Rice–wheat production in the Indo-gangetic plains (IGPs) of India faces major concerns such as depleting resources, rice residue burning, excessive fertilizer use, and decreasing nitrogen use efficiency. These issues threaten sustainable crop production in the future. Therefore, a field study was conducted during the winter seasons of 2020–21 and 2021–22 to evaluate the effect of combined conventional and nano fertilizers on nitrogen application just before or after irrigation to improve wheat productivity, profitability and NUE under conservation tillage. The study evaluated eight treatment combinations of nitrogen application through conventionally applied urea (46% N) and foliar applied nano urea (4% N) under zero tillage with rice residue retention. Results revealed that growth, physiological indices, yield, and quality parameters were enhanced with the application of 150 kg N/ha in three equal splits as basal and just before 1st and 2nd irrigation alone (T2) or along with a spray of nano urea (T5) compared to other treatments. T5 recorded 7.2%, 8.5%, and 7.8% more plant dry matter, number of tillers, and grain yield, respectively, over the conventional practice of applying 150 kg N/ha in three equal splits as basal and 7–10 days after 1st and 2nd irrigation . Although, T2 showed similar results to T5, T5 recorded significantly higher gross ($2542/ha) and net returns ($1279/ha) than the other treatments. However, the benefit–cost ratio of T2 and T5 was same (2.01). A significant and positive correlation coefficient between grain yield and physiological parameters such as CCI and NDVI confirmed that increasing the nitrogen dose enhanced the chlorophyll content, greenness, and plant vigor. Based on the results, it can be concluded that applying 150 kg N/ha in three equal splits as basal and just before 1st and 2nd irrigation under conservation agriculture, along with a single spray of nano urea (4% N) at 60–65 days after sowing, can improve growth, yield attributes, wheat yield, and NUE compared to farmers practice (T3) in India. However, India's wheat productivity is lower than the global wheat productivity. The Indo-Gangetic Plains (IGPs) of India, particularly Punjab and Haryana, are known as the grain bowl of the country where the rice–wheat cropping system is dominant. The productivity of wheat depends on proper monetary and non-monetary inputs, tillage methods, and better agronomic management practices. Among tillage options, conventional tillage involves intensive soil disturbance with multiple passes of tillage equipment to accomplish fine land preparation for seed sowing, which is a waste of energy resources, lacks sustainability and also results in environmental hazards2. These tillage operations require considerable amount of time and in many cases, it defers the wheat sowing especially in rice–wheat system where rice harvesting is delayed. The delay in wheat sowing beyond 15th November can reduce the yield by 26.8 kg/day/ha3. These concerns prompt the farmer to burn the rice residue for its rapid management and timely seeding of wheat crop in rice–wheat system especially in Punjab and Haryana states.India contributes approximately 13.9%  of the global wheat production, which is 770.3 mt5. In the IGPs of India, burning of crop residue, particularly of rice, is a problem that leads to degradation of soil health and environmental pollution7. To counter these negative impacts, conservation tillage gaining popularity among farmers due to its ability to address the challenges of residue management and timely sowing of wheat crop. CA has been suggested as a potential agricultural strategy due to its capacity to store carbon and slow down global warming9. Its practices allow timely sowing of crops, minimize cost, improve soil aggregate stability, and protect the environment in the long term. This practice is economically feasible, environmentally sound, socially acceptable and sustainable10. Happy Seeder-based wheat sowing is more profitable (10–20%) and has scalable residue management practices over burning6. In conservation tillage, wheat is directly seeded under no-till condition in the presence of previous crop residue using suitable machinery such as zero-till drill, happy seeder, strip-till drill, etc. The conservation agriculture has the potential to manage the 66.7% of total crop residue produced in India annually5.India produces more than 686 million tonnes of crop residue every year11. Conventional fertilizer uses efficiencies have not improved significantly over the years, with N, P, and K efficiencies hardly exceeding 30–35%, 18–20%, and 35–40%, respectively. The extent of multi-nutrient deficiencies is alarmingly increasing year by year, closely associated with a crop loss of nearly 25–30%. The extent of nutrient deficiencies in the country is high, with N, P, K, S, Zn, and B deficiencies ranging from 33 to 90%12. By 2025, the country will need to procure approximately 40–45 mt of nutrients to meet the demand13. Among all the essential nutrients, nitrogen is the primary and most vital one. In the sandy loam soils of the Indo-Gangetic Plains (IGPs) in India, nitrogen is typically found in low quantities, usually below 280 kg/ha. This necessitates the introduction of external fertilizer sources to supply nitrogen to the soil. Historically, nitrogen has predominantly been provided through urea in the IGPs of India. However, the imbalanced and excessive use of conventional urea (containing 46% nitrogen) with the sole aim of increasing productivity and profitability has led to a decline in the soil's response to fertilizer application. The nitrogen use efficiency of urea is typically low, ranging from 20 to 50% in most of the soils14. Nitrogen use efficiency decreases as nitrogen doses increase due to its susceptibility to various losses such as leaching, denitrification, and volatilization16. According to reports from the Fertilizer Association of India, the total urea consumption in India in the same period amounted to 34.18 million metric tons. Of this total, 25.08 million metric tons were domestically produced, while 9.14 million metric tons were imported. During the fiscal year 2021–22, the central government provided a subsidy of 75,902 crore rupees for urea, which includes both indigenous and imported varieties. The central government also implemented a nutrient-based subsidy during the winter cropping season of 2022–23, offering a subsidy of ₹98.02 per kilogram for nitrogen. This subsidy significantly exceeds the market selling price of nitrogen for farmers.Among monetary inputs, nutrient management is crucial for achieving self-sufficiency in food grain production, but blind use of fertilizers has resulted in higher nutrient consumption and lowered profits17. Nano-fertilizers have desirable features such as high solubility, stability, effectiveness, time-controlled release, targeted activity, low eco-toxicity, and easy modes of delivery and disposal18. A recent review on nano-fertilizers confirmed their high solubility, consistency, effectiveness, time-controlled discharge, targeted activity, and safe, simple delivery and disposal methods19. Crop residue recycling through the adoption of CAs can also be quite helpful as it contains a significant amount of nutrients.In recent times, nanotechnology has gained prominence, with a particular focus on the use of nano-fertilizers in order to enhance the use efficiency. These fertilizers can enhance nutrient use efficiency by exploiting the unique properties of particles ranging from 1 to 100 nm in sizeIn Indian farming practices, N application in wheat is recommended 7–10 days after irrigation, whereas under CA, there is an urgent need to apply just before irrigation. Hence, CA coupled with nano-fertilizers can play a greater role in improving crop production with environmental safety, ecological sustainability, and economic stability. Fertilizer nutrient use efficiency, particularly N, in crop production can be enhanced with the effective use of NFs. Nano-fertilizers improve crop growth and yield up to optimum applied doses and concentrations, but they also have an inhibitory effect on crop plants if the concentration is higher than the optimum, which might reduce growth and yield of the crop. There is a paucity of information on these aspects under Indian conditions, and systematic investigations are required.The experiment tested the hypothesis that rice residue management by CA and judicious N management with the use of conventional and nano-fertilizers of nitrogen enhance the nitrogen use efficiency, productivity, and profitability of wheat.A 2-year study was conducted at the ICAR-Indian Institute of Wheat and Barley Research’s Research Farm in Karnal Fig. , HaryanaThe experimental site is situated in the sub-tropical and semi-arid climate of Haryana, India. The region experiences cold winters from November to January, followed by mild temperatures in February and March. Mean weekly meteorological observations were taken during the cropping season from November 2020 to April 2021, and again from November 2021 to April 2022, and were recorded at the meteorological observatory of ICAR-Central Soil Salinity Research Institute in Karnal. These observations are presented in Figs. Weekly maximum and minimum temperatures ranged from 14.9 ℃ to 37.8 ℃ and from 3.5 ℃ to 17.1 ℃ in 2020–21 and from 12.6 ℃ to 40.6 ℃ and from 4.9 ℃ to 19.4 ℃ in 2021–22, respectively . The sowing date was 1st November 2020 and 9th November 2021 for 2020–21 and 2021–22, respectively.2O5) and muriate of potash (60% K2O), respectively. Nano urea (an IFFCO product) with 40,000 ppm of nitrogen was sprayed as per the treatment. Nano nitrogen was applied at a rate of 4 ml of nano urea/liter of water with a product dose of 1250 ml/ha. Foliar spray of nano urea was carried out using knapsack power sprayer having two nozzle spray boom after proper calibration and in synchrony with seed drilling. The detailed timing and weather conditions are given in Table a.i./ha were used for proper weed management. Termite attack was controlled by spraying chlorophyrifos 20% EC @ 2.5 l/ha, and rust was managed by spraying Propiconazole 25% EC @500 ml/ha just before flowering. At maturity, the crop was manually harvested and sun-dried. Mechanical threshing was done using Hadamba wheat thresher. The threshed grains were weighed and converted into kilograms per hectare for the estimation of yield.The experimental plots received different doses of nitrogen (with the recommended dose at 150 kg/ha) through prilled urea (46% N) as per the treatments outlined in Table 2, thousand grains weight (TGW), leaf chlorophyll content or greenness, and spectral reflectance of leaves or NDVI values. Plant height and dry matter accumulation were measured at harvest. The leaf area index was measured by using the “Sun Scan Canopy Analyser” from three sites in each plot. The grain yield was calculated from the net plot area and then converted into kg/ha. The number of effective tillers per meter row length was counted at two places in each plot and converted to per m2. The TGW was calculated by taking random grain samples and counting them using a Contador electronic seed counter  and weighing them.Data were collected on plant height, dry matter accumulation, leaf area index, grain yield, number of effective tillers per mThe readings of leaf chlorophyll content or greenness were taken with a handheld device Soil Plant Analysis Development  chlorophyll meter. Five readings were taken from newly and fully opened leaves of each plot with care so that the mid-rib of the leaf should not come under the eye of the instrument, and the average value was worked out.20 using a handheld optical sensor “GreenseekerTM handheld sensor” which measures the reflectance of a given crop area over a 61 cm × 61 cm area when the unit is positioned between 81 to 122 cm above the target area21. The NDVI is calculated from reflectance measurements in the red and near-infrared (NIR) portion of the spectrum.NIR is the reflectance of NIR radiation and RRed is the reflectance of visible red radiation.The readings of spectral reflectance of leaves or NDVI values were taken by moving the instrument over the plot at DC37 and DC65 stagesComposite soil samples were collected prior to setting up the experiment layout, and subsequent to crop harvest, samples were collected from each plot at three depths . These samples were then processed and subjected to analysis to determine the available nitrogen content. Other chemical properties such as pH, EC, organic carbon, available P, and K were also analyzed, but no significant differences were observed among treatments and are presented as supplementary information.22 wet-oxidation method. An alkaline permanganate method  was followed to determine the KMnO4-oxidizable N. Olsen’s extractable P (soil pH > 6.0) was determined using the ascorbic acid reductant method23. Potassium (K) was extracted by neutral NH4OAc and detected using a flame photometer23.Soil pH and EC were determined in a 1 and 2.5 ratio of soil and water suspension. The oxidizable organic C was determined usingRepresentative samples of crop produce (grain and straw) were collected randomly at harvest, dried, processed, and analyzed for nitrogen content. The amount of N removed by the crop was calculated by multiplying the percentage of nutrients with the yield of grain and straw separately and summing them up. The uptake of the crop was computed based on its dry weight as follows:fertilized plot and Yield control plot are yields (kg/ha) when quantity of N fertilizer applied was F and zero; Fapplied is the total nitrogen (kg/ha) applied24.Nitrogen use efficiency is the yield increment per unit of N fertilizer given to the crop. It is measured in kg grain yield/kg nitrogen applied.Nitrogen use efficiency (NUE) can be separated into two components: nitrogen uptake efficiency (NUpE) and nitrogen utilization efficiency (NUtE). NUpE describes the amount of nitrogen that a plant can take up from external sources, while NUtE describes the plant's ability to assimilate and remobilize nitrogen within its own tissues. NUE25 is the product of NUpE and NUtE27.25.The grain protein content of wheat was estimated by using Infratec™ 1241 (FOSS) instrument, a whole analyzer using near infrared (NIR) transmittance technologyWheat grain yield was multiplied by the minimum support price for 2021–22 (246.9 US $/ton) and 2022–23 (251.9 US $/ton) . The wheat straw yield was also multiplied by the market rate (100 US $/ton) and added to get the gross return. The cost of cultivation was calculated by considering field preparation, seed, fertilizer, irrigation, transportation, herbicide application, the cost involved in harvesting and threshing of produce, management charges, the rental value of land, interest on fixed capital, depreciation cost of implements, and farm buildings. The net return was calculated by subtracting the cost of cultivation from gross returns. The benefit–cost ratio was calculated by dividing the gross return by the total cost of cultivation. To convert into US$, the gross return, cost of cultivation, and net return were divided by the prevailing exchange rate ($1 = Rs. 80).28. Gross and net benefits were computed using the following formulas:A partial budget analysis was employed to assess the economic advantages of various nitrogen fertilizer application sources and timings in relation to wheat grain and straw yields. During this study, we identified the economically viable treatments by estimating their costs and benefits in accordance with the market prices for the specific research year. It's worth noting that experimental yields often surpass what farmers can realistically achieve when implementing the same treatments(1) Gross returns = wheat grain and straw yield × Market price of respective yields,a.(2) Net Benefit = Gross returns—Total variable costaTotal variable cost was computed by deducting the fixed land cost of from total cost of cultivation.28, was carried out to identify treatments that hold relevance for farmers in terms of earnings. A treatment is considered dominated when, despite incurring higher costs, it fails to yield a greater increase in net benefits. In such cases, it is dominated because there exists at least one other treatment with equal or lower costs that generates higher benefits. To conduct this analysis, treatments were arranged in ascending order of variable costs, and comparisons were made to determine whether an increase in costs was associated with a proportionally greater increase in net benefits.The calculation of the marginal rate of return (MRR) involved dividing the change in net benefit by the change in variable cost, which represents the additional return gained by increasing the input. Before computing the MRR, a simplified dominance analysis, as outlined by Maize and Center in 1988Analysis of variance (ANOVA) and ranking of treatments was completed using Tukey’s Range test at 0.05 (5%) level of significance. The General Linear Model (GLM) Procedure in SAS®9.3 version 6.1.7061 for Windows  was used for statistical analysis.All authors approve ethical responsibilities related with this manuscript.2 were significantly lowest in the control treatment compared to others. The number of grains per earhead and spike length were significantly higher in higher fertilized plots. Treatments with nitrogen doses of 100 or 150 kg/ha BI or AI with or without nano spray recorded significantly higher grains per earhead and spike length over other treatments. Zero nitrogen recorded the least number of grains per earhead (23.1) and spike length (8.87 cm). The thousand-grain weight did not vary significantly among treatments, and more values of thousand-grain weight were recorded in control plots.The Fig. Analysis of pooled data on grain yield Fig.  revealedPooled data showed that the leaf area index at the maximum tillering stage was significantly higher when 150 kg N/ha was applied BI in three equal splits with one nano urea (4% N) spray (T5) (4.23), which was non-significant with 150 kg N application in three equal splits before (T2) (4.10) and after irrigation (T3) (3.95). The readings from Greenseeker and SPAD meters, such as NDVI and CCI at DC37 and DC65, varied significantly among treatments , as shown in Fig. Nitrogen uptake by wheat grains, straw, and total uptake also varied significantly, as shown in Fig. Agronomic efficiency (AE) was highest (32.6 kg grain yield/kg nitrogen applied) in the treatment where 50 kg N/ha was applied as basal and four sprays of nano urea (4% N) were applied Fig. . It decrThe correlation coefficients among grain yield and other parameters were significant and highly positive, as shown in Fig. 29. However, the application of conventional urea (46% N) on the soil surface leads to significant losses ranging from 1 to 60% in the form of ammonia, volatilization, and nitrous oxide emissions32. The increase in growth parameters of wheat is linked to a sufficient supply of nitrogen that contributes to increased enzymatic activity30. The sandy loam texture and poor fertility condition of soils can lead to improved wheat growth characteristics and yield with nitrogen fertilization33. Increasing the nitrogen dose up to a certain level enhances the concentration of nitrogen in the leaves, thereby boosting the plant's capacity for photosynthesis and resulting in an increase in grain yield35. The use of nano fertilizers offers a solution to the problem of nitrogen volatilization, as they have variable solubility, effectiveness, high consistency, time-controlled discharge, enhanced targeted activity, and effective concentration19. Foliar application of nano-fertilizers can enter plants through the epidermis or stomata and then translocate through the apoplast or symplast pathways, which enhances nitrogen use efficiency37. However, it is essential to use a proper concentration of nano fertilizers to meet the crop’s nutrient requirements. Lower concentrated nano fertilizers could be used as a supplementary source to enhance quality without any significant loss in yields and profits. In our study, the foliar sprays of nano urea in addition to 150 kg N/ha applied through prilled urea enhanced grain yield, however the increase was not significant compared to a similar dose of nitrogen applied through urea. This lack of significance might be attributed to the lower concentration of nitrogen in nano urea, which did not effectively improve the yield attributes. Similar results have been reported by Rawate et al.38 and Saklani and Pal39. These results are in contradiction with Al-Juthery et al.40, Mehta and Bharat41, Fakharzadeh et al.42 and Poudel et al.43 which might be due to different nature of nanofertilizers (NFs) used, varying concentrations of NFs, prevailing conditions, timing and method of application, etc. A research paper recently published by Frank and Husted44 created controversy by challenging the manufacturer's claims regarding the poorly description of the product with no scientifically proven effects. In our study, we found that there are some effects of nano-urea on the growth and yield of wheat but cannot replace a bag of urea (45 kg urea or 20.7 kg of N) as claimed by product manufacturers. However, a recent research has supported two foliar sprays of nano-urea reduced the nitrogen load by 25% without negatively impacting crop yield of wheat, maize, mustard and pearl millet45.Nitrogen is one of the most crucial plant nutrients that affects the growth and development of wheat48.Applying nitrogen at a rate of 150 kg/ha with urea top dressing just before irrigation increased grain yield by 5.7–7.9% as compared to urea top dressing after irrigation. This improvement can be attributed to the percolation of urea with irrigation water below surface immediately after top dressing thus protect the hydrolysis products from volatilization, results in to nitrogen storage to the root zone of the crop, particularly in sandy loam soil. This method reduced the nitrogen losses through ammonia volatilization under conservation tillageIn summary, the application of nitrogen is critical for the growth and development of wheat. The use of nano fertilizers can enhance nitrogen use efficiency and reduce losses due to nitrogen volatilization. Therefore, it is necessary to use a proper concentration of nano fertilizers to meet the crop’s nutrient requirements, while lower concentrations can be used as a supplementary source to enhance quality without significant losses in yields and profits.49. Therefore, in conservation tillage, nitrogen should be applied before irrigation to maximize productivity and profitability. However, from an economic standpoint, complete replacement of conventional fertilizers with nano fertilizers is not economical. Instead, supplying nutrients in combination  has been shown to have a significant effect in increasing net returns50. Therefore, it is essential to manufacture nano fertilizers with the appropriate concentration to ensure their cost-effectiveness.Optimizing nitrogen management in conservation tillage requires careful timing of nitrogen application. Urea, which is rapidly hydrolyzed to ammonium, is susceptible to losses through ammonia volatilization. These losses can be reduced by either applying urea 1–2 cm below the soil surface or altering the timing of urea application (before or after irrigation). In coarse-textured soils with high water percolation rates, urea application should be done before irrigation to allow percolating water to carry urea to the root zone, minimizing the potential for ammonia volatilization. Studies have shown that applying nitrogen before irrigation moves urea to the 15–30 cm layer, which is later moved back to the soil surface with capillary rise due to water evaporation, making it more available to crop plants52. Similarly, CCI and NDVI values were positively correlated with nitrogen application, with an increase in wheat greenness, leaf area index, and vigorous growth observed as nitrogen application rates increased from zero to maximum54.Positive correlations were observed between nitrogen application rates and NDVI and CCI values in wheat. As the dose of nitrogen increased, its uptake intensified chlorophyll content and resulted in higher grain yield55. The retention of rice residue in the wheat crop was found to boost growth and production compared to no residue, attributed to the gradual provision of nutrients from rice remaining in the soil and moisture retention in the rhizosphere during increasing minimum temperature on later stages. Crop leftovers decay slowly over the course of the growing season, releasing nutrients that improved plant growth and increased yield. Conservation tillage was observed to increase wheat grain yield by 10–20% compared to conventional tillage57, which can be attributed to improved soil health and maintained soil moisture in the root zone, providing a better environment for wheat growth and development. An important advantage of conservation tillage is the reduction of production costs by US $33 to 5060, including the need for labor and fuel used in tillage operations and equipment maintenance. Among conservation tillage practices, zero tillage for wheat production was found to be most successful in terms of good crop establishment and increased yield63. The treatment with the highest gross and net returns was T5, directly proportional to the yield of grain and straw. Top dressing of urea just before irrigation resulted in higher gross returns and net returns over top dressing after irrigation owing to more grain and straw yield obtained in the former treatment at similar costs of cultivation. The profitability of these treatments is applicable only for the current agricultural year under investigation. This assessment will need to be conducted again in subsequent agricultural years because of natural fluctuations in prices.Conservation tillage practices, which involve retaining leftovers from previous crops, can improve agro-ecosystems under the rice–wheat cropping system by holding moisture, controlling weeds, and gradually supplying nutrients through decompositioni.e., 45 kg of prilled urea (46% N). The combined use of conventional urea (46% N) and nano urea (4%) can help in enhancing agronomic efficiencye, but there is a need to work on the concentration of nano urea, which is currently low compared to the requirement of wheat for proper physiological functioning.After 2 years of study, it can be concluded that applying 150 kg N/ha as basal and remaining 2/3rd just before 1st and 2nd irrigation in three equal splits under conservation agriculture, along with or without a single spray of nano urea (4% N), leads to better growth, yield attributes, and yield of wheat. The highest marginal rate of return recorded with the application of 150 kg N/ha as basal and remaining 2/3rd just before 1st and 2nd irrigation in three equal splits. The additional spray of nano urea has gained the net benefit but the MRR was further reduced. This application also enhanced the soil nitrogen status, nitrogen uptake by wheat, and grain protein content. But the additional spray of nano urea has not enhanced these parameters significantly. As claimed, nano urea cannot substitute the one bag Under Indian conditions, farmers need to shift from their current practice of applying N through urea 7–10 days after irrigation to before irrigation to achieve maximum wheat productivity, profitability, and agronomic efficiency. However, after N application, farmers must ensure irrigation under dry residue retention conditions, as otherwise, most of the N will be lost through volatilization. Nitrogen applied after irrigation has less nitrogen use efficiency as compared to nitrogen applied before irrigation. It can further be enhanced though nano urea but it can’t substitute the prilled urea due to lower concentration of nitrogen (4% N) particularly in wheat. However, further comprehensive research is required for the use of nano urea at higher concentrations by taking phytotoxicity into consideration.Supplementary Table 1.


The creatine shuttle translocates the energy generated by oxidative phosphorylation to the cytoplasm via mitochondrial creatine kinase (MTCK) and creatine kinase B (CKB) in the cytoplasm. It is not apparent how the creatine shuttle is related to cancer. Here, we analyzed the expression and function of CKB and MTCK in colorectal cancer (CRC) and investigated the role of the creatine shuttle in CRC. Compared with normal mucosa, 184 CRC tissues had higher levels of CKB and MTCK, and these levels were associated with histological grade, tumor invasion, and distant metastasis. CK inhibitor dinitrofluorobenzene (DNFB) on CRC cell lines HT29 and CT26 inhibited cell proliferation and stemness to less than 2/3 and 1/20 of their control levels, respectively. In this treatment, the production of reactive oxygen species increased, mitochondrial respiration decreased, and mitochondrial volume and membrane potential decreased. In a syngeneic BALB/c mouse model using CT26 cells pretreated with DNFB, peritoneal metastasis was suppressed to 70%. Phosphorylation of EGFR, AKT, and ERK1/2 was inhibited in DNFB-treated tumors. High ATP concentrations prevented EGFR phosphorylation in HT29 cells following DNFB treatment, CKB or MTCK knockdown, and cyclocreatine administration. Despite not being immunoprecipitated, CKB and EGFR were brought closer together by EGF stimulation. These findings imply that blocking the creatine shuttle decreases the energy supply, suppresses oxidative phosphorylation, and blocks ATP delivery to phosphorylation signals, preventing signal transduction. These findings highlight the critical role of the creatine shuttle in cancer cells and suggest a potential new cancer treatment target. In the United States, colorectal cancer (CRC) ranks third in terms of both new cases and cancer fatalities at 7.9% and 8.7%, respectively  AccordinAfter oxidative phosphorylation and glycolysis, the creatine shuttle is regarded as a third energy production mechanism. Normal tissues contain a rapidly available temporal energy buffer, a spatial energy buffer that connects adenosine triphosphate (ATP) generation sites  and intracellular ATP usage sites (such as ATPase), and an intracellular energy buffer. These buffers have been demonstrated to function as a metabolic regulator and energy transport system . The creThe Human Protein Atlas shows that colorectal cancer is a cancer with high expression of both CKB and MTCK , 11. TheRecently, scientists have been seeking to use energy metabolism as a novel target for cancer treatment ; howeverWe examined the expression of CKB and MTCK in CRC tissues by using tissue arrays . Both CKIn this study, dinitrofluorobenzene (DNFB) was used as an inhibitor of CK activity and its effect was examined in CT26 and HT29 colon cancer cells . ProteinThe effect of creatine shuttle inhibition by DNFB treatment on cell proliferation was examined . The numNext, we examined the effect of creatine shuttle inhibition by DNFB on mitochondria  and 5. IExamination of mitochondrial respiration indicated that inhibition of the creatine shuttle in both cell types decreased the oxygen consumption rate (OCR) and ATP production –5C. In cThe effect of creatine shuttle inhibition on cancer metastasis was examined using a model in which CT26 cells were disseminated into the peritoneal cavity of syngeneic BALB/c mice . Since DWe hypothesized that the creatine cycle supplies ATP to the phosphorylation signal because animal experiments have shown that CRC cells treated with DNFB exhibit a wide range of phosphorylation signal suppression . TreatmeFinally, we examined whether CKB and EGFR were physically associated with each other. Immunoprecipitation was used to examine whether CKB and EGFR exhibited molecular binding, but no binding was observed, regardless of the presence or absence of EGF treatment . HoweverIn this study, we showed that inhibition of the creatine shuttle by blocking CKB and MTCK activity suppressed the growth, stemness, and metastasis of cancer. It was suggested that the cause of this is related to inhibition of both mitochondrial energy metabolism and the phosphorylation signaling system.In this study, it was suggested that the creatine shuttle via CKB and MTCK may supply ATP for phosphorylation. Phosphorylation signals are essential for cellular activity, but the source of ATP for the phosphorylation process is not specific and is thought to be due to the passive diffusion of ATP within the cytoplasm . This inHowever, the NLR family pyrin domain containing 3 (NLRP3) inflammasome is supplied with ATP produced in the mitochondria via phosphocreatine . This fiOur data did not reveal a regulation of the spatial arrangement of the ATP donor CKB and recipient EGFR. The direct binding of both proteins has not been reported, and we could not confirm this by immunoprecipitation. However, we found that ligand stimulation brought both proteins into close proximity by DuoLink assay. In this assay, fluorescence occurs when two proteins are within 40 nm . This suIn this study, inhibition of the creatine shuttle suppressed mitochondrial respiration, decreased mitochondrial membrane potential, and increased mitochondrial ROS levels. This finding indicates that the creatine shuttle is not the only pathway for exporting the energy produced in the mitochondria but also affects various mitochondrial functions. Another significance of the creatine shuttle is that it does not deplete ADP in mitochondria during energy export. A strict ADP gradient exists within the mitochondria and is necessary for ATP production . AnotherReduced mitochondrial respiration due to creatine shuttle inhibition can be compensated in cancer cells by glycolysis and lactate fermentation, known as the Warburg effect. However, our data did not reveal an increase in glycolysis. It has been reported that intracellular ATP cannot be maintained by cyclocreatine treatment . In addiAnother unique finding of this study was that the creatine shuttle is closely correlated with cancer stemness. Creatine shuttles have attracted attention for their importance in energy metabolism, but their relationship with stemness has not been clarified. Recently, stem cells have been shown to produce energy through oxidative phosphorylation, revealing a relationship between stemness and oxidative phosphorylation . Low levIn our study, CKB and MTCK were upregulated in CRC. Although little is known about the regulation of CKB and MTCK expression, the most important point is that CKB expression is suppressed by p53 and enhanced by p53 silencing , 28. TheIn this study, DNFB was used as an inhibitor of CK activity. DNFB is known as a skin sensitizer  that enhin vitro [in vivo.Because DNFB reacts rapidly with amino groups to produce 2,4-dinitrophenylamine, it binds to plasma albumin and α1-acid glycoprotein, resulting in phenylation, and is not delivered to target tissues . For thiin vitro . Our resA human colorectal adenocarcinoma tissue microarray (product ID: BC000110 and BC051111), which contained 184 cases of CRCs, was purchased from US Biomax, Inc. . Clinicopathological parameters were obtained from the data pro-vided by the provider. All procedures were performed in accordance with the Ethical Guidelines for Human Genome/Gene Research issued by the Japanese Government and were approved by the Ethics Committee of Nara Medical University .Tissue microarray slides were processed for the immunohistochemical analysis of CKB and MTCK. Tissue micro array slides were incubated with antibodies against CKB  and MTCK1  and appropriate secondary antibodies  . The tissue sections were then color-developed with diamine benzidine hydrochloride  and counterstained with Meyer’s hematoxylin . To evaluate CKB and MTCK, we counted cells that exhibited immunoreactivity in the cytoplasm and scored staining strength as grade 0–3. The product of the grade (0–3) and frequency of positive cells (0–1) is the expression index.2.The HT29 human carcinoma cell line was purchased from Dainihon Pharmacy Co. . The CT26 murine colon carcinoma cell line was a gift from Professor I. J. Fidler . Cells were cultured in Dulbecco’s modified Eagle’s medium supplemented with 10% fetal bovine serum at 37°C in 5% CO1-Fluoro-2,4-dinitrobenzene (DNFB), human recombinant EGF, mouse recombinant EGF, phosphocreatine (pCr), oligomycin (Sigma), ATP, and cyclocreatine  were purchased from the indicated manufacturers.MTS assays were performed using the CellTiter 96 Aqueous One Solution Cell Proliferation Assay kit . The plates were read on a multiscan FC microplate photometer at a wavelength of 490 nm. The MTS value in cells cultured with the control oligonucleotide was used as the control.Stealth Select RNAi (siRNA) targeting human CKB, human MTCK, mouse CKB and mouse MTCK was purchased from Sigma. AllStars Negative Control siRNA was used as the control . The cells were transfected with 10 nM siRNA using Lipofectamine 3000 (Thermo Fisher Scientific) according to the manufacturer’s recommendations.The mitochondrial function was examined using fluorescent probes. Cells were incubated with the probes for 30 min at 37°C and then imaged using a BZ-X710 all-in-one fluorescence microscope . We used MitoROS to detect superoxide  and dihydrorhodamine 123 to detect H2O2  to assess oxidative stress, MitoGreen to detect mitochondrial volume , and tetrathylrhodamine ethyl ester  to assess mitochondrial membrane potential.4 cells/well, and incubated overnight. The following day, the medium in the XF plate was replaced with XF DMEM 1 h prior to the assay, and a Mito Stress Test  was performed according to the manufacturer’s protocol. The OCR was measured under the following conditions: 2 μM oligomycin, 0.5 μM carbonyl cyanide-p-trifluoromethoxyphenylhydrazone, and 0.5 μM rotenone/antimycin A. OCR was normalized to the total cellular protein concentration, which was determined after protein extraction from the analyzed cells.To analyze mitochondrial respiration and ATP production, we used a Seahorse XF Analyzer  to measure extracellular flux in live cells. The cells were collected immediately after treatment, transferred to the wells of an XF plate at a density of 2 × 10To prepare whole-cell lysates, cells were washed twice with cold PBS, harvested, and lysed with RIPA buffer containing 0.1% sodium dodecyl sulfate (SDS)  . Cell frWhole cell lysates were prepared as previously described . LysatesImmunoprecipitation was performed as previously described . LysatesAn ELISA kit was used to measure the concentrations of 4-hydroxynonenal , pEGFR , EGFR, pAKT, AKT (Abcam), pERK1/2, ERK , pCr , creatine , and ADP . CK activity was measured using a Creatine Kinase Assay Kit . The assay was performed using whole-cell lysates according to the manufacturer’s instructions.To assess mRNA expression, RT-PCR was performed with 2 μg of total RNA extracted from CT26 and HT29 cells using TRI REAGENT  according to the manufacturer’s protocol. cDNA was synthesized with 0.5 μg total RNA using the Prime Script RT reagent kit together with gDNA Eraser  in accordance with the manufacturer’s instructions. Gene expression was analyzed using qRT-PCR, with reactions performed in triplicate using a SYBR Green PCR kit (Takara). Primer sets used in this study are listed in 6) pretreated with DNFB (5 μM) or DMSO (vehicle) were inoculated into the peritoneal cavity of male BALB/c mouse (5 week old). Five mice were used in each group. One week after inoculation, the mice were euthanized and intraperitoneal tumors were observed. To measure tumor weight, mice were euthanized by aortic blood removal under the anesthesia sevoflurane  and the peritoneal tumors were dissected from the intestine, mesenterium, diaphragm, and abdominal wall, grossly removing non-tumoral tissues.Five-week old male BALB/c mice were purchased from SLC Japan . The animals were maintained in a pathogen-free animal facility under a 12/12 h light/dark cycle in a temperature (22°C)- and humidity-controlled environment, in accordance with the institutional guidelines approved by the Committee for Animal Experimentation of Nara Medical University, Kashihara, Japan, following current regulations and standards of the Japanese Ministry of Health, Labor and Welfare . Animals were acclimated to their housing for seven days before the start of the experiment. Mice were fed with CE-2 diet . CT26 cells (5 × 105) were seeded and incubated for 24 h on Nunc chamber slides (Thermo Fisher), and then incubated with Duolink® Blocking Solution at 37°C for 60 min. Anti-EGFR antibody  and anti-CKB antibody  were incubated with the Duolink® Antibody Diluent. The antibody mixture (40 μL) was added to the cell plate after removing Blocking Solution and incubated at 37°C for 2 h. After removing the antibody mixture, MINUS and PLUS probe solutions (each 8 μL) were added and the plate was incubated at 37°C for 1 h. After removing the probe solution and washing, a mixture of ligase and ligation buffer (40 μL) was added and the plate was incubated at 37°C for 30 min. After removing ligation mixture, a mixture of polymerase and amplification buffer (40 μL) was added, followed by incubation at 37°C for 100 min. After removing the probe solutions and washing, the cell plates were mounted with Duolink®In Situ Mounting Media containing DAPI. Cells were then observed using a BZ-X710 microscope .The assay was performed following the manufacturer’s instructions. The following is a brief description: HT29 cells  using InStat software . Correlations were tested using Pearson’s correlation tests. A two-sided


The objective of this study was to investigate the relation between swelling and tenderness of individual finger joints and grip force in patients with early rheumatoid arthritis (RA). In an inception cohort of patients with early RA (symptom duration < 12 months), all patients were examined by the same rheumatologist, and grip force was measured using the Grippit instrument at inclusion, 1 and 5 years. The average grip force values of each hand were evaluated and expressed as % of expected values, based on age- and sex-specific reference values. Linear regression analyses were used to assess the cross-sectional relation between the involvement of individual finger joints and grip force. In generalized estimating equations, the impact of time-varying synovitis/tenderness on grip force over time was estimated. Analyses were adjusted for wrist involvement, erythrocyte sedimentation rate, and patient-reported pain.In 215 patients with early RA, grip force was 39% of expected at diagnosis, and increased to 56% after 5 years. Synovitis of the first metacarpophalangeal (MCP) joint (60% and 69% at baseline in the right and left hand) was associated with reduced grip force at inclusion  and at all follow-up evaluations. Synovitis of MCP I and MCP IV (12% at baseline) was significantly associated with reduced grip force over time in both hands. Proximal interphalangeal (PIP) joint swelling, and tenderness of MCP or PIP joints, had less impact on grip force.MCP I synovitis is the major contributor to reduced grip force in patients with early RA. This underlines the importance of the involvement of the thumb for impaired hand function in RA. MCP IV synovitis, but not PIP involvement or finger joint tenderness, also has a substantial impact on grip force.The online version contains supplementary material available at 10.1186/s13075-023-03212-6. Rheumatoid arthritis (RA) often has a major impact on hand function. In severe cases, impairments due to successive progressive joint destruction generate disability and lead to limitations in performing activities of daily living (ADL) . Joint iPatients with RA have been shown to have both reduced grip force in comparison with age- and sex-matched healthy populations –10, and Grip strength in the hands is dependent on many different components. General muscle strength, body weight, and overall physical functioning are independently associated with grip strength . There aAdditionally, muscle strength in the upper extremity has been shown to correlate with grip force , 21. PatInformation on the contribution of individual joints to impaired grip strength may be helpful for guiding individualized management. We have previously reported that wrist synovitis and extensive metacarpophalangeal (MCP) joint synovitis are associated with reduced grip force in early RA, but the impact of individual finger joints has not been assessed . The objAn inception cohort of patients with early RA (symptom duration ≤ 12 months) recruited in 1995–2005, was investigated. The patients were diagnosed with RA by a rheumatologist and fulfilled the 1987 American College of Rheumatology (ACR) classification criteria for RA . The stuPatients were managed according to usual care, with no pre-specified protocol for pharmacotherapy or rehabilitation. In a structured follow-up program, all patients were examined by the same rheumatologist. Visits were scheduled at 6, 12, and 24 months as well as 5 years after inclusion. Using a standardized protocol, individual joints were assessed as swollen/not swollen and tender/not tender, and standard 28-joint swollen joint counts (SJC) and tender joint counts (TJC) were obtained. Disability was assessed using the Health Assessment Questionnaire Disability Index (HAQ-DI) , the SweGrip force  was measured by using the electronic instrument Grippit . This was performed at the same visit as the joint assessment (within 1 h). All Grippit procedures were performed after 9.20 AM, in order to limit the impact of morning stiffness. The patient was seated comfortably in a chair without armrests, with the shoulder, arm, and hand in standard positions as previously described . The othLinear regression analyses were used to assess the cross-sectional relation between the involvement of individual finger proximal interphalangeal (PIP) and MCP joints and grip force in the corresponding hand at inclusion, 1 and 5 years. In the main analysis, synovitis and joint tenderness of individual joints in both hands were combined. As wrist synovitis, high ESR, and severe patient-reported pain (measured by VAS) were independently associated with reduced grip force in a previous study of this patient sample , and as Generalized estimating equations were used to assess the relation between finger joint synovitis and grip force over time. With repeated measures of grip force at inclusion, 1- and 5-year visits as the dependent variable, we investigated whether time-varying synovitis or tenderness of individual MCP and PIP joints were associated with reduced grip force over time, adjusted for time-varying wrist synovitis/tenderness, ESR and VAS pain. In addition, models adjusting for only wrist involvement and unadjusted models were constructed.In exploratory analyses, the longitudinal analyses of the relation between individual synovitis/tenderness and grip force over time were stratified by autoantibody status (RF and/or anti-CCP2 positive vs seronegative for both antibodies). A total of 215 patients with early RA  were investigated. The median symptom duration at inclusion was 7 months; interquartile range 5–10. Data on average grip force were available for 215 patients at inclusion, 216 patients at 1 year, and 175 patients at 5 years, although one patient was not able to perform the grip force test for the right hand at any of the visits , there was a significant association between MCP I synovitis and reduced grip force in both hands in seronegative patients , and patient-reported pain, indicating an independent effect on grip force by MCP synovitis. PIP synovitis appeared to affect grip force to a lesser extent. Exploratory analyses suggested similar patterns in seropositive and seronegative RA, although the estimates indicated stronger associations for MCP I and MCP V involvement with reduced grip force in seronegative RA.Longitudinal analyses revealed lower grip force over time in those with synovitis of MCP I and MCP IV joints in both hands. Corresponding analyses of tender joints largely mirrored those of joint swelling, but with less consistent results in the right and the left hand. In analyses that were not adjusted for other factors known to influence grip force, including patient-reported pain, there were more and stronger associations between joint tenderness and reduced grip force, suggesting a general effect of pain/tenderness on performance when measuring grip force.It is a well-known phenomenon that pain based on inflammation is triggered and worsened by motion and encumbrance in the affected joint . StudiesOur results point to a particular importance of MCP I in this context. In general, the thumb is very important for hand function, as grip, pinch, and grasp are ineffective without thumb opposition . AlthougGrip force is known to be affected by active joint inflammation , and hasOur findings that tenderness of individual MCP and PIP joints also had some impact on grip force are compatible with the study by Ozer et al. , who fouWhen measuring grip force, grasping an elliptical handle is preferred, as this measures force rather than pressure, contrary to squeezing a rubber bulb  . This prSimilar to the Jamar dynamometer, Grippit uses test protocols with standardized position of the arm and hand, performed in accordance with the American Society of Hand Therapists recommendations . To measThere are several patient-related factors that may influence the result of grip force testing including age and gender , hand doLimitations of this study are related to the fact that patients were included before the principle of treat to target management of RA was established. Patients diagnosed in more recent years may experience less joint involvement and better hand function over time. However, associations at diagnosis should not be affected by changes in therapy standards. Although we adjusted for several relevant factors, including patient-reported pain, we did not have access to data on localized pain or hand discomfort. Furthermore, data on psychologic factors that may affect patient performance in functional tests were not collected in the present study.To sum up, we found that synovitis of MCP I, which occurs in the majority of patients with early RA, had the strongest association with grip strength. This information could be helpful for individualizing therapy, including intra-articular glucocorticoid injections, systemic anti-rheumatic treatment, and structured hand training. Such individualized treatment and hand rehabilitation may contribute to improved ability to perform daily activities, in particular those requiring substantial grip strength, and hence to improved health and quality of life for patients with RA.MCP synovitis of the thumb is common in patients with early RA, and a major contributor to reduced grip force over the first 5 years.Although less frequent, the involvement of MCP IV and MCP V may also have a significant impact on hand function.Despite improvement, grip force was still substantially reduced compared to the general population 5 years after RA diagnosis.This underlines the importance of both efficient treatment of synovitis and structured hand training in early RA.Additional file 1: Supplementary Table 1. Relation between involvement of individual MCP and PIP joints and grip force (% of expected). Adjusted for wrist synovitis/tenderness. Supplementary Table 2. Relation between involvement of individual MCP and PIP joints and grip force (% of expected). Unadjusted. Supplementary Table 3. Relation between synovitis of individual MCP and PIP joints and grip force (% of expected), separate for the right and left hand, fully adjusted. Supplementary Table 4. Relation between tenderness of individual MCP and PIP joints and grip force (% of expected), separate for the right and left hand, fully adjusted. Supplementary Table 5. Relation between synovitis of individual MCP and PIP joints and grip force of the right hand or left hand (% of expected) in patients with early RA. Unadjusted. Supplementary Table 6. Relation between synovitis of individual MCP and PIP joints and grip force of the right hand or left hand (% of expected) in patients with early RA. Adjusted for wrist synovitis. Supplementary Table 7. Relation between joint tenderness of individual MCP and PIP joints and grip force of the right hand or left hand (% of expected) in patients with early RA. Unadjusted. Supplementary Table 8. Relation between tenderness of individual MCP and PIP joints and grip force of the right hand or left hand (% of expected) in patients with early RA. Adjusted for wrist tenderness. Supplementary Table 9. RF/anti-CCP positive patients with RA. Relation over time between involvement of individual MCP and PIP joints and grip force. Supplementary Table 10. RF- and anti-CCP negative patients with RA. Relation over time between involvement of individual MCP and PIP joints and grip force.


ITU) were segmented on T2–weighted imaging, while peritumoral ROIs were segmented using two methods: ROIPTU_2mm, ROIPTU_4mm, and ROIPTU_6mm, obtained by dilating the boundary of ROIITU by 2 mm, 4 mm, and 6 mm, respectively; and ROIMR_F and ROIMR_BVLN, obtained by separating the fat and blood vessels + lymph nodes in the mesorectum. After feature extraction and selection, 12 logistic regression models were established using radiomics features derived from different ROIs or ROI combinations, and five–fold cross–validation was performed. The average area under the receiver operating characteristic curve (AUC) was used to evaluate the performance of the models. The study included 209 patients, consisting of 118 pGR and 91 non–pGR patients. The model that integrated ROIITU and ROIMR_BVLN features demonstrated the highest predictive ability, with an AUC  of 0.936 (0.904–0.972) in the training cohort and 0.859 (0.745–0.974) in the validation cohort. This model outperformed models that utilized ROIITU alone (AUC = 0.779), ROIMR_BVLN alone (AUC = 0.758), and other models. The radscore derived from the optimal model can predict the treatment response and prognosis after nCRT. Our findings validated that the integration of intratumoral and peritumoral radiomic features, especially those associated with mesorectal blood vessels and lymph nodes, serves as a potent predictor of pGR to nCRT in patients with LARC. Pending further corroboration in future research, these insights could provide novel imaging markers for refining therapeutic strategies.The objective of our study is to investigate the predictive value of various combinations of radiomic features from intratumoral and different peritumoral regions of interest (ROIs) for achieving a good pathological response (pGR) following neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced rectal cancer (LARC). This retrospective study was conducted using data from LARC patients who underwent nCRT between 2013 and 2021. Patients were divided into training and validation cohorts at a ratio of 4:1. Intratumoral ROIs (ROI Colorectal cancer is the second most common cause of cancer–related deaths worldwide, with rectal cancer accounting for over one–third of all colorectal cancer cases . RecentlHowever, a confirmation of nCRT response can only be obtained through the examination of resected specimens after surgery. Although previous studies have shown that several clinical factors and imaging assessments are associated with the response to nCRT in LARC patients ,13,14,15MR_F) and ROI for mesorectal vessels + lymph nodes (ROIMR_BVLN) based on signal differences in T2WI sequences. This approach, premised on the differentiation of tissue components, offers greater interpretability than traditional peritumoral ROI segmentation methods.The extant literature suggests that peritumoral radiomic features in LARC are associated with various clinical outcomes, including response to neoadjuvant treatment, lymph node metastasis, neural invasion, disease–free survival (DFS), and overall survival (OS) ,23,24,25MR_F and ROIMR_BVLN encompass crucial information pertinent to the prediction of the neoadjuvant treatment response. Thus, we aimed to investigate the value of radiomic features from intratumoral and different peritumoral ROIs for predicting the response to nCRT in LARC patients.We hypothesized that both ROIThis retrospective study was approved by the institutional review board of Peking University Third Hospital, Beijing, PR China (IRB00006761–M2022474). The board waived the requirement for obtaining informed patient consent.We included consecutive patients diagnosed with LARC who underwent nCRT between January 2013 and December 2021 at our hospital. The exclusion criteria were as follows: (1) distance from the anal verge greater than 10 cm; (2) not receiving standard nCRT or changing the nCRT regimen; (3) not undergoing TME surgery; (4) developing distant metastasis during the treatment period; (5) lacking pre–nCRT MRI data before treatment; (6) the absence of T2–weighted imaging (T2WI) sequences; (7) significant image artifacts that affect the determination of tumor boundaries; and (8) the absence of postoperative pathological results. The patient selection process is illustrated in All patients received nCRT treatment according to a specific protocol. The radiation doses ranged between 45 and 50 Gy, administered over 25 fractions. The radiation clinical target volume encompassed the primary rectal cancer, perirectal and internal iliac nodes, mesorectum, pelvic sidewalls, and presacral space, with the upper edge at the sacral promontory. Concomitant oral capecitabine or XELOX regimen chemotherapy was administered during radiotherapy.The patients’ pathologic tumor regression grade (TRG) was assessed based on the American Joint Committee on Cancer (AJCC) eighth edition classification standard . The TRGAll patients in our cohort underwent pretreatment rectal MRI consisting of standard high–resolution T2–weighted imaging (T2WI) on 3.0–T Discovery MR 750  or 3.0–T MAGNETOM Prisma . Detailed information regarding the parameters of the two scans is provided in (1)ITU): First, the location and extent of the lesion was confirmed by combining the DWI and T2WI sequences. Subsequently, the tumor was manually segmented with meticulous attention to detail, ensuring its proper inclusion within the rectal contour and extension beyond the serosa, while simultaneously excluding any fibrous bands or spicules surrounding it.Intratumoral region of interest (ROI(2)PTU_2mm) was generated by applying the “dilation” tool on the uAI platform to the initial ROIITU, thereby expanding its boundaries by 2 mm and retaining the added portion. To ensure that the ROI solely consisted of the rectal wall and mesorectum around the tumor, the areas outside the mesorectal fascia, within the rectal lumen, and inside the tumor were manually excluded.The 2 mm peritumoral region of interest (ROI(3)PTU_4mm) was segmented using the same method as ROIPTU_2mm, except that the dilation distance was increased to 4 mm.The 4 mm peritumoral region of interest (ROI(4)PTU_6mm) was segmented using the same method as ROIPTU_2mm, except that the dilation distance was increased to 6 mm.The 6 mm peritumoral region of interest (ROI(5)MR) refers to the area within the mesorectal fascia, outside the contours of the rectum and tumor, and below the peritoneal reflection.The mesorectal region of interest (ROI(6)MR_F) was created using the “threshold separation” tool on the uAI platform. The signal intensity threshold was adjusted to select only the fat signals  within the ROIMR, and a manual correction was carried out to remove the non–fat contents.The mesorectal fat region of interest (ROI(7)MR_BVLN) was created by adjusting the signal intensity threshold to select the middle to low signals within the ROIMR, which were mostly composed of the blood vessels and lymph nodes. A manual correction of the ROI was then performed to ensure that it only included blood vessels and lymph nodes.The mesorectal blood vessels + lymph nodes region of interest  format images of each patient were uploaded to the uAI research portal  for analysis. Radiologist 1  manually segmented all the regions of interest (ROIs), while radiologist 2  randomly selected 30% of all cases for re–segmentation to evaluate the inter–reader consistency. The two radiologists were kept unaware of the clinical and pathological information of the patients, as well as each other’s segmentation. Subsequently, an experienced radiologist  reviewed and modified the ROIs segmented by radiologist 1. The modified ROIs were then utilized for the final analysis. After utilizing the uAI platform to adjust the image’s window width and level appropriately for a clear display of the lesion and mesorectum, we proceeded to segment the ROIs as outlined below:The ROI segmentation process is shown in Two weeks after segmentation, the clinical features comprising baseline information and MRI assessments were collected. The baseline information included age, gender, body mass index (BMI), the presence or absence of diabetes/hypertension, clinical T stage (cT), clinical N stage (cN), white blood cell count (WBC), hemoglobin level (HGB), platelet count (PLT), lymphocyte count, neutrophil count, eosinophil count, monocyte count, neutrophil–to–lymphocyte ratio, lymphocyte–to–monocyte ratio, platelet–to–lymphocyte ratio, carcinoembryonic antigen (CEA), cancer antigen 125 (CA125), and cancer antigen 199 (CA199). The MRI assessments consisted of the distance from the mass to the anal verge (DTAV), the tumor length, mesorectal fascia involvement (MRF), extramural vascular invasion (EMVI), and lateral pelvic lymph node metastasis (LPLN). MRF positivity was defined as the minimum distance between the tumor  and the mesorectal fascia being ≤1 mm. EMVI positivity was defined as the presence of tumor signals within the blood vessels outside the rectal lumen where the tumor is located . LPLN poWe followed up the patients by reviewing their inpatient and outpatient medical records and conducting phone interviews. Overall survival (OS) was defined as the duration from the surgery date to the latest follow–up or death caused by any reasons. Disease–free survival (DFS) was defined as the interval between the surgery date and the first incidence of local tumor recurrence or distant metastasi. If disease progression did not occur, DFS was determined as the period from the surgery date to the last follow–up.https://pyradiomics.readthedocs.io/en/latest/features.html (accessed on 20 December 2022).The uAI platform was utilized to perform image preprocessing and radiomic feature extraction. To reduce image heterogeneity, anisotropic pixels were resampled using B–spline interpolation to generate isotropic pixels of 1.0 × 1.0 × 1.0 (mm). The extracted features included first–order statistical features, shape features, texture features, and filter features, resulting in a total of 2264 features extracted from each ROI. The radiomic features generated are based on Pyradiomics , an openWe evaluated the inter–rater reliability of the radiomic features extracted by two radiologists using the intra–class correlation coefficient (ICC). The ICCs ranges from 0 to 1, with a value between 0.80 and 1.0 indicating almost perfect agreement, 0.61 to 0.80 indicating substantial agreement, 0.41 to 0.60 indicating moderate agreement, 0.21 to 0.40 indicating fair agreement, and 0 to 0.20 indicating poor agreement. To ensure the extracted features were robust, only those with an ICC greater than 0.80 were included in subsequent analyses.mean)/s. Here, X denotes the original feature value; Xmean and s represent the mean value and the standard deviation of the feature in the training cohort, respectively. Then we applied the same method to the validation cohort using the mean and standard deviation of the training cohort. Next, we removed features with a variance less than 1.0 using the variance threshold method. Then, we performed a statistical test on each feature and retained only those with a p–value less than 0.05. Finally, we employed the least absolute shrinkage and selection operator (LASSO) with five–fold cross–validation to select the features with the highest predictive power for pGR.To make the features more comparable, we standardized the features of the training cohort using the z–score method: z =  method, and their nomenclature followed the LR + subscript format based on the corresponding ROI. The models established using a single ROI comprised LRTo train and validate the model and reduce the bias from data splitting, we used the five–fold cross–validation method. We randomly split 209 patients into five groups of similar sizes and proportions of pGR and pPR. We trained the model on four groups and validated it on the remaining one. We repeated this process five times so that every sample was in both the training and validation sets. We then evaluated the model’s performance using the average measures of the training and validation sets across all five groups.0 + β1X1 + β2X2 + β3X3 +···+ βnXn, where Xn refers to the nth selected feature and βn denotes the coefficient associated with the nth feature. Furthermore, clinical models, radscore models, and clinical–radscore models (cli–radscore) were built and their performance was evaluated on the validation cohort.The models’ performance was assessed by computing the average AUC of the validation cohort. The stability of the model was assessed by the coefficient of variation (CV) of the AUC in the validation cohorts of the five folds. Subsequently, for the model with the highest AUC, a radiomics score (radscore) was computed for each patient by utilizing the features and coefficients acquired from LASSO regression. The radscore was obtained using the following formula: radscore = β2 or Fisher’s exact test, while continuous variables were analyzed using either the independent–sample t–test  or the Wilcoxon rank–sum test . Variables with a p–value less than 0.1 in univariate analysis were subsequently included in a multiple stepwise logistic regression analysis, with the final selection of variables based on the Akaike’s Information Criterion (AIC) method. The AIC, which is a measure of the goodness–of–fit of a statistical model, was calculated as AIC = −2InL + 2k, where L represents the maximum likelihood of the model and k represents the number of adjustable parameters in the model. A smaller AIC value indicates a better fit of the model. Receiver operating characteristic (ROC) curves were plotted to quantify the differentiation performance of the established model, and the area under the curve (AUC) was calculated. DeLong’s test was utilized to compare any arbitrary two ROC curves. Moreover, decision curve analysis was employed to assess the clinical usefulness of each model. The “surv_cutpoint” function from the R package “survminer” was utilized to transform the continuous variables in survival analysis into categorical variables. Disease–free survival (DFS) durations were determined from the surgical date to either the occurrence of tumor recurrence/metastasis or the latest follow–up appointment. We designated the incidence of tumor recurrence/metastasis as an event, while patients who were lost to follow–up were considered censored. To visualize the DFS trends, we utilized Kaplan–Meier estimates to construct the DFS curves. Furthermore, the log–rank test was employed to scrutinize the differences across these curves. The Cox proportional hazards model was utilized for both the univariate and multivariate analyses to identify the risk factors associated with DFS. The predictive performance of the model for DFS was evaluated using the C–index. A two–tailed p–value < 0.05 was considered to indicate a statistically significant difference. All statistical analyses were performed with R software  and SPSS .The categorical variables were analyzed using either the χp < 0.05) observed in DTAV, tumor length, MRF, EMVI, platelet count, neutrophil count, NLR, and PLR between the two groups. No significant differences (p ≥ 0.05) were observed in the remaining clinical features , 74 (35%), 71 (34%), and 20 (10%) classified as TRG 0, 1, 2, and 3, respectively. Of these, 118 patients were classified as pGR, while 91 patients were classified as pPR. There were significant statistical differences . A multivariate stepwise logistic regression analysis was conducted on clinical factors with a p–value less than 0.1, revealing that two factors, namely DTAV > 4 cm  and PLR , were independent predictors of pGR. The results of the univariate and multivariate analyses are illustrated in In both the training and validation cohorts, the radscore of the pGR group was higher than that of the pPR group  experienced disease progression, with 10 cases (4.4%) showing local recurrence and 38 cases (16.6%) presenting distant metastasis. Specifically, lung metastasis was observed in 17 cases, liver metastasis in 16 cases, bone metastasis in 4 cases, lymph node metastasis in 3 cases, and metastasis of unknown location in 2 cases. Moreover, seven patients died during the follow–up period.p = 0.029)  a. We conITU and ROIMR_BVLN had the highest AUC of 0.859, with a sensitivity of 78.9%, specificity of 80.3%, and accuracy of 79.4%. This model could accurately distinguish between pGR and pPR patients and outperformed other combinations of tumoral and peritumoral ROIs. Notwithstanding the substantial differences in numerous clinical variables—such as DTAV, tumor length, MRF, EMVI, platelet count, neutrophil count, NLR, and PLR—observed between the pGR and pPR groups in our patient data comparisons, only DTAV and PLR retained their statistical significance following univariate and multivariate analyses on the training cohort. This suggests potential instability in the clinical factors under consideration. Additionally, our findings revealed that incorporating these clinical factors did not bolster the predictive accuracy of the radscore model. A plausible interpretation might be attributed to the inherent volatility of the clinical factors. These factors within an individual patient may demonstrate variability over time, be subjected to alterations across diverse physiological conditions, or fall prey to inaccuracies in measurement, culminating in unpredictable predictive outcomes. For example, the appraisal of radiological characteristics such as DTAV, tumor length, MRF, and EMVI can be subject to the physician’s expertise or inaccuracies in measurement. Moreover, hematological parameters including platelet count, neutrophil count, NLR, and PLR may undergo fluctuation, depending on the overall immune–inflammatory status of the patient.In this study, we established several models based on radiomic features of the intratumoral ROI and different peritumoral ROIs from pre–nCRT MRI. The model that combined features of ROIIn the realm of MRI for rectal cancer, high–resolution T2WI sequences are predominantly utilized, offering a vivid delineation of both the rectal neoplasm and its adjacent structures ,33. T2WIMR_F) and mesorectal blood vessels and lymph nodes (ROIMR_BVLN). Our findings revealed that the model (AUC = 0.859) that integrated features from ROIITU and ROIMR_BVLN outperformed the models employing ROIITU and ROIMR_BVLN separately. In this model, we utilized 15 texture features extracted from ROIITU, alongside 4 first–order features from ROIMR_BVLN and additional 9 texture features from ROIMR_BVLN. As an example, the “Original_GLSZM_HighGrayLevelZoneEmphasis” texture feature extracted from ROIMR_BVLN can provide insights into the distribution of high–intensity pixels in an image. This feature is indicative of the co–occurrence strength of the high gray–level values within the image, allowing for the identification of bright or light areas present in the image. A higher value of this feature corresponds to a greater prevalence of bright areas in the image. By comparing the values of this feature, we can discern differences in the signal intensity distribution between pGR and pPR patients. Our results indicated that the tumor, blood vessels, and lymph nodes in the rectal vicinity all harbored complementary information linked with response to nCRT. The radscore, predicated on the fusion of ROIITU and ROIMR_BVLN features, also correlated with the treatment response and prognosis of LARC patients post–nCRT. The radiomic features of the blood vessels and lymph nodes around the tumor could be potential imaging biomarkers for predicting the response to nCRT, potentially due to the following reasons: firstly, the growth and nutrient uptake of tumors are closely linked with microvascular density around the tumor; secondly, hematogenous and lymphatic metastasis are the principal pathways of rectal cancer metastasis; thirdly, radiotherapy per se affects the development of the microvessels around the tumor. These reasons could lead to morphological and signal alterations of blood vessels and lymph nodes, which are intimately linked with tumor growth and metastasis, and could be reflected in the radiomic features [Radiomics research has recently focused on the peritumoral ROI due to its potential to provide valuable information about the tumor microenvironment, which can aid in assessing treatment efficacy and predicting tumor prognosis. However, a standardized definition of the peritumoral ROI is currently lacking. Most studies define it as the area surrounding the tumor within a certain distance, but determining the optimal distance remains a challenge. For example, in a study predicting the prognosis of non–small cell lung cancer, the peritumoral ROI was defined as the area 15 mm outside the lesion . In anotfeatures ,41.The present study has several limitations that should be acknowledged. Firstly, it is a single–center retrospective study, which may lead to a potential selection bias, as we did not consider patients who underwent conservative treatment. Secondly, external validation was not performed, and therefore the generalization performance of the model requires further verification. Thirdly, although we segmented the region of interest based on different tissue components, the relationship between radiomic features and histopathological physiology remains unclear, and additional studies are needed to establish a connection between these features and biological behavior. Fourthly, the manual segmentation of ROI may lead to inter–reader variability, but we attempted to ensure the robustness of the features using ICC analysis, and we plan to develop automatic segmentation models as a future research direction.In conclusion, our findings validated that the integration of intratumoral and peritumoral radiomic features, especially those associated with mesorectal blood vessels and lymph nodes, serves as a potent predictor of pGR to nCRT in patients with LARC. Additionally, the radscore, extrapolated from this model, demonstrated a notable correlation with the duration of DFS following surgery in the patient cohort. Pending further corroboration in future research, these insights could provide novel imaging markers for refining therapeutic strategies.


To retrospectively evaluate the feasibility and effectiveness of vertebroplasty using Spinejack implantation for the treatment and stabilization of painful vertebral compression fractures, in patients diagnosed with Multiple Myeloma (MM), to allow both an effective pain reduction and a global structural spine stabilization.From July 2017 and May 2022 thirty-nine patients diagnosed MM, with forty-nine vertebral compression fractures underwent percutaneous Vertebroplasty using Spinejack Implants. We analyzed the feasibility and complications of the procedure, the decrease in pain using visual analogue scale (VAS) and Functional Mobility Scale (FMS).The technical success rate was 100%. No procedure-related major complications or death occurred. In the 6-month follow-up, the mean VAS score decreased from 5.4 ± 1.0 to 0.2 ± 0.5 with a mean reduction of 96.3%. FMS decreased from 2.3 ± 0.5 vs. 1.2 ± 0.4 with a mean reduction of −47.8%. There were no major complications related to incorrect positioning of the Expandable Titanium SpineJack Implants. In five patients, a cement leak was observed with no associated clinical manifestations. The average length of hospital stay was 6–8 Hours6.6 ± 1.2 h. No new bone fractures or local disease recurrence occurred during a median contrast-enhanced CT follow-up of 6 months.Our results suggest that vertebroplasty, using Spinejack implantation for the treatment and stabilization of painful vertebral compression fractures, secondary to Multiple Myeloma is a safe and effective procedure with long - term pain relief and restoration of vertebral height. Multiple myeloma (MM) is a clonal plasma cell proliferative disorder characterized by the abnormal increase of monoclonal immunoglobulins that can ultimately evolve to specific end-organ damage.MM represents about 1.8% of all new cancer cases diagnosed in the United States each year with a median age of about 70 years and is slightly more commonly seen in males than females (1.4:1).Bone lesions are seen in 80% of patients with MM which are complicated frequently by skeletal-related events (SRE) such as hypercalcemia, bone pain, pathological fractures, vertebral collapse, and spinal deformities.The most commonly used therapies in treatment of MM are radiotherapy (RT), antiresorptive therapies  and Systemic Anti-Myeloma Treatments .Pharmacological treatment options for vertebral fractures include bisphosphonates, denosumab, teriparatide, and estrogen therapy. These medications have been shown to increase bone density and reduce the risk of subsequent fractures. In addition, bisphosphonates and denosumab have been shown to reduce the risk of vertebral fractures in patients with multiple myeloma.Non-invasive treatments for vertebral fractures include bracing, physical therapy, and pain management. Bracing has been shown to improve pain and reduce the risk of further fractures in patients with acute vertebral fractures. Physical therapy can improve mobility and reduce pain in patients with chronic vertebral fractures. Pain management can be achieved through a variety of methods, including non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and nerve blocks .Interventional radiology plays a fundamental role in this pathology, especially in the treatment of pain associated with secondary vertebral fractures, mainly with the use of percutaneous kyphoplasty (KPT) and vertebroplasty (VPT) as indicated in 2017 CIRSE guidelines  were introduced in order to reduce the secondary loss of vertebral body height associated with PKP after balloon deﬂation and till cementation and to allow persistent restoration of vertebral height and restoration of a normal kyphotic angle .Despite the literature supporting the efficacy of SpineJack [SJ] implant for treatment of vertebral post-traumatic compression fractures , no repoOur goal was to evaluate, for the first time, the feasibility and technical effectiveness of vertebroplasty with SJ implantation for the treatment of painful vertebral compression fracture, secondary to MM, to allow both an effective and prolonged pain reduction, restoration of vertebral height and ensure the biomechanical stability of the spine.In this retrospective study, thirty- nine patients  with MM who underwent VPT with SJ implantation between July 2017 and May 2022 were included .A total of 49 vertebrae were treated with the implantation of 98 SJs.The inclusion criteria were: back pain associated with the presence of a vertebral compressive fracture diagnosticated by a Computed Tomography (CT) scan or a Magnetic Resonance Imaging (MRI) scan.The exclusion criteria were: extensive epidural and spinal canal infiltration , severe canal stenosis and moderate and severe neurologic deficits.A systemic chemo-immunotherapy was previously performed to treat the neoplastic malignancy, and the vertebral augmentation was considered as a supportive therapy to reach a rapid relief of the pain.All patients were previously treated with radiotherapy with persistent pain.The pre-operative evaluation consisted of a combined oncological-radiological interventional clinical visit and the severity of pain was measured using the visual analog scale (VAS) and Functional Mobility Scale (FMS).VAS score was evaluated at 1-week and 1- 3- 6-month follow-up.FMS was recorded 1 month after the treatment to assess the effect of treatment on level of mobility and ability to walk. A 4-point FMS classification was used: 4, bedridden; 3, use of wheelchair; 2, limited painful ambulation; 1, normal ambulation.Vertebroplasty with SpineJack Implants was performed under dual CT  and fluoroscopy guidance to monitor the correct visualization, advancement, and expansion of the implants, control potential posterior wall protrusion and monitor any leaks during cement injection.All interventions were performed under conscious sedation with continuous intravenous infusion of fentanyl citrate  and received local anesthesia with subcutaneous injection of lidocaine hydrochloride at 2% anesthesia.Antibiotic prophylaxis  was performed in all patients.Two 10-gauge bone trocars (Stryker) were inserted into the vertebral body via a bilateral transpedicular approach in the lumbar spine or via a costotransverse approach in the thoracic spine.A blunt guide wire was placed bilaterally and through these a designed drill, mounted on a working cannula, was gently advanced manually and coaxially into the vertebral body, until the desired position of the implant to create the vertebral space for the implants.After preparation of both sides, the two SpineJack®  implants were inserted into the vertebral body and were gradually and simultaneously deployed until height restoration and kyphosis reduction were judged satisfactory.After implant detachment Poly-Methyl-Methacrylate (PMMA) bone cement  was slowly injected, under real time fluoroscopy, through the same working cannula used to insert the implants into the vertebral body until satisfactory vertebral filling was obtained.If leaks of cement appear, the procedure has been interrupted.An immediate post-procedure no contrast-enhanced CT was performed to evaluate the results and any complications –3.According to clinical follow-up, contrast-enhanced CT scans were acquired 6 months after the procedure.p value less than 0.05 was taken as significant. Statistical analysis was performed using OpenStat software.For the purposes of this study, continuous variables were shown as mean ± standard deviation (SD). Differences between the average VAS score at 1 week, 1, 3 and 6 months and FMS at 1 month after the procedure were evaluated by means of Student'st test or Fisher's exact test as appropriate. A A total of 98 expandable Titanium SpineJack Implants were inserted into 49 vertebrae .In 6 patients the Spinejack implants were implanted bilaterally in two vertebrae in the same operative session due to the presence of a double active fracture  without major complications.Minimal leakage of cement occurred in 5 procedures (10%), 2 anterior venous leakages, 1 posterolateral, and 2 intradiscal leakages, without clinical repercussions.Four patients developed a secondary vertebral fracture in a caudal segment respectively 7,14,22 and 37 days after procedure.The SJ procedure had a mean procedure duration of 23 ± 4 min.Adjacent fractures were successfully treated with implantation of SpineJack implants ; a mean middle column height restoration of 4.2 mm (baseline 14.9 ± 3.5 mm vs. immediately postoperative 19.1 ± 3.6 mm p < 0.001).Vertebral height restoration was observed in 30 vertebrae (61%), with a mean anterior column height restoration of 2.0 mm .p < 0.000; One week after treatment the median VAS score of pain was 1.5 ± 1.2  with a mean reduction of 72.2%  with a mean reduction of 88.89%  with a mean reduction of 94.44%  with a mean reduction of 96.3% .p < 0.000;) compared with baseline evaluation.One month after treatment the median FMS of disability was 1.2 ± 0.4  with a mean reduction of −47.8%  is also associated with up to 18% of adjacent post-treatment vertebral fractures .Kado et al. showed that in older women with vertebral fractures, hyperkyphosis predicts increased risk of death, independent of underlying spinal osteoporosis and the extent and severity of vertebral fractures .As evidenced on human specimen models, endplate depression after associated with an osteoporotic vertebral fracture, impairs the ability of the disc to distribute load evenly to the adjacent segments.Load concentration on the anterior portion of the adjacent vertebrae may contribute to increased subsequent fracture risk after an osteoporotic vertebral fracture which may be associated with increased morbidity and mortality in these patients .This secondary alteration of the biomechanics of the spine can be reduced by a realignment of the vertebral endplates, restoring normal disk mechanics and load sharing, through KPT or PITs .Since 1996 percutaneous VPT  and sincIn a recent systematic review and meta-analysis, which retrospectively evaluated about 2 million patients, it was confirmed that the execution of VPT and KPT reduced by at least 22% the 10-year mortality after compression fracture.p < .001) and 0.87 , respectively  concluded that “Cement augmentation is a very effective way of stabilizing the anterior and middle spinal columns without the need for metalwork fixation” .In 2017 CIRSE guidelines, VPT, KPT and percutaneous implant techniques (PIT) are indicated in the treatment of painful vertebrae with extensive osteolysis due to malignant infiltration by multiple myeloma, lymphoma and metastasis  is an expandable titanium intravertebral implant that restores vertebral height and maintains a correct kyphotic angle of the spine resulting in a more balanced distribution of axial load on fractured vertebrae, a restoration of intervertebral disc function, both in the pathological segment and throughout the spine .Its use has been mainly studied in the treatment of acute vertebral compression fractures with good results in terms of pain reduction and preservation of spine stability in short and long-term follow-up –27.Comparative studies between SJ and KPT have shown that the use of SJ is associated with less spinal deformity; the incidence of adjacent fractures consequently is significantly lower when using the SJ (3% to 5%) than 15%–20% with KPT , 29.While SpineJack has been shown to be effective in the treatment of vertebral compression fractures, there are potential complications associated with the procedure.One potential complication is cement leakage, which occurs when the bone cement used to stabilize the fracture leaks into surrounding tissues.However, studies have shown that the incidence of cement leakage with SpineJack is relatively low compared to other vertebral augmentation procedures –27.Another potential complication of SpineJack is vertebral refracture, which can occur when the treated vertebrae are subjected to additional stress and fracture again. The risk of refracture can be reduced with appropriate patient selection criteria and post-procedure rehabilitation.In addition, there is a risk of infection with any invasive procedure, including SpineJack.Other potential complications associated with SpineJack include bleeding, nerve injury, and device failure. However, these complications are rare and can usually be managed through appropriate monitoring and intervention –29.Only one study has been published that evaluated the use of the SJ in the treatment of vertebral pathological compression fractures secondary to bone metastases, with good results in terms of pain relief and reduction of complications .To date, this is the first study analyzing the efficacy of SJ in the treatment of vertebral fractures secondary to MM.Our preliminary experience coincides with the study by Cornelis et al.  highlighFurthermore, vertebral height was significantly increased both anteriorly and centrally a homogeneous cement distribution with a small and not clinically significant percentage of cement leaks.We believe that the advantage of using the combined CT-Fluoroscopy technique is especially evident in patients in whom the spine has significant pre-existing deformity and the CT guide has allowed us easier access to the vertebra and greater precision in positioning the implants.The fluoroscopic guidance allowed us a real-time synchronous opening of the implants, with excellent control of the restoration of the vertebral height, the preservation of the posterior wall and finally the correct distribution of the cement .An important factor was the use of mild sedation which allowed a rapid postoperative recovery of the patient, control of vital functions and a consequent rapid discharge, significantly reducing hospitalization times.We also believe that this innovative methodology could represent a further therapeutic option to be taken into consideration in some cases, selected in a multidisciplinary context, even before radiotherapy, in order to prevent post-irradiation fractures.Our study has limitations, being a single-center, retrospective study based on a small cohort of patients and short follow-up.Prospective comparative studies with long follow-up between the use of KPT and SJ in patients with MM are also needed to highlight the effective superiority of SJ in terms of reduction of complications secondary to spine instability.Nevertheless, our preliminary study shows that this technique is feasible and safe also in the treatment of vertebral compression fractures secondary to MM with a good reduction of pain, restoration of mobility and increase of spinal stability.This preliminary study highlights that the use of bilateral expandable titanium SpineJack implants, followed by vertebroplasty, is a safe and effective procedure for the treatment of vertebral fracture from pathological compression secondary to MM, allowing an adequate restoration of the vertebral height and a correct distribution of the craniocaudal load forces on the vertebral column.We observed a rapid and persistent improvement from the pain, resulting in a rapid improvement in the patient's mobility and ambulation.