Gut

Esophageal adenocarcinoma (EAC) has a poor five-year survival rate and one of the fastest-rising incidences of any cancer. The presence of dysplasia in Barrett's esophagus (BE) is the main risk factor for EAC development and guides clinical management. Unfortunately, the current histopathological diagnosis of dysplasia is unreliable, with poor inter-observer agreement, highlighting the need for novel biomarkers that can improve diagnostic accuracy. Here, we performed transcriptome profiling across the full spectrum of BE-related neoplasia in 85 samples to delineate gene expression alterations in progressively worse disease stages and identify biomarkers that could complement histopathology to improve the detection of dysplasia and EAC in endoscopic biopsy specimens. Differential gene expression and pathway analyses revealed that the most extensive transcriptional changes occurred during the transition from normal squamous (NSq) to non-dysplastic BE (NDBE), consistent with metaplastic transformation. Compared to NDBE, dysplasia was characterized by enhanced cellular growth and proliferation; upregulation of immune processes and oncogenic signaling pathways were present in EAC. Using machine learning approaches, we identified a novel five-gene panel suitable for a potential RNAseq-based diagnostic test (SLC11A1, IL36A, LUCAT1, MIR215, RNU6-954P) and performed an initial validation of this signature in an additional 51 samples. We also identified several potential novel immunohistochemical markers that may warrant further evaluation, including TREM1, CXCL5, OSM, and motilin. In summary, by delineating transcriptional changes across the full disease spectrum, this study identifies several candidate biomarkers for improving current diagnostic methods for Barrett's dysplasia and EAC.

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.

Background & Aims: Immune-mediated liver injury from immune checkpoint inhibitors (ILICI) is a major immune-related adverse event that limits cancer immunotherapy, yet its tissue-level immunobiology is poorly defined and its management is largely extrapolated from autoimmune hepatitis (AIH). We previously identified a tri-cellular CD8+ T cell-macrophage-hepatocyte injury niche in a murine model of ILICI; here, we tested whether this niche is recapitulated in human disease. Methods: We applied imaging mass cytometry with a 32-marker panel to liver biopsies from patients with ILICI (n = 12), AIH as a disease comparator (n = 14), and healthy controls (n = 2), profiling approximately 297,000 single cells across 144 regions of interest with spatially resolved detection of apoptosis (cleaved caspase-3, cC3) and pyroptosis (cleaved gasdermin D, cGSDMD). Results: We detected histiocyte-rich granulomas in ILICI consisting of macrophages and CD8+ T cells, including activated memory-effector subsets. Permutation-based spatial analysis identified CD8+ T cell-macrophage co-localization as the most frequent significant interaction in ILICI, organizing into integrated innate-adaptive cellular neighborhoods that concentrated cC3- and cGSDMD-positive cells. Descriptively, this contrasted with AIH, in which immune cells and stroma were more spatially compartmentalized. CD8+ T-cell and macrophage densities correlated with Ishak necroinflammation scores, jaundice, and granuloma formation. Conclusions: These findings provide the first single-cell spatial proteomic characterization of human ILICI in situ; they recapitulate the tri-cellular CD8-macrophage-hepatocyte niche we previously defined in a murine model and characterize ILICI as a spatially organized innate-adaptive inflammatory process, nominating myeloid signaling and CD8-macrophage interactions as candidate liver-directed targets to uncouple hepatotoxicity from anti-tumor immunity.

Background National childhood respiratory pathogen spectra are diversifying nearly everywhere - within-country diversity rose in 203 of 204 countries between 1990 and 2023 - yet whether countries are diversifying toward a common spectrum or along divergent paths is unknown. We quantified between-country compositional distance of national pathogen spectra over the same period. Methods We built national pathogen share vectors from Global Burden of Disease Study 2023 lower respiratory infection etiologic attributions (26 pathogens, 204 countries, ages 0-19 years) at five timepoints spanning 1990-2023. Between-country distance was measured as all pairwise Jensen-Shannon divergences (JSD; primary) and Bray-Curtis dissimilarities, with Baselga and Jaccard decompositions; robustness was assessed across metrics, pathogen panels, low-count thresholds and a balanced panel of 107 countries. Results Mean pairwise JSD rose from 0.0084 in 1990 to 0.0283 in 2023 (+238%; trend p = 0.030), peaking in 2021 (+283%) with a partial 2023 pullback. Bray-Curtis dissimilarity rose +120% and the balanced panel +423%. Divergence was entirely balanced variation (share reallocation), with spectrum richness rising from 18.5 to 21.1 of 26 pathogens. Dispersion rose fastest for influenza (coefficient of variation 0.03 to 0.55) and respiratory syncytial virus (0.08 to 0.48). Within-region distance rose in every computable GBD super-region (five of seven): divergence occurs within regions, not between blocs. Conclusions National spectra are re-sorting along country-specific axes as vaccine-preventable dominance recedes at different speeds. Diversification is universal, but convergence is absent: the transition at the etiologic-spectrum level is asynchronous and path-dependent, with implications for empirical treatment policy and pathogen surveillance.

Background: Focal liver lesions (FLLs) encompass a wide spectrum of benign and malignant pathologies, and accurate diagnosis is essential for appropriate management. Although advances in imaging have improved lesion characterization, histopathologic assessment remains the diagnostic gold standard for indeterminate lesions. Data on the histopathologic spectrum and diagnostic utility of ultrasound-guided percutaneous liver biopsy (US-PLB) in sub-Saharan Africa (SSA) are limited. This study aimed to characterize the histopathologic findings of US-PLB performed for FLLs at a tertiary referral center in SSA and to identify factors associated with hepatocellular carcinoma (HCC). Methods: We conducted a retrospective observational study of adult patients ([&ge;]18 years) who underwent US-PLB for FLL between January 2021 and December 2024 at Adera Medical and Surgical Center. Patients with indeterminate pathology results, incomplete records, biopsies performed for diffuse liver disease, or lesions classified as LI-RADS 1, 2, or 5 were excluded. Demographic, clinical, laboratory, imaging, histopathologic, and outcome data were extracted from medical records. Descriptive statistics were used to summarize patient characteristics and histopathologic diagnoses. Logistic regression analysis was performed to identify factors associated with HCC. Results: A total of 119 were included in the final analysis. The median age was 56 years (IQR 45-65), and 59.7% were male. No major biopsy-related complications were reported. HCC was the most common histopathologic diagnosis, accounting for 42.9% of cases, followed by secondary metastatic tumors (15.9%) and regenerative nodules (15.9%). Other diagnoses included chronic hepatitis (8.4%), cholangiocarcinoma (5.9%), and hepatic abscess (3.4%). Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections were present in 14.3% and 12.4% of patients, respectively. On multivariate analysis, HBV infection (AOR 7.85, 95% CI 1.45-42.60; p=0.017), HCV infection (AOR 9.03, 95% CI 1.41-57.76; p=0.020), and larger tumor size (AOR 1.27, 95% CI 1.11-1.46; p<0.01) were significantly associated with HCC. Conclusion: Ultrasound-guided percutaneous liver biopsy demonstrated a favorable safety profile for the evaluation of FLL. HCC was the predominant histopathologic diagnosis, reflecting the substantial burden of primary liver cancer in this setting. Chronic viral hepatitis and larger tumor size were significantly associated with HCC. These findings support the continued role of US-PLB in the diagnostic evaluation of indeterminate focal liver lesions and underscores the importance of viral hepatitis prevention, surveillance, and early detection strategies in sub-Saharan Africa.

Background and objective: Colorectal cancer (CRC) is the third leading cause of cancer deaths worldwide. Early identification of high-risk individuals allows targeted prevention and early detection. Design: We constructed a polygenic risk score (PRS) for CRC risk using data from 1,448,354 individuals (103,401 cases). We evaluated its performance for identifying high-risk individuals in 6 major ancestries. Results: The PRS was strongly associated with CRC risk in Europeans (OR per SD =2.13, 95%CI=1.98-2.28), Africans (OR=1.35, 95%CI=1.11-1.64), Hispanics (OR=1.97, 95%CI =1.48-2.61), East Asians (OR=1.98, 95%CI=1.35-2.91), South Asians (OR=1.85, 95%CI=1.44 -2.37), and Middle Easterners (OR=3.10, 95%CI=1.38-6.95). Europeans in the top 10% genetic risk had 14-fold and 5-fold higher CRC risks compared to the bottom 10% (OR=13.50, 95%CI=8.67-21.00), and average (20-70%) risk groups (OR=4.64, 95%CI=3.89-5.52), respectively. The CRC risk in the top 10% individuals was equivalent to having three affected first degree relatives with CRC diagnosed at any age. Genetically high-risk individuals developed CRC up to 15 years earlier than the average. The PRS was strongly associated with early onset CRC risk e.g. in AFR (OR=3.22, 95%CI=1.79-5.81), and improved its prediction e.g. by 9% beyond clinical predictors in EUR. Conclusion: A comprehensive genetic prediction of CRC risk provides insights that could streamline screening and prevention guidelines.

Background Conversion surgery for stage IV gastric cancer is supported by a pooled overall survival hazard ratio of 0.36 (95% confidence interval 0.32-0.40) and, in the largest international cohort, median survival of 36.7 versus 12.5-13.8 months on chemotherapy. Survival is measured from diagnosis; the median diagnosis-to-gastrectomy interval is 124 days, which patients must survive to be counted surgical. Methods We simulated cohorts of 3,177 stage IV gastric cancer patients from published parameters: background median survival 14.5 months; median diagnosis-to-surgery interval 124 days (category-specific 92-174 days). Surgery had no effect (true hazard ratio 1.00 by construction). Data were analysed as the literature analyses them (exposure fixed at baseline, follow-up from diagnosis), and by time-varying Cox and landmark analysis. Confounding by indication was added in a second scenario. Results Under immortal time bias alone the naive analysis returned a hazard ratio of 0.794 (95% simulation interval 0.743-0.851), median survival 16.8 versus 12.8 months. Time-varying Cox recovered 1.000 and landmark analysis 1.000-1.004. Bias scaled with the interval: 0.849 at 92 days, 0.715 at 174 days. Adding confounding, the naive estimate fell to 0.601 (0.560-0.644) at strength 0.5 and 0.356 (0.323-0.385) at strength 1.5, overlapping the published estimate; median survival 21.9 versus 8.7 months. Correcting immortal time alone left residual bias (hazard ratio 0.439). Conclusions The reported survival advantage of conversion surgery is reproducible where the operation does nothing; published estimates cannot distinguish benefit from bias. Resolving this requires individual patient data analysed with methods that assign person-time correctly, or completion of JCOG2301.

Early- and average-onset colorectal cancer (CRC) are separated at age 50, but whether this defines a biological threshold remains unclear. To clarify this, we identified molecular profiles in nine harmonised cBioPortal CRC cohorts (4,609 patients) by fitting Bernoulli mixture models to 31 repair-state, genomic-burden and gene-alteration features, excluding age, sex and tumour site, and compared their prevalence using <50/[&ge;]50 and decade-resolved groups. Four profiles captured conventional/CIN-like (P1), intermediate MSS (P2), KRAS/PI3K/APC-rich (P3) and hypermutated/MSI-high (P4) states along a left-to-right gradient. Although molecular identities remained stable, profile prevalence followed non-linear P1/P4 and opposing linear P2/P3 age trajectories. Profile-prevalence patterns did not track chronological proximity: profile composition at 30-39 differed from 50-59 but not clearly from 60-69. The age-50 threshold captured only 17.8% of decade-resolved deviance, whereas the optimal age-70 cut-off retained only 51.3%. Validation in 2,579 non-overlapping MSK-IMPACT patients (2,476 age-evaluable) reproduced molecular-feature patterns (r=0.97-0.98), age trajectories (r=0.92) and limited binary-threshold performance: age 50 and the optimal age-66 cut-off retained 12.7% and 45.1%, respectively. Thus, age reorganizes the prevalence of shared CRC states rather than defining a biological threshold at age 50.

Ulcerative colitis (UC) is characterised by chronic colonic inflammation with marked heterogeneity in disease severity and therapeutic outcomes. Here, we define a spatially organised, polyfunctional cytotoxic CD4 T-cell state associated with mucosal inflammation and adverse therapeutic outcomes in UC. Integrating ex vivo T-cell receptor stimulation with multi-cohort bulk and single-cell transcriptomics and multiparameter flow cytometry, we show that GZMB CD4 T cells are preferentially enriched in inflamed UC mucosa, but not peripheral blood, and co-express cytotoxic molecules, Th1- and Th17-associated cytokines and chemokines, and immunoregulatory receptors. Single-cell analyses implicate inflammatory cytokine and antigen-presentation signals in the acquisition or maintenance of this state. High-resolution spatial profiling localised this programme predominantly to Th17 cells, which were preferentially enriched within multicellular inflammatory and tertiary lymphoid structure-associated niches. Across independent patient cohorts, a transcriptional signature derived from this state increased with endoscopic disease severity and was associated with reduced response to anti-TNF and anti-IL-12/23p40 therapies. Adoptive transfer of Gzma/Gzmb-deficient rather than wild-type CD4 T cells into Rag2-deficient recipient mice markedly attenuated experimental colitis and abrogated the polyfunctional cytokine phenotype, demonstrating that granzyme-dependent effector activity is a key mechanism driving CD4+ T-cell-mediated intestinal inflammation. Finally, human host-microbiome analysis linked this programme to intestinal dysbiosis, while transfer of dysbiotic microbiota promoted the emergence of a corresponding state in vivo. Collectively, these findings define a microbiota-responsive, spatially organised polyfunctional cytotoxic CD4 T-cell programme that contributes to intestinal inflammation and is associated with disease severity and treatment resistance in UC.

Environmental enteropathy (EE) is a chronic, subclinical disorder of the small intestine common in low- and middle-income countries (LMICs), where access to sanitation and exposure to enteric pathogens vary greatly by socioeconomic status (SES). Systemic immune cell activation by enteric microbial exposure is a suspected but poorly characterized driver of EE severity. We hypothesised that adults from Low-SES communities would have more severe EE than adults from High-SES communities and that this would be associated with distinct circulating immune cell phenotypes. We enrolled clinically healthy adults from High- (n=26) and Low-SES (n=76) communities in Lusaka, Zambia. Duodenal biopsies from these adults were used for microscopic morphometry assessments, while plasma and stool biomarkers of epithelial damage, intestinal inflammation, microbial translocation, and systemic inflammation were measured by ELISA. Circulating monocyte, neutrophil and T cell phenotypes were characterised in buffy coat cells by flow cytometry. Compared with the High-SES group, adults from Low-SES communities had higher duodenal villus width and crypt depth and lower epithelial surface area, indicative of more severe EE pathology, and higher levels of plasma biomarkers associated with microbial translocation and systemic inflammation. The Low-SES group also had higher expression of activation markers (CD86 and TLR4) and lower expression of HLA-DR on circulating classical monocytes and neutrophils, higher percentages of gut-homing (4{beta}7+) and activated/exhausted (PD-1+) T cells, including gut-homing (4{beta}7+) regulatory T cells. Principal Component Analysis identified key patterns of immune cell phenotypes across SES groups. Confounder-adjusted linear regression models showed that Principal Component 1 (monocyte/neutrophil activation) was inversely associated with duodenal villus height and epithelial surface area across SES groups. These findings indicate that EE severity varies by SES within LMIC and suggest that monocyte and neutrophil activation is linked to greater duodenal remodelling in adults with EE.

PURPOSE: To assess the predictive performance of panel protein biomarkers as well as an established algorithm that considers repeat biomarker testing for risk prediction of PDAC among a prospective cohort of patients with New-onset diabetes. PATIENTS AND METHODS: A panel of protein biomarkers (CA19-9, CA125, CEA, LRG1, REG3A and TIMP1) were assayed in 6,516 serially collected pre-diagnostic plasma samples from 2,121 NOD patients from the Consortium of Chronic Pancreatitis Diabetes and Pancreatic Cancer (CPDPC)-initiated NOD study who completed the 3-year study follow-up period. The specimen set included 25 pre-diagnostic samples from the 12 PDAC cases diagnosed during study follow-up. We applied a single threshold (ST) method, which considers biomarker levels at a single time point, as well as a previously established parametrical empirical Bayes (PEB) algorithm, which considers prior biomarker measurements, with case calls made based on pre-specified cutoffs corresponding to 1% 1-year risk. Resultant biomarker data as well as case calls were provided to the EDRN Data Management and Coordinating Center as part of a Prospective-sample-collection-Retrospective-Blinded-Evaluation (ProBE)-compliant Phase 3 biomarker validation study. Area under the Receiver Operating Characteristic Curves (AUC), sensitivity, specificity, population-level positive predictive value (PPV), and negative predictive value (NPV) are reported. RESULTS: The 3-year incidence of PDAC in the NOD cohort was 0.57%. When considering PDAC vs non-cancer controls, respective AUCs of individual protein biomarkers ranged from 0.52-0.94, with CA19-9 achieving the highest overall performance of 0.94 (95% CI: 0.86-1.00). At the pre-defined 1% 1-year risk threshold, CA19-9 yielded sensitivity of 83.3% at 97.2% specificity. Additional markers CEA, CA125, and TIMP1 demonstrated sensitivity of 33.3%, 41.7%, and 8.3%, respectively. In a subset of patients, CA19-9 first tested positive at a median (interquartile range [IQR]) of 7 months (4 to 14 months) prior to clinical PDAC diagnosis. Of the two PDAC cases missed by CA19-9 using the ST method, one (diagnosed with stage III PDAC) was detected using the PEBCA19-9 algorithm. CONCLUSION: In the setting of adult new onset diabetes, CA19-9 is a readily available and promising biomarker that can be leveraged for earlier detection of an underlying pancreatic cancer. Additional protein biomarkers may improve sensitivity for earlier detection of PDAC among cases with low CA19-9.

Small bowel gastrointestinal stromal tumors (GISTs) are more aggressive than gastric GISTs, yet the biologic basis for this difference remains poorly understood. We hypothesized that differential expression of immune checkpoints contributes to this site-specific behavior. Bulk RNA sequencing of 42 primary GISTs (36 gastric, 6 small bowel) revealed marked upregulation of VTCN1, which encodes the inhibitory checkpoint B7-H4, in small bowel tumors (log2FC = 7.95, adjusted P < 0.001). In contrast, expression of the therapeutically targeted checkpoints PD-L1, PD-1, and CTLA-4 was comparable between sites. Concordantly, B7-H4 enrichment was accompanied by an immunosuppressive tumor microenvironment, characterized by reduced antigen-presenting cells, fewer effector-memory CD8+ T cells, lower granzyme B expression, and suppression of interferon and inflammatory signaling pathways. Notably, the differences in B7-H4 expression were independent of imatinib-treatment status. These findings were corroborated in an external cohort of 77 untreated GISTs, in which VTCN1 was similarly enriched in small bowel tumors. Independent immunohistochemical analysis of a tissue microarray comprising 68 untreated primary GISTs confirmed the pattern, showing median B7-H4 positivity of 78.6% in duodenal, 20.5% in jejunal/ileal, and 0% in gastric tumors, with staining localized to tumor cells rather than stroma. Collectively, these data identify B7-H4 as a site-specific feature of small bowel GISTs and a potential therapeutic target for tumors that have not responded to conventional checkpoint blockade.

Background: Pancreatic ductal adenocarcinoma (PDAC) has remained one of the most serious malignancies and is still a leading cause of cancer-related deaths worldwide. Great attention has been paid to the relationship between diabetes mellitus and PDAC. The aim of our study was to analyse the mutual association of PDAC and diabetes mellitus in the entire population of the Czech Republic within a 5-year period. Methods: The incidence of PDAC in 2018-2022 was estimated based on the individual population data from the Czech National Cancer Registry. Another data source, the National Registry of Reimbursed Health Services that collects data from health insurance companies, was used to identify individuals recently diagnosed with diabetes mellitus. For the purpose of this study, diagnosis of new-onset of diabetes mellitus was defined as the time of the first prescription of any antidiabetic drug or another related health care service. Subsequently, patients diagnosed with PDAC in 2022 were followed retrospectively to see if they had been diagnosed with diabetes mellitus in the last five years before diagnosis of pancreatic cancer. Results: In 2022, 2,189 patients aged 60 years or older were diagnosed with pancreatic cancer. New-onset diabetes was observed in 17.4% within five years prior to diagnosis, with the highest occurrence (12.4%) within the last three years. Among patients aged 60-74 years, the respective proportions were 14.4% within three years and 5.7% four to five years prior to pancreatic cancer diagnosis. Conclusion: The incidence of pancreatic cancer in the Czech Republic is among the highest in Europe. One-fifth of PDAC cases are diagnosed following new-onset diabetes mellitus in patients over sixty. Unintended significant weight loss combined with new-onset diabetes thus must not be overlooked, as these can be early signs of PDAC. An individualised diagnostic work-up should follow without any unnecessary delay.

Interactions between intraepithelial lymphocytes (IELs) and the intestinal epithelium are central to mucosal homeostasis and disease. However, mechanistic in vitro studies describing their crosstalk in humans are limited by scarceness of primary material and insufficient knowledge about co-culture requirements. Here, we establish an autologous human duodenal IEL-organoid co-culture system encompassing expandable and bankable IEL and organoid protocols, with co-culture conditions that allow viability of both cell types. This system enables successive interrogation of lympho-epithelial interactions starting from minimal biopsy material. Under baseline conditions, CD45CD8CD103TCR{beta} IELs retain tissue-residency and effector features and induce an epithelial interferon response and chemokine production, without overt epithelial apoptosis. IL-15 and IL-21, essential cytokines involved in IEL-activation in intestinal enteropathies like celiac disease, increases granzyme B expression and interferon-{gamma} secretion but do not trigger epithelial cell death. However, enforcing IEL-epithelial contact using an anti-CD3-anti-Ep-CAM bispecific antibody induces epithelial apoptosis accompanied by increased tumor necrosis factor (TNF) and FAS-ligand (FASLG) secretion. These findings validate the platforms ability to resolve non-destructive and cytotoxic lympho-epithelial interaction and provide a tractable system for studying intestinal inflammation and immune-mediated epithelial cell death.

Purpose Modified FOLFIRINOX (FFX) and gemcitabine plus nab-paclitaxel (GNP) are standard first-line treatments for metastatic pancreatic ductal adenocarcinoma (PDAC), but no validated biomarker guides treatment selection. We developed MULTIPL, a multimodal machine learning system, and established the PASS-01 Challenge to benchmark prognostic and predictive biomarkers. Patients and Methods MULTIPL was trained in the COMPASS study (N=268), integrating clinical, digitized histopathology, whole-genome, and RNA-seq data. MULTIPL, PurIST, hENT1 expression, and HRDetect were evaluated in the PASS-01 trial, a randomized phase II trial of FFX versus GNP (N=160), within the Challenge. The primary endpoint was differential treatment benefit measured by concordance-for-benefit for progression-free survival. Results MULTIPL had the highest concordance index for OS among individually evaluated biomarkers (0.595; 95% confidence interval [CI], 0.55-0.65) and separated high- versus low-risk patients (hazard ratio, 1.62; 95% CI, 1.13-2.33; P=0.009). Patients recommended for GNP by MULTIPL had significantly longer OS with GNP than with FFX (hazard ratio, 0.47; 95% CI, 0.28-0.82; P=0.007), whereas patients recommended for FFX had similar OS between treatments. Interpretability analysis of MULTIPL in COMPASS identified KDM6A alterations and SSTR1 expression as prognostic biomarkers, which were validated in PASS-01. However, none of the tested biomarkers significantly predicted differential treatment benefit in the PASS-01 Challenge. Conclusion MULTIPL demonstrated robust prognostic performance in external validation, identified a subgroup enriched for benefit from GNP, and enabled discovery and validation of prognostic biomarkers in metastatic PDAC. However, no biomarker met the primary endpoint for differential treatment benefit, underscoring the value of the PASS-01 Challenge.

Purpose The Karolinska Liver Metastases (KaroLiver) cohort was established to investigate associations between clinical characteristics and histopathological features in patients treated with curative intent for colorectal cancer liver metastases (CRLM). The cohort combines whole-slide digital histopathology images with detailed oncological, surgical, radiological and survival data, enabling comprehensive analyses of treatment trajectories, clinical outcomes and metastatic tumour biology. Participants KaroLiver is a retrospective observational cohort comprising all consecutive patients who received curative-intent, liver-directed treatment for CRLM at Karolinska University Hospital in Stockholm, Sweden. The hospital is the primary regional referral centre for HPB surgery, serving the population of approximately 2.5 million people in the Stockholm-Gotland healthcare region. Patient enrolment is continuously updated in accordance with amended ethical approvals and evolving scientific questions. The cohort currently comprises 811 patients who underwent 1204 liver interventions between February 2012 and January 2022. Detailed clinical, oncological, surgical, pathological, molecular, recurrence and survival data are collected. Findings to date Median overall survival (OS) in the current cohort is 51.0 months (95% CI 46.2-57.1 months), and median recurrence-free survival (RFS) is 10.4 months (95% CI 9.2-11.9 months). The five-year OS rate is 44.9% (95% CI 41.2-48.8%). Studies using the cohort have so far identified a liver injury-derived stromal capsule in a subset of metastases, associated with improved survival. The cohort has also enabled the identification of histopathological markers of tumour biology, sex-based differences in treatment and survival, and associations between post-hepatectomy liver failure and oncological outcomes. Future plans Current research priorities include advanced histology-based prognostic scoring, sex differences in recurrence and retreatment, tumour biology and outcomes in early-onset versus average-onset CRLM, as well as CT- and MRI-based radiomics, all integrated within KaroLiver's histopathological framework. Data sharing is supported, given that regulatory requirements are met. Retrospective accrual and outcome updates will continue for current and future studies, subject to the required approvals.

Introduction: Illness perceptions, the cognitive and emotional beliefs patients hold about their condition, are key determinants of patient outcomes across a range of chronic health conditions. Although well-studied in several gastrointestinal disorders, their role remains poorly characterized within patients with functional dyspepsia (FD) and chronic nausea and vomiting syndrome (CNVS). This study examined the associations between illness perceptions, gastrointestinal symptoms, mental health, and gastric electrophysiology in these patients. Methods: Patients meeting self-reported Rome IV criteria for FD and/or CNVS underwent body surface gastric mapping (BSGM) using Gastric Alimetry (Alimetry, New Zealand). The standardized protocol included a 30-minute fasting baseline, 482 kCal meal, and a 4-hour postprandial recording, with concurrent symptom logging. From the BSGM data, patients were phenotyped using established rule-based criteria via the Auckland Classification. Illness perceptions were assessed using the Brief Illness Perceptions Questionnaire alongside validated psychological and quality of life metrics. Results: The cohort included 309 patients (80% female; median age= 36, 15-88) who reported highly negative illness perceptions, which were significantly correlated with worse symptomatology, quality of life, and mental health (medium-large effect sizes). Using multivariable analysis, perceived consequences and emotional responses emerged as the most robust predictors of these patient-reported outcomes. Additionally, illness perceptions significantly mediated the relationship between mental health and gastrointestinal symptoms, with large effect sizes. Associations with gastric electrophysiology were limited to BMI-Adjusted Amplitude, which was associated with poorer perceptions of treatment control and greater emotional response to symptoms. Furthermore, the Continuous Phenotype (normal spectral activity, with continuous symptoms) was associated with worse illness perceptions, including higher perceived consequences, symptom identity, concern, and emotional response, whilst the High Frequency Phenotype was associated with lower understanding. Discussion: The way patients perceive their condition is a quantifiable aspect of the illness experience that is associated with symptom burden, mental health, and quality of life in patients with FD and CNVS. The observed associations with gastric electrophysiology suggest that illness perceptions may also vary in relation to underlying patient physiology. These findings support the consideration of illness perceptions as part of multidisciplinary assessment and management, including targeted patient education and clinical interventions to address distressing or maladaptive illness beliefs.

Background: Recurrence rates following curative resection for hepatocellular carcinoma (HCC) remain persistently high, benefit from adjuvant immunotherapy varies substantially across patients, and the field currently lacks a standardized framework to characterize the postoperative host immune contexture. Purpose: To propose and validate a Multi-stage Precision Stratification (MPS) framework and evaluate its value in prognostic stratification and prediction of immunotherapy response. Methods: The Immune Health Index (IHI = S + R - E) integrating immune surveillance (S), immune exhaustion (E), and immune reserve (R) was constructed to define four immune phenotypes. Prognostic value was assessed in four public HCC cohorts (n=931) with single-cell transcriptomic validation (GSE140228, 61,690 cells); a blood-count-based clinical version cIHI_v8 was constructed in the Qinghai QPHCC cohort (n=490 survival analysis). Results: IHI was an independent protective prognostic factor in TCGA-LIHC (multivariate HR=0.795, P=0.034); four-cohort random-effects meta-analysis yielded HR=0.818 (95% CI: 0.696-0.961), I-squared=31.4%. QPHCC cIHI_v8 multivariate HR=0.452, HR=0.715 after ALBI adjustment; Bayesian evidence synthesis yielded BF_10=1280 for cIHI_v8 (>100 constitutes Decisive evidence), whereas the 4-cohort meta BF_10=2.19 (Anecdotal). Following NLP-based reverse stage derivation (n=490, achieving full AJCC/BCLC stage coverage from 0%), IHI remained significant after AJCC adjustment (HR=0.8642, P=0.000079), IHI provided positive incremental C-index across all stage-adjusted models; stratified analysis showed the strongest effect in early-stage (AJCC I-II: HR=0.8109, P<0.0001) and MVI-negative patients (HR=0.8538, P=0.0020). Bootstrap 1000x resampling: median HR=0.8646 (95% CI: 0.7985-0.9443), all iterations yielded HR<1. Conclusions: The MPS framework provides a mechanism-driven biological stratification tool for adjuvant immunotherapy in post-resection HCC, moving from "fixed-protocol extrapolation" to "immune contexture navigation."

Background: Pro-inflammatory and high-environmental-impact diets both threaten population and planetary health, but whether the two objectives align or conflict across countries is unresolved. We tested whether a supply-based dietary inflammatory index (sDII) is coupled to greenhouse-gas (GHG), land and freshwater footprints, and whether a nutrition-feasible reallocation can lower both simultaneously. Methods: From FAO Food Balance Sheets we built sDII (12 inflammatory-weighted components; construct validity r=0.9999) and five per-capita footprints using three independent life-cycle inventories for 182 national food-supply series. For each country, constrained optimisation reallocated 13 food-group supplies under isoenergetic, protein-preserving and food-group-bound constraints, minimising sDII and GHG jointly (Pareto frontier). Health burden was estimated via pooled relative-risk meta-analysis and 2023 World Bank population data. Results: sDII was only weakly associated with GHG (Spearman rho=0.14), land (rho=0.13) and freshwater (rho=0.28) in 2023. The balanced-Pareto reallocation lowered both sDII and GHG in 182/182 series (100% synergy): population-weighted delta sDII=-0.235, GHG -37.5%, land -49.3%, water -17.2%, i.e. 4.28 Gt CO2e/yr avoided. The associated reduction in metabolic-syndrome burden was directionally consistent but modest (~1.1% of the prevalent pool, ~2.84 million cases). Results were robust to three life-cycle inventories and three feasibility-bound regimes. Conclusions: Anti-inflammatory and low-carbon goals are decoupled rather than conflicting, and an isoenergetic, protein-preserving reallocation reconciles them in every country. Environmental gains are large and robust; health gains are directionally consistent but modest--triangulation, not a causal claim.

Regulatory T (Treg) cells expressing ROR{gamma}t accumulate in the intestinal mucosa, yet the signals that determine whether they remain suppressive or acquire inflammatory features are incompletely defined. We first reanalyzed human ileal single-cell data and identified Crohns disease-enriched FOXP3 states in which RORC, HIF1A, hypoxia-responsive, inflammatory, and metabolic programs converged. We then deleted Hif1a in ROR{gamma}t-expressing cells and tested acute DSS colitis, T cell transfer colitis, and azoxymethane/DSS-induced colitis-associated colorectal cancer (CAC). {Delta}Hif1a mice were protected in all three settings. In lymphopenic recipients given the same pathogenic naive T cells, changing only the genotype of the cotransferred Treg population enhanced protection, linking the phenotype to regulatory-cell function in vivo. Reanalysis of mouse colonic Treg single-cell ATAC-seq nominated suppressive and mitochondrial programs for cell-intrinsic testing during low HIF1- expression. {Delta}Hif1a ROR{gamma}t Treg produced more IL-10 and less IL-17A and IFN-{gamma}, limited responder-cell proliferation, contained fewer dysfunctional and mitochondrial-reactive-oxygen-species-high mitochondria, favored fusion-associated transcription, and displayed greater basal and maximal oxygen consumption and reserve capacity. During CAC, HIF-1 loss blunted inflammatory ROR{gamma}t Treg accumulation and reduced tumor burden. Human trajectory and gene-regulatory-network analyses further predicted that HIF1A perturbation would oppose selected disease-associated branches. Together, these findings identify HIF-1 as a context-dependent checkpoint that connects hypoxia-responsive transcription to mitochondrial fitness and inflammatory plasticity in intestinal ROR{gamma}t Treg.