Introduction

Cancer survivors are at a high risk to develop second primary malignancy (SPM) which constitutes a serious threat for them. Radiotherapy is the cornerstone for the management of many cancers as a loco-regional treatment modality. Due to the low liver tolerance, cirrhotic patients are at a high risk of developing radiation-induced liver toxicities despite the modern safe radiation delivery techniques. Radiation damage cells through direct energy deposition and reactive free radical generation. Recent studies demonstrated a potential risk of SPMs following radiotherapy with further investigations for strategies to decrease radiation-induced SPMs. However, it is insufficiently addressed if developing liver SPMs is a serious adverse event following radiotherapy for cirrhotic patients.

Aims & Methods

We aimed to quantitatively assess the risk of gastrointestinal (GI) and liver SPMs following radiotherapy in patients with chronic liver disease. SEER.stat version 8.4.3 was used to obtain and analyze the data of patients with chronic liver disease diagnosed from 2000 to 2020. Using Ishak fibrosis score: F0-4 for no to moderate fibrosis and F5-6 for advanced or severe cirrhosis. We subgrouped the patient according to the history of receiving radiotherapy for prior cancer treatment in two groups and excluded patients with unknown radiotherapy administration history. We used MP-SIR session to calculate the Standardized Incidence Ratio (SIR) as Observed/Expected (O/E) with 95% confidence interval (CI). We calculated the Excess Risk (ER) per 10,000. Significance was achieved at 0.05.

Results

Out of 15,168 patients with advanced liver cirrhosis, 88.4% received no radiotherapy and 11.6% received systemic radiotherapy. We observed 215 cirrhotic patients developed GI SPMs (O/E=2.76, 95%CI: 2.41- 3.16, P<0.05, ER= 45.51), 106 of them developed liver SPMs (O/E=8.80, P<0.05). Patients with liver cirrhosis who received radiotherapy had an increased risk for GI SPMs (Observed=24, O/E=3.34, 95%CI: 2.14- 4.96, P<0.05, ER= 64.43) compared to who received no radiotherapy (O/E=2.71, 95%CI: 2.34- 3.12, P<0.05, ER= 43.72). Liver SPMs after radiotherapy in cirrhotic patients had an O/E of 12.31 (Observed=13, P<0.05) while the group who received no radiotherapy had an O/E of 8.46 (Observed=93, P<0.05, ER=29.77). In non-cirrhotic patients, we observed 75 patients had GI SPMs with O/E of 3.13 (P<0.05), 30 of them had liver SPM (O/E= 8.44, P<0.05) and five patients had intrahepatic bile duct SPM (O/E= 10.59, P<0.05).

Conclusion

The results of this study give deep insights regarding the burden of SPMs in chronic liver disease. Liver cirrhosis with or without radiotherapy exposure have significantly increased the risk for GI SPMs. Cirrhotic patients who received radiotherapy had an increased risk for GI SPMs by three folds and a 12-fold increased risk for liver SPMs. However, who received no radiotherapy had an 8-fold increased risk for liver SPM. Thus, screening for HCC and GI SPMs in cirrhotic patients is a must for early detection and better management outcome especially after radiotherapy.

References

1. Kong J, Yu G, Si W, Li G, Chai J, Liu Y, et al. Second Primary Malignancies in Patients With Hepatocellular Carcinoma: A Population-Based Analysis. Front Oncol [Internet]. 2021 Aug 23 [cited 2024 Apr 18];11:713637. Available from: /pmc/articles/PMC8420091/
2. Koay EJ, Owen D, Das P. Radiation-Induced Liver Disease and Modern Radiotherapy [Internet]. Vol. 28, Seminars in Radiation Oncology. NIH Public Access; 2018 [cited 2024 Apr 18]. p. 321–31. Available from: /pmc/articles/PMC6402843/
3. Yang J, Gao J, Hu J, Hu W, Qiu X, Huang Q, et al. Carbon-ion radiotherapy in the treatment of radiation-induced second primary malignancies. Ann Transl Med [Internet]. 2022 Nov [cited 2024 Apr 18];10(22):1200–1200. Available from: /pmc/articles/PMC9761151/

Introduction

The therapeutic goal in inflammatory bowel disease (IBD), which includes Crohn´s disease (CD) and ulcerative colitis (UC), is the control of the inflammatory process through drugs (biologic and JAK-inhibitor therapies) that generally have a high cost and may have side effects. Unfortunately, only one-third of patients respond to these treatments and there are no markers that accurately predict this response.

Aims & Methods

The aim of this study was to identify potential serum metabolic biomarkers predictive of response to different drugs for IBD at baseline (before treatment), which could facilitate the selection of the most appropriate therapy for each patient. For this purpose, a prospective and multicenter study was conducted including CD and UC patients who initiate biologic (anti-TNF, ustekinumab or vedolizumab) or JAK-inhibitor (tofacitinib) therapies. Patients were assessed at 14 weeks to determine if they had achieved endoscopic response, based on the SES-CD and on the endoscopic sub score of the Partial Mayo Score. The analysis of the serum metabolome and deconvolution of the serum lipoprotein profile into 110 fractions were conducted using nuclear magnetic resonance for quantitative differential analysis comparing baseline serum samples of responders compared with non-responders.

Results

A total of 150 patients were included (30 CD anti-TNF, 30 UC anti-TNF, 30 CD ustekinumab, 30 UC vedolizumab, and 30 UC tofacitinib). Table 1 shows a summary of the most relevant results obtained during the metabolomic analysis, which revealed metabolites and lipoproteins (common or drug-specific) with significantly altered levels (p<0.05) in the baseline serum samples of subsequent responders compared to non-responders. Moreover, based on ROC curves, potential biomarkers with good sensitivity and specificity for distinguishing between responders and non-responders before treatment were identified. Finally, our analysis identified alanine, aspartate, glutamate, arginine and butanoate metabolism, and the citrate cycle, as the main baseline altered metabolic pathways that could be associated with the response to IBD treatment.

Table 1. Summary of identified potential metabolic biomarkers predictive of endoscopic response to IBD treatment.

Study group	Number of Biomarkers*		Best AUC values**
	Metabolites	Lipoproteins
CD anti-TNF	2	3	0.83; 0.81; 0.78; 0.75; 0.74
UC anti-TNF	1	7	0.88; 0.84; 0.83; 0.77; 0.76; 0.73
CD ustekinumab	4	24	0.96; 0.95; 0.94; 0.91; 0.90; 0.89; 0.87; 0.80
UC vedolizumab	5	8	0.90; 0.79; 0.78
UC tofacitinib	3	8	0.98; 0.96; 0.91; 0.88; 0.87; 0.85

​*Biomarkers with significantly altered levels (p<0.05) in the baseline serum of responders vs non-responders patients. **AUC corresponding to the biomarkers with the best sensitivity and specificity for distinguishing between responders and non-responders patients before treatment. AUC: Area Under the Curve calculated using the Metabolanalyst software in univariate analysis; CD: Crohn's disease; IBD: Inflammatory bowel disease; UC: Ulcerative colitis.

Conclusion

The present study represents an effort towards personalized medicine in targeted therapy selection in IBD patients, which is an important unmet need. Although it needs further validation, we were able to identify a number of serum metabolites and lipoproteins with the potential of predicting response to biologic and JAK-inhibitor therapies.

Introduction

Fibrostenosis represents one of the major clinical complications of Crohn’s Disease (CD). However, the molecular mechanisms underlying intestinal fibrogenesis remain poorly understood and anti-fibrotic therapy has not yet been developed. Growing evidence supports that oxidative stress and the epithelial-mesenchymal transition (EMT) process contribute to the development and progression of fibrosis.

Aims & Methods

Based on these evidences, we assessed the role of lipids in fibrogenesis and whether mitochondria dysfunction can support fibrosis formation.
Spatial metabolomics analysis and adipophilin (ADFP) staining were performed on surgical specimens from fibrotic ileum and the surrounding region (healthy) derived from CD patients. Fibroblasts isolated from fibrotic and healthy ileum and human induced pluripotent stem cell-derived intestinal organoids (iHOs) were treated for 1-3 weeks with lipid mix (2%) and analyzed by RNA sequencing. Pathways significantly modulated were validated by RT-PCR, WB, FACS analysis, and proliferative, migratory and contraction assays, and mitochondrial functions by Seahorse analyzer.

Results

Spatial metabolomics revealed a significant accumulation of lipids characterized by very long-chain fatty acids in the fibrotic area compared to surrounding healthy regions, which was further confirmed by ADFP staining. RNA-seq analysis showed overlapping dysregulated pathways between healthy fibroblasts stimulated with lipids and fibrotic fibroblasts, in particular genes related to cell cycle, cytoskeletal reorganization, migration, contractility and cell metabolism (oxidative stress) which were further confirmed by functional assays. Among the genes related to oxidative stress, lipid stimulation significantly decreased NFE2L2 and promoted an increase in CPT1A, gene encoding for a fatty oxidation mediator.
Moreover, lipid-stimulated fibroblasts showed a reduction in mitochondrial respiration, particularly basal and maximal respiration, and spare respiratory capacity by Seahorse analysis. On the other hand, long exposure of iHOs to lipids promoted the EMT process through the upregulation of TWIST, ZEB, and VIM.

Conclusion

Lipid stimulation induced myofibroblast activation through oxidative stress and alteration of mitochondrial metabolism, and increased the expression of EMT transcription factors in intestinal epithelial cells (iHOs) that may support fibroblast-mediated pro-fibrotic activity. These data indicate that regulators of fatty acid oxidation involved in the fibrotic process may represent new potential targets for the treatment of fibrostenotic CD patients.

Introduction

A deeper understanding of the pathogenesis of UC has led to the emergence of new therapeutic strategies. One of them consists of targeted exposure with biological drugs to certain molecules that regulate the interaction between leukocytes and endothelial cells in the inflammatory zone (mainly leukocyte integrins and endothelial cell adhesion molecules of the immunoglobulin superfamily).

Aims & Methods

Purpose of the study: To study the content of adhesion molecules ICAM-1, ICAM-2 and L-selectin in the peripheral blood of patients with ulcerative colitis (UC) and the effect of vedolizumab (Intivio) on their levels.
Materials and methods: We examined 12 patients with moderate and severe forms of UC and the ineffectiveness of previous standard therapy. The severity of the UC attack was calculated according to the Mayo index. Antivio® 300 mg was administered to patients intravenously according to the attached instructions. The content of adhesion molecules in the peripheral blood was studied before and 6 weeks after the first injection of vedilizumab. The control group consisted of 15 healthy volunteers. The content of ICAM-1, ICAM-2 and L-selectin in blood serum was determined by multilayer ELISA analysis (Bender med.Systems, Austria). Statistical processing of the obtained results was carried out using SPSS 13.0 software.

Results

It was found that the initial levels of ICAM-1 (461.9±28.4 ng/ml), ICAM-2 (323.3±18.4 ng/ml) and sL-selectin (1650±12.25 U/ml) ) in the peripheral blood of patients with UC were increased (P<0.05 with control), the Mayo index was 9 points. After four infusions of Vedolizumab (week 14), the levels of soluble molecules decreased in 4 patients, with a predominant decrease in sL-selectin (201±9.32 ng/ml, 197±8.54 pg/ml and 1008±15.3 U/ml respectively). The Mayo index was 5 points. In 8 patients, by the 6th week of treatment, the levels of the studied adhesive molecules did not change, although the Mayo index decreased by 3 points.

Conclusion

The initial level of ICAM-1, ICAM-2 and sL-selectin in the peripheral blood of patients with severe forms of UC is increased. The dynamics of the synthesis of adhesive molecules by immunocompetent cells under the influence of the fourth administration of Vedolizumab may predict the possibility of continuing the administration of the drug.