British Journal of Cancer

Abstract Background: High-grade serous ovarian cancer (HGSC) is characterized by extensive genomic heterogeneity and frequent alterations that promote replication stress (RS). Although RS has emerged as a promising therapeutic vulnerability, it remains unclear whether distinct RS-associated genomic alterations generate similar tumour states or drive unique biological programs and therapeutic dependencies. Methods: We developed and characterized a panel of syngeneic HGSC models representing recurrent RS-associated alterations, including overexpression of Ccne1, Brd4, Myc, Ndrg1, Pik3ca, and Brca1 heterozygosity, alongside previously established Pten/Nf1-deficient and Myc overexpressing models. Tumour fitness, transcriptomic programs, histopathology, extracellular matrix composition, immune organization, and therapeutic vulnerabilities were assessed using subcutaneous (s.c.) and intraperitoneal (i.p.) allografts, RNA sequencing (RNAseq), mass spectrometry (MS), cyclic-immunofluorescence (Cyc-IF), and preclinical therapeutic studies. Results: RS-associated genotypes exhibited marked differences in tumour fitness and generated distinct tumour ecosystem states despite sharing a common genetic background. Tumours harbouring BRCA1 heterozygosity displayed reduced tumour fitness, mesenchymal features, extracellular matrix remodelling, stromal expansion, and immune-excluded phenotypes. In contrast, tumours co-expressing Ccne1 and Brd4 exhibited the highest RS level together with strong activation of DNA damage response pathways and limited immune infiltration. Immune characterization identified immune-desert, immune-suppressed, and immune-excluded states across models, demonstrating substantial genotype-dependent immune heterogeneity. Elevated CD47 expression emerged as a defining feature of the Ccne1/Brd4 tumour state and was confirmed in human HGSC specimens with high CCNE1 and BRD4 protein expression. Therapeutic targeting of ATR and CD47 in intraperitoneal Ccne1/Brd4 allografts reduced tumour burden and induced histopathological responses compared with either monotherapy alone, supporting the translational relevance of this RS-high tumour state. Conclusions: Distinct RS-associated alterations do not converge on a common HGSC phenotype but instead generate diverse tumour ecosystem states with unique effects on tumour fitness, stromal remodelling, immune organization, and therapeutic vulnerabilities. These findings highlight the importance of considering the genetic origin of RS when developing therapeutic strategies and establish a framework for investigating genotype-specific vulnerabilities in HGSC.

Background: Although perioperative fluorouracil, leucovorin, oxaliplatin and docetaxel (FLOT) is the standard neoadjuvant regimen for resectable gastric and gastro-oesophageal junction adenocarcinoma, evidence describing treatment delivery in routine clinical practice remains limited, particularly regarding relative dose intensity (RDI) and treatment completion. Objectives: To evaluate real-world delivery of preoperative FLOT chemotherapy, including treatment completion, progression to surgery, RDI, toxicity and exploratory changes in estimated lean body mass (LBM). Methods: A retrospective single-centre service evaluation included consecutive patients receiving neoadjuvant FLOT during 2024. Outcomes included treatment completion, surgery, RDI, toxicity, pathological response and estimated LBM. Descriptive statistics were used. Results: Twelve patients were included (median age 68.6 years; 91.7% male). Eleven (91.6%) completed all four preoperative cycles and proceeded to surgery. Mean RDI was 76.7%. Pre-emptive dose capping was the predominant dose modification strategy, with only one reactive dose reduction. Two grade 3 adverse events occurred. Major pathological response (Mandard grade 1-2) was observed in 2/12 patients (16.7%). Mean estimated LBM declined from 54.3 to 53.4 kg. Greater LBM loss appeared to coincide with poorer clinical outcomes. Conclusions: High treatment completion and progression to surgery were achieved despite reduced RDI. These findings support prospective evaluation of strategies to optimise chemotherapy delivery while maintaining tolerability in routine clinical practice.

Background & Aims: Cholangiocarcinoma (CCA) is an aggressive malignancy with poor five-year survival. Improving outcomes requires preclinical models that faithfully recapitulate the native tumour microenvironment. Precision-Cut Tissue Slices (PCTS) retain in-vivo architecture and represent a promising candidate. We aimed to establish a patient-derived PCTS model of CCA, characterise its response to ex-vivo culture, and assess its use as a platform for therapeutic testing. Methods: PCTS were generated from 25 patients undergoing curative-intent resection for presumed CCA (2022-2024) and cultured for up to 15 days. Viability and histological architecture were assessed serially. Quantitative proteomics (SWATH-DIA) was performed at Days 0, 3, 7 and 15. A subset were treated with staurosporine or clinically relevant chemotherapy (5'-deoxy-5-fluorouridine, gemcitabine {+/-} cisplatin). Results: PCTS viability was maintained to Day 15, with no significant reduction from baseline. PCTS retain tumour architecture, cytokeratin-19-positivity and resident CD3+/CD68+ immune cells during culture. Proteomic profiling quantified 4,578 proteins and identified a staged response, with differentially abundant proteins increasing from 8 (Day 3) to 127 (Day 7) and 180 (Day 15), stabilising thereafter. This comprised of an early loss of inflammatory and stromal proteins, sustained cellular stress responses and metabolic reprogramming. CCA subtype-specific proteomic signatures were preserved throughout culture. Staurosporine produced dose-dependent cytotoxicity whilst chemotherapy responses were variable. Conclusions: Patient-derived CCA PCTS maintain viability, tumour architecture and subtype identity for 15 days while undergoing a defined proteomic response to culture, and retain pharmacological responsiveness,

Importance Two randomized trials have shown that screening with CA-125 is not of value for reducing ovarian cancer mortality. This appears to be because changes in CA-125 occur too late in the disease process to allow for surgical cure of early-stage disease. Objective To determine whether glycovariants of CA-125 could detect ovarian cancer years before clinical diagnosis. Design Case-control study of cryopreserved blood samples and data from the population-based Malmo Diet and Cancer cohort. Setting Population-based study in Sweden. Participants Serum was available for 17,297 women aged 44 to 73 collected at baseline in 1991to1996 and from 2,168 women re-sampled in 2007 to 2012. Participants' records were linked to the Swedish cancer registry to identify 82 women with incident ovarian cancer diagnosed up to 10 years after blood draw. Cases were matched 1:3 with controls by age and venipuncture date. Exposure Serum was measured for CA-125 glycovariants Sialyl-Thomsen-nouveau (STn) and Macrophage-Galactose-Lectin (MGL) using GLYVAR Ovarian I and II assays (Uniogen), conventional CA-125 (CanAg CA125 EIA, Fujirebio) and HE4 EIA (Fujirebio). Main outcome measure Ovarian cancer. Results The CA-125-STn was associated with subsequent ovarian cancer (p=0.002). In the primary analysis restricted to cases within 5 years, the area-under-the-curve for CA-125-STn was 0.68; with moving window analysis suggesting retained predictiveness up to 5-7 years. Of the cases diagnosed within 5 years, 27% were in the top 5% of CA-125-STn levels (>=2.3 U/ml), with 35% and 49% of cases diagnosed in the top 10% and 20% respectively. Our findings were replicated by independent measurements of a separate aliquot from a subset of cases and controls. Neither CA-125, HE4 nor CA-125 glycovariants detected by MGL importantly predicted subsequent ovarian cancer. Conclusions and Relevance CA-125-STn can detect ovarian cancer several years before clinical diagnosis. Further research is warranted on larger cohorts with sequential samples to determine the shape of the relationship between CA-125-STn and risk, the value of longitudinal sampling of CA-125-STn, and whether other markers could be combined with CA-125-STn to more accurately predict ovarian cancer risk.

Background: Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine neoplasms originating from chromaffin cells that express somatostatin receptors (SSTRs) and may therefore be susceptible to somatostatin analogue therapy. Despite this biological rationale, prospective evidence supporting the antiproliferative activity of somatostatin analogues in PPGL is limited. We conducted a multicenter phase 2 clinical trial to assess the efficacy and safety of lanreotide in patients with advanced or metastatic PPGL. [LAMPARA, NCT03946527] Methods: Patients with advanced or metastatic PPGL and evidence of recent disease progression received lanreotide depot/autogel 120 mg subcutaneously every 4 weeks. Treatment was planned for 52 weeks with an option to continue for an additional 52 weeks. Endpoints included overall survival (OS), progression-free survival (PFS), and response according to RECIST. Serum chromogranin A (CgA) was evaluated as an exploratory biomarker. A tumor growth rate analysis was planned to allow comparison with data from the CLARINET trial in gastroenteropancreatic NETs. Results: Eighteen patients (median age 42 years; range 28-77) across three centers participated; 78% carried SDHx mutations. Lanreotide was well tolerated with predominantly grade 1-2 adverse events and no treatment discontinuations due to toxicity. The most common treatment-emergent adverse events were diarrhea (67%), injection-site reaction (44%), constipation (39%), fatigue (39%), and abdominal pain (39%). Serious adverse events were reported in four patients and were assessed as not related or unlikely related to lanreotide. All 18 patients had at least one recorded post-baseline tumor assessment. Two partial responses were recorded during extended follow-up. At approximately 1 year, disease stabilization was observed in 11 of 13 patients (85%) with an available assessment, while two patients (15%) had progressive disease. Biomarker analysis showed substantial variability in serum CgA values. Tumor growth rate analysis revealed a median growth rate of 0.00124/day (tumor doubling time 559 days), comparable in order of magnitude to the rate of 0.00046/day observed in 83 lanreotide-treated patients in CLARINET, and consistent with a median PFS [≥]2 years. Conclusions: Lanreotide exhibits promising antiproliferative activity in PPGL, with a favorable safety profile and extended periods of disease stabilization. These findings support the consideration of SSAs as an option in managing SSTR-positive PPGLs, delaying more aggressive treatments until disease progression mandates escalation.

Background: Total neoadjuvant therapy (TNT) is increasingly used for treatment of locally advanced rectal cancer (LARC) to improve treatment compliance, oncological outcomes and opportunities for organ preservation. However, evidence describing its implementation and outcomes in low- and middle-income countries remains limited. This study evaluated the feasibility, treatment delivery, oncological outcomes and organ preservation outcomes of TNT in a real-world South African setting. Methods: This was a retrospective review of a prospective cohort of adults with histologically confirmed, non-metastatic LARC treated with TNT at the Wits Donald Gordon Medical Centre, Johannesburg, between March 2022 and January 2026. Treatment was individualised following multidisciplinary review and included induction and/or consolidation systemic chemotherapy with either long- or short-course radiotherapy. Following TNT, treatment response was assessed clinically, endoscopically and radiologically. Patients with a clinical complete response (cCR) were offered watch-and-wait (WW) surveillance, while those with an incomplete response were recommended for total mesorectal excision (TME). The primary outcome was organ preservation, assessed as TME-free survival. Secondary outcomes included tumour regrowth, disease-free survival (DFS), overall survival (OS), and local recurrence-free survival (LRFS) following TME. Results: Forty-six patients were included; median age was 63 years, 67.4% were male, 82.6% had T3-T4 tumours and 80.4% had node-positive disease. TNT was completed as planned in 95.7% of patients. Grade [≥]3 toxicity occurred in 19.5% during chemotherapy and 8.9% during radiotherapy. Twenty-one patients (45.7%) achieved a cCR and entered WW surveillance. TME-free survival was 46% (95% CI 31-60) at 1-year and 18% (95% CI 8-32) at 3-years. Three-year OS and DFS were 87% (95% CI 64-96) and 76% (95% CI 53-89), respectively. Among patients managed with WW, 3-year regrowth-free survival was 53% (95% CI 26-75). Three-year LRFS following TME was 94% (95% CI 68-99), and all patients undergoing TME or completed salvage surgery achieved an R0 resection. Conclusion: TNT was feasible and well tolerated in this real-world South African cohort, with high treatment completion and favourable medium-term oncological outcomes. Although almost half of patients initially achieved a cCR, declining TME-free and regrowth-free survival demonstrated that durable organ preservation was less frequent, highlighting the importance of structured surveillance and timely access to salvage surgery. These findings support the feasibility of delivering contemporary multimodal rectal cancer care in an appropriately resourced African setting.

Carriers of germline BRCA1 or BRCA2 alterations have a substantially increased lifetime risk of high-grade serous ovarian carcinoma (HGSOC), which originates from the secretory cells of the fallopian tube. However, comparative multi-omic analyses of bulk fallopian tube tissue from BRCA1/2 carriers and the general population have, to date, revealed only limited differences. New molecular biomarkers of early malignant transformation in the FT are needed to enable non-surgical cancer interception in high-risk individuals through window-of-opportunity trials prior to risk-reducing surgery. We performed a comprehensive single-cell, multi-regional analysis of fallopian tubes from 34 women, including 15 carriers of germline BRCA1/2 alterations. Using a metacell-based approach applied to single-cell transcriptomic data, we identify both established and previously unrecognised cellular populations, and characterise phenotypic variation associated with menopausal status, menstrual cycle phase, hormonal contraception use, and anatomical region of the fallopian tube. Menopause was associated with depletion of ciliated cells, whilst both secretory (SEC) and ciliated epithelial cells (CEC) shifted to a glandular phenotype in the luteal phase. Previous hormonal contraception usage had lasting effects including depletion of CD163-positive tissue resident macrophages and progesterone-specific increase of MHC-II expression in SECs. Metacell analysis further identified distinct subpopulations of SECs, most frequently in BRCA1/2 carriers, characterised by high TP53 expression and markedly elevated histone levels. This phenotype is consistent with replication stress, cell-cycle arrest, and activation of innate immune signalling pathways. Protein-level validation in matched samples showed enrichment of cells with increased {gamma}H2AX expression and persistent 53BP1 foci in BRCA1/2 carriers. Together our data supports the role of BRCA1/2 in maintaining genomic integrity and a BRCA1/2 haploinsufficient phenotype characterised by increased replication stress in the fallopian tube epithelium. Our findings provide evidence for distinct immune responses in users of hormonal contraception and demonstrate early events in malignant transformation. They establish potential biomarkers in microscopically normal FT and a framework for measurement of cancer risk with the goal of enabling molecularly informed cancer interception in high-risk individuals.

Introduction Patients undergoing polypectomy at colonoscopy remain at risk of metachronous neoplasia despite surveillance guided by histopathological features. Mutational profiling of adenomas, including canonical driver mutations in APC, KRAS, and TP53, may offer additional predictive value. This study aimed to determine whether mutational status in index adenomas was associated with metachronous lesion risk. Methods The INCISE cohort included patients aged 50 to 74 years who underwent polypectomy within the Scottish Bowel Screening Programme and subsequent surveillance colonoscopy within 6 years. Targeted next-generation sequencing was performed on formalin-fixed paraffin-embedded polyps. Driver mutation frequency, tumour mutational burden (TMB), and variant allele frequency (VAF) were analysed and correlated with histopathological features and metachronous outcomes using appropriate statistical models. Results A total of 895 adenomas from 723 patients were analysed. In conventional adenomas, as the number of high-risk histopathological features (size >=10mm, villous architecture, and high-grade dysplasia) increased there was a stepwise increase in the proportion of samples with a mutation in KRAS from 13% to 51% (padj<0.001) and TP53 from 8% to 35% (padj<0.001). However, neither mutation frequency (p=0.901), nor median tumour mutation burden (TMB) (2.27 vs 2.15 mut/Mb, p=0.242), in index adenomas was associated with the development of metachronous lesions. Conclusions While classical driver mutations reflect histopathological progression within adenomas, they do not predict metachronous lesion risk post-polypectomy. Targeted mutation profiling alone is insufficient for surveillance risk stratification, highlighting the need for integrated molecular approaches in this setting.

Objectives Low grade serous ovarian cancer (LGSOC) is characterized by frequent TP53 wild type status and limited responsiveness to conventional chemotherapy. This study investigated the cytotoxic effects of oxaliplatin combined with 5-fluorouracil on patient derived LGSOC cells. Results Clinically relevant concentrations of oxaliplatin and 5-fluorouracil had minimal effects on LGSOC cell viability but markedly reduced cellular proliferation and clonogenic recovery. Combined treatment induced pronounced accumulation of cells in the G0/G1 phase of the cell cycle and increased expression of p53 and p21, accompanied by reduced pRB phosphorylation, consistent with activation of the p53-p21-pRb pathway. Oxaliplatin plus 5-fluorouracil also increased senescence-associated beta-galactosidase activity, cellular enlargement and flattening, and reactive oxygen species production, supporting a senescence-like phenotype. However, after drug withdrawal, treated cells progressively regained proliferative capacity, indicating that the senescence phenotype was transient rather than fully irreversible. Together, these findings show that oxaliplatin plus 5-fluorouracil primarily arrest rather than kill LGSOC cells and induces a transient senescence-like phenotype and G0/G1-phase arrest by activating the p53-p21-pRb pathway.

Background: Transcriptomic FOLFIRINOX-component sensitivity signatures have been clinically evaluated in resected and advanced PDAC, but their relevance and longitudinal stability in the neoadjuvant BR/LA setting are unknown. Patients and methods: We retrospectively studied 77 patients with borderline resectable or locally advanced PDAC treated with neoadjuvant FOLFIRINOX followed by resection. Pretreatment sensitivity to 5-fluorouracil, oxaliplatin and irinotecan was determined using previously developed locked transcriptomic classifiers and integrated into a regimen-level FOLFIRINOX classification. The primary molecular cohort comprised 53 patients whose pretreatment biopsies had [&ge;]10% tumour cellularity. Cox models assessed associations with survival. Longitudinal changes were assessed in 35 paired tumours. Results: Thirty-one pretreatment tumours were classified as FOLFIRINOX-sensitive (FFX-Sens), and 22 were not classified as FOLFIRINOX-sensitive (FFX-Res). FFX-Sens status was associated with longer overall survival (OS; hazard ratio [HR] 0.48, 95% confidence interval [CI] 0.25-0.93; p=0.029). In the complete-case model adjusted for baseline carbohydrate antigen 19-9 (CA19-9) and tumour size (n=50), the association with OS persisted (adjusted HR 0.47, 95% CI 0.23-0.96; p=0.037), whereas the adjusted association with disease-free survival was not statistically significant (adjusted HR 0.55, 95% CI 0.28-1.10; p=0.090). Among paired tumours, 15 changed from FFX-Sens to FFX-Res and four in the opposite direction (exact McNemar p=0.019). The OS association also persisted after adjustment for postoperative pathological factors (adjusted HR 0.40; p=0.015). Conclusions: Pretreatment FOLFIRINOX sensitivity was associated with OS under neoadjuvant FOLFIRINOX, while matched pretreatment and residual-tumour analyses revealed significant directional reclassification after treatment. These findings extend the clinical evaluation of validated drug-specific FOLFIRINOX sensitivity classifiers to the neoadjuvant setting and provide a longitudinal assessment of their stability during treatment. They support prospective evaluation of both pretreatment stratification and molecular reassessment of residual disease.

Background The number of novel cancer therapies approved for use in England by the National Institute for Health and Care Excellence is increasing. Monitoring the adoption of new therapies is important to assess equity of access and evaluate real-world prescribing practices. OpenPrescribing Hospitals has recently been launched to facilitate analysis of open secondary care medicines data in England. Using this platform, we set out to describe the use of cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors, including the frequency of dose reductions, within National Health Service (NHS) hospitals in England between January 2019 and December 2024. Methods The monthly proportion of each CDK4/6 inhibitor relative to total CDK4/6 inhibitor use was calculated at hospital level. Regional variation was assessed across Cancer Alliances by comparing the proportions of each CDK4/6 inhibitor used within each alliance in 2021 and 2024. Use of lower strength palbociclib and abemaciclib was used as a proxy for dose reductions. Findings There was more than a 3-fold increase in the use of CDK4/6 inhibitors between 2019 and 2024. In 2019, 78.6%, 11.9% and 9.5% of CDK4/6 inhibitors used were palbociclib, abemaciclib and ribociclib, compared with 40.2%, 41.2% and 18.6% in 2024. There was variation in the relative percentage change in use of each agent by Cancer Alliance. Use of lower strengths was common for both palbociclib (60%) and abemaciclib (63%). Interpretation Changes in usage appeared responsive to publication of key evidence and regulatory milestones. There was a higher apparent frequency of dose reductions than reported in clinical trials. OpenPrescribing Hospitals is an accessible, publicly available tool for understanding uptake and use of medicines in NHS hospitals in England.

AbstractAdrenocortical carcinoma (ACC) is a rare and highly aggressive endocrine malignancy originating from the adrenal cortex with limited effective treatment options. The underlying pathophysiology of ACC is uniquely characterized by abnormal steroid production and increased metabolic activity, highlighting the critical role of mitochondria in adrenal steroid hormone biosynthesis and tumor metabolism. In this study, we investigated the therapeutic potential of TR-107, a novel and highly selective small-molecule agonist targeting the mitochondrial protease ClpP. Pharmacologic hyperactivation of ClpP disrupts mitochondrial proteostasis and bioenergetics and has shown promising antitumor activity in various preclinical models. Our results demonstrated that TR-107 induces potent dose-dependent cytotoxic effects at nanomolar concentrations in ACC cell lines NCI-H295R and mACC3 as well as short-term ACC patient-derived organoid (PDO) models, markedly reducing cell viability and confluency in vitro. Metabolic analyses revealed that TR-107 significantly impaired oxygen consumption, indicating a disruption of oxidative phosphorylation and substantial attenuation of basal cellular respiration. Mechanistic studies showed dose-dependent increases in reactive oxygen species (ROS) levels and upregulation of proteins involved in mediating the ferroptotic rheostat. Pharmacokinetic assessment uncovered that TR-107 was not a substrate of the ABCB1 (MDR1/P-glycoprotein) efflux transporter, suggesting potential to overcome common multidrug resistance mechanisms. Given the importance of IGF-2 signaling in ACC, we further explored the combinatorial effects of TR-107 with IGF-1 receptor (IGF-1R) inhibitors and discovered that co-treatment produced synergistic reductions in cell viability across NCI-H295R, mACC3, and ACC PDOs. Collectively, these findings support the potential of mitochondrial ClpP hyperactivation as a promising therapeutic strategy for ACC and demonstrate that TR-107 exhibits significant antitumor activity as a monotherapy or in combination with IGF-1R inhibitors. These findings provide a strong rationale for advancing ClpP agonists into clinical development for the management of ACC.

High-grade serous ovarian carcinoma (HGSOC) is the most common form of ovarian carcinoma and accounts for the majority of deaths from the disease, with fewer than half of patients surviving five years after diagnosis. Bulk transcriptomic profiling has identified molecular subtypes and gene-expression signatures associated with shorter or longer survival. However, because bulk profiling measures a composite of tumour and microenvironmental gene expression, the cellular origins of these signatures and their relationship to the tumour microenvironment remain unresolved. To address this, we applied Xenium spatial transcriptomics to treatment-naive HGSOC tumours from 122 patients using a custom 480-gene panel designed to measure tumour-intrinsic gene expression and distinguish immune and stromal cell populations in the surrounding microenvironment. Analysis of tumour-intrinsic gene expression identified 61 genes nominally associated with overall survival, from which Elastic-Net modelling prioritised five genes associated with longer survival and nine associated with shorter survival. Notably, 46 of the 61 associations did not reach the nominal significance threshold when expression was instead aggregated across all cells from the same patients, highlighting how whole-tissue expression can obscure tumour-cell-specific survival associations. Complementary analysis of tumour-proximal cell populations revealed that multiple immune populations were associated with longer survival, whereas two fibroblast populations were associated with shorter survival. Integrating these analyses revealed that survival-associated tumour-intrinsic gene expression was correlated with the abundance of neighbouring immune and stromal populations that were themselves associated with survival. Pairwise Cox regression demonstrated substantial overlap in the prognostic information captured by these features, while analysis of individual gene-cell combinations showed that survival associations differed according to the abundance of neighbouring populations. Consensus clustering further identified four patient groups with distinct combinations of tumour-intrinsic expression and microenvironmental composition, broadly separating patients with longer and shorter survival. Together, this cohort-scale spatial analysis identifies tumour-intrinsic and microenvironmental features associated with HGSOC survival and reveals how their correlated patterns and combined associations relate to patient outcome.

Purpose: To analyze the effect of radiotherapy timing relative to surgery on patients' survival and mortality rates in uveal melanoma (UM). Design: Retrospective cohort study using registry data from the Surveillance, Epidemiology, and End Results (SEER) database. Subjects: A total of 1,198 patients with UM were extracted from the SEER database and divided into three groups: preoperative radiotherapy, intraoperative radiotherapy (IORT), and postoperative radiotherapy. Methods: UM cases were extracted from the SEER database. Survival curves were generated based on the Kaplan-Meier method. An extended Cox regression was used to estimate the cancer-specific and all-cause mortality. Main Outcome Measures: Overall survival (including median survival) and hazard reductions for cancer-specific and all-cause mortality. Results: Preoperative radiotherapy revealed the highest median survival (4.93 years), followed by postoperative radiotherapy (4.76 years), and IORT (4.02 years). The preoperative strategy reduced the hazard of all-cause mortality by 42%, 50%, and 60% at 5-, 7-, and 10-year follow-up, respectively, compared with IORT. Findings were consistent in the cancer-specific sensitivity analysis (45%, 53%, and 62% reductions at the same time points). However, postoperative radiotherapy did not significantly reduce the cancer-specific mortality in comparison to IORT. Conclusions: Preoperative radiotherapy was associated with higher median overall survival and lower all-cause and cancer-specific mortality than IORT over 10 years of follow-up. Postoperative radiotherapy showed intermediate outcomes that did not differ significantly from IORT. Prospective studies with more detailed data on the temporal relation of radiotherapy timing and surgery are needed to confirm these findings.

BackgroundNHS-Galleri did not reach its prespecified primary endpoint of a reduction in combined stage III and IV cases, but reported fewer stage IV cancers after annual multi-cancer early detection screening. We estimated the potential five-year life-years associated with the cancer-specific stage IV differences observed during the two incident screening rounds. MethodsWe used intervention and control stage IV counts for ten prespecified cancers reported in the NHS-Galleri ASCO 2026 presentation. For each cancer, the randomized-arm count difference was multiplied by the difference in five-year restricted mean survival time between stage III and IV, estimated from England stage-specific five-year net survival using a constant-hazard fit. Adverse cancer-specific differences remained in the model. Results were annualized across the two incident rounds and scaled per million people screened. Sampling intervals used an independent Poisson approximation for arm-specific counts. FindingsAcross the ten evaluable cancers, the intervention and control arms had 180 and 239 stage IV diagnoses during the incident rounds. The conditional projection was 66.3 potential life-years over five years in the trial intervention cohort, equivalent to 466 per million people screened annually (95% sampling interval 190-743). For a population of 10 million, the corresponding projection was 4,664 annually (1,896-7,432). Colorectal, lung, and esophageal cancers accounted for 79% of the net projection. Pancreatic, ovarian, and lymphoid cancers contributed negatively because their observed stage IV counts favored control. InterpretationIf the observed incident-round reduction in stage IV diagnoses represents true downstaging to stage III, it could produce meaningful population health gains. This conditional estimate is not evidence of mortality reduction. Longer follow-up remains necessary to distinguish benefit from chance, lead-time and length biases, overdiagnosis, and differences in tumor biology.

Background: 177Lu-PSMA-617 radioligand treatment represents a major advancement in the management of metastatic castration-resistant prostate cancer (mCRPC), but key questions remain about tumor-cell dynamics and evolution in patients who have received this drug. Here, we used a circulating tumor cell (CTC) capture assay to assess the prognostic capacity of CTC subset dynamics following 177Lu-PSMA-617 treatment in a cohort of mCRPC patients. Methods: Using an AI-empowered holographic imaging platform combined with in-flow protein marker analysis, we prospectively analyzed serial CTC samples from patients receiving 177Lu-PSMA-617 therapy at pre-treatment and on-treatment time points (n=39 of 100 enrolled patients). PSMA and EpCAM proteins in CTCs were determined by immunofluorescence staining. Proportions and absolute counts of CTC subsets delineated by PSMA and EpCAM proteins were assessed in PSA50 responders (n=19) and non-responders (n=20). Within-patient changes in CTC subsets were compared using Wilcoxon signed-rank tests with Benjamini-Hochberg correction. Associations of CTC subset abundance and dynamics with overall survival were assessed using Kaplan-Meier estimates with log-rank tests and univariable Cox proportional hazards models. Results: PSMA and EpCAM stratified CTCs into subsets, some of which were associated with survival outcomes following 177Lu-PSMA-617. We observed an increase in the proportion of PSMA-/EpCAM+ CTCs following 177Lu-PSMA-617, with a larger increase occurring in PSA50 responders (6.2% to 18.7%; p=0.041) than non-responders (7.9% to 15.4%; p=0.023). This corresponded to a decrease in the proportion of PSMA+/EpCAM- CTCs, whereas the proportion of PSMA+/EpCAM+ CTCs did not decline. On-treatment counts of >5 CTCs, relative to [&le;]5 CTCs, were associated with shorter overall survival in the PSMA+/EpCAM+ (HR 3.56, 95%CI 1.32-9.60, p=0.012) and PSMA+/EpCAM- (HR 7.50, 95%CI 0.96-52.99, p=0.054) subsets. Finally, on-treatment declines in PSMA+/EpCAM+ (HR 0.74, p=0.49) and PSMA+/EpCAM- (HR 0.61, p=0.215) CTC subsets were not significantly associated with overall survival relative to sustained high levels of these cells. Conclusions: In mCRPC patients receiving 177Lu-PSMA-617, dynamic changes in CTC subsets delineated by PSMA and EpCAM expression may have prognostic value, justifying additional evaluation.

Purpose: Response-adapted bladder preservation has emerged as a potential alternative to immediate radical cystectomy for selected patients with muscle-invasive bladder cancer (MIBC), but biomarkers to guide treatment de-escalation are lacking. We report the clinical outcomes of the phase II RETAIN2 trial together with a retrospective circulating tumor DNA (ctDNA) analysis of the RETAIN1 and RETAIN2 studies. Patients and Methods: RETAIN2 prospectively evaluated neoadjuvant accelerated methotrexate, vinblastine, doxorubicin, and cisplatin (AMVAC) plus nivolumab followed by response-adapted management based on clinical restaging. A retrospective tumor-informed ctDNA analysis evaluated longitudinal ctDNA dynamics and associations with clinical outcomes. Results: Seventy one evaluable patients were enrolled in RETAIN2. The trial met its primary endpoint, with a 2 year metastasis free rate of 77.5% after a median follow-up of 34.7 months. Among 22 patients managed with active surveillance, 15 (68.2%) remained metastasis free with an intact, non irradiated bladder and 3 (13.6%) developed metastatic disease. In a sensitivity analysis using time to metastasis, the Kaplan Meier estimated 2 year metastasis free probability was 83.7% overall and 85.5% with active surveillance. Retrospective ctDNA analyses were performed in 111 patients from RETAIN1 and RETAIN2. Baseline and post-treatment ctDNA positivity were associated with metastatic progression and inferior overall survival. Among patients managed with active surveillance who were ctDNA-negative after treatment, the 2 year Kaplan Meier estimated metastasis free probability and overall survival were 91% and 97%, respectively. Plasma ctDNA predicted metastatic progression but not intravesical recurrence. Conclusion: Response adapted bladder preservation after neoadjuvant AMVAC plus nivolumab achieved encouraging long term outcomes in selected patients with MIBC. Retrospective ctDNA analyses suggest that plasma ctDNA reflects occult systemic disease rather than bladder confined recurrence and may refine patient selection for bladder preservation. These findings support prospective evaluation of ctDNA guided strategies while emphasizing the continued need for bladder directed surveillance and complementary urinary biomarkers.

Objective Extranodal spread is an adverse prognostic factor in several cancers. In clinically early-stage cervical cancer and positive lymph nodes after radical hysterectomy, extranodal spread is routinely registered in pathology reports, but it does not influence adjuvant treatment decisions. This nationwide study assessed the prognostic value of extranodal spread. Methods Patients diagnosed between 2009 and 2024 with clinical early-stage cervical cancer (TNM T1 to T2a2) and pathologically positive regional lymph nodes after radical hysterectomy were identified from the Netherlands Cancer Registry. Cox proportional-hazard models assessed differences in overall survival and recurrence-free survival. A Bayesian Cox model with informative prior was applied to complement overall survival analysis. Recurrence patterns were compared by extranodal spread status. Results Among 408 patients, 46 (11.3%) had extranodal spread. In multivariable frequentist analysis, extranodal spread was significantly associated with poorer recurrence-free survival (hazard ratio [HR] 1.97, 95% confidence interval [CI] 1.11-3.49), but not with overall survival (HR 1.37, CI 0.78-2.41). Bayesian analysis showed a significant difference in overall survival (HR 1.63, CI 1.14-2.27). Among patients with recurrence, the distribution of locoregional and distant recurrence patterns did not significantly differ between those with and without extranodal spread (p=0.09). Conclusion Extranodal spread is associated with poorer recurrence-free survival in clinically early-stage cervical cancer treated with radical hysterectomy. For overall survival, results were directionally consistent but dependent on the analytical approach, likely reflecting limited statistical power. These findings suggest a role for extranodal spread in risk stratification and follow-up, warranting further investigation before informing treatment decisions.

Advanced prostate cancer exhibits profound cellular and molecular heterogeneity, frequently becoming resistant to androgen receptor (AR) targeting through lineage plasticity and neuroendocrine differentiation. Immunotherapies have shown limited efficacy in prostate cancer, largely due to its immunosuppressive tumour microenvironment. Hypersialylation contributes to immune evasion by engaging sialic acid-binding immunoglobulin-like lectins (Siglecs) on immune cells, forming glyco-immune checkpoints. Although this pathway represents a promising therapeutic target, the distribution of Siglec ligands across diverse prostate cancer phenotypes and their response to standard-of-care hormone therapy remain poorly understood. Here, we utilised high-affinity engineered sialoglycan-binding reagents (HYDRA) to perform comprehensive immunohistochemical profiling of Siglec-7 and Siglec-9 ligands across a panel of 40 Washington Carcinoma of the Prostate (LuCaP) patient-derived xenograft (PDX) models. Ligand expression was evaluated in relation to AR status and neuroendocrine phenotype. To determine the impact of androgen deprivation on the tumour glycome, ligand expression was compared between matched PDX lines grown in intact and castrated mice. Our findings reveal widespread but heterogeneous expression of Siglec-7 and Siglec-9 ligands across the LuCaP cohort. Expression levels were comparable between AR-positive adenocarcinoma models and AR-negative neuroendocrine variants, demonstrating that this glyco-immune checkpoint is maintained across distinct prostate cancer lineages. Under castration conditions, glycan remodelling occurred in a model-dependent manner. A subset of PDX models exhibited reduced Siglec ligand expression following castration, suggesting partial AR dependence. In contrast, other models displayed increased ligand expression, consistent with adaptive immune evasion in response to therapeutic stress, while a third group remained largely unchanged. Collectively, our study demonstrates that the Siglec-7/9 glyco-immune checkpoint axis is broadly maintained across the spectrum of prostate cancer lineage plasticity but is dynamically remodelled by androgen deprivation in a patient-specific manner. These findings support the sialoglycan-Siglec axis as a lineage-independent immunotherapeutic target and suggest that strategies aimed at disrupting Siglec-mediated immune suppression, such as tumour desialylation, may be most effective when combined with androgen deprivation therapy to enhance anti-tumour immunity.

Background Immune checkpoint blockade (ICB) has become the standard of treatment for metastatic melanoma (MM). However, patients with melanoma brain metastases (MBM) are often excluded from clinical trials. Here we analyse patients within the real-world OxCITE cohort receiving ICB treatment for metastatic melanoma, with a focus on MBM, aiming to discern outcomes, prognostic factors and peripheral biomarkers. Methods Patients eligible for ICB treatment were recruited prospectively. Demographic, clinical and radiological data were collected from electronic patient records. Plasma samples were collected prior to the first cycle of treatment for plasma proteomic analysis. Results 307 patients were included, 81 of whom had MBM on commencing ICB. No difference in overall survival between patients with and without brain metastases was noted on multivariable analysis (HR=1.1, 95% CI 0.73-1.6, p=0.68), whereas hepatic metastases were associated with increased risk of death (HR 1.7, 95% CI 1.2-2.4, p=0.0019). Within the MBM group, steroid treatment (HR=2.5, 95% CI 1.3-5.0, p=0.006) was associated with poor OS, whilst treatment with single agent ICB (HR=1.9, 95% CI 0.86-3.9, p=0.11), symptomatic first presentation of MBM (HR=1.5, 95% CI 0.76-2.8, p=0.25) and anti-seizure drug treatment (HR=1.74, 95% CI 0.89-3.4, p=0.10) were not. Amongst all patients carriage of a BRAF mutation was associated with increased risk of MBM (OR 2.49, 95% CI 1.4-4.4, p=0.0007), and increased propensity to new brain metastases on ICB treatment (OR 2.5, 95% CI 1.1-5.9, p=0.036). Analysis of blood and plasma samples demonstrated that patients with MBM have altered haematological profiles, with raised NLR and increased plasma glial fibrillary acidic protein levels, reinforcing the distinct systemic features of MBM. Conclusions In this real-world cohort of patients receiving ICB for metastatic melanoma, the presence of MBM did not associate with worse OS. Conversely, baseline corticosteroid use was adversely prognostic. Intriguingly, plasma GFAP was significantly elevated in patients with MBM and correlated with the burden of intracranial disease, highlighting a potential role for GFAP as a candidate biomarker for MBM in high-risk surveillance. Our observations indicate the adversely prognostic weight historically attached to M1d disease is no longer applicable in the ICB era.