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Pancreatic ductal adenocarcinoma (PDAC) is an aggressive cancer with poor outcomes. Obesity increases the risk of PDAC through metabolic dysregulation and inflammation. Ketogenic diet (KD) can alter metabolism and has been evaluated for its effects on tumor progression in nonobese PDAC using genetically engineered mouse models (GEMM). We hypothesized that KD may also prevent obesity-associated PDAC progression by altering body composition and cancer metabolism. Therefore, male PDAC GEMMs were subjected to diet-induced obesity (DIO) using high-fat diets or maintained on a low-fat diet (LFD) for 15 weeks. Mice were then randomized to continue the initial diets or switch to a KD or matched control diet for 6 weeks. Body weight and composition, glucose tolerance, ketone levels, pancreas histology, and tissue metabolomics were assessed. Furthermore, murine pancreas-derived organoids from DIO or LFD-fed GEMMs were treated with a ketone body and analyzed using untargeted metabolomics. In obese PDAC GEMMs, KD delayed cancer progression independent of weight loss, an effect not observed in nonobese LFD-fed mice. KD-mediated PDAC suppression was associated with enrichment of pancreatic metabolic pathways that support nonglucose energy production. Ketone-treated organoids recapitulated a subset of the KD-associated metabolic differences observed in vivo, suggesting a direct metabolic effect on cancer cells. These findings suggest potential benefits of a KD in preventing obesity-associated PDAC. The diet-cancer metabolic interactions highlight potential opportunities for dietary or metabolic interventions to prevent PDAC in high-risk obese populations. Ketogenic diet prevents pancreatic cancer progression in obese, but not in nonobese, genetically engineered mouse models and modifies pancreatic metabolic pathways, informing future dietary and therapeutic strategies for high-risk obese populations.

Pancreatic ductal adenocarcinoma (PDAC) is notorious for its aggressive, therapy-resistant nature that is in part driven by the desmoplastic, hypoperfused, and immunosuppressive tumor microenvironment (TME). In this study, we demonstrated that the αv integrin and neuropilin-1 (NRP-1) dual targeting iRGD peptide reverses some of these TME features by inhibiting transforming growth factor β (TGFβ) activation in the tumor, a process mediated by the αvβ5 integrin. In addition to PDAC epithelial cells and fibroblasts, regulatory T cells (Treg) in PDAC tumors also expressed the αvβ5 integrin and NRP-1. The αvβ5+ Tregs potently inhibited T-cell proliferation, and systemic iRGD therapy not only depleted αvβ5+ Tregs from PDAC tumors but also reduced their αvβ5- counterparts. Mechanistically, iRGD inhibited the activation of TGFβ mediated by the αvβ5-rich TME, thereby depriving Tregs of the cytokine essential for their development and maintenance. NRP-1-dependent tumor penetration was required for this effect because a traditional RGD peptide without an NRP-1-binding motif failed to inhibit TGFβ signaling or deplete Tregs in vivo. Treatment with iRGD induced a series of additional TME changes, such as improved vascular patency and perfusion, reduced stromal fibers, and increased CD8+ T-cell entry into the core of the tumors. Combining iRGD with immune checkpoint blockade led to an enhanced antitumor effect. Together, these findings support targeting the αvβ5 integrin with affinity ligands such as iRGD as a potential approach to enhance immunotherapy efficacy against PDAC and other desmoplastic tumors with high TGFβ and αvβ5 expression. The iRGD tumor penetrating peptide inhibits αvβ5 integrin-dependent TGF-β activation in pancreatic cancer to normalize the desmoplastic and immunosuppressive tumor microenvironment.

Despite the availability of RAS inhibitors and the dependence of >90% of pancreatic ductal adenocarcinomas (PDAC) on oncogenic KRAS mutations, resistance to KRAS inhibition remains a serious obstacle. We showed here that phosphoinositide 3-kinase (PI3K) plays a major role in this resistance through upstream activation of wild-type (WT) RAS signaling-beyond its known KRAS effector function. The combination of proximity labeling, CRISPR screening, live-cell imaging, and functional assays revealed that PI3K orchestrates phosphoinositide-mediated GAB1 recruitment to the plasma membrane, nucleating assembly of RAS signaling complexes that activate mitogen-activated protein kinase (MAPK) in an EGFR/SHP2/SOS1-dependent manner. Inhibiting PI3K enhanced sensitivity to mutant-specific KRAS inhibitors in PDAC cells, including in cells with clinically identified PIK3CA mutations. These findings refine RAS-PI3K signaling paradigms, reveal that PI3K-driven WT RAS activation drives resistance to KRAS inhibition, and illuminate avenues for augmenting KRAS-targeted therapies in PDAC. PI3K plays a functional upstream role in assembling wild-type RAS signaling complexes that confer KRAS inhibitor resistance, providing a rationale for combined targeting of PI3K and KRAS in pancreatic cancer.

Lymph node (LN) metastasis (LNM) in early-stage pancreatic ductal adenocarcinoma (PDAC) predicts systemic dissemination and poor survival, yet its underlying mechanisms remain elusive. In this study, we demonstrated that senescent cancer-associated fibroblasts (senCAF) drive lymphatic remodeling and LNM in early-stage PDAC. Mechanistically, senCAFs increased glucose metabolism and lactate production, which activated lactylation-mediated serine metabolism to protect lymphatic endothelial cells from oxidative stress. Moreover, we discovered CCR4+ regulatory T cells from the draining LNs accumulated around lymphatic vessels, which established an immunosuppressive perilymphatic niche. High-throughput drug screening determined selective clearance of senCAFs via chidamide, attenuated tumor progression, and improved chemoimmunotherapeutic efficacy. We subsequently initiated a clinical trial (chidamide and nab-paclitaxel/gemcitabine plus anti-PD-1/CTLA-4) in patients with metastatic PDAC and reported its preliminary promising results. Collectively, these findings reveal a closed link between cellular senescence and PDAC metastasis, offering the potential senolytic means to improve chemoimmunotherapy efficacy. Our findings have revealed a closed link between cellular senescence, metabolic reprograming, and spatial immunosuppressive niche and PDAC metastasis, offering the potential senolytic drugs to improve chemoimmunotherapy efficacy in patients with PDAC.

RNF43 is frequently inactivated by mutations in pancreatic ductal adenocarcinoma (PDAC), but the molecular mechanisms and therapeutic vulnerabilities associated with RNF43 loss remain poorly defined. Here, we demonstrate that RNF43 functions as an E3 ubiquitin ligase targeting YBX1 for degradation, thereby suppressing mitochondrial oxidative phosphorylation (OXPHOS). In RNF43-deficient PDAC models, stabilized YBX1 activates MYC through dual mechanisms-enhancing MYC mRNA stability via IGF2BP1 and physically interacting with c-Myc protein-leading to transcriptional upregulation of IDH2 and IDH3A and subsequent OXPHOS activation. Importantly, RNF43 loss conferred sensitivity to OXPHOS inhibition both in vitro and in vivo. Treatment with the OXPHOS inhibitor IACS-010759 suppressed the proliferation, migration, invasion, and metastasis of RNF43-mutant tumors. Our findings identify a RNF43-YBX1-MYC signaling axis associated with metabolic reprogramming in pancreatic cancer and suggest that OXPHOS inhibition may represent a potential therapeutic vulnerability in tumors with RNF43-inactivating mutations.

Pancreatic ductal adenocarcinoma (PDAC) remains one of the most lethal human cancers, mostly due to its insidious onset that consequently leads to diagnosis at advanced stages. The complex biology of PDAC limits effective therapeutic options, yet over 90% of cases harbor KRAS mutations, making it a compelling therapeutic target. KRAS had a notorious history of being "undruggable." Emerging novel inhibitors, however, have fundamentally shifted this paradigm by demonstrating the possibility of direct KRAS targeting. Although promising in preclinical efficacy, the clinical benefit of these inhibitors was frequently curtailed by rapid and heterogeneous resistance due to the intrinsic complexity of PDAC. Concurrently, building on structure-based drug discovery, artificial intelligence (AI) is now infusing this traditional workflow with dynamic and extensive enhancements. AI-enabled approaches in molecular biology-including high-accuracy protein structure prediction, large-scale virtual screening, and the uprising of generative molecular design-have accelerated the discovery of potent and selective molecular structures. Comprehensive hybrid models and quantum-level data processing enabled the exploration of previously latent chemical spaces, thereby creating more opportunities for the search for effective PDAC therapies. Discussions of progress in KRAS inhibitors and in AI drug discovery are rising but remain largely in parallel. As a result, this review aims to bridge these two exciting fields together. Through discussions of novel strategies to target KRAS in PDAC, emerging paradigms to address KRAS resistance in clinical trials, and current innovations in AI algorithms for molecule screening and design, we hope to underscore the unique challenges and prospects of leveraging artificial intelligence to accelerate the discovery of effective therapies for PDAC.

The aryl hydrocarbon receptor (AhR) plays a pivotal role in modulating immune responses and influencing tumor development by detecting metabolites derived from tryptophan breakdown. In patients suffering from pancreatic ductal adenocarcinoma (PDAC), elevated levels of AhR are strongly correlated with poor clinical outcomes. Despite this, the cell-autonomous functions of AhR in pancreatic tumor cells, particularly its role in modulating anti-tumor immunity within the tumor microenvironment, remain poorly characterized and require further investigation. CRISPR-Cas9 technology was used to generate Ahr-/-/AHR-/- Pan02, B16-F10 and Panc-1 cells. Subcutaneous tumor models in nude and C57BL/6J mice were used to evaluate the effect of tumor cell intrinsic Ahr on the anti-tumor immune response. Transcriptome sequencing, ATAC sequencing, CUT&Tag sequencing, ChIP and IP-MS were used to elucidate how AhR controls the expression and accessibility of major histocompatibility complex class I (MHC-I). Elevated AhR levels in PDAC patients correlate with worse outcomes. AhR protein is located in both cytoplasm and nucleus of tumor cells. Deletion of Ahr in Pan02 and B16-F10 leads to a significant upregulation of MHC-I and related gene expression. AhR drives tumor growth by suppressing T cell-mediated immunity. Mechanistically, AhR specifically suppressed MHC-I expression in pancreatic tumor cells by interacting with protein arginine methyltransferase 5 (PRMT5) to decrease chromatin accessibility, which led to impaired antigen presentation. We demonstrated that AhR inhibition improved the therapeutic efficacy of immune checkpoint blockade, chemotherapy, and PRMT5-targeted therapy in pancreatic cancer models. Tumor cell intrinsic AhR inhibits MHC-I expression in PDAC cells by epigenetic regulation mediated by PRMT5, resulting in reduced immunogenicity of pancreatic tumor cells. The discovery of the AhR-PRMT5-H4R3me2s-MHC-I axis provides critical mechanistic insights into how tumor-intrinsic epigenetic regulation of antigen presentation promotes the progression of PDAC.

The distinction between benign and neoplastic bile duct strictures remains challenging. Pathologic assessment of endoscopic retrograde cholangiopancreatography (ERCP)-obtained specimens has limited sensitivity, particularly among patients with primary sclerosing cholangitis (PSC). Next-generation sequencing of bile duct specimens provides a promising diagnostic approach, but a prospective, multi-institutional, and comprehensive DNA/RNA analysis is lacking. A 6-year, prospective, multi-institutional study was conducted using BiliSeq version 2 (28 cancer-associated genes and 167 fusion genes) and BiliSeq version 3 (161 cancer-associated genes and 763 fusion genes) for 2908 ERCP-obtained brushings, biopsies, and bile from 2116 patients at 28 medical institutions. Molecular results were compared with clinical, imaging, and pathologic parameters including diagnostic pathology and/or at least 1-year follow-up. BiliSeqV2/V3 testing was performed for 2865 (99%) specimens from 2080 (98%) patients. Based on follow-up from 1979 (95%) patients, BiliSeq version 2/version 3 demonstrated 82% sensitivity and 98% specificity for a neoplastic stricture. In comparison, pathologic assessment had a sensitivity of 44% and a specificity of 99%. Combining BiliSeq version 2/version 3 testing with pathologic assessment improved the sensitivity to 88% and maintained a high specificity of 97%. High-risk populations, such as Hispanic, germline carrier, and PSC patients, also showed improvement in sensitivity with BiliSeq version 2/version 3 (74% to 86%) compared with pathologic assessment (26% to 50%). Further, actionable molecular alterations were identified in 20% of BiliSeq version 3-positive neoplasms and modified patient management in 30% of these cases. Applying BiliSeq version 2/version V3 testing to ERCP-obtained specimens improved the diagnostic evaluation of bile duct strictures, achieving higher sensitivity, especially for PSC, and maintained high specificity compared with traditional methods. This study highlights the importance of next-generation sequencing for precise diagnosis and therapeutic intervention.

In DESTINY-PanTumor02 Part 1, trastuzumab deruxtecan (T-DXd) demonstrated a clinically meaningful benefit in human epidermal growth factor receptor 2 (HER2)-expressing tumors. In this article, we report subgroup analyses in the biliary tract cancer (BTC) and pancreatic cancer (PC) cohorts from DESTINY-PanTumor02 Part 1. DESTINY-PanTumor02 (NCT04482309) Part 1 evaluated T-DXd 5.4 mg/kg in locally advanced/metastatic HER2 immunohistochemistry (IHC) 3+/2+ (local/central testing) tumors that had progressed after systemic treatment or without treatment options. The primary endpoint was objective response rate (ORR) by investigator assessment (INV). Secondary endpoints included progression-free survival, overall survival, and safety. Exploratory endpoints included outcomes by biomarker status and treatment history. Overall, 41 patients with BTC and 25 patients with PC had received T-DXd; median (range) follow-up duration was 6.01 (0.7-29.1) months and 4.99 (1.1-27.2) months, respectively. By INV, ORR was 22.0% [95% confidence interval (CI) 10.6%-37.6%] in the BTC cohort and 4.0% (95% CI 0.1%-20.4%) in the PC cohort; by independent central review, ORR was 26.8% (95% CI 14.2%-42.9%) and 12.0% (95% CI 2.5%-31.2%), respectively. Responses were seen across most patient subgroups in the BTC cohort; the highest ORR (56.3%, 95% CI 29.9%-80.2%) by INV was observed for those with HER2 IHC 3+ tumors (central test). Best objective response (by INV) of stable disease was observed in 61.0% of the BTC cohort and 68.0% of the PC cohort; median overall survival was 7.0 (95% CI 4.6-10.2) and 5.0 (95% CI 3.8-14.2) months, respectively. Adjudicated drug-related interstitial lung disease/pneumonitis occurred in 17.1% of patients with BTC and 4.0% of patients with PC. These data further support T-DXd as a recommended treatment in pretreated HER2 IHC 3+ tumors. Interpretation of PC cohort findings was limited by sample size and potentially confounded by the low number of patients with IHC 3+ PC. Safety was consistent with the known profile.

Cholangiocarcinoma (CCA) is a biliary cancer with a poor prognosis and marked chemoresistance. The transcription factor SOX17, which is essential for cholangiocyte differentiation, is frequently downregulated in CCA, as is the case with several tumor suppressor genes. This study provides a proof-of-concept for further development of cellular therapeutic strategies to restore SOX17 expression in CCA cells. For this aim, we used EGI-1 cells as the target cell model derived from extrahepatic CCA. Recombinant Tat-SOX17 protein was first produced in bacteria and purified using Ni-NTA affinity columns and asymmetric flow-field-flow fractionation. Tat-SOX17 entered EGI-1 cells and reached their nucleus. The addition of the α-fetoprotein signal peptide (AFPsp) to the chimeric protein enabled the efficient secretion of the fusion protein formed by AFPsp, SOX17, and reverse Tat (TatR) by donor cells. For the production of secretome enriched in AFPsp-SOX17-TatR protein, HEK293T cells, derived from embryonic kidney, were used. In EGI-1 cells cultured in the presence of this secretome, target gene expression, cell cycle progression, apoptosis, proliferation, colony formation, and cell migration were assessed. Protein expression and localization were analyzed by Western blotting and immunofluorescence. AFPsp-SOX17-TatR enters EGI-1 cells, reaches their nucleus, and modulates the expression of SOX17-dependent genes, such as ABCB1 and ABCG2. Moreover, a marked reduction in proliferation and colony-forming ability was found. In contrast, no significant effect on cell cycle progression, apoptosis, or cell migration was observed. Similar treatment of immortalized human cholangiocytes also increased their SOX17 content, resulting in upregulation of the cholangiolar marker cytokeratin 7 (CK7), but did not affect their proliferation rate. In conclusion, using chimeric proteins such as AFPsp-SOX17-TatR, which contain components for secretion from donor cells and entry into target cancer cells, can provide a promising approach for treating tumors such as CCA, which are characterized by reduced expression of tumor suppressor genes, including SOX17.

Activated AKT and YAP signaling have been implicated in the pathogenesis of intrahepatic cholangiocarcinoma (iCCA), but their specific roles in tumor progression and regulation of the tumor microenvironment remain unclear. We developed two doxycycline-inducible iCCA mouse models, Akt/TRE-YAP and TRE-Akt/YAP, allowing selective inhibition of YAP or AKT in established tumors upon doxycycline withdrawal. Histological and molecular analyses were then performed to assess phenotypic changes and pathway regulation. YAP suppression in the Akt/TRE-YAP model initially induced tumor regression but ultimately led to transformation into steatosis-associated HCC due to persistent AKT signaling. Conversely, AKT suppression in the TRE-Akt/YAP model induced more profound iCCA regression with minimal tumor burden. Mechanistically, both AKT and YAP regulate tumor cell proliferation, while RNF125 acts as a tumor suppressor inhibited by YAP during iCCA pathogenesis. AKT uniquely regulates tumor metabolic pathways, whereas YAP controls iCCA differentiation and the immune microenvironment. YAP inhibition depleted neutrophils and increased CD4+ and CD8+ T-cell infiltration. The immunosuppressive role of YAP was confirmed by ectopic YAP activation in mouse iCCA and validated in human iCCA, where YAP/TAZ activation correlated with immunosuppressive features. Although YAP inhibition increased T-cell infiltration, these T cells expressed PD-1. Combined YAP suppression and anti-PD-L1 treatment further enhanced tumor regression. We define distinct molecular roles for AKT and YAP in iCCA progression and identify YAP as a key regulator of the tumor immune microenvironment. These findings support combining YAP inhibition with immune checkpoint blockade for iCCA treatment. Our studies elucidate the distinct contributions of AKT and YAP signaling to intrahepatic cholangiocarcinoma (iCCA) progression. Using innovative doxycycline-inducible models, we show that both pathways regulate tumor cell proliferation - YAP by repressing the tumor suppressor RNF125 - while AKT primarily governs metabolism and YAP controls differentiation and suppresses the immune microenvironment. Importantly, YAP inhibition reshapes the tumor immune landscape, and its combination with PD-L1 blockade induces profound tumor regression. These findings establish YAP as a key regulator of the iCCA immune microenvironment and provide a strong preclinical rationale for combining YAP pathway inhibition with immune checkpoint blockade in iCCA therapy.

Perfluorooctanoic acid (PFOA) has been classified as a human carcinogen based partly on limited epidemiologic evidence of increased kidney and testicular cancer risk. We conducted an updated analysis of cancer incidence in a high PFOA-exposed cohort of community members and workers in the mid-Ohio Valley with follow-up extended by approximately 10 years on average and linkage to the Virtual Pooled Registry-Cancer Linkage System to better characterize risk of malignancies of a priori interest and to explore risk of other cancers. Based on estimates of annual serum PFOA concentrations during 1952-2020, we evaluated associations between cumulative PFOA exposure and site-specific cancer incidence through 2020 among 32,050 participants (28,398 community members and 3,652 workers). Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using Cox proportional hazards models adjusted for potential confounding factors. In the overall study population, we observed positive associations with kidney and testicular cancers. Associations with kidney cancer for high PFOA exposure were most pronounced among younger community members (≤60 years: HRQ4 = 1.82, 95% CI 1.02-3.26; Ptrend = 0.03) and those with localized disease (HRQ4 = 1.72, 95% CI 1.01-2.95; Ptrend = 0.17). High PFOA exposure was also associated with increased testicular cancer risk among community members (HRQ4 = 3.62, 95% CI 1.03-12.7; Ptrend = 0.12). We also observed positive associations with thyroid cancer, particularly among female participants, and with pancreatic cancer among older participants; notably, exposure-response relationships for both thyroid and pancreatic cancer were strongest among the more highly exposed workers (per 1-unit increase on the natural log scale, HRcont = 1.79, 95% CI 1.07-2.97; and HRcont = 1.70, 95% CI 1.08-2.67 for thyroid and pancreatic cancers, respectively). Our findings in this high PFOA-exposed cohort provide additional epidemiologic evidence of increased kidney and testicular cancer risk, as well as new evidence of associations with thyroid and pancreatic cancers. These findings have important implications regarding our understanding of the carcinogenic potential of PFOA and the cancer burden related to this ubiquitous environmental contaminant.

Ultrasound-induced luminescence offers a light-free imaging modality with deep tissue penetration and spatiotemporal controllability; however, its broader application is hindered by weak luminescent signals that limit imaging depth and signal-to-noise ratios. Here, we report an organic-inorganic heterojunction sonosensitizer, TA@TiO2, formed by coupling a trianthracene derivative (TA) with titanium oxide (TiO2). Under ultrasound irradiation, the nanoscale charge-transfer interface promotes interfacial charge transfer, significantly enhancing reactive oxygen species (ROS) generation. This increased ROS triggers amplified chemical energy conversion, resulting in a markedly enhanced ultrasound-induced luminescence signal for deep-tissue optical imaging. Compared to TA nanoparticles, TA@TiO2 exhibits superior signal transmission in scattering media and maintains high luminescence at lower power densities. In vivo studies demonstrate that TA@TiO2 enables high-contrast imaging of deep-seated tumors, such as pancreatic cancer and glioma, while providing enhanced sonodynamic therapy efficacy. The positive correlation between ultrasound-induced luminescence intensity and ROS generation allows for dynamic, imaging-guided tumor therapy. These results establish heterojunction engineering as a potent strategy for advancing ultrasound-activated theranostics.

Adoptive cell therapy (ACT) against solid tumors is constrained by tumor heterogeneity, immunosuppressive microenvironments, and insufficient T cell potency and persistence. Although IL-12 has long been recognized as a potent enhancer of T-cell immunity, its clinical application has been hindered by systemic toxicity and the lack of a strategy to harness its benefits without chronic exposure. Here, we show that ex vivo IL-12 preconditioning programs tumor-specific T cells with increased antigen sensitivity, yielding superior antitumor activity compared with IL-7/IL-15. Systemic delivery of Pro-IL-12 further rejuvenates exhausted CD8+ tumor-infiltrating lymphocytes (TILs) by restoring IL-2 hypersensitivity, sustaining persistence, and strengthening effector machinery. When combined with ACT, a single dose of Pro-IL-12 reinstated IFN-γ production in exhausted TILs and doubled intratumoral T-cell accumulation via upregulation of IL-2Rα and increased IL-2 sensitivity. Pro-IL-12 markedly improved therapeutic outcomes, inducing durable complete tumor regression, promoting antigen spreading, and establishing long-term immune memory that prevented relapse from antigen-loss tumor. Across multiple xenograft models, including pancreatic cancer, lymphoma and triple negative breast cancer, distinct human CAR-T products paired with Pro-IL-12 enhanced tumor eradication without cytokine release syndrome. Together, these findings establish precision delivery of IL-12 as a translatable strategy that harnesses known IL-12 biology to achieve robust antitumor efficacy without systemic toxicity.

Advanced primary liver cancers remain difficult to treat after failure of first-line therapy. The 2025 French Genomic Medicine Initiative aimed to identify actionable targets for personalized treatment. Patients with PLC progressing on systemic therapy were enrolled across eight centers. Tumor and blood samples were analyzed using whole-genome, whole-exome, and RNA sequencing to identify targetable alterations classified according to the ESCAT scale. Genomic results and potential therapies were reviewed by a molecular tumor board. A total of 120 patients were enrolled: 80 with hepatocellular carcinoma (HCC), 25 with cholangiocarcinoma (CCA), 9 with combined hepatocellular-cholagiocarcinoma (cHCC-CCA), 4 with fibrolamellar carcinoma, 1 with hepatic sarcoma, and 1 with hepatic epithelioid hemangioendothelioma (HEHE). Recurrent genomic alterations included TP53 (46%), TERT (44%), and CTNNB1 (20%) in HCC; TP53 (55%), ARID1A (20%), and BAP1 in CCA; and TP53 (67%), PIK3CA (22%), and ARID2 (11%) in cHCC-CCA. Among 103 interpretable genomes, 67 patients harbored at least one actionable alteration (HCC: 59%, CCA: 80%, cHCC-CCA: 78%). Thirty-one patients (22 HCC, 5 CCA, 3 cHCC-CCA, 1 HEHE, 1 hepatic sarcoma) received matched therapies: 1 ESCAT I, 2 ESCAT II, 21 ESCAT III, and 7 ESCAT IV. These patients had received prior systemic therapy, including ≥2 lines in 69% of cases. Disease control (DC; radiological response/stable disease) was achieved in 10 of 31 patients (32.3%), including 23% of HCC, 75% of CCA, and 67% of cHCC-CCA cases. DC was observed exclusively in patients treated for ESCAT I-III alterations (41.7%), with no clinical benefit in those treated for ESCAT IV alterations. Median progression-free survival was significantly longer in patients achieving DC compared with those with progressive disease (11.8 vs. 2.4 months; p = 0.009). Comprehensive genomic profiling in advanced PLC refractory to systemic treatment is feasible and associated with DC in a subset of pretreated patients with ESCAT I/II/III alterations. Our research demonstrates that comprehensive genomic profiling through the French Genomic Medicine 2025 (FGM2025) initiative is feasible and clinically impactful in advanced primary liver cancers, including rare subtypes. By integrating whole-genome, whole-exome, and RNA sequencing, actionable genomic alterations were identified in nearly two-thirds of patients - well beyond the reach of standard next-generation sequencing panels. These findings provide a strong rationale for implementing early, broad molecular profiling to optimize therapeutic matching, preserve liver function, and expand access to precision medicine. Ultimately, our work highlights the transformative potential of genomics-guided strategies in improving clinical outcomes and advancing personalized care for patients with hepatobiliary malignancies.

Cardiac complications after major hepatic surgery are frequent, yet how hepatic ischemia-reperfusion injury (HIRI) damages the remote heart is unknown. In 382 hepatectomy patients, the incidence of myocardial injury after noncardiac surgery (MINS) rose from 20.5% to 50% with increasing postoperative liver damage severity (P < 0.0001). In a murine HIRI model, cardiac dysfunction lagged behind hepatic injury; circulating ATP surged within one hour of reperfusion from the ischemic liver and was both sufficient and necessary to drive remote cardiac damage. Extracellular ATP activated the P2X7 receptor on cardiac macrophages, triggering NLRP3 inflammasome assembly and gasdermin D (GSDMD)-dependent cardiomyocyte pyroptosis; siRNA-based dominant-gating co-culture identified macrophage P2X7 as the upstream gating step, with cardiomyocyte-side P2X7 knockdown failing to abrogate downstream pyroptosis. Single-cell profiling traced this program to monocyte-derived macrophages differentiating into inflammatory macrophages, and macrophages amplified hepatocyte-derived ATP into IL-1β-driven cardiomyocyte pyroptosis in vitro. Clodronate-mediated macrophage depletion preserved cardiac function. The selective P2X7 antagonist JNJ-47965567 polarized cardiac macrophages toward an anti-inflammatory phenotype and suppressed NLRP3-GSDMD pyroptosis when administered up to approximately 3 h after reperfusion onset, defining a clinically relevant therapeutic window. Adenosine activated the A2A receptor and attenuated cardiac injury dose-dependently, reversed by SCH-58261, and conferred greater cardiac protection than dexamethasone or N-acetylcysteine. These findings establish cardiac macrophages as amplifiers of liver-derived danger signals and identify the ATP-P2X7/adenosine-A2A purinergic axis as a potential pharmacological target for perioperative cardioprotection.

Biliary tract cancers (BTCs) are a group of rare but highly lethal malignancies that include intrahepatic cholangiocarcinoma (iCCA), extrahepatic cholangiocarcinoma (eCCA), and gallbladder carcinoma (GBC). A major challenge in modeling and treating these cancers is their highly heterogeneous mutational landscapes, both within and across subtypes, as well as across geographic and etiological contexts. This heterogeneity necessitates large cohorts to enable robust statistical analyses. Here, we collate and analyze data from more than 30 next-generation sequencing studies to provide a comprehensive overview of BTC mutational patterns and their potential clinical implications. Mutation data from 5,123 BTC samples from 13 countries were standardized, focusing on a set of 29 bona fide oncogenes and tumor suppressor genes. We performed statistical analyses to evaluate hypotheses related to mutation prevalence, etiology, co-mutation patterns, and recurrent mutations. This analysis provides robust estimates of mutation prevalence across geographic regions, BTC subtypes, and hepatitis status, highlighting genes whose alteration frequencies vary by anatomical location and etiology. or example, iCCA in Eastern vs. Western hemispheres showed large differences in alteration prevalence for FGFR2, IDH1, KRAS, TP53, CDKN2A, and BAP1, whereas eCCA and GBC exhibited only modest hemispheric differences. We further show that these differences, as well as those observed between iCCA and eCCA, are partly explained by variation in the mutation profiles and prevalences of small- vs. large-duct subtypes. The large sample size also enabled systematic characterization of gene-gene co-occurrence and mutual exclusivity across BTC subtypes, along with a clinically oriented catalogue of recurrent mutations in oncogenes and tumor suppressor genes. This integrative cross-study analysis provides a global view of BTC genomics, clarifying how geography, etiology, and anatomical subtype collectively shape driver mutation landscapes. Our results provide statistical depth, uncover new mutational relationships, and suggest high-priority avenues for basic and translational research in biliary tract cancer. By integrating data across diverse geographic and etiological contexts, this study highlights how mutation prevalence and co-mutation patterns vary systematically with anatomical subtype, hepatitis status, and region. These findings offer a more nuanced framework for interpreting BTC genomics and underscore the importance of stratified approaches to research and treatment. Collectively, this work establishes a robust foundation for future biological studies, biomarker development, and the design of clinical trials that are tailored to geographic origin, underlying etiology, and specific mutational and co-mutation landscapes, ultimately supporting more precise and effective therapeutic strategies in BTC.

Intrahepatic cholangiocarcinoma (ICC) is a highly heterogeneous and aggressive malignancy with poor prognosis and limited treatment options. The lack of precise molecular classification and incomplete understanding of the tumor microenvironment (TME) impede therapeutic development. This study aims to dissect the cellular heterogeneity and intercellular interactions in ICC, with a particular focus on SPINK1-overexpressing epithelial subsets. We sought to determine the role of SPINK1 in modulating immune cell recruitment and tumor metabolism, and to evaluate its clinical relevance. We performed single-cell RNA sequencing (scRNA-seq) on human ICC tumors and adjacent normal tissues to construct a transcriptomic atlas. Integrative proteomic analysis, transwell assays, co-culture systems, and functional perturbation experiments (SPINK1 knockdown and ASCT2 inhibition) were conducted to explore epithelial-macrophage interactions and metabolic dynamics. ScRNA-seq identified a SPINK1-overexpressing epithelial subcluster enriched in ICC tumors. High SPINK1 expression correlated with significantly shorter patient survival. SPINK1-overexpressing epithelial subcluster secretes CCL20, which recruits lipid-associated macrophages (LAMs). This effect was reversed by CCL20 neutralizing antibodies. In co-culture, LAMs increased intracellular glutamine levels in SPINK1-overexpressing epithelial subcluster, promoting proliferation. Disruption of SPINK1 expression or glutamine transport abolished this metabolic support. Our findings uncover a novel SPINK1-CCL20-LAMs axis that orchestrates immune recruitment and metabolic reprogramming in ICC. SPINK1 facilitates tumor growth by establishing a glutamine-rich microenvironment via LAMs. These insights highlight SPINK1 as a potential therapeutic target and prognostic biomarker in ICC.