tissue-specific microenvironments but also more broadly if the microenvironment is expanded to systemic effects as well. Another consideration is the changes in stroma from early (pre-neoplastic) disease through metastatic disease, which likely abide by stage-specific regulatory networks and yield unique changes for each cancer type. While many microfluidic or other engineered model systems are being developed to address the interactions of multiple cell types, development of new models may be necessary to address these fundamental questions.Cells from multiple origins may perform similar functions. We have discussed CAF heterogeneity broadly in terms of function and marker expression, but these cells may be derived from a variety of sources, including bone marrow-derived mesenchymal stem cells, adipocytes, or even cancer cells which have undergone EMT . DespiteFinally, we need to determine what therapeutic opportunities exist within the TME that may improve the current standard-of-care for each cancer type and disease stage. Understanding some of the questions outlined above may unveil new therapeutic strategies, but widely useful platforms to test novel strategies both in primary and metastatic disease settings are also necessary, particularly because a response in the primary setting does not dictate a response in the metastatic setting. Likewise, established tumors are not one and the same as an early lesion, and are therefore unlikely to follow the same set of “biological rules.” Since the TME is complex and evolves with disease progression, there are many opportunities for discovery. Ultimately, a greater research effort in tumor stroma will lead to precision medicine with optimal therapeutic intervention and better patient outcomes.


Thyroid cancer incidence is on the rise; however, fortunately, the death rate is stable. Most persons with well-differentiated thyroid cancer have a low risk of recurrence at the time of diagnosis and can expect a normal life expectancy. Over the last two decades, guidelines have recommended less aggressive therapy for low-risk cancer and a more personalized approach to treatment of thyroid cancer overall. The American Thyroid Association (ATA) and National Comprehensive Cancer Network (NCCN) thyroid cancer guidelines recommend hemithyroidectomy as an acceptable surgical treatment option for low-risk thyroid cancer. Given this change in treatment paradigms, an increasing number of people are undergoing hemithyroidectomy rather than total or near-total thyroidectomy as their primary surgical treatment of thyroid cancer. The postoperative follow-up of hemithyroidectomy patients differs from those who have undergone total or near-total thyroidectomy, and the long-term monitoring with imaging and biomarkers can also be different. This article reviews indications for hemithyroidectomy, as well as postoperative considerations and management recommendations for those who have undergone hemithyroidectomy. The incidence of differentiated thyroid cancer has increased significantly in the past few decades . During The evaluation and treatment of thyroid cancer requires a coordinated team approach which consists of endocrinologists, surgeons, pathologists, radiologists, and occasionally medical oncologists. Physicians meet patients at different time points of their evaluation and treatment journey, and it is important that each member of the team is aware of the rationale for decision-making at each step of therapy. The purpose of this article is to review not only current indications for hemithyroidectomy, but also the pros and cons of hemithyroidectomy and indications for completion thyroidectomy; the long-term follow-up and management of those who have undergone hemithyroidectomy are also discussed.The extent of initial surgery should be individualized to each patient and should be based on a combination of factors: thyroid nodule imaging characteristics, fine-needle aspiration (FNA) cytology results, molecular testing if applicable, local symptoms, personal or family history of thyroid cancer, hereditary syndromes, history of radiation exposure, baseline thyroid hormone levels or presence of autoimmune thyroid disease, presence of contralateral thyroid nodules, and patient preference for short- and long-term management.Hemithyroidectomy entails removal of the entire ipsilateral thyroid lobe and isthmus, with or without removal of central neck lymph nodes. Total thyroidectomy entails removal of the entire thyroid gland with or without removal of central neck lymph nodes. Whether hemithyroidectomy or total thyroidectomy is elected as the index operation, meticulous dissection to preserve the parathyroid glands and protect the recurrent laryngeal nerve is essential. Partial removal of the ipsilateral thyroid lobe is not recommended for the treatment of thyroid nodules or well-differentiated thyroid carcinoma. Size is an important consideration when determining appropriate thyroid surgery. Both the American Thyroid Association (ATA) and National Comprehensive Cancer Network (NCCN) thyroid cancer guidelines recommend consideration of hemithyroidectomy for nodules smaller than 4 cm without other worrisome features . Active Nodules that appear to have radiologic evidence of extrathyroidal extension (ETE) or invasion into adjacent structures suggest a higher risk of aggressive disease and local recurrence. In those cases, consideration of a total thyroidectomy as the initial surgery is important. If histopathology confirms micro or macroscopic ETE after hemithyroidectomy, this would be considered ATA intermediate- high risk of recurrence, and completion thyroidectomy with or without radioactive iodine ablation (RAI) may be indicated postoperatively. If ETE is suspected preoperatively, hemithyroidectomy may not be the best option, and recommending a total thyroidectomy could obviate the need for a second surgery.Thorough preoperative imaging of not only the thyroid gland, but also the central and lateral neck lymph node compartments is essential when evaluating thyroid nodules. The preferred imaging modality is ultrasound. Pathologic lymph nodes (LNs) in the central (level VI) or lateral lymph node compartments (levels II–V) should be biopsied, and thyroglobulin washings should be obtained from the needle rinse. If only the thyroid was imaged on initial evaluation, then lymph node mapping should also be performed preoperatively, especially for nodules with indeterminate or malignant cytology, and when surgery is planned . MetastaIf the contralateral lobe is normal, then initial hemithyroidectomy is appropriate if also meeting the above criteria. However, if the contralateral lobe contains nodules, then those nodules should also be evaluated preoperatively in order to make a comprehensive decision regarding the appropriate surgery. A thorough discussion with the patient about postoperative surveillance, especially if the histopathology shows malignancy, is important. Those with bilateral nodules will need more frequent postoperative surveillance imaging. This can increase patients’ anxiety, as well as add to long-term follow-up cost.The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) established a standardized reporting system for thyroid FNA specimens that was most recently updated in 2017. The six diagnostic categories are (1) nondiagnostic or unsatisfactory, (2) benign, (3) atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS), (4) follicular neoplasm or suspicious for a follicular neoplasm, (5) suspicious for malignancy, and (6) malignant . The ATA 2015 thyroid cancer guidelines favor a hemithyroidectomy for solitary thyroid nodules with Bethesda III or IV indeterminate cytology . HoweverPreoperative molecular testing results influencing the extent of surgery are very controversial. The mutation BRAFV600E is common in up to 60% of papillary thyroid carcinomas ,11,12. S2 compared with 2.99 mL/m2 in patients who did require thyroid hormone supplementation . Th. Th25]. In 2014, Momesso et al. developed a modified risk stratification utilizing a Tg cutoff of 30 ng/dL for patients after hemithyroidectomy to define an excellent response to therapy  34], an, an34], The exact Tg threshold to predict thyroid cancer recurrence, however, remains controversial. More recent studies showed a limited value of Tg as an independent predictor of thyroid cancer recurrence in patients with hemithyroidectomy ,37. In 2Currently, periodic imaging of the neck with ultrasound is the preferred way to detect structural recurrence. Some clinicians check Tg and Tgab levels with yearly TSH, but the utility of this is debated.The indolent behavior of the encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC) has been recognized for the past decade. In 2016, the Endocrine Pathology Society working group adopted a new nomenclature for the noninvasive EFVPTC, now known as noninvasive follicular thyroid neoplasm with papillary-like nuclear features or NIFTP . NIFTP hCompletion thyroidectomy is not recommended for this type of tumor. NIFTP has an excellent prognosis, with extremely low risk of recurrence, even when treated conservatively with a hemithyroidectomy and no RAI therapy ,39,40. XThe increased incidence and diagnosis of low-risk thyroid cancer combined with a stable mortality rate resulted in a large, growing pool of thyroid cancer survivors in need of surveillance. In 2015, Wang et al. estimated the cost of detecting a recurrence after total thyroidectomy for low-risk thyroid cancer at USD 147,819 . Shrime Long-term surveillance is a key part of thyroid cancer management. An approach that addresses patient HRQOL in addition to survival benefits is essential. Studies have shown that even patients who have low-risk thyroid cancer with excellent prognosis had significant anxiety and worries related to their diagnosis ,46. ThisChronic asthenia following total thyroidectomy has also been recognized as a possible contributor to worse QOL in thyroid cancer patients. Rosato et al. compared rates of asthenia following total thyroidectomy versus hemithyroidectomy and reported significant differences with 25% of the total thyroidectomy group reporting asthenia, compared with 0% of the hemithyroidectomy group . ConversHemithyroidectomy is a good treatment option for many low-risk thyroid cancers and is associated with less extensive surgery, lower rates of surgical complications, and a lower risk of postoperative asthenia in appropriately selected patients. When recommending hemithyroidectomy, it is important to ensure that adequate preoperative evaluation has been completed and that not only the short-term surgical plan is discussed, but also the long-term issues regarding thyroid hormone therapy, surveillance, need for additional surgery and follow-up, ability to predict recurrence, and QOL. Involving the patient in the discussion with the multidisciplinary team regarding appropriate treatment options is a great way to address all of these issues preoperatively.


Dendritic spines are small protrusions studding neuronal dendrites, first described in 1888 by Ramón y Cajal using his famous Golgi stainings. Around 50 years later the advance of electron microscopy (EM) confirmed Cajal’s intuition that spines constitute the postsynaptic site of most excitatory synapses in the mammalian brain. The finding that spine density decreases between young and adult ages in fixed tissues suggested that spines are dynamic. It is only a decade ago that two-photon microscopy (TPM) has unambiguously proven the dynamic nature of spines, through the repeated imaging of single spines in live animals. Spine dynamics comprise formation, disappearance, and stabilization of spines and are modulated by neuronal activity and developmental age. Here, we review several emerging concepts in the field that start to answer the following key questions: What are the external signals triggering spine dynamics and the molecular mechanisms involved? What is, in return, the role of spine dynamics in circuit-rewiring, learning, and neuropsychiatric disorders? Ramón y Cajal in 1888 was the first to observe these small protrusions 1.0–1.5 μm in length in Golgi stainings . Depriving visual input of one eye, also called monocular deprivation (MD), and recording visual signals in the contralateral visual cortex show increased responsiveness towards the non-deprived, ipsilateral eye while the deprived eye responses fade , is paired with a neutral stimulus such as a sound or an environmental context (conditioned stimulus or CS), the animal rapidly learns to associate the CS with the US and will now freeze whenever the CS is presented alone , TSC (Tuberous sclerosis), and UBE3a  is associated with most cases of Angelman syndrome, which is a rare syndrome of developmental delay, ID and ASD  is a psychiatric illness that is characterized by low mood and lack of feeling pleasure. MDD patients show altered glucocorticoid levels, which speaks for dysregulation of the HPA axis . F-actin provides the force necessary for the formation of nascent protrusions and modifications in spine shape, such that actin polymerization/depolymerization is the main determinant of spine structural dynamics. A LTP inducing stimulation increases actin polymerization in spines  and is mainly restricted to the stimulated spine , and the Ca2+-CaM complex then activates the holoenzyme CaMKII that is necessary and sufficient for LTP induction  where it forms complexes with NMDA receptor and other PSD molecules, allowing its stabilization. There, CamKII kinase activity enhances AMPAR-mediated transmission in two ways. First, CaMKII phosphorylates AMPA receptors, which leads to an increase in the average conductance of such channels , Rho kinase (ROCK), and LIM kinase  structural changes at single stimulated dendritic spines. A growing number of genetic studies have linked neurodevelopmental disorders to various synaptic GEFs and GAPs for Rho GTPases , which triggers protein-synthesis-dependent forms of spine plasticity by activating extracellular signal-regulated kinase (ERK) or mammalian target of rapamycin (mTOR) pathways , such as echanism  that remechanism .Cpg15 , an activity-regulated gene highly expressed at developmental times of synaptogenesis  and hippocampus have enlightened the role of the neuromodulators dopamine and serotonin in spine enlargement and elongation. In slices, dopamine secreted by VTA neurons was shown to promote glutamate-induced spinogenesis in nucleus accumbens medium spiny neurons. Researchers optically stimulated dopaminergic and glutamatergic inputs separately and found that dopamine promoted spine enlargement only during a narrow time window (0.3–2 s) after the glutamatergic inputs. The downstream spine effector mechanisms included calcium entry, cAMP, and PKA activation , which suggests that NEUROD2 is a nexus in a gene network that controls spine turnover in the postnatal cortex.The predominant influence of stress and the circadian cycle highlights the critical role of glucocorticoid in spine dynamics. The two receptors for glucocorticoids GR and MR are involved in glucocorticoid actions , correspond to mature excitatory synapses, and these contain PSD-95. Most of these PSD-95 positive spines are stable, but, in the rare cases that they lose PSD-95 and disappear, or are formed de novo and gain PSD-95, their dynamics result in a persistent synapse gain or loss and permanent circuit rewiring associated with learning and memory, respectively. The remaining 20% of adult spines are PSD-95 negative. Most of them have immature synaptic currents due to low AMPA receptor contents and thus form unstable synapses. PSD-95 negative spines are highly dynamic and mostly transient, rarely gaining PSD-95 or persisting. Their dynamics likely reflect a sampling strategy for searching potential presynaptic partners in the extracellular space, and the rare spines gaining PSD-95 would be the ones inducing permanent circuit rewiring. In sum, the recent in vivo TPM experiments have shown that PSD95 is necessary for spine stabilization but not for spine initiation  plasmid can be used to image experience-dependent AMPA receptor trafficking in real-time in vivo (Zhang et al., in vivo role remains to be assessed, possibly via similar approaches.In the future, several approaches might be indicated to accelerate knowledge in the field. in utero electroporation of more than a single fluorochrome will allow capturing not only each spine’s morphology and location but also its subtype identity in real-time in vivo has been published (Mower et al., in vivo than in slice cultures (Mikuni et al., Importantly, the development of 2pFLIM on organotypic slices has allowed exploring the spatiotemporal dynamics of biochemical signaling in dendritic spines, and a proof-of-principle Besides spines, inhibitory synapses can now be imaged longitudinally by TPM of Gephyrin-fused fluorophores. Nedivi et al.  found thAnother prospective advance in the field will be to track presynaptic axons and circuits connecting the dendritic spines whose dynamics are observed. The Gan team has nicely shown that axonal boutons are largely stable in the barrel cortex of adult mice (Qiao et al., AC and KR wrote the article. KR designed the tables. AC made the figures. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


DNA nanotechnology, based on sequence-specific DNA recognition, could allow programmed self-assembly of sophisticated nanostructures with molecular precision. Extension of this technique to the preparation of broader types of nanomaterials would significantly improve nanofabrication technique to lower nanometer scale and even achieve single molecule operation. Using such exquisite DNA nanostructures as templates, chemical synthesis of polymer and inorganic nanomaterials could also be programmed with unprecedented accuracy and flexibility. This review summarizes recent advances in the synthesis and assembly of polymer and inorganic nanomaterials using DNA nanostructures as templates, and discusses the current challenges and future outlook of DNA templated nanotechnology. DNA, often known as the genetic code, exists in natural organisms. In 1953, the double helix structure of DNA was discovered, which revealed the mystery of life and enabled people to understand clearly the composition and transmission of genetic information . In the In recent decades, enthusiasm for DNA molecules has expanded from the initial biological and chemical arena to that of nanomaterials. Given the advantages of accuracy and design flexibility, advances in DNA self-assembly techniques  have madIntriguingly, the glamour of life is that DNA is not only capable of storing genetic information, but can also precisely translate this information into another material—protein. The sequence-dependent hybridization mechanism ensures that DNA can stably store genetic information and its heredity. In its natural state, DNA provides limited structural features and functional diversity. Therefore, DNA does not directly serve as a functional material, but instead, its sequence-encoded information is transcribed and expanded into the sequence of protein, and, in this way, renders diversity in life. Such an elegant strategy has also inspired material chemists. If DNA nanotechnology could be expanded to prepare diverse materials, the programmable features of DNA nanostructures might endow them with exquisite and unlimited physical and chemical properties, thus bringing a potential revolution to nanomaterial science. Encouraged by this vision, the use of DNA nanostructures as templates to control the precise synthesis of organic and inorganic materials has attracted increasing attention in recent years. In this review, we discuss the latest progress in the field of DNA-programmed material science, with a focus on the synthesis of polymer and inorganic materials employing DNA nanostructures as templates in order to achieve unprecedented accuracy at the nano scale Fig. .Fig. 1DNAs the most important storage material of natural genetic information, DNA can encode the synthesis of proteins in natural organisms and, accordingly, determine all of life’s activities. The ability to synthesize protein macromolecules using nucleic acids as templates enables proteins to evolve into complex structures and functions with remarkable specificity and reliability. In contrast, traditional chemical polymerization reactions cannot precisely control the sequence of monomers, or their molecular weight distribution. Therefore, synthetic polymers typically could not display defined structures and functions as proteins –19. DespInspired by the DNA transcription process, Hollige et al. , 27 desiLiu and other researchers also attempted to mimic the principle of the natural gene translation process to achieve chemical synthesis of sequence-controlled polymers based on DNA templates –31. TheyAs an extension of synthetic polymers encoded by simple DNA strands, in recent years, DNA nanostructures with 2D and 3D spatial conformation have also been used as templates for the synthesis of polymer nanomaterials. At present, there are two major objectives for these studies. On the one hand, researchers aim to improve the physical and chemical properties of DNA nanomaterials by polymer modification. Since DNA-folded “nano-robots” have been proposed as ideal intelligent drug carriers at the nanometer scale , there hVarious types of substances have been used to encapsulate DNA nanostructures to improve their physical and chemical stability. For instance, by immobilizing lipid-modified DNA on the nanostructure surface, liposome can be formed around the DNA nanostructure to enhance cell uptake efficiency Fig. a 41]. H. H41]. HApart from their attractive properties and as yet not fully exploited potential as drug carriers, a role for DNA origami nanostructures as templates to control the growth of polymer nanomaterials has also been envisioned. Conventional synthetic polymerization reactions in liquid phase normally result in randomly entangled polymer chains. In contrast, by combining traditional polymer synthesis methods with DNA strands or nanostructures based on site-specific modification strategy, pre-designed polymer nanomaterials were successfully obtained. This could be achieved by in situ atom transfer radical polymerization (ATRP) polymerization on DNA chains—a technique established by Matyjaszewski and coworkers . By modiIn addition to controlled radical polymerization, DNA template technology can also be applied to the synthesis of other patterned polymers. Ding’s group reported the catalytic polymerization of aniline on DNA nanostructures , 53. In In addition to DNA nanostructure-templated in situ polymer synthesis, Liu and colleagues have developed a series of methods to use DNA nanostructures as scaffolds to control the morphology of polymersomes and liposomes, which have been collectively named as the “frame guided assembly” technique. It is well known that spontaneously self-assembled vesicles of amphiphilic polymersomes and liposomes are usually spherical. However, Liu’s methods allowed construction of cubic shaped polymersomes and nanometer liposome sheets depending on the DNA template used. Hereby, they could even overcome the surface tension force in nature Fig. a 56, 5757.Fig. 6Other than controlling the shape and morphology of polymers, DNA templates allow the installation of functional handles on defined positions of polymer nanoparticles. Toward this end, Sleiman and colleagues reported a method of synthesizing DNA-imprinted polymer nanoparticles with monodispersity and prescribed DNA-strand patterns inside a DNA cage Fig. b 58]. T. T58]. TIn addition to controlling the morphology of polymer nanomaterials, DNA nanostructures can even be used to manipulate the molecular conformation of an individual polymer chain. Gothelf and colleagues prepared synthetic polymer wires containing short oligonucleotides that extend from each repeat . T. T62]. TFrom the perspective of chemical structure, the DNA strand is an organic macromolecule composed of C, H, O, N, and P. Among the virtues of DNA molecules are their controllable structure, adjustable sequence and ease of modification. However, they lack the mechanical strength and quantum optical properties that are commonly available in inorganic nanomaterials. On the other hand, it remains challenging for conventional synthesis of inorganic nanoparticles to achieve arbitrary shapes and controllable assembly, which are highly important in achieving the desired optical and mechanical properties. Therefore, combining the benefits of both materials, DNA-assisted inorganic nanoparticle synthesis and assembly presents an attractive way to create rationally designed nanomaterials with unique features. In this context, modifying nanoparticles  with oligonucleotides was found valuable to create nanoparticle crystals with the desired lattice form. DNA nanostructures could even serve as molds to control the morphology of inorganic nanoparticles during synthesis. Moreover, using DNA nanostructures as templates could even fabricate chiral plasmonic metamolecules. This section will summarize recent developments in this area. Nature at the same time that revealed the possibility of using oligonucleotide-conjugated gold nanoparticles to guide the formation of nanoparticle assembly , thus a silica shell was formed on DNA origami templates. This represents the first protocol to access highly sophisticated but flexibly designed silica oxide nanostructures that could not be realized by conventional silica nanofabrication techniques. The feasibility of this method was also demonstrated in a parallel study by Heuer-Jungemann . A. A97]. Aungemann , which cOn the basis of controlling the crystallization and in situ growth of gold nanoparticles, DNA-templated synthesis and assembly techniques can also manipulate the assembly behavior of other diverse inorganic nanoparticles, and even change their inherent physical and chemical properties. It is known that when metal particles are placed in close proximity, their particle plasmons (collective oscillations of conduction electrons) become coupled and induce numerous interesting optical phenomena –104. HowIn this context, some pioneering work was carried out by Ding and co-workers, who prepared AuNPs arranged linearly on a rectangular DNA origami sheet with precisely controlled positions and particle spacing, and then assembled them into a 3D helical geometry with chiral plasmonic phenomenon by rational rolling of the DNA origami sheet. This study opened up the possibility of realizing programmable 3D plasmonic structures with desired optical properties . Thereaf+ stimuli was observed by CD signal changes. Similarly, strand displacement reactions were also applied to drive the plasmonic walking of AuNRs, which were recorded as dynamic CD signal changes (Fig. In addition to the above-mentioned static chiral plasmonic nanostructures, Liu et al. also developed dynamic chiral plasmonic nanostructures based on DNA origami templates. For example, light-responsive azobenzene-modified DNA strands Fig. d 114] a a114] anges Fig. e 116]. . + stimuges Fig. f 117] a a+ stimuges Fig. g 118]..+ stimulThis review summarizes recent progress in nanomaterials synthesis based on DNA nanostructure templates. With computer-aided design, the use of DNA synthesizers, and the rapid development of DNA nanotechnology, we can construct a large variety of DNA nanomaterials. This technique provides valuable opportunities for more controllable preparation of organic and inorganic materials, polymer materials and other synthetic materials, indicating that its influence has distinctly penetrated all aspects of material science. Mimicking the central dogma, translating DNA sequence to other synthetic polymeric materials provides a valuable method of achieving sequence-controlled polymers. Based on larger DNA nanostructures, one can confine polymer synthesis to obtain more sophisticated polymer nanostructures or anisotropic polymer films, or even control the alignment of a single polymer chain to fabricate single molecular level electronic circuits. The self-assembly of inorganic nanoparticles based on DNA nanostructure templates can also be manipulated by DNA nanotechnology to achieve precise regulation at the nanoscale, including lattice regulation, chiral regulation and dynamic growth regulation. Moreover, in situ synthesis of inorganic nanomaterials inside a DNA model or outside a DNA template has also emerged as a powerful method to achieve inorganic nanostructures with intricate details.The structural variability and the capability of precise customization make DNA nanostructures an extremely powerful tool for improving high precision and controllable preparation techniques for nanomaterials. Undoubtedly, DNA-encoded synthesis technology will also bring more innovations in the field of chemical materials preparation, especially given the advantages in high-precision control of nanomaterial assembly and highly complex nanomaterial processing. This has broad application prospects in biomedicine, fine electronics, flexible materials and other fields. Despite their extraordinary prospects, several limitations have to be overcome before the widespread use of DNA nanostructures. Firstly, the cost of DNA materials has to be further reduced, which might be possible with advances in DNA synthesis techniques or the development of synthetic biology to allow direct production of DNA nanostructures in microorganisms; secondly, the yield and robustness of these methods have to be further proved. Since most of these methods require several steps of self-assembly and reactions, reliable scale up has been shown only rarely and further optimization is required. Thirdly, DNA nanotechnology has irreplaceable advantages in achieving elaborate nanostructures from several to hundreds of nanometers, but assembly of even larger structures is relatively inefficient. Therefore, the combination of DNA-based materials synthesis together with other nanofabrication techniques, such as lithography or 3D printing, would be essential to achieve desired materials with rational designed structure from micro- to macro-level.Overall, the development of DNA-programmed material synthesis is just beginning, and extensive efforts are still required. However, along with increasing knowledge about structure–function relationships in materials, improving the precision of nanofabrication techniques for advanced material synthesis is apparently in highly demand. Therefore, one can envision that this field will develop rapidly in the next few years. The first application breakthroughs might be in medicinal and healthcare materials, considering their favorable biocompatibility and relatively high cost.


Background: Preoperative anxiety causes profound psychological and physiological reactions that may lead to a worse postoperative recovery, higher intensity of acute and persistent postsurgical pain and impaired quality of life in the postoperative period. Previous randomized controlled trials (RCTs) suggest that auricular acupuncture (AA) is safe and effective in the treatment of preoperative anxiety; however there is a lack of systematic evidence on this topic. Therefore, this protocol was developed following the PRISMA guidelines to adequately evaluate the existing literature regarding the value of AA for the reduction in anxiety in patients in a preoperative setting, compared to other forms of acupuncture, pharmacological, or no control interventions and measured with questionnaires regarding anxiety and fear. Methods: The following databases will be searched: MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, and Scopus Database. RCTs will be included if an abstract is available in English. Data collection and analysis will be conducted by two reviewers independently. Quality and risk assessment of included studies will be done using the Cochrane 5.1.0 handbook criteria and meta-analysis of effectiveness and symptom scores will be conducted using the statistical software RevMan V.5.3. Conclusions: This systematic review will evaluate the efficacy and safety of AA for preoperative anxiety. Since all data used in this systematic review and meta-analysis have been published, this review does not require ethical approval. The results may be published in a peer-reviewed journal or be presented in relevant conferences. Registration number: PROSPERO ID CRD42020. Preoperative anxiety is the most frequent burden affecting patients before various surgical procedures . Facing A large variety of approaches is used to treat preoperative anxiety including both psychological and pharmacological interventions; however, none of them seem to be ideal in providing effective, safe and low-cost therapy ,10,11.Auricular stimulation (including acupuncture and comparable techniques such as electroacupuncture and acupressure) is a method of complementary medicine, based on stimulation of cranial nerves. It has already been used to treat situational anxiety in experimental and clinical conditions . In seveThe potential mechanism of auricular stimulation is attributed to the neuroanatomical conditions of external auricle. It is presumed that auricular stimulation exerts its anxiolytic effects via the involvement of cranial nerves , which lAlthough the majority of RCTs on auricular stimulation for preoperative anxiety were in favor of this technique, these clinical investigations demonstrated a heterogeneity in regard to surgical procedures, control conditions and effect size, thus making it difficult to draw any definitive recommendations. It seems possible that auricular stimulation might serve as an effective replacement for insufficient conventional pharmacological premedication ,22, thusOnly randomized controlled trials (RCTs) in European languages will be included. Results from quasi RCT will be discussed if little evidence is available, but they will not be part of the analysis. The funding source will be registered. Case reports, case-series, non-randomized case-control studies and retrospective data will not be included in the analysis.No restrictions on study populations will be made, as long as they are described as patients undergoing surgical procedures, including all medical interventions requiring intra-procedural sedation or analgesia. There will be no restrictions regarding the age, gender or ethnicity of participants.This review will include all studies, comparing auricular stimulation or related interventions  alone or in addition to routine care with a variety of control conditions, such as: sham acupuncture, sham acupressure, placebo, routine care, various cognitive-behavioral therapies (CBTs) such as relaxation techniques, music therapy, hypnosis, etc.The primary outcome of this review will be the intensity of preoperative anxiety, measured using patient-reported psychophysical anxiety scales, such as the State Trait Anxiety Inventory (STAI), Anxiety Visual Analogue Scale-100 (VAS-100), the Amsterdam Preoperative Anxiety and Information Scale (APAIS), Self-Rating Anxiety Scale (SAS), extensively described elsewhere . Since aAdverse events and serious adverse events reporting will be analyzed, including events such as pain, inflammation and infection at the sites of auricular stimulation, and vasovagal reactions during the auricular interventions.The search will be done across the following electronic databases and registries, from their inception until June 2020: MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, Scopus Database. The search terms will include: auricular, acupuncture, acupressure, preoperative anxiety, randomized clinical trials .Two researchers will screen the titles and abstracts of articles found in the search, and discard trials that are not eligible. They will independently assess whether the trials meet the inclusion criteria, with disagreements to be resolved by discussion with a third researcher following objective criteria. When articles contain insufficient information to make a decision about eligibility, one of the researchers will attempt to contact the authors of the original reports to obtain further details via email. The details of data search and management are given as Following the selection for inclusion, two researchers will independently extract data according to the standardized form designed by the review group . A thirdTwo researchers will assess all included trials for risk of bias, blind to each other’s assessments. Random sequence generation, allocation concealment, blinding of participants and personnel, incomplete outcome data, selective reporting and other potential sources of bias will be evaluated regarding low, high and unclear risk of bias according to Cochrane Collaboration assessment tool. Any disagreements will be resolved by discussion or by involving a third researcher to adjudicate.Since all outcome measures of this review represent continuous data, they will be presented as mean differences with 95% confidence intervals (CI), or as standardized mean differences (SMD).All outcomes will be analyzed on an intention-to-treat basis. Corresponding authors from the trials with incomplete or insufficient data will be contacted via email to complete the data. Trials with greater than 20% of the data missing will be excluded from the analysis.T2, I2 and Chi2 statistics calculated by RevMan software. Heterogeneity will be regarded as substantial if T2 is greater than zero and either I2 is greater than 50% or there is a low P value (less than 0.10) in the Chi2 test for heterogeneity.Statistical heterogeneity will be assessed in each meta-analysis using the If the meta-analysis includes more than 10 investigations, reporting biases will be studied using a funnel plot with asymmetry testing.T2 and I2.Statistical analysis will be carried out using the RevMan software. Fixed-effect meta-analysis for combining data including primary outcome  will be performed to estimate the treatment effect using SMD and 95% CI. In case of substantial clinical or statistical heterogeneity, a random-effects (RE) meta-analysis will be done to yield an overall summary. If RE analyses are necessary, their results will be presented as the average treatment effect with its 95% confidence interval, and the estimates of To assess potential heterogeneity, subgroup analyses will be performed including the following comparisons: adult versus pediatric patients; female versus male patients; emergency surgery versus elective surgery; inpatient versus outpatient surgery, as well as auricular acupuncture or auricular acupressure versus auricular acupuncture or acupressure plus other treatments (if applicable). The differences between subgroups will be assessed by interaction tests for fixed-effect inverse variance meta-analyses. For fixed-effect meta-analyses and RE using methods other than inverse variance, the comparison of subgroups’ confidence intervals will be used: non-overlapping confidence intervals indicate a statistically significant difference in the treatment effect between the subgroups.Where subgroup analysis fails to explain the heterogeneity, data analysis using the RE model will be used. A priori sensitivity analyses on results will be done to look at the possible contribution of differences in methodological quality, comparing trials with a low risk of bias to all trials.The quality of outcome evidence will be summarized using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Each grade of evidence will be rated as: high, moderate, low or very low.Although almost 50% of adult patients scheduled for elective surgery suffer from preoperative anxiety , there iAn array of data suggest that auricular stimulation might become such an effective, safe and easy-to-perform treatment for preoperative anxiety in adults scheduled for elective surgery and painful procedures with sedation ,15,16,17This review and meta-analysis will fill this gap, analyzing the RCTs based on this protocol, which was designed according to the PRISMA statement . The revThe results of this systematic review may be biased, since only the trials described in European languages will be considered, excluding the full format papers in native languages from the countries of the Far East, where auricular stimulation is widely used in traditional medicine . FurtherIn summary, this systematic review will evaluate the existing evidence on the treatment of preoperative anxiety using auricular acupuncture and related procedures. The scheduled meta-analysis will estimate the effect of auricular stimulation on several perioperative parameters that are known to be influenced by preoperative anxiety. The results of this review will provide the basis for a better understanding of auricular acupuncture in the treatment of perioperative anxiety and will yield the evidence for the implementation of this method in clinical practice.The data search is being performed for the present systematic review.


ANCA+ associated vasculitis (AAV) is a group of rare diseases with potentially vision-threatening complications. Ocular and orbital complications of these diseases are caused by vasculitis of the small vessels of the eye or by granulomatous mass formation. ANCA (anti-neutrophil cytoplasmic antibodies) represent a key component of pathophysiological pathways as well as a diagnostic marker. Various manifestations are reported in literature, scleritis and episcleritis being the most common, followed by pseudotumor orbitae. In vision-threatening orbital or ocular disease, aggressive systemic treatment with a combination of high-dose glucocorticoids and either cyclophosphamide or rituximab is needed. Certain cases require locoregional surgical management to preserve ocular integrity or vision. Ocular involvement of AAV remains a challenge in clinical practice, requiring multi-specialty cooperation in order to ensure the best possible visual outcome.Abbreviations: AAV = ANCA+ associated vasculitis, ANCA = anti-neutrophil cytoplasmic antibodies, GPA = granulomatosis with polyangiitis, EGPA = eosinophilic granulomatosis with polyangiitis, MPA = microscopic polyangiitis These three conditions are known and studied together as ANCA negative associated vasculitis (AAV). The combined incidence of AAV vasculitis is approximately 20 cases per million in the general population. Among the three types, EGPA has the lowest incidence, with each of the other two types occupying the first place depending on geographical and ethnical factors [2]. There is a slight male predominance. AAV predominantly occurs between the ages of 35 and 55, but it can occur at any age, including in rare pediatric cases.Vasculitis is a heterogenous group of rare systemic diseases with unclear causes that are characterized by inflammatory cellular infiltrates with or without necrosis in the vessel walls. ANCA (anti-neutrophil cytoplasmic antibodies) are the hallmark of three small-vessel vasculitis, namely granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA) and microscopic polyangiitis (MPA) [3].Apart from the potentially life-threatening systemic complications of the disease, patients can also present ocular and/ or orbital manifestations, some of them serious and vision-threatening. A retrospective study of 1286 patients with necrotizing vasculitis showed that up to one half of the patients with GPA present some form of ocular involvement, which can sometimes be the inaugural presentation of the disease. Ocular complications occur much less frequently in EGPA and MPA, with reported findings of less than 10% of the patients [4] showed that almost 20% stated that visual abnormalities are an important aspect of their disease. We can safely conclude that ophthalmologists play an important role in the management of AAV-related ocular complications and they should be prepared in case they encounter this rare, but possibly vision impairing disease.When patients affected by AAV were asked about the subjective impact the disease has on their lives, a Mexican study .Two immunological pathways are described. The first one is the neutrophil pathway: ANCA bind to membrane-bound myeloperoxidase (MPO) and proteinase-3 (PR-3) molecules of neutrophils, causing them to adhere to the endothelial wall of small vessels and degranulate, resulting mainly in the necrotizing vasculitis component of the disease. Thus, it is important to note that ANCA are not only a marker of AAV, but also have a crucial role in its pathogenesis. The second pathway involves T cells: it was demonstrated that the upregulation of effector memory T cells and downregulation of regulatory T cells lead mainly to granulomatous inflammation of tissues and promote the ANCA production via T cell-B cell interaction . Orbital masses can appear as part of a systemic disease or can be described as a limited form of AAV.Orbital inflammation usually translates into orbital granulomatous masses, often appearing as tumoral masses. The granulomas can develop from the retroorbital fat or, more commonly, through contiguity from the neighboring structures, specifically the paranasal sinuses, meninges, or lacrimal gland . The pseudotumor can cause proptosis, diplopia, orbital pain and optic nerve compression with visual acuity (VA) reduction. The evolution of the disease can be extremely severe, with vision loss and local pain that ultimately lead to enucleation [7]. There are case reports of granulomas appearing within the vascularized structures of the eye, mainly the choroid, although these remain extremely rare .The granulomatous inflammation can develop in the orbit, causing inflammatory pseudotumor. It develops in up to 30% of the patients with GPA, with few cases appearing in patients with EGPA and virtually none in the MPA arm of AAV [3]. These ocular findings can be isolated but are often found as associations. To our knowledge, there is no study that systematically describes the characteristics of keratitis in AAV. However, according to multiple case reports, it occurs primarily in the form of peripheral ulcerative keratitis [10-12].Vasculitis of the conjunctival, episcleral, scleral, limbal and uveal vessels can cause inflammation of their respective structures of the eye. In GPA, episcleritis and scleritis are prominent findings among patients, with uveitis and keratitis manifesting more rarely [12], although it is not a specific finding, as the reported prevalence of dry eye ranges from 5% up to 50% in the general population [13]. On the other hand, epiphora is one of the most common symptoms reported by patients, which is caused by the obstruction of the lacrimal drainage system by inflammation and nasal involvement [14].Dry eye syndrome is reported to occur in patients with AAV [15]. Similarly, retinal vessel occlusions have been reported in rare instances .Rare reports of retinal and choroidal vasculitis have been presented, most of them appearing in GPA patients . Therefore, ANCA immunoassays should be ordered only in high probability clinical situations. Different types and targets of ANCA can offer more information on the type of AAV and its characteristics.Laboratory work-up and serologic tests should be performed. ANCA testing remains an important pillar in the decision-making process regarding the diagnosis and treatment of AAV. Still, a low probability of AAV diagnosis will yield a low post-test probability of the disease , although the lack of biopsiable tissue should not delay the initiation of treatment [1].A biopsy of the affected organ should be performed every time it is possible in order to confirm the specific alterations of the necrotizing vasculitis in the specimens and help establish the diagnosis [20]. EULAR, together with ERA  and EUVAS (European Vasculitis Society), published the latest update in 2016. Although this particular guideline does not explain the course of action in case of ocular complications, the Canadian Vasculitis research network (CanVasc) defines severe ANCA-associated vasculitis as any lesion that represents a major organ-threatening condition, including eye involvement [21]. Thus, the therapy recommendations in the case of severe disease can be extrapolated to the ophthalmological field.Regarding the therapy of ANCA-associated vasculitis, the most recently updated comprehensive guideline was developed in 2008 by an international task force coordinated by EULAR (European League against Rheumatism) [19]. These are the high-level recommendations for GPA and MPA. There are no definite treatment recommendations for EGPA, because of its rarity and unique pathogenetic features, which led to some non-conclusive clinical trials [22]. Traditionally, EGPA flares are managed using high-dose corticosteroids. Despite the limited evidence, immunomodulators are used to induce and maintain remission of cortico-resistant EGPA with ocular involvement and some success [23]. Newer therapy agents, including rituximab, mepolizumab and omalizumab, were used in EGPA, but to the authors’ knowledge, there has been no study or case report involving ocular presentation published to date.In case of organ-threatening disease, the course of action recommended by the EULAR guideline for obtaining a remission is a combination of a high-dose systemic corticosteroid and either cyclophosphamide or rituximab. After achieving remission, cyclophosphamide must be discontinued due to its severe long-term side effects. Treatment will be continued with another maintenance drug , along with continued corticosteroid tapering. Absence of remission should be managed by switching to rituximab if using cyclophosphamide or vice versa. In addition, the refractory cases should be referred to expert centers and possibly included in clinical trials. Relapses should be treated with the previously mentioned remission-inducing agents, as if dealing with a newly presented disease [24] of 13 patients (19 eyes) suffering from scleritis, uveitis and/ or peripheral ulcerative keratitis proved that both cyclophosphamide and rituximab induced remission of the inflammation, with most of the treated eyes (79%) preserving or improving vision at follow-up. Another study [25] of 16 patients with GPA and peripheral ulcerative keratitis showed slightly better results in controlling inflammation and long-term relapse rate after treatment with rituximab than cyclophosphamide.The EULAR guideline can be applied in ophthalmological context, as studies and case reports showed efficacy in treating ocular inflammation. For instance, a small study [10] of GPA with scleritis showed signs of worsening and occurrence of peripheral ulcerative keratitis under treatment with cyclophosphamide, but induction of remission under rituximab proved that switching between the two main remission-inducing agents is beneficial in severe ocular involvement.A case report .Scleral and corneal thinning may be severe enough to endanger the visual function through perforation or rupture, regardless of systemic medication, thus necessitating surgical management, such as conjunctival resections, scleral grafts, tissue gluing and patching, lamellar or penetrating keratoplasty or tarsorrhaphy , rituximab seemed to provide better results than cyclophosphamide. However, granulomatous masses remain difficult to treat, as there is a significant number of refractory or worsening cases, patients necessitating multiple lines of treatment, complications leading to visual impairment and loss of vision .Regarding the orbital masses that are found mainly in GPA patients, high-dose corticosteroids alone or, more often, associated with immunomodulators represent the first-line treatment. In two series of case reports .Surgical management of orbital masses is required in up to 50% of the cases, specifically those presenting persistent pain or progressive loss of vision despite the optimal medication. Orbitotomy with orbital decompression or orbital debulking surgery is the preferred approach, but in certain severe cases, with marked proptosis, blindness, and severe pain, exenteration may be required. Orbital corticosteroid injections can be administered. Distinction between active inflammatory masses and fibrous sequelae of previous active episodes is necessary, because both medical and surgical treatment show little or no benefit in chronic changes with fibrosis. Orbital fibrosis manifests with enophthalmos, eye movement limitation and loss of vision [31]. Dry eye syndrome has no particularity in AAV and is managed as per usual [12].Non-vision-threatening inflammation of the eye  can be safely treated with topical corticosteroids only . The prerequisite for surgical success is a good control of local inflammation using the previously mentioned medications.Regarding epiphora caused by nasolacrimal duct obstruction in GPA, external dacryocystorhinostomy with silicone tubing is the surgical technique of choice, with good results and few postoperative complications [AAV is a group of rare diseases with potentially disastrous visual consequences. Ocular manifestations in AAV are the result of either small-vessel vasculitis or granulomatous inflammation. Ocular and orbital inflammation can take many forms, but the most common remain episcleritis/ scleritis and orbital granuloma mass. A high degree of suspicion must be maintained and prompt liaison with rheumatologists must be established in order to initiate treatment in proper time. Often, local surgical management is necessary to maintain ocular integrity or vision.Conflicts of interestNone.AcknowledgementsNone.Sources of fundingNone.DisclosuresNone.