BACKGROUND:A multicenter study on the DNA mismatch repair (MMR) genes enabled us to study the profiling of germline variants in MMR genes of colorectal cancer (CRC) patients with MMR deficiency (dMMR). The clinicopathological differences between Lynch syndrome (LS) patients and sporadic dMMR CRC patients were compared by Student's t-test and χ2 test. The molecular profiling of germline variants in MMR genes in Chinese CRC patients with dMMR is clarified. METHODS:A total of 326 CRC patients with dMMR were enrolled. Next-generation sequencing (NGS) and Sanger sequencing were performed using tumor-adjacent tissues of enrolled patients. Four MMR genes (MLH1, MSH2, MSH6, and PMS2) are included in the NGS panel. RESULTS:A total of 113 germline variants were detected, including 81 pathogenic and likely pathogenic variants. The clinicopathologic differences between CRC patients with/without LS were observed in age, family history, lesion location, and dMMR patterns. The CRC cohort with IHC-MSH6 negative alone shows the highest prevalence rate of LS. MLH1 was detected with the most germline variants. The mutational hotspot region of MLH1 is Exon 8, Exon 4 for MSH6, Exon 11 for PMS2, and Exon 7 for MSH2. Several germline hotspots were labeled on each MMR gene sequence by fixed-size bin analysis. In addition, some variants were novel discovered based on the presence or absence of the RS number and allele frequency record. CONCLUSIONS:Our study classified the clinicopathological features between sporadic CRC patients and LS patients. More importantly, the molecular profiling of the MMR gene germline variant was experimentally elucidated, which deepens the knowledge of MMR genes and provides a new perspective for the subsequent studies on the landscape of germline variants of Chinese LS patients.

The persistent high burden of lung cancer in China highlights a critical demand for the identification of new therapeutic targets and intervention approaches. Our initial integrative analysis of metabolomic and transcriptomic data revealed a previously uncharacterized tumor-suppressive mechanism mediated by CCDC6 in lung adenocarcinoma. We discovered an interaction between CCDC6 and ASS1, concomitant with marked reductions in citrulline and aspartate within tumor tissues. compared to the adjacent normal tissues. Additionally, co-stimulation with citrulline and aspartate induces ASS1 localization in the mitochondria ASS1 localized in the mitochondria, but the underlying mechanism remains unclear. This study aimed to delineate the dual tumor-suppressive actions of ASS1: firstly, through the recruitment of the deubiquitinase OTUD7A to remove ubiquitin chains from MFN1/2 and OPA1, thereby stabilizing the mitochondrial fusion machinery and inducing hyperfused network formation; and secondly, via the CCDC6-ASS1 complex, which instigates mitochondrial reactive oxygen species accumulation, compromises ATP synthesis, and reduces mitochondrial membrane potential, consequently inducing a state of metabolic dormancy in tumor cells. This study elucidates the mechanism by which the ASS1-CCDC6 axis suppresses lung adenocarcinoma progression by remodeling mitochondrial dynamics and metabolic homeostasis,, thereby establishing a theoretical basis for mitochondria-targeted precision therapy.

Oxidative stress plays a significant regulatory role in tumor immune responses and can influence the efficacy of immunotherapy. Accordingly, therapeutic interventions targeting oxidative stress-related mechanisms, whether alone or in combination with other modalities, represent a compelling strategy to enhance cancer therapy. In this study, we first profiled the landscape of oxidative stress responses within the tumor microenvironment by integrating pan-cancer single-cell RNA sequencing datasets, which revealed that cancer-associated fibroblasts (CAFs) possessed the highest oxidative stress response score. Based on this finding, we developed a fibroblast-derived oxidative stress-related signature (FOSR.Sig) by screening for genes most correlated with oxidative stress responses in CAFs. Furthermore, with a machine learning framework, our model achieved exceptional accuracy in predicting ICI response, and its robustness was subsequently validated. Importantly, a prognostic model incorporating the FOSR.Sig was developed using TCGA pan-cancer datasets and LASSO regression analysis, which provides novel prognostic biomarkers applicable across diverse cancer types. Mechanistic investigation of TFG, the top risk score gene, revealed its critical role in the tumor microenvironment through comprehensive in vitro and in vivo experiments and RNA-seq assays. Our study highlights the therapeutic potential of targeting oxidative stress in cancer-associated fibroblasts as a novel strategy to empower antitumor immunity and prevent immune escape. And provide a promising powerful tool for predicting responses to tumor immunotherapy and patient outcomes.

Micronuclei are small, independent cytoplasmic structures containing nuclear material. They typically form during cell division due to DNA damage or division abnormalities, serve as biomarkers of genetic damage, and are closely associated with chromosomal instability (CIN). Emerging evidence suggests that micronuclei actively promote and exacerbate CIN, with significant implications in disease pathology and potential therapeutic applications. This review provides a comprehensive overview of micronuclei by exploring their origins, formation mechanisms, and functional consequences, and detailing the fate of micronuclei post-formation, which is essential for elucidating their role in genomic instability and potential therapeutic implications. Furthermore, micronuclei can contribute to extreme chromosomal shattering and genomic instability. These processes are increasingly recognized as critical contributors to disease progression, particularly in cancer. Although micronuclei have traditionally been viewed as markers of genomic instability, recent evidence suggests that they may also serve functional roles. Their potential use as treatments for certain diseases appears theoretically feasible; however, challenges remain in selectively targeting cells to induce the formation of favorable micronuclei and maintain optimal immune responses. Addressing these questions could open new avenues for therapeutic interventions.

The aryl hydrocarbon receptor (AHR) is an environmental sensor in mammals and a ligand-dependent, highly conserved transcription factor. It belongs to the basic helix-loop-helix family of transcription factors and is the only known ligand-activated member within this family. Previous studies have revealed its significant roles in physiological regulation, metabolic homeostasis, and tumorigenesis. AHR governs transcriptional regulation and epigenetic modifications through diverse mechanisms and plays an important role in various types of cancer. In this review, we introduce the history and structure of AHR and summarize its modes of action via canonical and non-canonical pathways. We elaborate on the distinct impact of AHR on mitochondrial metabolism, epigenetics, as well as cell death and fate. Furthermore, we systematically discuss the relationship between AHR and tumor immunity. Finally, we explore the prospects of AHR in the tumor microenvironment, cancer immunity and therapy, and its potential as an immunotherapeutic target, along with current achievements in drug development targeting AHR. These research findings may provide insights into the relationship between AHR and its regulated molecules and pathways in cancer, as well as mechanisms for cancer treatment and intervention.

Cancer immunotherapy is frequently hindered by the immunosuppressive tumor microenvironment. Although metal ions have been viewed as essential nutrients or cytotoxic payloads, emerging evidence reveals that they are potent immune modulators that orchestrate the cancer-immunity cycle. Here, we synthesize how ionic competition dictates immune cell plasticity and metabolic fate. We detail how metal ions regulate cell death pathways and immune signaling cascades, including the cyclic GMP-AMP synthase-stimulator of interferon genes and nuclear factor kappa B pathways, as well as immunological synapse formation and immune cell responses. Finally, we evaluate the clinical potential of targeting the metal ions-immune axis, from metallomic biomarkers, including Zrt-/Irt-like protein transporters and ion channels, to metallo-immunotherapy strategies. This framework provides a mechanistic roadmap for developing combination therapies to overcome immunotherapy resistance and harness the cellular metallome for precision oncology.

Hepatocellular carcinoma (HCC) is a highly aggressive malignancy with a poor prognosis, highlighting the urgent need for novel diagnostic and therapeutic targets. In this study, through integrated proteomic profiling, we identify AP4M1 as a potential therapeutic vulnerability for HCC and characterize its upstream regulatory and downstream effector mechanisms. We show that AP4M1 is markedly upregulated in HCC, correlates with unfavorable prognosis, and is functionally involved in driving HCC progression. Mechanistically, the deubiquitinase USP15 stabilizes AP4M1 by removing K11- and K48-linked polyubiquitin chains at lysine 163 (K163). Additionally, MINK1-mediated phosphorylation of AP4M1 at threonine 69 (T69) is critical for its interaction with GPX4. Through upregulating GPX4, AP4M1 reduces intracellular lipid peroxidation, thereby suppressing ferroptosis and facilitating HCC tumorigenesis and progression. Importantly, combined treatment with the USP15 inhibitor USP15-IN-1 and the GPX4 inhibitor RSL3 exhibits potent anti-tumor efficacy in both in vitro and in vivo models, underscoring the therapeutic potential of targeting the AP4M1 axis in HCC. Collectively, this study delineates the USP15/AP4M1/MINK1/GPX4 axis as a previously unrecognized ferroptosis-suppressive pathway that promotes HCC progression, providing a critical theoretical basis for AP4M1-targeted therapeutic strategies in HCC.

The global prevalence of metabolic diseases, notably obesity, diabetes mellitus, and thyroid disorders, has risen dramatically in recent decades, posing a significant threat to public health. While conventional pharmacological interventions remain the cornerstone of management, they face considerable limitations, including adverse effects and the development of drug resistance, underscoring the urgent need for alternative therapeutic strategies. Intriguingly, immune checkpoint molecules, originally recognized for their transformative role in cancer immunotherapy, are now gaining attention as pivotal regulators of metabolic homeostasis. Growing research demonstrates that immune checkpoint pathways, particularly the PD-1/PD-L1 axis, play dual roles in immune regulation and metabolic modulation by orchestrating inflammatory responses and energy metabolism. For instance, in obesity, PD-1/PD-L1 signaling promotes the polarization of adipose tissue macrophages from a proinflammatory M1 phenotype toward an anti-inflammatory M2 state, thereby mitigating chronic low-grade inflammation and associated metabolic dysfunction. These findings highlight the potential of immune checkpoint modulation as a novel therapeutic strategy for metabolic disorders. However, despite these advances, the role of immune checkpoints in metabolic diseases remains underexplored, with limited comprehensive reviews on the subject. This review comprehensively elucidates the pathophysiological mechanisms and translational potential of immune checkpoint regulation in obesity, diabetes, and thyroid disease while proposing novel directions for clinical intervention.

INTRODUCTION:While peroxisome-associated molecules have been implicated in ferroptosis, the mechanistic relationship between peroxisomes and ferroptosis remains poorly understood. Key unresolved questions include whether peroxisomal hydrogen peroxide (H2O2)-generating enzymes, such as hydroxyacid oxidase 1 (HAO1), contribute to ferroptosis, as well as how they function at the molecular level. OBJECTIVES:This study was designed to investigate the role of HAO1-mediated peroxisomal H2O2 production in ferroptosis and its impact on liver cancer progression. METHODS:We evaluated HAO1 expression in liver cancer and its association with patient prognosis using clinical samples and bioinformatic analyses. RNA sequencing was performed to identify HAO1-regulated biological pathways. Cell viability was measured with a CCK-8 assay, and ferroptosis was assessed using a C11-BODIPY 581/591 probe, iron assay, and GSH detection. To delineate how HAO1-induced alterations in peroxisomal H2O2 affect ferroptosis, we employed the H2O2-specific HyPer probe in conjunction with immunofluorescence and flow cytometry. The role of HAO1 in malignant progression was further examined through in vitro and in vivo functional experiments. RESULTS:HAO1 was found to enhance lipid peroxidation in liver cancer cells by boosting reactive oxygen species (ROS) levels within peroxisomes in an enzyme activity-dependent manner. Furthermore, HAO1 downregulated the p-STAT3/SLC7A11/GPX4 pathway, disrupting glutathione synthesis and impeding ROS scavenging, thereby heightening the susceptibility of cancer cells to ferroptosis. Through this dual mechanism, HAO1 synergistically promoted lipid peroxidation, triggering ferroptosis and inhibiting liver cancer cell proliferation and metastasis. Moreover, coenzyme Flavin Mononucleotide (FMN) was shown to augment the tumor-suppressive activity of HAO1. CONCLUSION:Our findings shed light on the key role of HAO1 in the peroxisome-mediated redox regulation of ferroptosis during liver cancer progression, suggesting a potential therapeutic strategy.

Lung cancer is the deadliest cancer globally. Non-small cell lung cancer (NSCLC), including adenocarcinoma, squamous cell carcinoma, and large cell carcinoma, constitutes a significant portion of cases. Adenocarcinoma, the most prevalent type, has seen a rising incidence. Immune checkpoint inhibitors (ICIs) have improved outcomes in lung adenocarcinoma (LUAD), yet response rates remain unsatisfactory. PD-1/PD-L1 inhibitors are primary ICIs for LUAD, targeting the PD-1/PD-L1 pathway between CD8+ T cells and tumor cells. However, LUAD presents a "cold tumor" phenotype with fewer CD8+ T cells and lower PD-1 expression, leading to resistance to ICIs. Thus, understanding the function of other immune cell in tumor microenvironment is crucial for developing novel immunotherapies for LUAD. B cells, which is part of the adaptive immune system, have gained attention for its role in cancer immunology. While research on B cells lags behind T cells, recent studies reveal their close correlation with prognosis and immunotherapy effectiveness in various solid tumors, including lung cancer. B cells show higher abundance, activity, and prognostic significance in LUAD than that in LUSC. This review summarizes the difference of B cell immunity between LUAD and other lung cancers, outlines the role of B cell immunity in LUAD.

Ferroptosis is a type of cell death that differs from general forms of cell death such as apoptosis. Iron accumulation and lipid peroxidation are distinct biochemical features of ferroptosis. Accumulation of iron ions in ferrodead cells can increase the probability of the Fenton reaction and produce more reactive oxygen species (ROS). Further, iron ions are cofactors for some intracellular oxidases. ROS, which are normally produced in the mitochondria, attack the phospholipid bilayer of the cell and produce lipid peroxides that ultimately kill the cell. Since the discovery of ferroptosis, its mechanism and relationship with diseases, such as nervous system diseases, tumors, and sepsis has been studied. Controlling disease development by regulating ferroptosis has thus become a popular topic of current research. This article summarizes the recent research progress on the mechanism of ferroptosis and its relationship with diseases. Overall, this study can provide a valuable reference for future ferroptosis studies.

Background: GPCRs play an important role in the development of cancer. However, as a member of the G protein-coupled receptor family, the function of GPR141 is still unclear, and its function in pan-cancer is even less known. Methods: In this study, a series of bioinformatics methods were used to explore the potential carcinogenic effects of GPR141, including analysis of GPR141 expression in different tumors, related prognosis, mutations, gene correlation analysis, gene enrichment analysis, immune cell infiltration and other factors. All results and data are available from TIMER, GEPIA2.0, TISIDB, cBioportal and other data portals. In addition, we collected lung adenocarcinoma samples, hepatocellular carcinoma and adjacent tissues for immunohistochemical analysis. And we stably knocked down GPR141 in lung adenocarcinoma cell lines A549 and H1975, and the changes of cell proliferation, migration and invasion were detected by CCK8, Transwell migration and invasion experiments. Results: GPR141 is differentially expressed in a variety of cancers. GPR141 is closely related to the prognosis, genetic changes and immune infiltrating cells of tumor patients. Gene enrichment analysis showed that GPR141 was mainly involved in immune-related pathways in pan-cancer. In pan-cancer, the expression levels of PTPRC, TLRB, PLEK, NCKAP1L, PGS18 and CLEC12A were positively correlated with GPR141. Immunohistochemical results showed that the expression of GPR141 in lung adenocarcinoma and hepatocellular carcinoma was higher than that in adjacent tissues. After knocking down GPR141 in A549 and H1975, we found that the proliferation, migration and invasion of lung adenocarcinoma cells decreased after knocking down GPR141. Conclusion: GPR141 may be a new prognostic marker and therapeutic target for human tumors, providing a theoretical basis for the development of more effective and targeted clinical treatment of cancer.

The significance of biomedical applications of Ti alloys is best emphasized by their widespread utilization as implantable materials, such as internal supports and bone replacements. Ti alloys are sensitive to fretting wear, which leads to the early failure of Ti implants. Improved wear resistance of such implants is essential to ensure a prolonged implant life. Based on the structure-function-integrated concept, this work unprecedentedly designs and fabricates an antibacterial 8SiC/Ti-3Cu composite with improved wear resistance using microwave sintering from pure Ti, Cu, and nano-SiC powders. For comparison, SiC-free Ti-3Cu composite is manufactured under the same conditions using microwave sintering. The addition of 8 vol.% SiC to Ti-3Cu significantly reduces the porosity and pore size of composites. The 8SiC/Ti-3Cu shows a Vickers hardness of 353 HV, compressive strength of 803 MPa, elastic modulus of 28.7 GPa, and a significantly increased wear resistance (wear rate decreased by 70% compared to Ti-3Cu). In addition, 8SiC/Ti-3Cu exhibits excellent electrochemical corrosion resistance, biocompatibility in relation to MC3T3-E1 cells, and a bacteriostatic rate over 99% against E. coli. The combination of the wear-resistant nano-reinforced SiC and antibacterial Ti2Cu in the 8SiC/Ti-3Cu composite renders it a highly promising implant material.

Glutathione (GSH) is a thiol-containing antioxidant composed of glutamic acid, cysteine and glycine. GSH can form a disulfide bond with the cysteine sulfhydryl group of a protein, resulting in S-glutathionylation (-SSG). S-glutathionylation is a reversible posttranslational modification that plays important roles in redox regulation, detoxification, cell signaling pathway regulation, cell death, infection and inflammation. Recent studies have shown that GSH and glutathionylation also have a significant effect on a variety of common cancers. GSH has the potential to serve as an auxiliary diagnostic tool for cancer. S-glutathionylation can regulate the level of the modified protein to regulate tumor cell proliferation and patient survival. In addition, glutathionylation can affect resistance to anticancer clinical drugs, as well as immunotherapy. These findings provide a new therapeutic target for cancer treatment. This review comprehensively reviews the key roles of glutathionylation and its potential mechanisms in a variety of common cancers. Finally, we discuss in depth the role of glutathionylation in resistance to radiotherapy, chemotherapy, targeted drugs and immune checkpoint inhibitors. This study provides a theoretical basis for the development of new cancer treatment drugs.

BACKGROUND:Hepatocellular carcinoma (HCC) is an aggressive liver cancer with poor prognosis. Deubiquitinating enzymes (DUBs) are critical regulators of tumor progression, yet the functional significance of DUBs in HCC remains poorly understood. METHODS:HCC patient-derived organoids (PDOs), HCC cell lines and animal models were used to evaluate the anticancer responses of ubiquitin-specific protease (USP)2 inhibition. We analyzed the correlation of USP2 expression and immune cells infiltration using single-cell RNA sequencing and flow cytometry analysis. Mechanistically, we established an in vitro co-culture system and analyzed metabolic data to find out the bridge between tumor cell USP2 and macrophage in the microenvironment. Immunofluorescence, co-immunoprecipitation, CUT&RUN, ELISA, and mass spectrometry were conducted to explore the molecular pathway. RESULTS:We found that the inhibitor (ML364) targeting USP2 shows effective anticancer responses against HCC PDOs. Targeting USP2 significantly inhibits lipid metabolism of HCC and induces cell ferroptosis. Single-cell RNA sequencing analysis and multiplex immunohistochemistry analysis indicated that high expression of USP2 in HCC was associated with the infiltration of M2 macrophage. Mechanistically, USP2 deubiquitinates and stabilizes peroxisome proliferator-activated receptor gamma (PPARγ) via removing the K48-linked ubiquitin chain at the K142 site. PPARγ promotes the transcription of fatty acid biosynthesis-related genes (ATP-citrate lyase, acetyl-CoA carboxylase and ACSS2) and de novo synthesis of fatty acids including oleic acid. HCC cell-derived oleic acid promotes M2 macrophage polarization by enhancing the fatty acid oxidation of macrophages. Polarized M2 macrophages further secrete interleukin-10, which created an IL-10/STAT3/USP2 positive-feedback loop to activate USP2 expression continuously. CONCLUSION:Our data suggest that USP2, a key molecule mediating the interaction between HCC cells and tumor-associated macrophages, may be a promising therapeutic target for HCC.

Oral submucous fibrosis (OSF) is a chronic and inflammatory mucosal disease caused by betel quid chewing, which belongs to oral potentially malignant disorders. Abnormal fibroblast differentiation leading to disordered collagen metabolism is the core process underlying OSF development. The epithelium, which is the first line of defense against the external environment, can convert external signals into pathological signals and participate in the remodeling of the fibrotic microenvironment. However, the specific mechanisms by which the epithelium drives fibroblast differentiation remain unclear. In this study, we found that Arecoline-exposed epithelium communicated with the fibrotic microenvironment by secreting exosomes. MiR-17-5p was encapsulated in epithelial cell-derived exosomes and absorbed by fibroblasts, where it promoted cell secretion, contraction, migration and fibrogenic marker (α-SMA and collagen type I) expression. The underlying molecular mechanism involved miR-17-5p targeting Smad7 and suppressing the degradation of TGF-β receptor 1 (TGFBR1) through the E3 ubiquitination ligase WWP1, thus facilitating downstream TGF-β pathway signaling. Treatment of fibroblasts with an inhibitor of miR-17-5p reversed the contraction and migration phenotypes induced by epithelial-derived exosomes. Exosomal miR-17-5p was confirmed to function as a key regulator of the phenotypic transformation of fibroblasts. In conclusion, we demonstrated that Arecoline triggers aberrant epithelium-fibroblast crosstalk and identified that epithelial cell-derived miR-17-5p mediates fibroblast differentiation through the classical TGF-β fibrotic pathway, which provided a new perspective and strategy for the diagnosis and treatment of OSF.

Retinoic acid-related orphan receptor gamma (RORγ) plays critical roles in regulating various biological processes and has been linked to immunodeficiency disorders and cancers. DNA recognition is essential for RORγ to exert its functions. However, the underlying mechanism of the DNA binding by RORγ remains unclear. In this study, we present the crystal structure of the complex of RORγ1 DNA-binding domain (RORγ1-DBD)/direct repeat DNA element DR2 at 2.3 Å resolution. We demonstrate that RORγ1-DBD binds the DR2 motif as a homodimer, with the C-terminal extension (CTE) region of RORγ1-DBD contributing to the DNA recognition and the formation of dimeric interface. Further studies reveal that REV-ERB-DBD and RXR-DBD, also bind the DR2 site as a homodimer, while NR4A2-DBD binds DR2 as a monomer. Our research uncovers a binding mechanism of RORγ1 to the DR2 site and provides insights into the biological functions of RORγ1 and the broader RORs subfamily.

Various forms of programmed cell death (PCD) exhibit distinct characteristics depending on their specific molecular mechanisms, and there are interactions among these different forms. Ferroptosis, which is related to autophagy and apoptosis, has an unknown potential interaction with pyroptosis. This study revealed a mutually antagonistic relationship between ferroptosis and pyroptosis, with 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) playing a key role in their interaction. It is found that HMGCR predominantly localized to mitochondria during ferroptosis but shifted to the endoplasmic reticulum following treatment with a pyroptosis inducer. Furthermore, this study demonstrated that BRCC36 (BRCA1/BRCA2-containing complex subunit 36) deubiquitinated HMGCR in a manner dependent on deubiquitinating enzyme (DUB) activity, and inhibited ferroptosis and promoted pyroptosis. Moreover, as an oncogene in hepatocellular carcinoma (HCC), BRCC36 promoted cancer cell proliferation, migration, invasion, and tumor growth. Thiolutin, an inhibitor of BRCC36, effectively suppressed the interaction between BRCC36 and HMGCR, leading to the inhibition of HCC growth. Therefore, targeting BRCC36 can offer a novel and promising therapeutic strategy for HCC treatment. In conclusion, these findings provide new theoretical evidence for further characterizing tumor heterogeneity and offer new molecular targets for the diagnosis and treatment of HCC.

Triple-negative breast cancer (TNBC) poses a challenging prognosis due to early metastasis driven by anoikis resistance. Identifying crucial regulators to overcome this resistance is vital for improving patient outcomes. In this study, a genome-wide CRISPR/Cas9 knockout screen in TNBC cells has identified tyrosine-protein phosphatase nonreceptor type 14 (PTPN14) as a key regulator of anoikis resistance. PTPN14 expression has shown a progressive decrease from normal breast tissue to metastatic tumors. Overexpressing PTPN14 has induced anoikis and inhibited cell proliferation in TNBC cells, while normal human breast cells are unaffected. Mechanistically, PTPN14 is identified as a key factor in dephosphorylating breast cancer antiestrogen resistance 3, a novel substrate, leading to the subsequent inhibition of PI3K/AKT and ERK signaling pathways. Local delivery of in vitro transcribed PTPN14 mRNA encapsulated by lipid nanoparticles in a TNBC mouse model has effectively inhibited tumor growth and metastasis, prolonging survival. The study underscores PTPN14 as a potential therapeutic target for metastatic TNBC, with the therapeutic strategy based on mRNA expression of PTPN14 demonstrating clinical application prospects in alleviating the burden of both primary tumors and metastatic disease.