Toripalimab combined with targeted therapy and chemotherapy achieves pathologic

lNTRODUCTlON

Gastric carcinoma has a high incidence in China. Surgery might be a radical cure for gastric carcinoma;however, it is limited to only early-stage gastric carcinoma (stage I). The 5-year survival rate of patients with locally advanced gastric carcinoma (late stage) is 30%-50%[1], even with an extended area of resection and lymph node dissection. Many studies have confirmed that the combination of adjuvant/neoadjuvant chemotherapy/chemoradiotherapy can improve patients’ prognosis, enhance R0 resection rates, reduce distant metastases and recurrence rates, and improve survival rates through tumor downstaging[2-4]. In the European randomized controlled phase III AIO-fluorouracil (FLOT)-4 trial, resectable gastric carcinoma patients received either the FLOT (docetaxel, oxaliplatin, calcium folinate, and fluorouracil) or epirubicin, cisplatin, and fluorouracil (ECF) regimen before and after surgery. The results showed that the FLOT regimen had better efficacy, higher R0 resection rate, better disease-free survival (DFS), and better overall survival (OS) than the ECF regimen, which laid the foundation for the FLOT regimen to become a new standard perioperative therapy for advanced gastric carcinoma. Therefore, a regimen that combines surgery with neoadjuvant or perioperative chemotherapy has been recommended by the guidelines of the Chinese Society of Clinical Oncology, the European Society for Medical Oncology, and the National Comprehensive Cancer Network (NCCN).

The KEYNOTE-059[5] and ATTRACTION-02[6] trials have suggested that programmed death-1 (PD-1) inhibitors are effective for advanced gastric carcinoma/adenocarcinoma of the gastroesophageal junction. The United States Food and Drug Administration (FDA) and the National Medical Products Administration have approved the indications for pembrolizumab in patients with a programmed death-ligand 1 (PD-L1) combined positive score (CPS) ≥ 1 and nivolumab in the third-line and posteriorline treatment of advanced gastric carcinoma. The CheckMate-649[7] and ATTRACTION-04[8] trials have revealed that nivolumab plus chemotherapy has significantly better efficacy than chemotherapy alone in the first-line treatment of advanced gastric carcinoma/adenocarcinoma. In China, as the first approved immunotherapy targeting PD-1, toripalimab (JS001) induces the endocytosis of PD-1, reduces the expression of PD-1 on the membrane surface, and relieves the immunosuppression of T cells,thereby achieving strong antitumor effects. In 2020, the American Society of Clinical Oncology reported the clinical response and biomarker analysis of first-line toripalimab combined with standard chemotherapy for solid tumors in a phase II cohort study[9]. The study found that the objective response rate (ORR) was 54.5%, the disease control rate was 84.8%, and the duration of response was 8.3 mo. Moreover, in the randomized controlled phase III KEYNOTE-585[10] trial, which is currently enrolling patients, therapy-naive patients with locally advanced gastric carcinoma/adenocarcinoma of the gastroesophageal junction in the experimental group will receive pembrolizumab combined with neoadjuvant chemotherapy before surgery and pembrolizumab combined with adjuvant chemotherapy after surgery, whereas those in the control group will receive placebo combined with chemotherapy.

The patient has been suffering from hepatitis B virus (HBV) infection for more than 30 years, without history of hypertension, coronary heart disease, diabetes, or tuberculosis.

Human epidermal growth factor receptor 2 (HER2), also known as erythroblastic oncogene B2(ERBB2), is a proto-oncogenic protein encoded by thegene on human chromosome 17. Tyrosine kinase receptor that binds to the membrane is a protein product of this gene. This receptor can promote cell proliferation and inhibit apoptosis, leading to neoplasm formation[11].overexpression or amplification is found in 13%-22% of patients with gastric carcinoma or adenocarcinoma of the esophagogastric junction[12]. Immunohistochemistry (IHC) staining and fluorescenthybridization (FISH) are recommended by the guidelines for the detection ofoverexpression in patients with advanced gastric adenocarcinoma. In 2010, trastuzumab was approved by the FDA as a first-line drug in combination chemotherapy for HER2-positive gastric carcinoma. In another study[13],preliminary results were obtained for combined immunotherapy, trastuzumab, and chemotherapy for gastric carcinoma/esophageal cancer/adenocarcinoma of the esophagogastric junction. The study found that the 6-mo progression-free survival (PFS) rate was 75%, the ORR was 91%, the median PFS was 13 mo, and the median OS was 27.3 mo. The above data were better than the previous data for HER2-positive advanced gastric carcinoma.

由于N组信号的内积值得到积累，尤其对于弱信号而言，内积值得到提高，因此信噪比下仍然可以较好的实现重构，降低重构误差.

In this study, we report a case in which pathologic complete response (pCR) was achieved by neoadjuvant toripalimab, Herceptin, and FLOT chemotherapy followed by surgery for HER2- and PDL1-positive locally advanced gastric carcinoma. We hope to provide more evidence for neoadjuvant therapies in gastric carcinoma patients by reporting this case.

CASE PRESENTATlON

Chief complaints

A 63-year-old male patient experienced dysphagia, poor appetite, night sweats, and fatigue on July 2,2020, and sought medical attention at the Hulunbuir People’s Hospital in Inner Mongolia, China.

History of present illness

Apart from the above aspects,is a crucial tumor suppressor gene, andmutation occurs at an incidence of approximately 45% in gastric carcinoma[21]. The efficacy of immunotherapy varies with themutation. According to the retrospective meta-analysis mentioned above,mutation was negatively correlated with the patients’ OS with either colon cancer or gastric carcinoma who received immunotherapy but was positively correlated with the efficacy of immunotherapy for lung cancer[21].In this study,c.329G＞C p.Arg110Pro mutation was detected using NGS in the baseline tissues of the patient. Therefore, additional prospective cohort studies are required to conclude and explore the correlation betweenmutation and the efficacy of immunotherapy for gastric carcinoma.

History of past illness

3）规范化原则：系统设计中的所有参数与技术指标均应参照现行的国家标准、行业标准和技术规范，并从系统实际需求出发，制定出科学合理的数据标准与规范，推动信息系统进一步规范化与标准化的实现。

我国理财市场发展处于初级阶段，银监会对银行、信托公司等进行监管，正确、基金、期货等公司由证监会监管，保险公司则由保监会监管，银行理财产品涉及以上监管多项内容，对产品的审批、份额管理以及保底承诺管控深度不同，对资金托管、风险控制以及信息披露等问题管控程度有限，造成监管机构监管执行力度不足，监管效率不高，为行业发展带来影响。

直到这时，周教授方才明白一切都是那个当导演的朋友搞的恶作剧。周教授心情一下颇不舒畅起来，气极败坏地走到院外拨通了那个导演朋友的电话，大声说，你怎么能这样么，玩笑开得太大了么。说完，像怀了深仇大恨似的，猛地摁了关机键。

Personal and family history

The patient’s family history is not applicable.

Physical examination

The tissues obtained from the bite biopsy were tested for PD-1, revealing CPS positivity (CPS = 1)(Figure 1C) and TPS negativity.

Laboratory examinations

On July 22, 2020, gastroscopy revealed protuberant lesions in the cardia and fundus; bite biopsy revealed adenocarcinoma of the cardia; IHC revealed HER-2 positivity (2+, FISH was recommended);hybridization revealed(-); and FISH revealedpositivity. Next-generation sequencing(NGS) revealed tumor protein p53 () c.329G＞C p.Arg110Pro (abundance 33.82%), andcopy number amplification (= 4.5).

Imaging examinations

On July 30, 2020, a computed tomography (CT) scan was performed (Figure 2A).

FlNAL DlAGNOSlS

(1) Thickened wall of the cardia and adjacent lesser curvature of the stomach, suggestive of carcinoma of the cardia, and invaded fundus and multiple lymph nodes in the hepatogastric ligament region, for which clinical and endoscopic examination needed to be performed; (2) Multiple cysts in the liver; (3)Cyst of the right kidney; (4) Slightly thickened left adrenal gland, with follow-up visits recommended;(5) Prostatic calcification; (6) Subpleural ground-glass opacity in the right lung and scattered nodules and granules on the pleura of both lungs and under the interlobar pleura, with follow-up visits recommended; and (7) A dot-like compact shadow on the 5right rib, for which follow-up visits were recommended.

TREATMENT

From July 30, 2020 to September 2020, four-cycle targeted therapy, chemotherapy, and immunotherapy were administered. The specific regimen was as follows: Trastuzumab: 420 mg in the first cycle and 280 mg in the second cycle; docetaxel: 90 mg, ivd, d1; oxaliplatin: 150 mg, ivd, d1; calcium folinate: 700 mg,ivd, d1; fluorouracil: 4800, civ, 46 h; and toripalimab: 240 mg, ivd, d2; Q2W. Grade I gastrointestinal reaction occurred and improved after symptomatic treatment.

The imaging findings (CT on October 15, 2020, compared with that on July 30, 2020) after the four cycles of therapy were as follows (Figure 2B): The wall thickness of the cardia and adjacent lesser curvature was less than that before therapy; lymph nodes in the hepatogastric ligament region were reduced in size; and subpleural infiltration in the right lower lobe was more absorbed. No other significant changes were noted. Upper gastrointestinal tract radiography revealed carcinoma of the cardia.

Here, we demonstrated that in a patient with HER2-positive locally advanced gastric carcinoma, there was scope for resection; therefore, a regimen composed of Herceptin, chemotherapy, and immunotherapy was carefully selected to achieve higher efficacy and better surgical resection. The patient was administered with the perioperative regimen comprising Herceptin, FLOT, and toripalimab. The postoperative pathological findings revealed that this regimen led to complete tumor response and the levels of tumor biomarkers returned to normal. Furthermore, no circulating tumor cell was detected and no significant immune-related adverse effects were noted, demonstrating that this regimen had sufficient efficacy and safety. The four-cycle chemotherapy was continued postoperatively and completed in the patient, in line with the principle of “effective treatment should be continued if the symptoms are relieved”. This patient is currently in the quarterly follow-up period. A previous study suggested that the ability to achieve postoperative pCR in patients with neoadjuvant therapy is positively correlated with longer durations of survival[22]. Thus far, all tumors have been removed from this patient using this regimen, and we hope that this regimen will lead to long-time survival benefits.

Under general anesthesia, the patient underwent laparoscopic radical D2 gastrectomy for gastric carcinoma on October 23, 2020. Surgical findings revealed a neoplasm at the fundus of the stomach from the cardia, which presented as a 4 cm × 2 cm ulcer with local serosal invasion. No significantly enlarged lymph nodes were found around the stomach. The lesions presented post-chemotherapy scar-like changes. Multiple small lymph nodes were noted around the stomach, most of which were postchemotherapy changes. The postoperative pathological findings revealed focal (proximal stomach) mild atypical glandular hyperplasia with chronic mucosal inflammation, no clear residual tumor (tumor regression grade 0), no regional lymph node metastasis, and negative upper and lower cut ends. The grading was as follows: Station 10/9, Station 20/6, Station 3A 0/12, Station 3B 0/2, Station 4SA soft tissue (-), Station 4SB 0/1 and soft tissue (-), Station 4D 0/2, Station 5 soft tissue (-), Station 60/1,Station 7 soft tissue (-), Station 8 soft tissue (-), Station 90/4, Station 12A soft tissue (-), Station 190/1,and Station 200/2. No circulating tumor microemboli or circulating tumor cells were detected. A retest of tumor markers showed a return to normal levels.

OUTCOME AND FOLLOW-UP

Informed written consent was obtained from the patient for the publication of this

DlSCUSSlON

report and any accompanying images.

It is believed that the basis for immunotherapy to benefit HER2-positive patients is that trastuzumab induces antibody-dependent cell-mediated cytotoxicity, improves the presentation of tumor antigens,and paves the way for immune reaction of tumors[14]. Clinical data also show that HER2-positive breast cancer has more types of tumor-infiltrating lymphocytes than average, which demonstrates the importance of trastuzumab in immunity induction[15]. In addition, studies have confirmed that trastuzumab can increase the expression level of PD-L1 in immune cells of patients with breast cancer[16]. Combined with the encouraging clinical outcome of this patient, it is promising to investigate the systemic immune responses in depth, for instance, the lymphocyte infiltration, immune marker dynamics, and functional cytokine secretion. Moreover, this patient has been infected with HBV for many years, which may have an impact on his immune system. Large cohorts are necessary to draw conclusions regarding this aspect if feasible.

There are many ongoing studies of neoadjuvant immunotherapy combined with chemotherapy or radiotherapy; however, most of these studies are phase II studies with small cohorts. According to some of the results reported thus far, these combined regimens have shown promising efficacy and safety[17-19] (Table 1). Many studies have shown that chemotherapy can: (1) Boost the release of damageassociated molecular patterns from tumor cells and improve tumor cell immunogenicity; and (2) Elevate the levels of major histocompatibility complex molecules and enhance tumor antigen presentation[20].Additionally, chemotherapy promotes the expression of PD-1/PD-L1 through a variety of signaling pathways. Therefore, in this case, chemotherapy and immunotherapy were applied for the patient before the surgical removal. For gastric carcinoma, first-line immunotherapy combined with chemotherapy is recommended by NCCN guidelines for patients with a PD-L1 CPS ≥ 5. However, the CheckMate 649 study[7] suggested that nivolumab combined with chemotherapy improves the OS and DFS of all patients, including those with a CPS ≥ 5 and CPS ≥ 1. In line with this, our patient’s IHC results revealed PD-L1 with a CPS of 1. More prospective cohort studies are needed to determine the selection of biomarkers in neoadjuvant therapies involving immunotherapy and chemotherapy.

On July 22, 2020, gastroscopy revealed protuberant lesions in the cardia and fundus; bite biopsy revealed adenocarcinoma of the cardia (Figure 1A); IHC revealed HER2 positivity (2+, FISH was recommended);hybridization revealed(-); and FISH revealedpositivity (Figure 1B).

区块链：描绘物联网安全新愿景………………………………………………………… 徐恪，吴波，沈蒙 24-6-52

CONCLUSlON

在实验三中做了下列手术，这个手术的设计相当于将实验二中具有“库身份”的A段连接在实验二被实验证明必死的B段上方。

FOOTNOTES

Liu R designed the experiments, processed the data, applied for fund support, and wrote the first draft; Wang X performed the data collection; Ji Z, Deng T, Li HL, Zhang YH, Yang YC, Ge SH, Zhang L, Bai M and Ning T performed the data analysis; Ba Y modified the article.

本研究从全金安区四个级别随机抽取159个定级单元作为检验样点，通过采用统计分析软件SPSS中的相关性分析的功能计算定级指数与经营效益分值间的相关程度。

Chinese Research Hospital Association, No. Y2019FH-DTCC-SC3.

With good postoperative recovery, the postoperative CT film (performed on November 16, 2020,Figure 2C) was stored, and the four-cycle chemotherapy regimen was continued at the same dosage as that administered previously. Until February 27, 2022, the patient was examined quarterly for 12 mo (4 times), and he was in a good condition without disease progression. The timeline of this case report is indicated in Figure 3.

In a study of combined immunotherapy and trastuzumab treatment for HER2-positive gastric carcinoma[13], 25 patients received immunotherapy and targeted therapy as the initial treatment and chemotherapy in the second cycle, whereas 12 patients received immunotherapy, targeted therapy, and chemotherapy as the initial treatment. In the initial treatment, no significant difference was observed in PFS and 12-mo OS between the 25-patient and 12-patient groups. While in our case, the patient did not receive chemotherapy in the initial treatment; more specifically, the patient received Herceptin and toripalimab in the first cycle and chemotherapy in the second cycle. Previous studies have found no difference in survival between groups receiving chemotherapy and groups not receiving chemotherapy in the initial treatment. Our study suggested that, for HER2-positive gastric carcinoma patients, it is worthy to further evaluate whether the first-line “de-chemotherapy” can be carried out with a large cohort sample.

Nothing to disclose.

给排水工程管材的选择需要根据给排水工程的实际情况，进行择优选择，按照不同的特性，选择适合当地环境标准的管材。给排水管材的选用一般遵循以下原则：①管道的安全性与卫生性。根据环保健康与安全要求，选用给水管材必须满足卫生环保要求。尤其是生活给水管道，选用管材必须符合国家现行有关产品标准的要求，确保运输过程中的水质卫生情况。②管材的实用性。即选用的管材必须满足使用要求，首先要求管道在运输压力及温度环境下要具有足够强的机械强度，其次管道内还具有良好耐腐蚀性。确保所选的材料能够具有较强的环境适应性。③管材的经济性。设计时应该选择既经济，又具有良好性能和安装维修方面的管材。

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

Rui Liu 0000-0003-1287-2589; Xia Wang 0000-0002-2935-0691; Zhi Ji 0000-0002-2935-0692; Ting Deng 0001-0002-2935-0694; Hong-Li Li 0000-0002-8476-0936; Yan-Hui Zhang 0002-0002-3546-0876; Yu-Chong Yang 0000-0002-2935-0698; Shao-Hua Ge 0001-0002-2935-7642; Le Zhang 0001-0002-2935-0699; Ming Bai 0000-0002-2935-0666; Tao Ning 0000-0002-2935-0654; Yi Ba 0000-0002-2935-0634.

2017年，彩云社区在进行居民情况调查时，了解到杨家的事。李敬益打算啃啃硬骨头，牵头调解试试看。他把杨家七个兄妹都找来，挨个了解了下他们的想法；再把老太太的两个兄弟请来，“两个舅舅一来，讲了句公道话，‘都是一家人，现在就剩下你们妈妈了，也得考虑考虑她。’”李敬益听完，心里大概有了数，这一家人的目光总围着商铺转，如果按着以往的思路往下走，只讨论商铺的归属，这矛盾怕是难解。得转换个思路，综合考虑、综合盘算。

Fan JR

Wang TQ

贵州省积极创新水利投融资模式，建立健全水利投入稳定增长机制，全面落实好水利建设基金、提取土地出让收益金12%用于农田水利建设、鼓励信贷融资等各项政策，从公共财政、信贷融资、社会投入等多渠道筹集水利建设资金。预计全年完成水利投资185.52亿元，比2012年增长8.5%，再次创下历史新高。其中，完成中央投资72.52亿元、地方投资73亿元、社会投资40亿元。

Fan JR