Purpose To investigate how IL-6-mediated monocytes/macrophages suppress the effector function of natural killer(NK)cells through the PD-L1/PD-1 axis in acute-on-chronic liver failure(ACLF).Methods HE stai-ning and Masson's trichrome staining were used to assess hepatic inflammatory infiltration and fibrosis.Immunofluores-cence staining was performed to detect IL-6 expression in hepatic macrophages.Flow cytometry was applied to evaluate the phenotypes and functions of monocytes/macrophages and NK cells.Recombinant IL-6 was used to treat peripheral blood mononuclear cells,and PD-L1 expression on monocytes was examined.Monocytes and NK cells were co-cul-tured,and after PD-1 blockade,NK cell effector function was evaluated.Results The ACLF patients,the degree of hepatic fibrosis increased with higher serum IL-6 level.Hepatic macrophages secreted more IL-6,and the circulating monocytes showed an increased percentage[(9.89±0.65)％],absolute count[(0.58±0.04)× 106/mL],prolif-erative capacity[(36.65±6.810)％],and IL-6 secretion[(16.97±2.387)％].In ACLF mice,hepatic inflamma-tory infiltration and fibrosis were aggravated,and IL-6+macrophages exhibited enhanced pro-inflammatory activity.IL-6 had mediated the upregulation of PD-L1 expression in monocytes,while NK cells showed increased PD-1 expression and impaired effector function.When monocytes and NK cells were co-cultured,PD-1 blockade restored,NK cell ef-fector functions.Conclusion In ACLF,elevated IL-6 levels were associated with hepatic fibrosis and disease severi-ty.IL-6 mediated monocytes-induced suppression of NK cell effector functions via the PD-L1/PD-1 axis,suggesting that IL-6 plays a critical role in ACLF-related immune dysregulation.

Malakoplakia is a rare granulomatous inflammatory disease，Almost 75% of cases of malakoplakia mainly affect the genitourinary tracts，and a small proportion affect the intestines. Its occurrence in the adrenal gland is extremely rare. We report a case of adrenal malakoplakia. Who was presented to the hospital for chronic left upper abdominal pain and fever. The patient was admitted to our hospital due to the discovery of a huge mass in the left adrenal gland by CT. Pathological features of Michaelis Gutmann bodies（M-G bodies）were observed through adrenal biopsy，which revealed adrenal Malakoplakia. E. coli was cultured from both blood and the pus in the left renal parenchymal aera. After regular antibiotics treatment，the patient's fever symptoms improved compared to before. CT imaging showed that the adrenal mass had decreased in size，indicating effective treatment. Adrenal malakoplakia is easily misdiagnosed as malignant disease because of its radiological occupying performance. And its gold standard is pathology. For patients with symptoms of infection，we recommend urine，blood，pus in the pararenal area culture tests，and treatment with sensitive antibiotics according to the results of drug sensitivity testing.

Purpose To investigate how IL-6-mediated monocytes/macrophages suppress the effector function of natural killer(NK)cells through the PD-L1/PD-1 axis in acute-on-chronic liver failure(ACLF).Methods HE stai-ning and Masson's trichrome staining were used to assess hepatic inflammatory infiltration and fibrosis.Immunofluores-cence staining was performed to detect IL-6 expression in hepatic macrophages.Flow cytometry was applied to evaluate the phenotypes and functions of monocytes/macrophages and NK cells.Recombinant IL-6 was used to treat peripheral blood mononuclear cells,and PD-L1 expression on monocytes was examined.Monocytes and NK cells were co-cul-tured,and after PD-1 blockade,NK cell effector function was evaluated.Results The ACLF patients,the degree of hepatic fibrosis increased with higher serum IL-6 level.Hepatic macrophages secreted more IL-6,and the circulating monocytes showed an increased percentage[(9.89±0.65)％],absolute count[(0.58±0.04)× 106/mL],prolif-erative capacity[(36.65±6.810)％],and IL-6 secretion[(16.97±2.387)％].In ACLF mice,hepatic inflamma-tory infiltration and fibrosis were aggravated,and IL-6+macrophages exhibited enhanced pro-inflammatory activity.IL-6 had mediated the upregulation of PD-L1 expression in monocytes,while NK cells showed increased PD-1 expression and impaired effector function.When monocytes and NK cells were co-cultured,PD-1 blockade restored,NK cell ef-fector functions.Conclusion In ACLF,elevated IL-6 levels were associated with hepatic fibrosis and disease severi-ty.IL-6 mediated monocytes-induced suppression of NK cell effector functions via the PD-L1/PD-1 axis,suggesting that IL-6 plays a critical role in ACLF-related immune dysregulation.

Malakoplakia is a rare granulomatous inflammatory disease，Almost 75% of cases of malakoplakia mainly affect the genitourinary tracts，and a small proportion affect the intestines. Its occurrence in the adrenal gland is extremely rare. We report a case of adrenal malakoplakia. Who was presented to the hospital for chronic left upper abdominal pain and fever. The patient was admitted to our hospital due to the discovery of a huge mass in the left adrenal gland by CT. Pathological features of Michaelis Gutmann bodies（M-G bodies）were observed through adrenal biopsy，which revealed adrenal Malakoplakia. E. coli was cultured from both blood and the pus in the left renal parenchymal aera. After regular antibiotics treatment，the patient's fever symptoms improved compared to before. CT imaging showed that the adrenal mass had decreased in size，indicating effective treatment. Adrenal malakoplakia is easily misdiagnosed as malignant disease because of its radiological occupying performance. And its gold standard is pathology. For patients with symptoms of infection，we recommend urine，blood，pus in the pararenal area culture tests，and treatment with sensitive antibiotics according to the results of drug sensitivity testing.

Objective:To demonstrate the three-dimensional structures of the limbic system and its fiber connections through fiber dissection,and to provide reference for relevant professionals to master the anatomy of the limbic system.Methods:Ten cerebral hemispheres were treated and dissected according to Kelinger method,and the limbic system and its fiber connections were displayed.Results:The limbic system was arranged around the thalamus and corpus cal-losum in a double-layer concentric circle structure.The outer layer structures mainly consisted of the cingulate gyrus and the parahippocampal gyrus,while the inner layer structures included the amygdala,hippocampus and fornix.The main association fiber of the outer layer is the cingulum,whose superior trunk is mainly located in the cingulate gyrus,and the inferior trunk is mainly located in the parahippocampal gyrus.The fiber structures of the inner layer includes the striae terminalis and ansa peduncularis emanating from the amygdala and the fornix of the hippocampus.Conclusion:Limbic system is an important connection structure between telencephalon and diencephalon,and its anatomical struc-ture is complex.Fiber dissection method can effectively demonstrate the complex spatial structure of limbic system,which is of great benefit to relevant professionals to understand its three-dimensional structure.

Objective:To demonstrate the three-dimensional structures of the limbic system and its fiber connections through fiber dissection,and to provide reference for relevant professionals to master the anatomy of the limbic system.Methods:Ten cerebral hemispheres were treated and dissected according to Kelinger method,and the limbic system and its fiber connections were displayed.Results:The limbic system was arranged around the thalamus and corpus cal-losum in a double-layer concentric circle structure.The outer layer structures mainly consisted of the cingulate gyrus and the parahippocampal gyrus,while the inner layer structures included the amygdala,hippocampus and fornix.The main association fiber of the outer layer is the cingulum,whose superior trunk is mainly located in the cingulate gyrus,and the inferior trunk is mainly located in the parahippocampal gyrus.The fiber structures of the inner layer includes the striae terminalis and ansa peduncularis emanating from the amygdala and the fornix of the hippocampus.Conclusion:Limbic system is an important connection structure between telencephalon and diencephalon,and its anatomical struc-ture is complex.Fiber dissection method can effectively demonstrate the complex spatial structure of limbic system,which is of great benefit to relevant professionals to understand its three-dimensional structure.

Purpose To investigate the clinicopathological characteristics,diagnosis,and differential diagnosis of invasive mucinous adenocarcinoma(IMA)and mixed invasive mucinous and non-mucinous adenocarcinoma(mIMA).Methods The clinical data were collected in 36 patients with primary IMA and 17 patients with mIMA,and the expression of TTF-1,CK7,CK20,SATB2,CDX2,EGFR,HNF4a,etc.was detected by immunohistochemical EnVision two-step method.The Sanger se-quencing and the FISH were used for KRAS mutation and NRG1 gene rearrangement detection.The clinicopathological character-istics were analyzed with review of relevant literature.Results There were 9 cases(25.0％)and 3(8.3％)cases of papillary and micropapillary structures in IMA,while 13 cases(76.5％)(P＜0.001)and 9 cases(52.9％)(P=0.001)were present in mIMA.There were 5 cases(13.9％)of high nuclear grade of IMA and 10 cases(58.8％)of high nuclear grade of mIMA(P=0.002).TTF-1 had a positive rate of 37.5％in IMA,but 60.0％and 80.0％in the mucinous adenocarcinoma and non-mucinous adenocarcinoma components of mIMA(P=0.021),respectively.The positive rates of CK7,CK20,and CDX2 in IMA were 90.6％,21.9％,and 9.4％,and the positive rates in mucinous adenocarcinoma and non-mucinous adenocarcinoma components of mIMA were 100％,20％,20％and 100％,6.7％,6.7％,respectively and no SATB2 expression was found in all cases.There was no significant difference in the expres-sion of total EGFR and two EGFR mutation-specific antibodies(L858R,DEL19)between IMA and mIMA.There were 3 cases of mucinous adenocarcinoma with L858R positive in mIMA,and 2 of them were negative for non-mueinous adenocarcinoma.In another case,the non-mueinous adenocarcinoma component of mIMA expressed DEL19,but the mucinous adenocarcinoma component was not expressed.The positive rate of HNF4a in IMA was 72.0％(18/25),and those of HNF4a in mucinous adenocarcinoma and non-mucinous adenocarcinoma in mIMA were 41.7％(5/12)and 33.3％(4/12),respectively(P=0.048).KRAS gene sequencing was carried out in 19 cases of IMA,among which 9 cases(47.4％)had mutations,G12D and G12V were most commonly detected,and 4 cases of mIMA were sequenced,but none of them showed KRAS mutations.FISH detection showed that 2 cases(7.1％)IMAs had NRG1 translocation rearrangement.Conclusion Pulmonary mIMA is more aggressive than IMA.For example,mIMA has significantly more papillary structure,micropapillary structure,and high nu-clear grade cases than IMA.The differences in immunohisto-chemical expression and KRAS mutation between the two are sta-tistically significant.

Background/Aims: Epstein-Barr virus-associated gastric cancers (EBVaGCs) have unique molecular and clinicopathological characteristics. The cyclic GMP-AMP synthase-stimulator of interferon genes (STING) pathway is recently recognized as the critical innate immunity against pathogens and tumors. STING is also a master regulator in the cancer-immunity cycle and targeting STING could synergize with existing immune-checkpoint therapies. However, the role of STING in GC, especially in EBVaGC, and its correlation with programmed death-ligand 1 (PD-L1) remain largely unclear. Methods: We collected 78 cases of EBVaGCs and 210 cases of EBV-negative GC (EBVnGC) from a total of 1,443 cases of GC analyzed by EBV-encoded small RNA in situ hybridization. We investigated STING and PD-L1 expression and their concomitant prognostic value in EBVaGCs and EBVnGCs using tissue microarray and immunohistochemistry. The effects of STING and PD-L1 expression on the overall survival of patients with EBVaGC or EBVnGC were assessed by univariate and multivariate analysis. Results: We found that both STING and PD-L1 exhibited significantly higher expression in the EBVaGCs than that in the EBVnGCs. The expression of STING was positively correlated with that of PD-L1 in EBVaGCs. Simultaneous negative expression of STING and PD-L1, and positive expression of STING were independent prognostic risk factors for EBVaGC and EBVnGC, respectively. Conclusions This is the first prognostic retrospective study of STING and PD-L1 expression and the prognosis among EBVaGC and EBVnGC. The expression and prognostic value of STING and PD-L1 are different in the two types of GCs. STING and PD-L1 are promising prognostic biomarkers and therapeutic targets for EBVaGC and EBVnGC.

Objective:To propose a method of cervical cytology screening based on deep convolutional neural network and compare it with the diagnosis of cytologists.Method:The deep segmentation network was used to extract 618 333 regions of interest (ROI) from 5, 516 cytological pathological images. Combined with the experience of physicians, the deep classification network with the ability to analyze ROI was trained. The classification results were used to construct features, and the decision model was used to complete the classification of cytopathological images.Results:The sensitivity and specificity were 89.72%, 58.48%, 33.95% and 95.94% respectively. Among the smears derived from four different preparation methods, this algorithm had the best effect on natural fallout with a sensitivity of 91.10%, specificity of 69.32%, positive predictive rate of 41.41%, and negative predictive rate of 97.03%.Conclusion:Deep convolutional neural network image recognition technology can be applied to cervical cytology screening.

Objective:To investigate the clinicopathologic and immunophenotypic features of metastatic gastrointestinal hepatoid adenocarcinomas in the liver.Methods:Eight cases of hepatic metastatic gastrointestinal hepatoid adenocarcinoma diagnosed at the Affiliated Drum Tower Hospital, Nanjing University Medical School from January 2009 to January 2019 were retrospectively analyzed. The clinical data, histopathologic features and immunohistochemical (IHC) characteristics performed by EnVision method were analyzed.Results:There were five males and three females with a mean age of 66 years. The primary sites included one case each from the distal esophagus and the right colon, and the other six cases were from the stomach. Pre-treatment serum AFP levels were increased in four patients, normal in two, and was not known in two other patients. Liver metastases occurred in all eight patients at initial diagnosis. Microscopically, the primary tumor was composed of areas showing hepatic differentiation with or without typical adenocarcinoma component; and the areas with hepatic differentiation morphologically resembled hepatocellular carcinoma (HCC). IHC staining showed variable expression of HCC markers such as Glypican 3, AFP, SALL4 and HepPar-1, and gastrointestinal adenocarcinoma markers such as CK19, CDX-2 and Villin in both the primary and metastatic foci of hepatoid adenocarcinoma.Conclusions:Hepatoid adenocarcinoma in the digestive tract gives rise to only non-specific symptoms, and shows high propensity for invasion and metastasis. When liver metastasis is the presenting symptom, it is difficult to distinguish metastatic hepatoid adenocarcinoma from the primary HCC based on histopathologic characteristics alone. The accurate diagnosis of metastatic hepatoid adenocarcinoma in the liver requires combination of clinical, radiologic, histopathologic and IHC findings.