Introduction

Cancer exhibits high mortality due to lymph node and distant metastasis, which substantially compromises treatment efficacy. Esophageal squamous cell carcinoma (ESCC) is a highly prevalent and lethal cancer with tendency of early lymph node metastasis. However, the molecular mechanisms underlying esophageal cancer metastasis, including the interactions among genome, transcriptome, proteome, and post-translational modifications (PTMs), remain incompletely characterized. Furthermore, recent studies showed that lactate serves as a signaling molecule that can induce lysine lactylation (Kla) ^[1], a novel type of PTM, which was extensively involved in tumor biological processes ^[2].

Aims & Methods

Herein, we performed a multi-omics analysis integrating genomic, transcriptomic, proteomic, and lactylome data from 99 samples across 36 metastatic ESCC patients. The interactions among the genome, transcriptome, proteome were comprehensively investigated. Key proteins and Kla sites driving ESCC metastasis were identified from the integrative analysis. Their clinical relevance and prognostic significance were validated by immunohistochemical assay on clinical samples. Furthermore, their biological functions and underlying mechanism in ESCC cell migration and invasion were verified through in-vitro and in-vivo experiments.

Results

We first established the genome, transcriptome, proteome, and lactylome landscape of metastatic ESCC. We identified prognosis-relevant immunity-driving waves in the metastatic cascade, with intercellular adhesion molecule 1 functioning as a critical regulator of invasion and migration both in vitro and in vivo. We demonstrated extensive involvement of lysine Kla in metastasis, primarily through metabolic pathway modulation. The ESCC proteome, modulated by Kla, exhibited comprehensive interactions with genomic and transcriptomic elements through both cis- and trans-regulatory mechanisms. Notably, phosphoglycerate mutase 1 (PGAM1) K251 lactylation promoted metastasis both in vitro and in vivo by enhancing its molecular interaction with actin gamma 1, thereby affecting actin kinetics and cell motility.

Conclusion

We first established the genome, transcriptome, proteome, and lactylome landscape of metastatic ESCC. We identified prognosis-relevant immunity-driving waves in the metastatic cascade, with intercellular adhesion molecule 1 functioning as a critical regulator of invasion and migration both in vitro and in vivo. We demonstrated extensive involvement of lysine Kla in metastasis, primarily through metabolic pathway modulation. The ESCC proteome, modulated by Kla, exhibited comprehensive interactions with genomic and transcriptomic elements through both cis- and trans-regulatory mechanisms. Notably, phosphoglycerate mutase 1 (PGAM1) K251 lactylation promoted metastasis both in vitro and in vivo by enhancing its molecular interaction with actin gamma 1, thereby affecting actin kinetics and cell motility.

References

[1] Zhang, D., Tang, Z., Huang, H., Zhou, G., Cui, C., Weng, Y., Liu, W., Kim, S., Lee, S., Perez-Neut, M., et al. (2019). Metabolic regulation of gene expression by histone lactylation. Nature 574, 575-580. Doi:10.1038/s41586-019-1678-1.
[2] Li H, Sun L, Gao P, Hu H. Lactylation in cancer: Current understanding and challenges. Cancer Cell. 2024 Nov 11;42(11):1803-1807. Doi: 10.1016/j.ccell.2024.09.006. Epub 2024 Oct 10.

Introduction

Colorectal cancer (CRC) ranks among the most prevalent malignancies of the gastrointestinal tract and remains a leading cause of cancer-related mortality worldwide. Although telomere biology has been increasingly implicated in immune modulation and tumor progression, its clinical significance in CRC remains poorly understood.

Aims & Methods

We developed a telomere score, termed TELscore, by integrating transcriptomic and intratumoral microbiome profiles from publicly available colorectal cancer (CRC) cohorts. To comprehensively characterize TELscore subgroups, we performed pathway enrichment analysis, tumor immune microenvironment (TIME) profiling, and microbiome niche assessment. Whole-slide histopathological images (WSIs) and immunohistochemical (IHC) staining were utilized to visualize immune features, including tertiary lymphoid structures (TLSs), across subgroups. Patients were stratified into high and low TELscore categories, and the predictive robustness was validated across multiple independent training and validation cohorts. Chemotherapeutic drug sensitivity was evaluated using pharmacogenomic data from the Genomics of Drug Sensitivity in Cancer (GDSC) database. Furthermore, the predictive capacity of TELscore for immunotherapy response was independently assessed in an external cohort. Finally, single-cell RNA sequencing (scRNA-seq) analysis was conducted to further dissect the cellular landscape and immunological heterogeneity within the TME.

Results

TELscore stratified patients into two biologically and clinically distinct subgroups. The high TELscore group, which exhibited significantly shorter DFS, showed marked enrichment of tumorigenic pathways such as EMT, along with a distinctly immunosuppressive TME. This was reflected by elevated ESTIMATE/TIDE scores and corroborated by CIBERSORT, which revealed increased infiltration of M0 macrophages and upregulation of immunosuppressive signatures. In contrast, the low TELscore group was enriched for cell cycle related pathways, including E2F targets and the G2/M checkpoint, and demonstrated higher infiltration of pro-inflammatory M1 macrophages. 16S rRNA sequencing further revealed a divergent intratumoral microbiome between subgroups, the high TELscore group harbored significantly greater relative abundance of Selenomonas and Lachnoclostridium, two pathogenic genera previously associated with colorectal tumorigenesis. Complementary histopathological assessment via WSI demonstrated a marked absence of intraTLSs in high TELscore tumors. From a therapeutic standpoint, high TELscore tumors exhibited reduced sensitivity to standard chemotherapeutic agents—including Fluorouracil, Irinotecan, Oxaliplatin, and Docetaxel—as reflected by elevated IC50 values. Conversely, these tumors demonstrated increased susceptibility to MAPK pathway inhibitors, such as Selumetinib and Trametinib. Notably, TELscore also served as a robust predictor of immunotherapy response, which was validated in the IMvigor210 cohort. Finally, scRNA analysis highlighted profound cellular and functional divergence between TELscore subgroups. We identified intensified intercellular communication between inflammatory macrophages and fibroblasts, reinforcing the presence of an immunosuppressive niche.

Conclusion

TELscore is a robust stratification tool that captures the interplay between tumor biology, immune characteristics, and microbial ecology in colorectal cancer. By identifying clinically relevant subtypes with distinct therapeutic vulnerabilities, TELscore offers a powerful framework to advance personalized treatment and precision oncology.

References

Siegel RL, Miller KD, Goding Sauer A, Fedewa SA, Butterly LF, Anderson JC, et al. Colorectal cancer statistics, 2020. CA Cancer J Clin. 2020 May;70(3):145–64.
Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74(3):229–63.
Brenner H, Kloor M, Pox CP. Colorectal cancer. Lancet Lond Engl. 2014 Apr 26;383(9927):1490–502.
Shay JW. Role of Telomeres and Telomerase in Aging and Cancer. Cancer Discov. 2016 Jun;6(6):584–93.

Disclosure

The authors have no relevant financial or non-financial interests to disclose.

Introduction

The safety and efficacy of endoscopic haemostasis in patients with upper gastrointestinal (UGI) bleeding has been widely assessed over the years. However, to date no study addressed the management of UGI bleeding specifically in the setting of patients with surgically altered anatomy.

Aims & Methods

Our study is focused on the evaluation of the endoscopic management of UGI bleeding in these patients with specific concern about the techniques used to achieve haemostasis, the management of technical failure and the rate of adverse events. We conducted a multicentre retrospective- prospective observational study in 13 endoscopy units in Italy. All consecutive patients with UGI bleeding and surgically altered anatomy managed endoscopically were collected from January 2023 to November 2024.

Results

We enrolled 162 patients (73% males) with a mean age of 69 years. 45% of patients had history of oncologic surgery while 20% underwent bariatric surgery. The most common clinical manifestations were melena (59%) followed by hematemesis (22%). At bleeding event patients were taking anticoagulants and antiplatelet in 32% and 16% of cases, respectively. In 43% of cases from 1 to 4 blood units were needed, in 15% more than 4 blood units, while in 42% of patients no transfusions ware required. 42% of endoscopic procedures were performed with anesthesiologist assistance. Bleeding was located at anastomotic site in 70% of cases and ulcer was the most common source of bleeding (54% of patients). The most frequently used treatments were adrenaline combined with TTSC (40 %) and TTSC alone (24%). Haemostatic powder or gel and adrenaline combined with thermal treatment were used only in 6 and 4% of cases respectively while OTSC was used in 1 patient alone after failure of adrenaline combined with TTSC. Bleeding control during endoscopy was achieved in 94% of patients. In 12 patients rebleeding occurred, which was managed with surgery in 2 patients, interventional radiology in 1 case and with new endoscopic treatment in 4 cases. No serious adverse events linked to endoscopy were reported.

Conclusion

Our preliminary results showed that patients with altered anatomy often had severe bleeding requiring a large amount of blood transfusions. The standard endoscopic homeostatic techniques seemed to be effective for the management of bleeding, although a not negligible rate of patients needed additional treatments. However, further data are needed to better assess clinical outcomes in this setting and to better define possible predictive predictors of clinical success and therefore which technique should be preferred to achieve haemostasis.

References

1. S. G. Lim et al., “Endoscopic Approach for Postoperative Complications Following Laparoscopic-Assisted Gastrectomy in Early Gastric Cancer: Literature Review,” Hepatogastroenterology., vol. 59, pp. 1308–1312, 2012.
2. J.-H. Park et al., “Safety and efficacy of post-anastomotic intraoperative endoscopy to avoid early anastomotic complications during gastrectomy for gastric cancer.,” Surg. Endosc., vol. 34, no. 12, pp. 5312–5319, Dec. 2020.
3. K.-H. Kim, M.-C. Kim, G.-J. Jung, J.-S. Jang, and S.-R. Choi, “Endoscopic treatment and risk factors of postoperative anastomotic bleeding after gastrectomy for gastric cancer.,” Int. J. Surg., vol. 10, no. 10, pp. 593–597, 2012.
4. Shen, Y.; Xiao, M.; Weng, J.; Yang, L.; Feng, Y.; Ye, Y.; Zheng, P. Diagnosis and treatment of postoperative bleeding in patients after gastrectomy: A retrospective case series study. J. Gastrointest. Oncol. 2023, 14, 110–118.
5. Wichmann, D.; Fusco, S.; Werner, C.R.; Voesch, S.; Duckworth-Mothes, B.; Schweizer, U.; Stüker, D.; Königsrainer, A.; Thiel, K.; Quante, M. Endoscopic Management for Post-Surgical Complications after Resection of Esophageal Cancer. Cancers 2022, 14, 980.

Introduction

Post-liver transplant (LT) bile leaks (BLs) are successfully treated by endoscopic retrograde cholangiopancreatography (ERCP). While fully covered self-expandable metal stents (fc-SEMSs) have shown promising results, their use is often limited by concerns regarding adverse events (AEs), with limited data comparing their efficacy and safety. Moreover, European guidelines do not clearly endorse their up-front use over plastic stents. To date, no studies have directly compared these two treatments for post-LT BLs.

Aims & Methods

This study aims to compare the safety and efficacy of plastic versus fc-SEMS in treating post-LT BLs.
We conducted a retrospective study in single tertiary endoscopy center, reviewing cases from January 2018 to March 2024. Among 223 ERCPs performed in LT recipients, 30 patients treated with ERCP as first-line therapy for post-LT BLs were included. Patients with biliodigestive anastomosis dehiscence or prior interventions (percutaneous drainage or surgery) were excluded.

Results

Of the 30 patients (96.7% duct-to-duct anastomosis), 14 (46.7%) received plastic stents and 16 (53.3%) received fc-SEMSs. Anastomotic leaks were the predominant type (85.7% in the plastic stent group vs. 87.5% in the fc-SEMS group).Both groups achieved 100% technical and clinical success. No significant differences in AE rates were observed (42.9% for plastic vs. 37.5% for fc-SEMS, p=0.1), and no severe complications occurred. Among the 13 patients in whom biliary strictures (BSs) were reported, 4 cases were de novo strictures, occurring equally in the plastic stent group (n=2) and the fc-SEMS group (n=2). The remaining 9 strictures were present prior to BL treatment (3 in the plastic stent group and 6 in the fc-SEMS group). Resolution of BSs was achieved in 66.7% (4/6) of patients treated with fc-SEMSs, compared to 33.3% (1/3) in the plastic stent group, showing a borderline statistically significant difference (p=0.05), though this was limited by the small sample size. No patient required rescue procedures for persistent BL. A median of 2 ERCP sessions per patient (SD ±1) was needed for complete BL resolution. During a median follow-up of 8 months (IQR 1–27.3), only one recurrence occurred in the plastic stent group, successfully managed with fc-SEMS.

Conclusion

ERCP with either plastic stents or fc-SEMSs effectively treats post-LT BLs, with no significant differences in AEs between the two groups. Given their comparable success and safety, fc-SEMS could be considered not only as a rescue therapy but also as a primary, effective and safe treatment option.

References

1. Moy BT, Birk JW. A Review on the Management of Biliary Complications after Orthotopic Liver Transplantation. J Clin Transl Hepatol. 2019;7(1):61-71
2. Phillips MS, Bonatti H, Sauer BG, et al. Elevated stricture rate following the use of fully covered self-expandable metal biliary stents for biliary leaks following liver transplantation. Endoscopy. 2011;43(6):512-517
3. Dumonceau JM, Kapral C, Aabakken L, et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020;52(02):127-149

Introduction

The incidence of superficial non-ampullary duodenal epithelial tumors (SNADETs) has markedly increased in recent endoscopic practice [1, 2]. Nevertheless, the detection rate during esophagogastroduodenoscopy remains low, with 0.15% for adenomas and 0.05% for carcinomas [3]. Large SNADETs, akin to other gastrointestinal malignancies, should be resected en bloc via endoscopic submucosal dissection (ESD). However, the incidence of perforation associated with duodenal ESD is notably high (11.6–35.7%), often necessitating invasive interventions such as pancreatoduodenectomy [4–6]. Endoscopists must learn duodenal ESD procedures through on-the-job training, as no suitable animal or simulation model exists. Although cadaver surgical training (CST) has become prevalent in surgical practice, its application in gastrointestinal endoscopic treatment has been infrequently documented. CST may provide superior anatomical landmarks and tissue fidelity compared to animal or simulation training. This study investigated the potential application of CST as a training model for duodenal ESD.

Aims & Methods

Between July 2024 and February 2025, CST was conducted on four donors preserved using the Thiel method. Upper gastrointestinal examination (UGIE) and multiple duodenal ESD procedures were performed. Among the participants, three had prior experience with these procedures (Experience; Group E), while four did not have such experience (Non-Experience; Group NE). Both groups executed all procedures, and subsequent retrospective studies were conducted: 1) the feasibility of UGIE and the performance of the duodenal ESD procedure for each donor, and 2) questionnaires administered to the participants (n=7) to assess the feasibility of each procedure (marking, submucosal injection, circumferential incision, submucosal dissection), realism of the simulation, and psychological barriers, using a 5-point rating scale ("1: significantly more challenging–5: significantly easier" or "1: strongly disagree–5: strongly agree"). Each score was compiled and presented as the median score.

Results

1) UGIE was feasible in all four cases, although one instance of duodenal perforation occurred due to duodenal stretching. Duodenal ESD was feasible in all four cases and was performed a total of seven times.
2) In UGIE, procedural scores, such as insertion and observation at each location, were predominantly rated 4 or 5, with a score of 3 exclusively noted for intragastric observation. In duodenal ESD, all procedural scores for tasks such as submucosal injection and dissection were consistently assigned a rating of 4. The questionnaire score for the item "Was the duodenal mural architecture preserved?" was 4.5. The scores for the items "Is there psychological stress associated with handling cadavers?" and "Is CST useful for learning duodenal ESD technique?" were 4 and 4.5, respectively. No significant differences were observed in the scores between the E and NE groups for any of the evaluations.

Conclusion

The mural architecture of the gastrointestinal tract in CST, when fixed using the Theil method, closely resembles that of a living organism. It was subsequently identified that CST could serve as an effective educational model for duodenal ESD, marking this as the inaugural report on the subject. This methodology is expected to have broader applications in the education of endoscopic treatments, particularly for rare and challenging procedures such as duodenal ESD, and to contribute to the advancement of endoscopic techniques in future research.

References

1. Legué LM, Bernards N, Gerritse SL, et al. Trends in incidence, treatment and survival of small bowel adenocarcinomas between 1999 and 2013: a population-based study in The Netherlands. Acta Oncol. 2016;55:1183-1189.
2. Yoshida M, Yabuuchi Y, Kakushima N, et al. The incidence of non-ampullary duodenal cancer in Japan: The first analysis of a national cancer registry. J Gastroenterol Hepatol. 2021;36:1216-1221.
3. Yoshimizu S, Hirasawa T, Horiuchi Y, et al. Differences in upper gastrointestinal neoplasm detection rates based on inspection time and esophagogastroduodenoscopy training. Endosc Int Open. 2018;06:E1190–E1197.
4. Hoteya S, Furuhata T, Takahito T, et al. Endoscopic Submucosal Dissection and Endoscopic Mucosal Resection for Non-Ampullary Superficial Duodenal Tumor. Digestion. 2017;95:36-42.
5. Jung JH, KD. C, JY. A, et al. Endoscopic submucosal dissection for sessile, nonampullary duodenal adenomas. Endoscopy. 2013;45:133-135.
6. Kato M, Takeuchi Y, Hoteya S, et al. Outcomes of endoscopic resection for superficial duodenal tumors: 10 years' experience in 18 Japanese high volume centers. Endoscopy. 2022;54:663-670.

Clinical Case Summary

A 46-year-old male with stenosing colonic Crohn’s disease (CD) and perianal fistulas, treated with Infliximab and Azathioprine, achieved clinical and endoscopic remission (CDAI 35, fecal calprotectin 73 µg/g, and SES-CD 1) after 36 months of therapy. Following three years of immunosuppression, he developed dysphagia, weight loss, fever and night sweats – no respiratory symptoms were present. The patient was hospitalized for further evaluation and nutritional support. Infectious screening ruled out bacterial infections, CMV, EBV, HIV, HBV, HCV, tuberculosis, toxoplasmosis, and syphilis. Upper gastrointestinal endoscopy revealed active, ill-defined ulcers in the larynx and pharynx [1] ; two well-defined, clean-based ulcers with non-erythematous edges in the distal esophagus; and elevated, reddened, non-friable post-bulbar lesions. Pharyngeal biopsies collected by the otolaryngology team demonstrated a marked inflammatory response with loose granulomas. Fungal testing revealed numerous fungi consistent with Histoplasma capsulatum (Figure 3B). CT scans indicated adrenal thickening and enlarged para-aortic lymph nodes, supporting the diagnosis of disseminated histoplasmosis. The patient was treated with liposomal amphotericin B, followed by oral itraconazole, resulting in clinical improvement. Given the remission of CD and the confirmed disseminated granulomatous infection, immunosuppressive therapy was discontinued. This case highlights the risk of opportunistic infections in patients with inflammatory bowel disease (IBD) undergoing long-term immunosuppression, particularly when in anti-TNF combination therapy. Gastrointestinal histoplasmosis, especially in the absence of pulmonary symptoms, is a rare infection that is often misdiagnosed due to symptom overlap with IBD. Clinicians must maintain a high index of suspicion to ensure early diagnosis and appropriate management, as delayed treatment is potentially life-threatening.

References

Castro HM, Fullana MP, Canale HL. Disseminated histoplasmosis in immunosuppressed patient. Med Clin (Barc). 2021 Jan 8;156(1):48. English, Spanish. doi: 10.1016/j.medcli.2019.10.002. Epub 2019 Nov 26. PMID: 31784112.