Breast cancers located centrally require excision of nipple-areola complex. A simple central wide excision is a safe option but results in suboptimal aesthetic outcome. An oncoplastic option involves therapeutic mammoplasty with or without areolar reconstruction, limited to moderate and large ptotic breasts. For small non-ptotic breasts, most surgeons would resort to mastectomy with/without reconstruction.Lateral chest wall perforator flap (CWPF) is an option for partial breast reconstruction in small to moderate sized, non-ptotic breasts for laterally located tumours. We have extended the application of CWPF for central tumours to avoid mastectomy in selected patients.We here present a case series of four patients with small to medium-sized non-ptotic breasts, who had centrally located breast cancer or ductal carcinoma in-situ (DCIS). Three patients had single stage CWPF reconstruction, and one had central excision with immediate reconstruction following a failed attempt at therapeutic mammoplasty. All had the areola reconstructed using flap skin; one patient had simultaneous nipple reconstruction.CWPF is an option for treatment of centrally located breast cancers/DCIS needing nipple-areola complex excision for patients wishing to avoid mastectomy. Patients with small to medium-sized non-ptotic breasts are suitable, and need to be carefully selected. Breast conserving surgery (BCS) with adjuvant breast radiotherapy is the standard of care for early breast cancer. Trials have shown equivalence of this treatment to mastectomy with respect to survival and local disease control –5. It leBetween 5% and 20% of breast cancers are located centrally –18. HistTherapeutic mammoplasty with or without areolar reconstruction has been used to treat centrally located breast cancers with good outcomes –33. It i et al [et al [The evolution of OBS has seen various surgical techniques being employed for partial breast reconstruction in an attempt to improve the aesthetic outcomes and reduce mastectomy rates. Volume replacement using chest wall perforator flap (CWPF) is one such procedure, initially used by Holmström and Lossing et al , and latl [et al –38. Thesl [et al , 40. Thel [et al .We report challenging cases of centrally located breast cancers with nipple involvement or proximity to nipple necessitating excision of nipple-areola complex. The defect after wide local excision was reconstructed using the tissue from the CWPF and areola was reconstructed using the flap skin.These women had small to moderate sized non-ptotic breasts with relatively high tumour to breast ratio, as judged by imaging ). All these women were keen to avoid mastectomy, thus partial breast reconstruction was performed using LICAP and/or LTAP based flap. The CWPF was tunnelled deep to the native breast tissue on the lateral aspect and then folded to ensure adequate volume to fill the defect, such that skin was oriented anteriorly, after folding, to reconstruct the areola. The resultant tunnelling led to fullness on the lateral aspect of breast but that did not seem to be of significant concern and did not result in significant asymmetry after radiotherapy. The aesthetic outcome was assessed by the clinical team using Harris scale  in the out-patient clinic between 1 and 3 years post-radiotherapy. All these women had ER positive, Her-2 negative breast cancer and received adjuvant treatment as per Multidisciplinary Team discussion. These cases took between 2 and 3 hours to operate and patients were discharged home the day after surgery. These patients encountered no significant complications, and no delay in adjuvant therapy was observed. One patient required margin re-excision and all patients received adjuvant radiotherapy. All patients have completed at least 1-year follow-up and are happy with the aesthetic outcome.Case 1: This lady was identified to have bifocal breast cancer in her left breast on her first screening mammogram at the age of 50. She was on hormone replacement therapy. There were two areas, one measuring 24 mm just lateral to the left nipple (with nipple tethering), grade I invasive cancer on core biopsy. The second lesion was 15 mm in the upper outer quadrant (17 mm away from the first lesion), confirmed to be grade II invasive cancer on biopsy. The total extent was 54 mm in the cranio-caudal plane and 30 mm in the medio-lateral plane. Both the tumours were oestrogen receptor (ER) 8, progesterone receptor (PR) 8 and human epidermal growth factor receptor (Her-2) negative.The patient had symmetrical breasts with a bra size of 32B. There was a prominent fold of tissue excess on the lateral chest wall, rendering CWPF as a potential option. She was offered mastectomy with immediate reconstruction, as the total size of the two cancers together made BCS a borderline option. The patient preferred to have breast conservation; therefore, staged approach to partial breast reconstruction was discussed. Patient chose to have one stage approach after careful deliberation, accepting the option of simple mastectomy if BCS was not successful. She had central wide excision and sentinel node biopsy with single stage partial breast reconstruction using LICAP flap with neo-areolar inset using the skin from the lateral chest wall.Histopathology confirmed bifocal invasive grade 2 cancer measuring 16 and 25 mm, with intermediate grade (IG) DCIS. The whole tumour size was 60 mm, and was excised with clear margins . The sentinel node removed was positive for macrometastasis (6 mm tumour deposit) with no extra-capsular spread. Histopathological examination of the nipple showed DCIS 2 mm from the skin surface. She was recommended adjuvant chemotherapy, radiotherapy to breast (with tumour bed boost), axilla and supra-clavicular fossa along with endocrine therapy. She consented to enter the POSNOC trial  and was Case 2: A 72-year-old lady presented symptomatically with left sub-areolar lump. This was occult on mammogram and ultrasound. A clinical core biopsy confirmed grade 2 invasive lobular carcinoma (ILC). The tumour was ER8, PR8 and Her-2 negative. MRI of breasts suggested a unifocal lesion measuring 26 mm. She was fit and well with an active lifestyle. She declined the option of central wide local excision with therapeutic mammoplasty, as she did not wish asymmetry or need for external prosthesis and was keen to avoid contralateral breast surgery. She agreed to central wide local excision and immediate partial breast reconstruction with CWPF with sentinel node biopsy. She underwent simultaneous nipple reconstruction.Histopathology revealed bifocal grade 2 invasive lobular cancers measuring 26 and 8 mm within high grade (HG) DCIS, total extent of DCIS was 50 mm. The inferior margin was focally involved with DCIS. One out of two sentinel nodes showed evidence of macrometastasis . The inferior margin was re-excised a few weeks later; access was gained via peri-areolar scar. No further disease was seen on histology. Her recovery was uneventful and there were no complications with full healing of the reconstructed nipple. She declined participation in the POSNOC trial  hence reBreast multidisciplinary team recommended adjuvant radiotherapy to breast, axilla and supraclavicular fossa (SCF) with endocrine therapy. The National Health Service (NHS) PREDICT suggested 4% survival benefit with third-generation chemotherapy at 10 years, therefore OncotypeDX testing was recommended, which reported a low recurrence score of 11, suggesting very small benefit from chemotherapy. She was advised Anastrozole as endocrine therapy. She was reviewed in clinic a year after radiotherapy and has achieved an excellent aesthetic outcome with regard to size/shape of breast and symmetry .Case 3: A 40-year-old lady was evaluated in a symptomatic clinic for a lump corresponding to a 35 mm mass on mammogram without calcifications in the lower outer quadrant of breast. This mass measured 22 mm on ultrasound, while axillary nodes were normal. Core biopsy confirmed grade 3 invasive ductal carcinoma (IDC) with HG DCIS. Receptor profile was ER8, PR6 and Her-2 negative. This lady had difficult family circumstances and was caring for a disabled family member. She was offered breast conservation with vertical scar therapeutic mammoplasty and sentinel node biopsy.The histopathology showed 35 mm of invasive ductal cancer associated with extensive HG DCIS with a total tumour extent of 60 mm. Lymphovascular invasion was present. A separate medial shave sent during surgery showed the presence of DCIS within 1 mm from the final margin. The single sentinel node removed showed micrometastasis with a tumour deposit of 1 mm. As the medial margin was the margin adjacent to nipple, re-excision of this margin mandated a central nipple-areola excision. She was, therefore, offered mastectomy with reconstructive options due to presence of extensive, non-calcified DCIS, the extent of which was impossible to estimate with the available imaging.A decision was made in favour of adjuvant chemotherapy with a plan to do a completion mastectomy following chemotherapy. She was not keen for autologous reconstruction due to the extent of surgery and the recovery period involved. Implant reconstruction was considered suboptimal in light of the recommendation for adjuvant radiotherapy. The patient was very keen to consider the possibility of BCS. Upon reviewing her surgical options post chemotherapy and noting the limited choices available, she was offered an attempt at breast conservation by performing a central excision and partial breast reconstruction with a CWPF and neo-areolar inset. She understood that if this were to fail on account of finding more extensive disease, she would be recommended mastectomy. She underwent the proposed procedure and the histology did not reveal any residual malignancy. Following second surgery, her affected breast looked bigger than the opposite breast, this settled following radiotherapy to the whole breast with a boost to the tumour bed. She continues on Tamoxifen and is very pleased with the aesthetic outcome achieved .Case 4: A 36-year-old lady was assessed in a symptomatic breast clinic for unilateral single duct nipple discharge. Ultrasound did not reveal any focal pathology, while the nipple discharge cytology showed epithelial cells suggesting an epithelial lesion. She had total duct excision. Histology revealed 6 mm of grade1 incidental mucinous carcinoma with 17 mm of HG DCIS, with DCIS involving the margins. The tumour was ER 8, PR 5 and Her-2 negative. She was recommended therapeutic surgery.She was slim and small breasted with a bra cup of AA, but there was some redundant tissue on the lateral chest wall. Patient declined mastectomy, therefore BCS with partial breast reconstruction was offered as a potential alternative.She underwent central wide local excision and sentinel node biopsy with partial breast reconstruction using a CWPF with neo-areolar inset. Central excision specimen showed a further 3 mm of grade 2 mucinous carcinoma with HG DCIS. This was excised with clear margins, with the closest peripheral margin being more than 10 mm. She made a good recovery and received adjuvant whole breast radiotherapy. She continues on Tamoxifen and is very pleased with the aesthetic outcome.The clinico-pathological and treatment details of these patients have been summarised in Centrally located cancers have traditionally been treated with mastectomy; however, in the era of oncoplastic surgery, it would be inappropriate to offer mastectomy purely due to location of tumour. Small central tumours could be managed with simple central wide local excision and primary closure. Various closure techniques have been attempted including purse-string, vertical or horizontal closure , 43. Thi et al [ et al [Volume displacement oncoplastic techniques advocated for central cancers include Grisotti’s infero-lateral dermo-glandular flap, mammoplasty with inferior dermo-glandular flap or melon-slice mammoplasty. These techniques either rely on creating neo-areola from patch of skin located inferior/infero-lateral to nipple-areola, or simply closing the breast in a way that maintains the shape of breast , 44, 45. et al  first de [ et al . HoweverVolume replacement technique for central tumours described in the literature involves partial breast reconstruction using a latissimus dorsi flap , 46–51, CWPF has been increasingly used in the last decade for treatment of laterally placed breast cancers in small to moderate sized non-ptotic breasts . They haIt has been shown that these flaps do not interfere with radiological surveillance, and recall rates for biopsy are low , 55. TheSkin island on the flap is used to reconstruct areola while nipple could be reconstructed either in the immediate or delayed setting. Patients could then have areolar tattooing to improve the aesthetics . FollowiIt is important to assess the impact on radiotherapy planning as some of these reconstruction patterns could add to the complexity of radiotherapy planning. All cases presented in this article had radiotherapy after the surgery. There was no interference reported by oncology colleagues in radiotherapy planning. Our centre practices CT planning for radiotherapy and the flap layout is clearly demonstrated on the cross section . It is, The described approach to reconstruct central breast defect in small to moderate sized non-ptotic breasts using a CWPF offers an additional surgical option in women keen to avoid mastectomy. Patient selection is based on the extent of tumour, size of breast, degree of ptosis and presence of redundant lateral chest wall fold. They should however be warned of mastectomy, if the disease is more extensive than anticipated on initial imaging.Our case series lacks the patient related outcome measure data, given the small sample size. All patients were pleased to avoid mastectomy and were happy with the aesthetic outcome of the breast as judged between 1 and 2 years after radiotherapy.Partial breast reconstruction with CWPF and areolar reconstruction (with or without nipple reconstruction) provides an alternative surgical option for central breast tumours in small to moderate non-ptotic breast. This is the first report described in the literature. Our series have shown excellent aesthetic results in the short-term follow-up period after radiotherapy. This approach obviates the need for mastectomy and potentially for contralateral symmetrisation, as this intervention aims to restore the breast to its pre-treatment size.CWPF, Chest wall perforator flap; DCIS, Ductal carcinoma in-situ; BCS, Breast conserving surgery; OBS, Oncoplastic breast surgery; LICAP, Lateral intercostal artery perforators; LTAP, Lateral thoracic artery perforator; ER, Oestrogen receptor; PR, Progesterone receptor.This study was carried out in line with clinical protocols with approval by the local hospital ethics committee (number 4317).For this type of study, formal consent is not required.The authors declare that they have no conflicts of interest to disclose.Level V, Case Series.No funding received.


Microglia are the resident immune cells of the central nervous system (CNS). It is well established that microglia are activated and polarized to acquire different inflammatory phenotypes, either pro-inflammatory or anti-inflammatory phenotypes, which act as a critical component in the neuroinflammation following intracerebral hemorrhage (ICH). Microglia produce pro-inflammatory mediators at the early stages after ICH onset, anti-inflammatory microglia with neuroprotective effects appear to be suppressed. Previous research found that driving microglia towards an anti-inflammatory phenotype could restrict inflammation and engulf cellular debris. The principal objective of this review is to analyze the phenotypes and dynamic profiles of microglia as well as their shift in functional response following ICH. The results may further the understanding of the body’s self-regulatory functions involving microglia following ICH. On this basis, suggestions for future clinical development and research are provided. Microglia constitute 5% to 10% of adult brain cells and form the largest group of immune cells in the CNS . Under pPathological analysis of microglial activity during ICH has revealed that microglia induce potent immune responses after extravasation of blood into the brain . The strThe role of microglia following ICH is complex, and the entirely different action of different phenotypes of microglia plays an essential role in the development of cerebral inflammatory injury and recovery of the brain after ICH Figure 2The dual role of reactive microglia in inflammation processes has a biphasic influence on the brain, which acts as a double‐edged offensive and defensive sword in brain injury. This paper reviews recent empirical studies on microglial activity following ICH to identify the most critical factors that influence this process, offering a fresh perspective for developing novel therapeutic strategies.Destruction of the blood-brain barrier (BBB) and consequent brain edema is the most common secondary causes of life-threatening events after ICH . One recvia IL-4 and IL-10 can induce an anti-inflammatory phenotype of microglia, it can be targeted for ICH treatment through modulating BBB physiology   –23  has been discovered through genome-wide transcriptomic analyses of microglia under different disease conditions. Although the gene profile of DAM and M1 microglia partially overlapped, the molecular signatures have shown apparent differences . InteresMany studies have investigated the spatially and temporally restricted subsets of microglia during development and disease, further identifying the distinct molecular hallmarks and diverse cellular kinetics using massively parallel single-cell analysis and computational modeling , 41. ForIn summary, microglia are activated by various pathologic events or changes in brain homeostasis, which are highly diverse and depend on the context and type of stressor or pathology. The complicated functional roles of microglia support the existence of distinct pro-inflammatory and anti-inflammatory functional states following ICH. The significance of defining microglial subtypes is to identify novel microglial functional conditions; determine the impact of molecules on microglia types, and discover ways to mediate functions in healthy physiology or disease . During Much of the literature has emphasized the autoregulation of microglia during ICH progress. For example, studies by Wu et al. showed that soluble epoxide hydrolase expression is upregulated in microglia after ICH, which causes neuroinflammatory responses by degrading anti-inflammatory epoxyeicosatrienoic acid . Other sMicroglia have similarly been shown to be involved in anti-inflammatory and phagocytic effects on the hematoma, contributing to neurologic recovery after ICH. The correlation between regulatory T lymphocytes (Tregs) and neuroinflammatory response after ICH has been defined. In vitro experiments have demonstrated that Tregs modulate microglia polarization toward the anti-inflammation phenotype through the IL-10/GSK3β/PTEN axis in this regulatory process , 50.via activation of microglia and astrocytes  was identified as a directly negatively regulated target of miR−222 in microglial cells, leading to the attenuation of inflammation and apoptosis . Besidesvia clearing up the cell rubbish and oxidative-stress products , which are involved in hemoglobin-mediated activation of microglial autophagy and inflammatory responses . The speproducts , 58, recproducts , 60.Anti-inflammatory microglia functions are accomplished by combining various signaling pathways that compose a complex network involved in multiple biological processes. Exploring the network of biological signaling pathways and its molecular basis contributes to novel interventions targeting signaling pathways that block the pathological progression of ICH Figure 3It has been demonstrated that adenosine monophosphate-activated protein kinase (AMPK) can drive the phenotypic shift from a pro-inflammatory state to an anti-inflammatory state . The expin vivo, mainly by activate NF-κB through the JNK pathway  plays a crucial role in the innate immune response. It can be concluded that loss of TLR4 reduces the recruitment of pro-inflammatory microglia and markedly alleviates inflammation around the hematoma in the animal model . FurtherThe role of TLR4 in secondary brain damage following ICH has been elaborated in detail, and therapeutic strategies targeting TLR4 are relatively well-developed. Therefore, TLR4 remains a promising target for inhibiting undesired microglial responses, and interventions targeting TLR4-related pathways may represent future candidates for ICH therapy.As the regulatory effects of intracellular signaling pathways on microglia after ICH have been discussed, the final section of this paper addresses how extracellular signaling regulators influence microglial morphology and function. Compared with intracellular signals, extracellular signals are more complicated and vulnerable to disruption, which means they have the potential to be translated into clinically effective targeted therapies for ICH.The interleukins (ILs) level is intimately associated with the development and progression of ICH, which may be achieved by modulation of microglia functions. For example, activation of the IL-4/transcription 6 (STAT6) axis improved long-term functional recovery in a mouse model of ICH . ConversBesides, antibodies against IL-17A can prevent ICH-induced expression of TNF-α, IL-1β, and IL-6 and inhibit microglial activation . FurtherEvidence has suggested that NF-κB translocates to the nucleus, and pro-inflammatory mediators  are produced following inflammatory response after ICH. These results suggest that combined targeting of NF-κB signaling pathway inhibition may be a more effective anti-neuroinflammatory strategy following ICH .in vitro shows that has thrombin release after ICH led to the increased expression of NF-κB in microglia  exerts a potent pro-inflammatory effect following ICH . StudiesIt is interesting to note that the molecular mechanism by which lithium salt can treat ICH in clinical practice has already been elucidated. Recently, it has been shown that LiCl treatment decreased the death of mature oligodendrocytes (OLGs) in ICH mice, which may be regulated by the LiCl-induced inhibition of glycogen synthase kinase-3β (GSK-3β) .The phagocytic activity of microglia is required to remove the hematoma after ICH; however, the pro-inflammatory mediators and free radicals released as a result of microglial activation and phagocytosis are toxic to neighboring cells and lead to secondary brain damage following ICH . ICH mouStudies have demonstrated that PPAR-γ activation is imperative for enhancing the phagocytic ability of anti-inflammatory microglia by CD36 . FurtherBased on in-depth basic research, PPAR-γ agonists have been widely used in clinical treatment. For example, the neuroprotective effects of statins following ICH through PPAR-γ activation and enhancement of microglia-induced erythrocyte phagocytosis have been established . BesidesCaspase-mediated cascades play an essential role in mediating anti-inflammatory microglial death . For exaClinical studies have found that fimasartan (an angiotensin II receptor blocker) significantly reduces the activation of the caspase-1 pathway after ICH , suggestThe first serious discussions of MMP-12, which is harmful and contributes to secondary damage after ICH, emerged in 2005 . SubsequMMP-mediated microglial activation has become a potential therapeutic target for ICH. For example, minocycline, a widely available drug that alleviates brain damage, effectively reduces early upregulation of MMP-12 expression , 94and iIron overload is a significant cause of brain damage because iron toxicity contributes to pro-inflammatory microglial activation following collagenase-induced ICH. Therefore, reducing the accumulation of iron can moderately improve the outcomes after ICH . As an iThe evidence from observational studies shows that microglia function is controlled by complex regulatory networks Table 1,Exploring the regulatory mechanism of microglial immunophenotype changes may help identify the hematoma scavenging mechanism and a precise therapeutic target for ICH. The multi-omics technologies have made significant achievements in the research of microglial activation . The appvia intracellular and extracellular signal-regulated pathways. Besides, this review provides the first comprehensive assessment of cellular and molecular mechanisms and pathways responsible for regulating microglia, including an in-depth analysis of signaling pathways strongly associated with microglia following ICH. Notwithstanding the relatively limited number of reliable clinical trials and the lack of molecular genetic studies on the phenotypic change of microglia, this work offers valuable insights into a novel therapeutic strategy for ICH that targets microglia. Further research on interventions associated with microglial physiology is an essential next step in confirming a framework for assessing the feasibility of the novel therapy mentioned above.This review aimed to objectively discuss and assess the role of microglia in regulating neuronal injury after ICH. The findings indicate that pro-inflammatory or anti-inflammatory microglia have divergent effects, which have significant implications for understanding microglia function https://pubmed.ncbi.nlm.nih.gov/. Data sharing is not applicable to this article as no new data were created or analyzed in this study.The data that support the findings of this study are openly available in pubmed at All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication. All authors contributed to the article and approved the submitted version.This work was supported by a grant from National Natural Science Foundation of China (81771294) and the National undergraduate innovation training project (2020105330289).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.


Despite the encouraging breakthroughs in medical development, cancer remains one of the principle causes of death and threatens human health around the world. Conventional treatment strategies often kill cancer cells at the expense of serious adverse effects or great pain, which yet is not able to achieve an effective cure. Therefore, it is urgent to seek for other novel anticancer approaches to improve the survival rate and life quality of cancer patients. During the past decades, nanotechnology has made tremendous progress in cancer therapy due to many advantages such as targeted drug delivery, decreased dosage-related adverse effects and prolonged drug circulation time. In the context of nanomedicine, carbon nanomaterials occupy very significant positions. Owing to their innate outstanding optical, thermal, electronic, and mechanic features, easy functionalization possibility and large surface for drug loading, carbon nanomaterials serve as not only drug carriers, but also multifunctional platforms to combine with diverse treatment and diagnosis modalities against cancer. Therefore, developing more carbon-based nanoplatforms plays a critical role in cancer theranostics and an update overview that summarizes the recent achievement of carbon nanomaterial-mediated anticancer theranostic approaches is of necessity. In this review, five typical and widely investigated carbon nanomaterials including graphene, graphdiyne, fullerene, carbon nanotubes and carbon quantum dots are introduced in detail from the aspect of treatment strategies based on both cancer cells and tumor microenvironment-involved therapeutic targets. Meanwhile, modern diagnostic methods and clinical translatability of carbon nanomaterials will be highlighted as well. According to the fresh statistics in 2021, cancer is still one of the most challenging diseases that causes a considerable mortality in contemporary society Figure 1). More excitingly, the natural optical characteristics of carbon nanostructures make them indispensible and dependable materials in multi-mode anticancer theranostics, which is able to integrate targeted drug delivery, phototherapy, cancer imaging and other conventional treatment strategies in one platform, largely enriching the therapeutic field of multiple cancer treatment and diagnosis Owing to the achievements in nanobiotechnology, application of nanomaterials in cancer theranostics is receiving immense attention Effective management and precise elimination of malignant tumors require an accurate understanding of tumor features and the interplays between tumor cells and their surrounding microenvironment. Currently, many anticancer strategies are focusing on targeting tumor cells or the components in tumor microenvironment (TME) where tumor cells live. Targeting tumor parenchyma can directly kill tumor cells, while targeting TME elements is able to impact on their survival by disturbing their living environment, both playing key roles in developing anticancer strategies Figure 2). Altogether, compared to the existing papers related to this topic, the novelty of this review is that we comprehensively outlined the anticancer applications of various carbon-based nanoplatforms from the perspective of different therapeutic targets and focused on their theranostic applications against many cancer types based on fresh reported data.Encouragingly, dedicated efforts have been devoted in the advancement of cancer nanomedicine. With the help of numerous researchers around the world, the field of carbon nanomaterials in cancer theranostics has been enriched with a lot of valuable pre-clinical data. In this review, we mainly summarized the recent achievements of carbon nanomaterials in cancer treatment and diagnosis. Different therapeutic strategies based on various carbon-related nanostructures aiming at a series of intracellular targeting spots or TME elements will be highlighted. In addition, diverse diagnostic approaches like various imaging technologies and cancer biosensors dependent on these carbonaceous nanomaterials will also be discussed .Graphene-based nanomaterials have been broadly studied in biomedical territory for anticancer drug delivery since they were discovered in 2004 et al. fabricated a novel nanoplatform using PEGylated and oxidized sodium alginate (OSA)-modified GO nanosheets to load anticancer drug paclitaxel (PTX) for PTX-resistant gastric cancer treatment, which could achieve synergistic chemotherapy/PTT/PDT effect in vitro and in vivo that this newly prepared nanocomposite could lead to enhanced cytotoxicity upon NIR irradiation than free PTX in the gastric cancer model, demonstrating a promising therapeutic strategy to reverse gastric cancer cell resistance by combining chemotherapy and phototherapy.Guo  et al. firstly reported a gene therapy strategy for OSCC treatment by using positively charged PEI-functionalized GO to transport the inhibitor of miR-214 for suppressing OSCC cell proliferation In vitro and in vivo results showed that this nanocarrier could remarkably inhibit Cal27 and SCC9 tumor cell growth and migration by targeting phosphatase and tensin homolog (PTEN) and p53. Besides, in vitro experiments proved that GO-PEI was able to elevate the transfection efficiency of miR-214 inhibitor in Ca127 and SCC9 cells, while miR-214 inhibitor alone was not capable of penetrating the membrane of tumor cells, and the transfection rate was 10 times higher than that of naked inhibitor, verifying GO as an ideal carrier for intracellular delivery of miRNA. Jaleel et al. designed a targeted antitumor gene therapy strategy using GO-based non-viral vectors In vitro protein expression study successfully proved that this GO-based delivery system could improve gene transfection efficiency compared to pDNA-TNF-α alone. In addition, after 14 days of co-incubation with the chorioallantoic membrane (CAM) and Hela cells, the anti-angiogenesis effect was observed in GO-based formulation while no similar phenomenon could be found in the control group.Antitumor therapeutic strategies targeting microRNAs (miRNAs) have become a hot spot for decades. Among them, miR-214 can promote oral squamous cell carcinoma (OSCC) cell proliferation by regulating multiple signaling pathways + and CD8+ cells in TME to perform cellular or humoral immune responses to produce killing effects on tumors et al. synthesized a nanovaccine with sustained-release behavior based on hydrogel, which was composed of PEI modified GO to encapsulate ovalbumin (OVA) encoding mRNA (mOVA) and hydrophobic immune adjuvants Resiquimod (R848) for melanoma treatment + T cells as well as produce antigen-specific antibodies and inflammatory factors such as TNF-α. The Western blot analysis demonstrated that OVA proteins were highly expressed in RAW264.7 and DC2.4 cells treated with GO-based hydrogel, indicating that the mOVA vaccine could be successfully expressed. The B16-OVA melanoma model was established to testify the antitumor effect of the hydrogel in vivo. As the obtained results showed, the tumor size and weight were significantly decreased compared to other groups, which demonstrated that the mRNA vaccine could activate immune cells to produce the antitumor effect. Moreover, OVA-specific antibodies were found in the serum after treatment with GO-based hydrogel and the formation of lung metastasis were significantly prevented as observed, both results further proving the bright application prospect of mRNA vaccine in antitumor therapy. Strong aggressiveness and extremely rapid tumor cell proliferation are key challenges during the ovarian cancer treatment in advanced stage. Lee et al. brought a fresh tumor-targeted therapeutic strategy by decorating a sonosensitizer chlorin e6 (Ce6) and 4-arm PEG with good compatibility on the GNR to construct GNR-PEG-Ce6 nanocomplexes for metastatic ovarian cancer treatment  Figure .Immune cells are very important constituents of TME. The dynamic interactions between immune cells and other cell types within TME play vital roles in tumorigenesis, thus, anticancer strategies focusing on immunotherapy are of great significance. Messenger RNA (mRNA) vaccine generally refer to the mRNA which can activate dormant T cells for immune detection and automatically kill abnormal tumor cells. These mRNAs can get ingested by antigen-presenting cells (APCs) and express tumor-associated antigens (TAAs), thus activating CD4et al. fabricated a pH/redox/enzymatic sensitive nanohybrid drug delivery system by assembling GSH sensitive bovine serum albumin (BSA) encapsulated DOX and MMP-2 sensitive gelatin onto GO nanosheets to achieve controlled drug release  in vitro photothermal experiments showed, this novel nanosystem could reach to 45.6 °C after irradiating for 5 min, which was high enough to ablate MCF-7 cells.Because of the abnormal metabolic properties of tumor cells, TME is often featured as weakly acidic, high GSH amount and overexpressed matrix metalloproteinase-2 (MMP-2) level, therefore, many efforts have been made to design intelligent and responsive delivery system based on the internal properties of TME for efficient drug delivery 2-hybridized planar structure with uniformly distributed nanopores, broad absorption range, and great photoelectronic features. The fundamental structural unit to constitute GDY is a big triangular ring that contains eighteen carbon atoms composed of benzene rings with sp2-hybridization and acetenyl groups with sp-hybridization 2-hybridized carbon nanomaterials, the conjugated structure of GDY can still retain after functionalization, meanwhile, the sp-hybridized carbon atom also endows GDY with reducibility 2-hybridized structure and specific surface area make GDY an ideal delivery vehicle to transport a number of anticancer agents including genes, small molecule drugs, functional polymers, and biomacromolecules through π-π stacking, hydrophobic and electrostatic interaction between drugs and vehicles Figure 6) Graphdiyne (GDY), a 2D periodic material experimentally synthesized firstly in 2010, has become a kind of emerging carbon-related nanomaterial since its discovery et al. developed a GDY-based nanoplatform that firmly anchored and dispersed CeO2 nanoparticles (NPs) to form GDY-CeO2 nanocomposites, which displayed excellent catalase activity due to CeO2 NPs, remarkably relieving tumor hypoxia through the decomposition of H2O2 into O2  2 nanocomposites to elevate the sensitivity of radiotherapy against esophageal squamous cell carcinoma (ESCC). Besides, iRGD-grafted PEG was employed to encapsulate the constructed GDY-CeO2-miR181a to achieve enhanced tumor targeting and penetration, as well as protecting miRNA from degradation. In vitro and in vivo results illustrated that the designed nanocomposites were able to facilitate DNA damage and significantly downregulate the HIF-1α expression level by relieving the hypoxic tumor environment. Crucially, delivery of miR181a through GDY-CeO2 nanoplatform showed a remarkable efficacy in sensitizing tumor upon radiotherapy based on subcutaneous tumor and ESCC PDX models, which provided a prospective therapeutic strategy for personalized ESCC treatment .miRNAs regulate DNA damage response that is beneficial to genome integrity and stability, yet there are still existing obstacles that impede the wide application of miRNA-based therapy, such as internal degradation and rapid blood clearance. To overcome these limitations, lots of multifunctional nanosized carriers have been developed to prevent miRNAs from degradation, enhance tumor targeting and endow miRNAs with lysosomal escape ability et al. established a multifunctional 3D carrier based on modified graphdiyne oxide (GDYO), which was hybridized with cisplatin (CDDP) to load DOX via π-π stacking and integrated cancer diagnosis and photo-chemotherapy because of the fluorescent characteristic of DOX  Targeted synergistic therapy has become the research focus of cancer therapy at the present. Xing 2O2 into another member of ROS, namely hydroxyl radicals. However, the efficiency of Fenton reaction is always restricted by insufficient delivery of catalytic agents, unsuitable pH level and excess GSH in TME et al. designed a tumor targeted iron sponge (TTIS) nanoplatform by depositing Fe3O4 NPs onto the surface of GDYO, which was further decorated with tumor targeting polymer to improve its biocompatibility and targetability  3+ and Fe2+ from TTIS, achieving the goal of synergistic PTT and Fenton reaction-mediated anticancer strategy. Both in vivo and in vitro experiments based on 4T1 tumor model confirmed the excellent antitumor effect of this nanoplatform with negligible toxicity, implying the great translational potential of this biocompatible nanoplatform in clinic. The poor vascular perfusion in hypoxic TME can contribute to tumor development, metastasis, and drug resistance. Rationally, tumor reoxygenation and blood perfusion enhancement are able to improve the therapeutic effect in cancer treatment. In light of this, Jiang et al reported a biomimetic ultrathin GDYO nanosheet which was cloaked with iRGD peptide-engineered erythrocyte membrane (termed as GDYO@i-RBM)   in vivo and in vitro studies based on EMT-6 tumor models verified the markedly enhanced antitumor efficacy after the combination of GDYO@i-RBM plus laser irradiation, providing new insights in relieving tumor hypoxia through GDYO-based novel nanoplatform. Apart from the examples mentioned above, other TME-based strategies like designing pH/photo-dual responsive GDY nanosheet that could achieve controlled drug release in acid TME upon laser irradiation, or combining magnetic targeting with GDY-based therapeutic strategies also display promising research potential in cancer treatment ROS-mediated oncotherapy has gathered much attention because of its high selectivity and low adverse effects. Fenton reaction-based strategy is an emerging anticancer treatment approach, which can provide a catalyst to convert endogenous Het al. in 1985, who was awarded with Nobel prize of chemistry in 1996 for their amazing discovery Fullerene was discovered as carbon allotropes by Kroto et al. fabricated a novel targeted anticancer agent by constructing a kind of highly water-soluble hexakis-glucosamine fullerene derivative for treating pancreatic cancer, which was termed as Sweet-C60 and could majorly accumulate in pancreatic stellate cells (PSCs) nucleus in vitro results of phototoxicity studies indicated that Sweet-C60 was nontoxic within 1 mg/ml concentrations, and exhibited strong photoactive and photodynamic cytotoxic effect on PSCs under blue and green light, illustrating the great potential of Sweet-C60 in PDT.It is well known that intracellular signaling pathways and metabolic processes are vital players in oncogenesis, tumor progression, and neoplastic dissemination. Therefore, based on the unique advantages of fullerene and its derivatives in cancer treatment, they have been broadly investigated as potential drug delivery platforms for intracellular targeting over the years et al. constructed a kind of amphiphilic fullerene derivative (C60-Dex-NH2) to deliver siRNA into cancer cells, which not only promoted the lysosomal entrapment, but also cause lysosomal membrane destruction through triggering controllable ROS under visible light irradiation in vitro and in vivo, presenting an innovative approach for siRNA delivery.RNA interference (RNAi) has shown great therapeutic potential in various diseases including cancers due to its ability in silencing certain oncogenes, however, the efficiency of RNAi can be greatly affected due to the lysosomal-mediated degradation et al. prepared a kind of C70 fullerene derivatives (C70-EDA) modified with multiple ethylenediamine (EDA) moieties, which was able to inhibit cancer cell migration, modulate intracellular MYH9 distribution, and hinder EMT through binding on MYH9 protein 70-EDA, an inhibitory effect on cancer cell migration and EMT process reversion was observed in vitro. Therefore, this work by Zhou's group unveiled a novel therapeutic target based on MYH9 and opened a new door to use C70-EDA as a promising agent against cancer metastasis.Tumorigenesis is often accompanied with metastasis, which is the primary reason of mortality. A variety of proteins that exist in the cytoplasm are associated with tumor metastasis, therefore, these cell metastasis-associated proteins are becoming specific antineoplastic targets in precise cancer treatment et al. via the arc discharge method, which had a high adhesive capacity with cancer cells to change their behavior and reduce their proliferation  In vitro cell viability and proliferation assessment using HepG2 and C3A liver cancer cells demonstrated that this nanofilm could suppress the proliferation of HCC cells with good biocompatibility. Moreover, other in vitro results revealed that this fabricated nanofilm could contribute to the termination of cell cycle of HCC through mechanotransduction, implying that the application of fullerene nanostructures as artificial ECM-like structures could effectively attenuate cancer cell malignancy to improve anticancer therapeutic efficacy. Reprogramming the immunosuppressive TME (ITM) is very important to achieve successful immunotherapy effect. Li et al. proposed a strategy by modifying gadofullerene (Gd@C82) with β-alanines (GF-Ala) to rebuild ITM, which could induce macrophages to transform from tumor-supportive M2 type to M1 type, ultimately triggering robust antitumor immunity In vitro results based on RAW264.7 cells, 4T1 and A549 cancer cells confirmed that both the M1-related cytokines and protein expression were significantly upregulated, and the proliferation of tumor cells showed a remarkable reduction up to 57.9% after GF-Ala treatment, indicating that GF-Ala was able to polarize macrophages to exert an inhibitory tumor growth.ECM can not only provide structural and mechanical support for TME components, but also determines cell behavior and phenotype. Dysregulated interactions between ECM and other cell types can lead to serious pathological consequences, such as the occurrence of hepatocellular carcinoma (HCC) Figure 10).CNTs, one of the most widely investigated carbon-based nanostructures, have gained much attention in biomedical fields with multiple application potentials et al. reported a gene delivery approach using CNTs as carriers to combine with synergistic PTT in vitro and in vivo, which could be attributed to the combinational effect of gene therapy and PTT. Notably, some tumors even totally disappeared after treatment with SWNT-PL-carried siRNA for 21 days, indicating the high gene transport capacity of CNTs-based vectors to achieve controlled gene release inside tumor cells. In addition, both SWNT- or MWNT-based gene vectors showed negligible cytotoxicity even their concentrations were up to 60 μg/mL, implying their promising translational potential in the future. Insulin-like growth factor receptor (IGFR) was reported to overexpress in pancreatic cancer cells that are very aggressive, therefore IGFR has widely been regarded as an attractive target against pancreatic cancer et al. designed a type of water-soluble, biostable and low-toxic SWNT-based nanocomplexes that were linked with CY7 imaging agent and anti-IGF-1R antibody for pancreatic cancer treatment in vivo, which showed notable therapeutic effect with increased body weight and prolonged survival rate than the control groups, confirming the combinational effect resulted from the adequate accumulation of SWNT-based nanocomplexes in tumor tissues and laser treatment could efficiently ablate pancreatic cancer.The combinational strategy of gene therapy with PTT was reported to result in better treatment effect than single modality et al. designed a fresh antitumor strategy aiming at deep-penetrated tumor based on SWNTs that served as microwave absorbing agents in targeting mitochondria, which effectively converted microwave power into TA shock wave for selective destruction of tumor mitochondria, thus causing tumor cell apoptosis 2 to target mitochondria and were triggered by external ultrashort microwave. The TAT effect was investigated in vivo using H22 orthotopic liver tumor mice to study the antitumor effect of TAT in deep tumors, which showed that 77.5% of tumor cells were killed due to mitochondrial damage-related apoptosis. Furthermore, microwave is able to penetrate deep in biological tissues, which brought the effective treatment for deep tumors. In vivo results confirmed the outstanding antitumor effect of TAT in inhibiting tumor growth, indicating the bright future of CNTs as a kind of promising thermoacoustic agents for cancer treatment.Despite the encouraging effect of PTT, their applications were challenging in deep orthotopic tumor with unavoidable thermal damage to surrounding tissues because of the restricted penetrative ability of laser. To overcome the limitation of phototherapy, a novel therapeutic strategy called thermoacoustic therapy (TAT) based on microwave pulse has emerged. TAT adopts microwave pulse to excite thermoelasticity, and then generates a strong thermoacoustic (TA) shockwave with deep penetrative capability et al. designed a type of multimodal nanoplatform using SWNTs to realize noninvasive imaging and specific targeting towards breast CSCs et al. harnessed MWNTs as vehicles to co-deliver immunoadjuvants CpG and anti-CD40 Ig, and OVA antigen for enhanced immunotherapy effect in vitro and in C57BL/6 mice. Afterwards, anti-CD40 Ig was loaded as the second immunoadjuvant to amplify the antitumor immune reactions. Moreover, MWNTs could improve the co-loading ability of OVA, CpG and anti-CD40 Ig, which significantly inhibited the tumor growth and metastasis in OVA-expressing B16F10 melanoma model. Therefore, this study provided an alternative method to co-incorporate multiple immunotherapeutic agents for efficient cancer immunotherapy.The failure of many currently adopted breast cancer treatment is partly attributed to the presence of CSCs that are very difficult to be eliminated through the classical approaches νβ3 has been broadly studied as a therapeutic target for anticancer therapy because of its close correlation with angiogenesis. RGD peptides were demonstrated to bind with integrin ανβ3, therefore, it can be applied as targeting ligand for anticancer drug delivery 2) through electrostatic interaction to generate the final nanocomplexes. The constructed vector successfully delivered candesartan and pAT2 into tumor cells, which contributed to significant tumor growth inhibition and neovascularization suppression in A549 lung cancer model, establishing a perspective platform based on the anti-angiogenetic strategy for lung cancer treatment.Tumor vasculature targeting or anti-angiogenesis are promising strategies in cancer treatment. In our previous research, a co-delivery platform based on PEI-functionalized MWNTs was fabricated to address angiogenesis for lung cancer treatment Figure ). CQDs can be generally synthesized in two ways: one is "top-down", which indicates the stripping of large-size carbon sources like active carbon, CNTs, carbon fibers and fullerenes into small-size CQDs by electrochemical synthesis, arc discharge and laser ablation Figure ). Glucose, urea, and ionic liquids are commonly used as raw materials to synthesize CQDs via this method CQDs are a novel type of carbon-structured 0D materials, which were discovered by Xu's team in 2004 when they prepared SWNTs in vivo  The carbon cores of CQDs are non-toxic, however, the modification method and applied dosage will affect their toxicity. For instance, when the concentration of CQDs is higher than 50 μg /mL, it will cause obvious toxicity et al. reported a pH/reduction dual-responsive prodrug micelle composed of hydrophobic acid-labile DOX conjugated CQDs and PEG tail with an average diameter of 127 nm for liver cancer treatment  In vitro drug release results verified that CQDs-based micelle was able to be cleaved off under the simulated tumor intracellular microenvironment where GSH is overexpressed. Moreover, in vitro cellular uptake experiments confirmed that DOX could be released from the carrier and accumulated in the nuclei of cancer cells. In vitro cytotoxicity assays also revealed that the proposed micelle could result in more inhibitory effects on HepG2 cell growth than free DOX, indicating the good effect of this nanocarrier in on-demand drug delivery to target tumor parenchyma. Due to the photoluminescence property of CQDs, delivery systems based on CQDs can reflect tumor-related information. In the context of CQDs-based gene therapy, Wang et al. adopted positively charged Alkyl-PEI2k to passivate CQDs via electrostatic interactions to load siRNA and pDNA because CQDs and pDNA molecules are both negatively charged, the gene cannot attach to the CQDs tightly if without surface modification In vitro transfection experiment proved that the nanocomplex was conducive to promote pDNA delivery into the cytoplasm and then transport it to nucleus for gene expression. In addition, siRNA was also successfully delivered into the breast tumor cells to achieve remarkable gene silencing effect. This study verified that CQDs could be applied as a reliable gene vector for efficient gene therapy.The particle size of CQDs is usually smaller than 10 nm, which facilitates their clearance from the body to limit their application  et al. combined mitochondria-targeted triphenylphosphine (TPP) and TPGS to fluorescent CQDs to deliver DOX by self-assembly for resistant breast cancer treatment In vitro cell viability assay using DOX-resistant MCF-7 cells demonstrated that the IC50 of CQDs nanocomplexes-treated cells was much lower than free DOX, indicating the novel nanocomplexes had better treatment efficiency than free DOX. Moreover, the substantially reduced drug resistance index (RI) reflected that the nanocomplex successfully converting highly DOX resistant cells (MCF-7/ADR) into moderately resistant. Furthermore, the constructed nanocomplex caused significant decreases in mitochondrial membrane potential (ΔΨm), whose numerical decline was a symbol of mitochondria-triggered apoptosis. Notably, the nanocomplexes-treated multicellular tumor spheroids presented not only significant morphological changes but also a remarkably reduced volume, indicated that CQDs-based mitochondrial-targeted drug delivery system could inhibit MDR development and provided new ideas for antitumor therapy.Multidrug resistance (MDR) is a challenging obstacle that limits the efficacy of chemotherapeutics. Many approaches have been developed to overcome MDR such as inhibition of P-gp overexpression, and D-α-tocopheryl polyethylene glycol succinate (TPGS) was reported to suppress the overexpression of P-gp  et al. firstly fabricated TME targeted CQDs/Cu2O nanocomplexes for ovarian cancer treatment in vitro experiments showed that CQDs/Cu2O could not only destroy the structural integrity of F-actin but also cause downregulatory expression of MMP-2/9 and VEGFR2, which greatly hindered angiogenesis in TME. Furthermore, the novel nanocomplex could regulate the expression of multiple genes in cancer cells to effectively inhibit their growth and migration. Suppressor of tumorigenicity 14 (st14) is a type II transmembrane serine protease that is specifically expressed on the tumor surface, reducing the expression of st14 gene or preventing proteolysis activity can significantly inhibit the proliferation and metastasis of tumor cells in vivo greatly restricts the scope of its application et al. combined CQDs with KD1 for breast cancer treatment. On one hand, the nanocomplexes could specifically reach the microenvironment of tumor sites. On the other hand, they could effectively inhibit the activity of st14 in vitro imaging experiments indicated that CQDs-KD1 distributed around tumor cells and took effect in TME. Besides, in vitro invasion results proved that CQDs-KD1 could suppress the invasion of MCF-7 cancer cells by reducing the degradation of base membranes (BMs) and ECM. Moreover, in vivo experimental results marked that the accumulation of CQDs-KD1 in tumor tissue was about 3.6 times higher than that of free CQDs, which resulted in a smaller tumor size and weight with significant lung metastasis suppression compared to the control group.MMPs are a class of enzymes overexpressed in TME that have the ability to decompose ECM, reshape tumor basement membranes, accelerate angiogenesis and promote the process of tumorigenesis. Cu-metal-organic framework (MOF) materials are capable of destroying the structural integrity of F-actin which is the cytoskeleton component of ovarian cancer cells, thus inducing tumor cell necrosis Figure 12).Diagnostic technology is crucial for the detection and prediction of multiple cancers. The early diagnosis and intervention for cancer patients can not only prolong their survival rate, but also improve their life quality, therefore, cancer diagnostic technology is particularly significant in cancer treatment. However, the commonly adopted diagnostic methods have the shortcomings of adverse effects, low security, high cost, poor sensitivity and bad targeting effect, thus, developing and updating the existing cancer diagnostic approaches are of great necessity Cancer imaging plays an important role in cancer diagnosis. There are many imaging technologies such as computed tomography (CT), fluorescence imaging, MRI, PAI, single-photon-emission computed tomography (SPECT), ultrasonography (US), and positron emission tomography (PET) and Raman spectra, all of which constitute the crucial part of cancer imaging Table 2 is the summary of some representative applications of carbon-based nanosystems in cancer imaging.The majority of carbon nanomaterials possess extensive infrared absorption, excellent fluorescence properties and obviously intrinsic Raman vibration signals, therefore, they are able to be utilized as effective tools for cancer imaging Graphene and its derivatives have gained plenty of attention in cancer imaging because of their unique physiochemical properties. For instance, graphene and its oxide possess strong fluorescence quenching ability, while graphene quantum dots (GQDs) have photoluminescence characteristics, which are closely related to their preparation methods and morphological features et al. labeled two Cy5 molecules on the relative ends of a stem-loop molecular beacon (MB) that can specifically identify nucleic acid, and their fluorescence signals would decrease due to the self-quenching effect in vitro and in vivo results demonstrated, the constructed nanocomplexes had great imaging ability for multiple tumor cells, indicating that GO-based nanomaterials had promising potential in cancer diagnosis. Moreover, GO and rGO are also considered as outstanding PA reagents. Hu et al. prepared a nanosystem based on polydopamine (PDA)-rGO and connected the diagnostic reagent ICG to it for breast tumor PTT and PAI In vivo imaging experiments showed that the ICG-PDA-rGO processed higher sensitivity and PAI ability than other control groups. Meanwhile, the vascular tissue could also be clearly observed in tumor tissue because of the endogenous contrast agent hemoglobin. The above observations indicated that rGO-based nanomaterials could not only be used in PTT to improve the efficiency of cancer treatment but also could be applied in PAI for tumor diagnosis.Yang et al. reported 9T-GQDs with strong absorption in the NIR-II region by adjusting the decomposition of H2O2 and using phenol as the precursor in a 9T magnetic field for breast, cervical and lung cancer imaging et al. reported a dual imaging nanoprobe based on GQDs that attached to core/shell structure Fe3O4@SiO2 and loaded DOX for MRI imaging of cancer cells 3O4 could enhance the negative image contrast of Hela cells which was conducive to MRI, illustrating the potential of GQDs-based nanosystem for cancer diagnosis.Liu et al. synthesized a kind of hyaluronated fullerenes with strong NIR fluorescence intensity, which enabled the in vivo florescent imaging of tumor sites with high-resolution et al. reported a PAI-guided strategy for cancer diagnosis based on fullerene In vivo results obtained from HeLa cell-bearing mice showed that the constructed nanocomplexes could produce a strong PA signal for biological imaging, which guided the synergistic PDT and PTT for efficient cancer elimination.Recently, fullerene and its derivatives are used as effective tool for cancer imaging because of their optical features such as excellent fluorescence properties. Kwag et al. reported a sort of CNTs-based nanohoop that could generate fluorescence for in vivo cervical carcinoma cell imaging et al. functionalized PEGylated CNTs with gold or silver to realize the surface enhanced Raman scattering (SERS) effect of constructed nanocomposites et al. functionalized MWNTs with gadolinium NPs (GdN), magnetofluorescent CQDs and FA for dual-modal targeted cancer imaging  In vitro results showed that the nanocomplexes could amplify the longitudinal proton relaxation process, which testified the feasibility of these nanocomplexes to be used as T1 contrast agents in MRI.As a class of inorganic nanomaterials with many distinct features, CNTs have gained much interest in cancer diagnosis. CNTs can be applied in various cancer imaging techniques like MRI, PAI, Raman imaging, ultrasonography, radionuclide imaging and NIR fluorescence imaging et al. synthesized a type of amine-rich CQDs with blue fluorescence, which was conjugated with tumor nucleolar targeting aptamer AS141 and connected to the NIR fluorescence group Ce6 through a substrate that was sensitive to Cathepsin B overexpressed in the lysosome et al. designed an approach for long-term Golgi imaging using L-cysteine modified CQDs (LC-CQDs) CQDs are a kind of novel fluorescent nanomaterials with excellent biocompatibility, optical characteristics and accessible synthesis methods, making them a rising star with wide application perspectives in cancer diagnosis. Nevertheless, bare CQDs are often weakly fluorescent, therefore, engineering CQDs to endow them with desirable labeling and imaging properties is of great significance Biosensor usually refers to the device that combines bio-sensitive components with converters to detect certain bioactive or chemical substances with good specificity and selectivity et al. designed a novel biosensor by modifying 3D rGO-MWNTs on the carbon electrode to improve their conductivity and increase their specific surface area, then they connected the carbon electrode to polyamidoamine-linked gold NPs to further increase their conductivity and the number of antibody loads In vitro performance analysis experiment verified that the linear range of the immunosensor is wide, and the detection limit was as low as 6 μU/mL. Similarly, Biswas et al. covered the carbon electrode with CNTs to connect them with a kind of MOF material Zr-trimesic acid, which displayed excellent electrocatalytic ability and protein compatibility to detect CA 125 antigen et al. designed an ultrasensitive electrochemical based on thiol group multi-labeled C60 NPs for miRNA-141 detection 60 exhibited more excellent recognition ability and better analysis efficiency. In addition, Zhang et al. developed a novel electrochemical biosensor based on CQDs Figure 13).Cancer antigen 125 (CA 125) is a kind of mucin-like glycoprotein overexpressed in ovarian tumor cells, so it can be considered as a biomolecule marker antigen for the detection of ovarian cancer in vivo, acute and latent toxicity The clinical translatability of carbon nanomaterials is an issue that cannot be avoided and many challenges remain to be overcome before their successful translation in practice. Although carbon nanomaterials can serve as effective tools with outstanding properties in cancer theranostics, bridging the gap between laboratory research and clinical transformation still needs a long way to go. The biodegradability and metabolism of carbon nanomaterials are important concerns that hinder their clinical application. For graphene and derivatives, their toxicity is a major concern that should be taken into consideration for biomedical application in clinic. The cytotoxicity of these nanomaterials is highly dependent on their inherent flake sizes, their structure and shape, surface chemistry, and the type of cultured cells The anti-tumor properties of fullerene derivatives have attracted many researchers' attention worldwide For CNT-mediated drug delivery, free CNTs can be retained in the body after drug dissociation, which causes secondary damage CQDs are widely used as fluorescent nanomaterials in various biomedical fields due to their good biocompatibility, multifunctionality, adjustability and designability 124I which were termed as Cornell dots for the PET imaging of patients with metastatic melanoma, instilling more confidence in the clinical transformation of radiolabeled inorganic NPs for cancer diagnosis Encouragingly, compared with carbon nanomaterials, another kind of inorganic nanomaterials, silica nanoparticles (SiNPs), have already achieved success in their clinical practice. Bradbury and teammates reported the first-in-human clinical trial of ultrasmall hybrid SiNPs labeled by This review provides an overview of the update achievements of carbon nanomaterials in cancer treatment and diagnosis using substantial examples and cases. There is no doubt that the flourished development of nanotechnology has contributed a lot to biomedical fields. From all the nanomaterials, carbon-related nanostructures have shown tremendous advantages in cancer theranostics due to their distinctive physiochemical properties. Their extensive surface area can be conjugated with many therapeutic agents, imaging molecules and targeting moieties, which significantly improves their targetability, specificity and therapeutic performance. Because of their natural optical features, thermal ablation of tumor cells can be realized through NIR irradiation. Moreover, multifunctional platform that integrate diagnostic and therapeutic functions can be simultaneously achieved because of their versatility, which largely benefits the development of a number of novel theranostic modalities. Of course, in addition to the aforementioned carbon nanostructures, other carbonaceous nanoplatforms like carbon nanohorn and porous carbon all show tremendous potential against various cancer types Despite the inspired advancements in this fascinating field, issues and challenges still exist, which requires more efforts to be dedicated in addressing them. For instance, their long-term nanotoxicity and pharmacokinetics should be carefully evaluated using more suitable animal models because these properties are highly dependent on many parameters such as the structure, synthesis method, antitumor mechanism, dosage and exposure time. It is also necessary to study the impact of carbon nanostructures on immune system, central nervous system and reproductive system, however, excluding these influence needs more thorough and careful investigation. Besides, carbon-related nanomaterials are usually non-uniform, which causes difficulties in standardizing the preparation and functionalization methods of these nanomaterials, so there is still some space for improvement to establish more stable and repeatable approaches in constructing carbon-based nanoplatforms However, opportunities and challenges always coexist. Solving each of these aforementioned obstacles will add more chances in developing novel theranostic tools based on carbon nanomaterials. With the rapid progress in scientific technology, it can be expected in the future that these challenges can be overcome and carbon nanomaterials will show excellent performance in the arena of cancer theranostics.


Finally, we discuss several crucial challenges and present our perspective on 3D bioprinting techniques in the field of CTE.Heart disease is the main cause of death worldwide. Because death of the myocardium is irreversible, it remains a significant clinical challenge to rescue myocardial deficiency. Cardiac tissue engineering (CTE) is a promising strategy for repairing heart defects and offers platforms for studying cardiac tissue. Numerous achievements have been made in CTE in the past decades based on various advanced engineering approaches. 3D bioprinting has attracted much attention due to its ability to integrate multiple cells within printed scaffolds with complex 3D structures, and many advancements in bioprinted CTE have been reported recently. Herein, we review the recent progress in 3D bioprinting for CTE. After a brief overview of CTE with conventional methods, the current 3D printing strategies are discussed. Bioink formulations based on various biomaterials are introduced, and strategies utilizing composite bioinks are further discussed. Moreover, several applications including heart patches, tissue-engineered cardiac muscle, and other bionic structures created  The following scaffold properties are important for CTE applications: (i) Biocompatibility: scaffolds should show low immunogenicity and coagulability when implanted Figure ) Figure ) Figure ) 2+ compared with flat films Figure ) Figure ) Various methods have been developed to fabricate scaffolds that induce cell orientations including micropatterning et al.Figure ). This multi-layered construct showed strong spontaneous beating and frequency-dependent opening/closing actuation under a low external electric field. However, CMs within the structure presented a random orientation, which is detrimental to heart contraction. In contrast, we previously developed core-shell scaffolds with electrospun aligned nanofiber yarns (NFYs) as the core and hydrogel as the shell that not only induced cell alignment and elongation but also provided a suitable 3D environment for cellular nutrient exchange and mechanical protection via layer-by-layer assembly with a slight angular shift to mimic the gradual transition in alignment between myocardium layers  et al.via electrospinning and laser patterning to engineer aligned cardiac tissues, and then stacked several of these grooved scaffolds with a slight angular shift . Unfortunately, this layer-by-layer stacking strategy significantly increases the complexity of cell culture, and precise 3D cell and matrix organization is limited. In contrast, 3D printing showed the advantages for fabricating scaffolds with 3D complex structure, and these drawbacks of the traditional scaffolds are now being overcome by computer-assisted 3DBP Hydrogel matrix systems present a 3D environment similar to that of native tissues, and cells can be encapsulated within hydrogel matrices homogeneously. Moreover, external stimulation approaches such as mechanical stimulation or electrical stimulation have been applied to control 3D cell alignment and elongation within hydrogel scaffolds 3DBP, which similar to traditional 3D printing, is also an additive manufacturing technique but the printed inks or resins are replaced with cells only or biomaterials and cells mixture Figure ). Inkjet bioprinting devices are classified into two types including thermal 2D inkjet printers are modified for 3DBP by replacing the ink cartridge with biological material and adding an electronically controlled elevator stage for z-axis movement  et al.in vivo, which indicated that the rapid DLP printing approach was able to fabricate complex CTE scaffolds. However, several limitations still need to be overcome to apply DLP printing to CTE. First, biomaterials used for DLP printing must be photocurable; however, UV light exposure potentially damages cell DNA during the 3D printing process et al.et al.In digital light processing (DLP) printing, a digital micromirror array device is used to selectively solidify photocurable bioinks in a layer-by-layer process controlled by a moveable stage along the z-axis , which permits faster, simpler, and more affordable bioprinting compared with other techniques. Moreover, the deposited cell densities could be high and close to physiological CM densities (108-109 cells mL-1), which is particularly crucial for CTE 7 mPa s) or when a thin nozzle is used Extrusion printing uses pneumatic- or mechanical-driven fluid dispensing systems to constantly extrude bioink onto a platform . The support bath in this strategy was composed of gelatin microparticles and acted like a Bingham plastic during printing. Bingham plastics behave as a rigid body at low shear stresses but flow as a viscous fluid at high shear stresses. This meant that there was little mechanical resistance when a needle-like nozzle moved through the bath, yet hydrogel extruded out of the nozzle and deposited within the bath was held in place. Thus, printed soft materials maintained the intended 3D geometry in this support bath. After solidification, the printed scaffold was easily taken out by melting the support bath . In a subsequent study, Feinberg's group decreased the size of the gelatin microparticles in the support bath from ~65 μm to 25 μm and renamed the system FRESH v2.0  et al.Figure ). Hinton et al.Figure ). FRE printing also has great potential for the fabrication of complicated structures. For example, Bhattacharjee et al.Figure ). Even a whole neonatal-scale human heart has been successfully printed Hydrogels are excellent candidates for supporting cell proliferation in 3D environments. However, most hydrogels suffer from poor mechanical properties, which potentially results in a collapse during printing of hollow structures due to gravity  Table Various biomaterials have been applied as bioinks for CTE applications recentlyFigure ). Therefore, hdECM recapitulates most of the chemical cues of native heart tissue to promote cell survival, differentiation, and functionality et al.-1) had relatively low viscosity, and the bioprinted layers were hard to sustain their previously defined 3D structure. Although previous studies have developed some printing methods to overcome the poor printability of hdECM, there are still two main issues worth attention -1) is significantly higher than that used in therapeutic studies, which is limiting because the preparation of hdECM requires extensive harvesting from porcine sources. Second, pure hdECM-printed structures are relatively hard to print and potentially rupture when applied as a patch for heart regeneration due to their low mechanical modulus and fibrous nature Figure ). Collagen provides cell adhesion molecules to ensure the required bioactivity, while methacrylate allows adjustable construct stiffness due to methacrylate photopolymerizability under UV light Figure ) Among the various natural biomaterials, heart-derived dECM (hdECM) is one of the most typic natural bioinks. dECM is obtained from the organ of interest by detergent treatment to remove cells, which preserves the ECM and maintains the architecture of cell-cell interactions . In general, synthetic bioinks offer better physical integrity, higher mechanical strength, and enhanced printability compared with natural bioinks. Synthetic polymers potentially have controllable physicochemical properties  via adjustment of their molecular weight or post-printing management et al.et al.Figure ). This hydrogel exhibited high flexibility and elasticity, withstanding large deformations from stretching, compression, and twisting without any obvious breakage, and recover quickly from deformation. However, the hydrophobic surface of synthetic polyesters prevents hydration and protein absorption, and the absence of Arg-Gly-Asp (RGD) peptides prevents cell attachment et al.et al.et al. Synthetic polymers have also been widely used as bioinks in 3DBP for CTE applications . Instantaneous gelation of the hybrid bioink took place at the tip of the inner needle; therefore, the GelMA-alginate bioink was capable of generating self-supported multi-layered structures. The scaffold was further treated with UV irradiation for photocrosslinking, which improved its structural stability. Colosi et al.et al.et al.Figure ) Figure ) or multi-printer devices . The printed synthetic polymers are usually used as support frameworks, which allows mechanically weaker bioinks to be printed on top et al. in vitro drug screening studies.Hybrid bioinks refer to any permutation of multiple natural or synthetic polymers. Since every biomaterial has merits and faults, hybrid bioinks aim to combine strengths and circumvent weaknesses to form more suitable bioinks for 3DBP. Most hybrid bioinks take advantage of the cell-supportive properties of natural polymers and the mechanical properties and tunability of synthetic polymers. For example, PCL is a widely used biomaterial in 3DBP, but its lack of bioactivity reduces cell affinity and the high hydrophobicity leads to low tissue regeneration rates et al.et al.et al.in vitro. In addition, polypyrrole (PPy), a heterocyclic conductive polymer in vitro and in vivo biocompatibility et al.-1) Native myocardium is an electroactive tissue that spontaneously contracts under electric signal propagation Table 1) including cell lines, primary myocardial cells, neonatal human cardiac progenitor cells, and stem cell-derived CMs. Established CM cell lines  are useful alternatives to primary cells for various CTE studies. The H9C2 cell line was originally derived from embryonic rat ventricular tissue via 3DBP technology for regenerative medicine, drug screening, and potentially disease modeling et al.et al.Various types of cells have been used in 3DBP for CTE . Park et al.et al.or PGS. In their subsequent study, You's group designed a perfusable, multifunctional epicardial device (PerMed) based on PGS/PCL via 3D printing with a subcutaneously implanted drug delivery system and showed the feasibility of minimally invasive surgical PerMed implantation in pigs, which also demonstrated its promise for clinical translation to treat heart disease Figure ). The microstructure or pattern also influences the properties of heart patches. Two microarchitectural features defined by the interstrand distance and strand alignment angle have been identified as major parameters for assessing the electrical/mechanical and structural behaviors of 3D‐printed constructs Left ventricular (LV) remodeling is a pathological process characterized by LV dilation and altered chamber geometry, which is attributable to CM deficiencies. These compensatory mechanisms temporarily ensure adequate cardiac output by increasing stroke volume, at the cost of changing the LV architecture and impairing cardiac contractility. However, CMs have a limited regenerative capacity, and the cardiac ECM is modified and replaced by scar tissue during the progression of heart failure Ex vivo cardiac muscle models are one of the primary applications of CTE. They aim to facilitate research on the basic physiology of the heart or to serve as high-throughput drug screening platforms in vitro. Organized cell alignment is important for the realization of functional engineered cardiac muscle. Therefore, most CTE studies follow the principle that scaffolds should be designed to induce cardiac cell orientation. In particular, free-form 3DBP technologies allow for easy modification of the constructed pattern given their flexibility compared with other techniques. For example, Tijore et al.Figure ). Elongated cells with significant βMHC expression (a differentiation-related gene) were observed on microchanneled scaffolds with 500 μm spacing. CMs on the microchanneled scaffolds showed more obvious spontaneous beating than those on plain scaffolds. Conversely, on wide microchanneled surfaces (∼800 μm spacing), aligned cells contacting the channel edges tended to have less influence on cells adhered centrally and failed to confer any guidance cues in vitro 2D cell culture models, meaning they have great potential for drug screening. Moreover, organ-on-a-chip is expected to overcome limitations of traditional animal models such as high costs, time-consuming, and interspecies variation.et al.Figure ); therefore, stress could be read by calculating the change in resistance, which was much more accessible and straightforward compared with microscopy coupled with optical tracking analysis. Other studies have induced an inverse opal structure to reveal the heartbeat by a change in color Furthermore, the cells in organ-on-a-chip allow for the use of patient-derived iPSCs for tailoring of medical compounds to individual patients et al.Figure ). The collagen tri-leaflet valve had well-separated leaflets and was robust enough to be handled in air. The authors quantified the flow through the valves and demonstrated <15% regurgitation. Furthermore, HUVECs cultured on unfixed collagen leaflets formed a confluent monolayer. Moreover, the microscale internal structure of the printed neonatal-scale collagen heart, such as trabeculae, matched the architecture defined in the G-code file. In another study, Noor et al.Figure ). Moreover, the mechanical properties of the printed hearts closely resembled the properties of decellularized rat hearts. One day after printing, high magnification of the cells comprising the printed heart showed a homogeneous distribution of CMs. In summary, recent developments in whole heart printing present the possibility for 3DBP with high-resolution and precise deposition of boinks. Additionally, the concept of FRE printing offers a theoretical basis on which to build up these complicated crafts, which might make it the most promising strategy for printing advanced tissue scaffolds for a wide range of organ systems Engineering a whole heart organ with full functions comparable to native tissue is the ultimate goal of CTE to solve the short supply of donated organs. Thanks to the convenience of computer-assisted 3D printing technology, the heart computer-aided design (CAD) models of human hearts were developed from CT and MRI scans or downloaded from the model library. The parameters of the CAD models would be further tuned to make them suitable for 3DBP. However, printing an intact 3D structure with heart geometry is still challenging and is limited by the ability to combine multiple types of cells and fabricate multi-scale structures with different biomaterials. Recently, many elaborate structures have been bioprinted by FRE printing that mimics the macroscopic anatomical heart. For instance, Lee In the past decade, 3DBP has evolved to become more sophisticated, and some bioprinted human anatomical parts  have already been used in the clinic Another research direction in 3DBP is the development of bioinks. Ideal bioinks should be printable, bioactive, biodegradable, stable, affordable, and commercially available with appropriate regulatory guidelines for clinical use et al.de novo formation of myofibers. Intravital 3DBP takes advantage of commonly available multiphoton microscopes for the accurate positioning and orientation of the bioprinted structures into specific anatomical sites, which has enabled the fabrication of complex structures inside tissues of live mice, including the dermis, skeletal muscle, and brain. Intravital 3DBP might serve as an in vivo alternative to conventional bioprinting.Another interesting area of research in CTE is the fabrication of 3D structures and functional tissues directly in live animals. For example, Urciuolo et al.Figure ). Fukunishi et al.Figure ). The vascular grafts were implanted as an inferior vena cava interposition conduit in a sheep model. All sheep survived after 6 months without aneurysm formation or ectopic calcification, which indicated the clinical potential of the grafts. Castilho et al.Figure ). The printed cardiac scaffolds had highly organized fiber architectures with a rectangular pattern that promoted CPC alignment and were found to approximate the broad mechanical properties of native myocardial tissue. He et al.Another research trend in CTE is the combination of 3DBP with other biofabrication techniques. Since every printing technique has intrinsic shortcomings, 3DBP has been combined with other biofabrication techniques to benefit from their merit. For example, Maiullari 3DBP is a promising technique for CTE owing to its ability to print heterogeneous structures and make full use of advanced achievements in cell and material engineering fields. Although there are still many challenges facing CTE for clinical applications, recent developments in printing strategies, such as emerging technologies, new bioinks, and better combinations of cells, will enable 3DBP to satisfy myriads of practical applications, including personalized drug screening, cardiac muscle reconstruction, and organ transplantation.