Obesity represents a well-established risk factor for numerous cancers, contributing substantially to the global burden of this disease. In parallel, accumulating evidence supports the relevant biological effects of physical activity in counteracting the pathological mechanisms linking obesity to carcinogenesis and tumor progression, including chronic low-grade inflammation, adipocyte dysfunction, and insulin resistance, which collectively promote the establishment of a pro-tumorigenic microenvironment. Despite the growing body of evidence on the benefits of physical activity in oncological patients, its translation into practical recommendations for individuals with both obesity and cancer remains limited, representing a critical clinical and scientific gap. The present review aims to provide a critical overview of the biological basis and available evidence, with the goal of proposing a pragmatic evidence-informed clinical framework for the integration and prescription of physical exercise in the management of patients with cancer and obesity. Major international guidelines on physical activity in oncology will be analyzed, highlighting areas of convergence and operational gaps, with particular emphasis on the absence of specific recommendations for this dual pathological condition. Exercise modality, dose, progression, and timing will be discussed, with attention to the most relevant individual and systemic barriers. Collectively, the available evidence supports the integration of individualized exercise prescription as a core component of multidisciplinary care for patients with obesity-associated cancer, while highlighting the urgent need for dedicated clinical trials and consensus recommendations specifically addressing this high-risk population.
Extracellular chromatin fragments, including cell-free DNA (cfDNA) and histones, have emerged as promising non-invasive biomarkers for cancer screening and monitoring. While aberrant DNA methylation patterns in cfDNA are already established hallmarks of cancer and are increasingly used in liquid biopsy assays, circulating histones and nucleosomes reflect complementary aspects of tumor-associated epigenetic dysregulation and chromatin remodeling. This review integrates current knowledge on intracellular and extracellular histones in cancer, highlighting their release via necrosis, apoptosis, or neutrophil extracellular traps (NETs), and their dual roles as damage-associated molecular patterns and modulators of the tumor microenvironment. We discuss the intricate mechanistic links between DNA methylation and histone modifications, histone variants, and post-translational modifications, including the bidirectional crosstalk mediated by enzymes such as DNMTs, UHRF1, and PAD4. Special emphasis is placed on NETosis and its epigenetic regulation, which further connects histone citrullination with DNA methylation machinery and tumor progression. We evaluate the clinical potential of combining cfDNA methylation profiling with circulating histone levels, histone variants, and nucleosome-associated post-translational modifications. Evidence from multiple cancer types demonstrates that multimodal epigenetic approaches, incorporating fragmentomics, histone marks, and methylation signatures, significantly improve diagnostic accuracy, tissue-of-origin identification, and early detection compared to single-modality or conventional protein biomarkers in several cancer types. Fragmentomics, reflecting nucleosome positioning and chromatin accessibility, adds a functional layer to methylation-based assays. Collectively, extracellular chromatin components offer a rich, biologically interconnected source of information. Their integrated analysis holds substantial promise for advancing precision oncology through improved screening, prognosis, treatment monitoring, and development of safer epigenetic therapies.
Monoclonal gammopathy of undetermined significance (MGUS), monoclonal B-cell lymphocytosis (MBL), and clonal hematopoiesis (CH) of indeterminate potential represent highly prevalent, age-associated precursor states characterized by detectable serological, cellular, or genetic alterations in otherwise asymptomatic individuals. The advent of high-sensitivity technologies, including mass spectrometry, multiparametric flow cytometry, and next-generation sequencing, has revealed that these conditions are far more widespread than previously appreciated, yet only a minority of affected individuals progress to overt malignancies such as multiple myeloma, chronic lymphocytic leukemia, or myeloid neoplasms. Across these entities, a unifying paradigm is emerging in which malignant transformation is governed not simply by the presence of driver lesions, but by dynamic clonal evolution shaped by intrinsic fitness, temporal acquisition of alterations, and selective pressures imposed by the aging microenvironment. In CH, mutation-specific growth kinetics and inflammation-driven selection define both hematologic and systemic risks. In MBL, antigenic stimulation, immune dysfunction, and genetic complexity modulate progression to CLL. In MGUS, disease evolution reflects a gradual co-evolution between plasma cell clones and a progressively permissive niche. Aging-associated inflammation and tissue remodeling act as common denominators, fostering a competitive landscape that selectively advantages aberrant clones while suppressing normal hematopoiesis. In turn, these clones actively remodel their microenvironment, establishing feed-forward loops that sustain clonal expansion and malignant potential. Integrating insights across CH, MBL, and MGUS highlights shared biological principles and supports a shift toward "precision prevention" strategies aimed at intercepting high-risk trajectories while minimizing unnecessary surveillance in low-risk individuals.
BACKGROUND:Oligometastatic and oligoprogressive disease treated with stereotactic ablative radiotherapy (SABR) represents a clinically heterogeneous entity. Increasing evidence suggests that anatomical definitions alone may not adequately capture underlying biological diversity. This systematic review aimed to synthesize translational evidence exploring evolutionary dynamics, resistance mechanisms, and biomarker-driven stratification in patients treated with SABR. METHODS:A systematic literature review was performed including prospective and retrospective studies evaluating translational biomarkers in oligometastatic or oligoprogressive settings treated with SABR. Studies assessing genomic, transcriptomic, circulating or immune-related biomarkers were included. Data were summarized qualitatively according to predefined translational domains: (i) evolutionary dynamics under systemic therapy pressure, (ii) baseline biological stratification, (iii) longitudinal circulating biomarkers, and (iv) systemic immune remodeling. Exploratory quantitative visual syntheses were performed using reported hazard ratios when conceptually comparable endpoints were available. RESULTS:19 studies comprising 1527 patients were included. Across tumor types and treatment contexts, translational analyses consistently indicated that anatomically defined oligometastatic states encompass biologically distinct subgroups with different risks of systemic progression. Studies evaluating oligoprogression under ongoing systemic therapy suggested a distinction between spatially constrained resistance and systemic molecular escape, supported by circulating tumor DNA and tissue- or plasma-based molecular profiling (including genomic and transcriptomic analyses). Baseline biological features, including adverse genomic signatures and circulating biomarkers, were associated with inferior progression outcomes despite metastasis-directed therapy. Longitudinal biomarkers provided early signals of treatment response and systemic control. Immune remodeling after SABR showed context-dependent effects, both systemic immune activation and treatment-related immunosuppression reported across studies.
The tumor microenvironment (TME) and its complex, dynamic interactions play a pivotal role in cancer development, progression and therapy response. However, faithful recapitulation of the diverse cellular and structural components of the TME in vitro remains a major challenge in cancer research. Traditional 2D cancer cell cultures fail to preserve TME interactions and tissue organization that critically impacts tumor behavior, while advanced 3D systems, including organoids, 3D-bioprinted structures and microfluidic platforms capture only selected aspects of TME complexity and host physiology. Recent advances in the culture of primary tumor specimens with minimal disruption to tissue architecture has led to a rapidly evolving set of model systems that benefit TME research. These ex vivo cultures (EVCs), as we collectively refer to them here, are established from fresh primary tumor tissue and preserve the native tumor architecture, extracellular matrix composition, immune and stromal compartments and their multilayered crosstalk within a physiologically relevant context. This review outlines the historical evolution of 2D and 3D model systems in oncology, followed by a comprehensive overview of current EVC methodologies. Furthermore, we address their applications in fundamental cancer research, personalized medicine and drug discovery, while highlighting their advances and challenges for the future.
Cellular plasticity refers to the ability of healthy cells to shift between phenotypic states and modify their characteristics to maintain tissue homeostasis and integrity. In the tumor context, cancer stem cells (CSCs) exploit this flexibility to withstand stress, facilitate tumor dissemination, and evade therapeutic interventions. Epigenetic regulation, particularly DNA methylation at CpG sites, is recognized as a well-known driver of tumor plasticity by repressing differentiation programs through modulation of chromatin accessibility. More recently, RNA modifications (epitranscriptomics) have emerged as crucial post-transcriptional regulators of gene expression that shape RNA fate and function. Among these, N6-methyladenosine (m6A), 5-methylcytosine (m5C), N1-methyladenosine (m1A), and N7-methylguanosine (m7G) contribute to the regulation of cell identity by modulating stemness-differentiation balance, stress adaptation, and epithelial-to-mesenchymal transition (EMT). Notably, dysregulation of both DNA and RNA methylation signatures is frequently observed in tumors, suggesting potential functional interactions between these regulatory layers. Emerging evidence indicates that DNA CpG methylation and RNA methylation pathways may cooperate to influence stemness, survival, and EMT-associated signaling, thereby supporting CSCs' plasticity. Although the molecular mechanisms underlying this crosstalk remain incompletely understood, accumulating studies suggest that DNA and RNA methylation could converge within interconnected regulatory networks that contribute to the control of cancer cell identity. A deeper understanding of these interactions may uncover novel vulnerabilities for targeting tumor plasticity. In this review, we summarize the current knowledge on the interplay between DNA and RNA methylation in regulating tumor plasticity, highlighting emerging mechanistic insights, functional interactions, and potential implications for future epigenetic and epitranscriptomic therapeutic strategies.
The oral microbiome is comparable to the gut microbiome in ecological complexity and is now recognized as a contributor to anticancer immune responses. Although the relationship between the gut microbiome and anticancer immunity is well established, the connection between the oral microbiome and anticancer immunity has received increasing attention, with accumulating evidence pointing to the direct effects of the oral microbiome on immune cell populations. The relationship between cancer and the oral microbiome is bidirectional: each influences the behavior of the other. The tumor microenvironment (TME) and oncological therapies such as chemotherapy and radiation can cause oral microbiome dysbiosis. Once dysbiosis is established, it creates conditions that favor tumor initiation and recurrence through chronic inflammation and impaired immune surveillance. Furthermore, the oral microbiome indirectly affects distant cancers and contributes to systemic inflammation and microbial dissemination through gastrointestinal, respiratory, hematogenous, neurological, and lymphatic pathways. Prebiotics, probiotics, postbiotics, and microbiota transplantation represent promising therapies targeting this microbial community to enhance the efficacy of cancer immunotherapy.
Tumor heterogeneity-encompassing diverse cellular phenotypes, genomic alterations, and microenvironmental contexts-is a principal barrier to effective cancer therapy. Single-cell RNA sequencing (scRNA-seq) has transformed our ability to resolve this complexity by capturing transcriptomes at single-cell resolution. Here, we review the technical foundations required for high-quality scRNA-seq studies. We then trace the evolution of scRNA-seq platforms from manual micromanipulation to high-throughput systems, and describe the computational pipelines that enable reliable data interpretation. The application of scRNA-seq is exemplarily shown in the context of lung cancer, where single-cell profiling has revealed (i) the clonal and sub-clonal architecture of tumors, (ii) extensive remodeling of the immune microenvironment, iii) key mechanisms underlying resistance to targeted agents and immune-checkpoint blockade, and (iv) the dynamics of neo-antigen-specific T-cell responses. Integrating machine-learning techniques-such as deep-learning classifiers and graph-based models-with single-cell transcriptomic data has markedly sped up biomarker discovery, produced more accurate risk-stratification scores, and enabled the generation of patient-specific therapeutic predictions. We surveyed the major trial registry ClinicalTrials.gov and identified ∼380 ongoing or completed studies that explicitly incorporate scRNA-seq as a correlative or pharmacodynamic endpoint. Overall, the analysis shows that scRNA-seq becomes an increasingly important component of modern trials, providing high-resolution cellular and molecular readouts that complement conventional imaging and bulk-omics endpoints. While key challenges remain, ranging from costs, scalability and need for rigorous validation before routine clinical deployment, ongoing technological advances continue to expand the potential of scRNA-seq as a cornerstone of precision medicine.
Tumor heterogeneity in cutaneous melanoma (CM) is attributed to the functional and structural diversity of tumor cells, immune cells, and the tumor stroma, and determines patients' response to therapy. The tumor immune microenvironment (TIME) comprises a diverse array of cellular and non-cellular components. Cells include cancer-associated fibroblasts, T cells, NK cells, B cells, dendritic cells, myeloid-derived suppressor cells, and monocytes. Non-cellular components include cytokines, growth factors, and extracellular matrix (ECM). In this review, we specifically focus on the critical roles of ECM molecules, namely collagen, fibronectin, laminin, hyaluronic acid, galectin, and matrix metalloproteinase, in shaping the melanoma TIME. We explore ECM components by examining how their physical properties and biological functions regulate the interactions between cancer and immune cells, thereby impacting immunity in melanoma and underscoring their clinical significance.
Glioblastoma (GBM) remains the most lethal primary brain tumor in adults. These aggressive tumors evolve as dynamic, spatially organized ecosystems in which tumor cells continuously interact with the surrounding brain parenchyma and systemic environment. These reciprocal interactions actively drive invasion, therapeutic resistance, and ultimately, inevitable recurrence. Modelling this level of complexity has long required significant compromise. GBM organoids have emerged as a promising intermediate platform, bridging the gap between costly, low-throughput animal models and overly simplistic two-dimensional in vitro cultures. In this review, we summarize the diverse protocols currently used for GBM organoid derivation and long-term maintenance, focusing on the recapitulation of microenvironmental traits. We further discuss how these systems enable the investigation of tumor niche architecture and dynamic crosstalk with key components of the tumor microenvironment, including neural and immune elements, vascular-associated signals, and extracellular matrix cues. Although the inherent limitations of ex vivo systems must be carefully considered, increasingly advanced and well-designed protocols will enable robust interrogation of interactions within the GBM ecosystem and provide powerful platforms for therapeutic testing.
Extracellular vesicles (EVs) are emerging as pivotal mediators of tumor progression, metastasis, and therapy resistance, reflecting the dynamic complexity of the tumor microenvironment. Their stability in biofluids makes EVs promising candidates for both tailored cancer therapies and liquid biopsy-based cancer diagnostics. However, their nanoscale size and molecular heterogeneity continue to challenge standardized isolation and analysis. Recent advances in microfluidic and organ-on-chip technologies are transforming EV research by enabling high-resolution separation, label-free detection, and real-time monitoring within physiologically relevant microenvironments. These platforms not only enhance analytical precision but also recapitulate tumor-stromal interactions that govern EV biogenesis, trafficking, and uptake. When coupled with complementary methods (such as immunoaffinity capture, size-exclusion chromatography, and viscoelastic or magnetophoretic sorting) microfluidic systems offer unprecedented control over EV isolation and characterization. Moreover, emerging wearable microfluidic devices and metabolic labeling strategies open new avenues for personalized EV delivery and nascent vesicle tracking in cancer models. Real-time monitoring of EV transfer between cancer and stromal cells within microfluidic environments further deepens our understanding of EV-mediated communication and its role in metastatic niche formation. In this review, we highlight the latest technological innovations and translational perspectives in EV isolation and analysis, emphasizing how microfluidic platforms are reshaping cancer diagnostics and therapy. Thanks to microfluidics, these integrated systems hold promise for accelerating the clinical deployment of EVs as functional biomarkers and therapeutic agents in precision oncology and nanomedicine-based cancer treatment.
Emerging evidence suggests that systemic dyslipidemias, traditionally recognized as major risk factors for cardiovascular disease, are critical modulators of immune responses. Meanwhile, cancer immunology research focuses on exploiting the immune system to more effectively target tumor cells by enhancing antitumor immunity and overcoming immune suppression within the tumor microenvironment (TME). The growing evidence connecting dyslipidemia-related diseases to tumor progression highlights lipid dysregulation as a potential driver of immune dysfunction in cancer. Elevated circulating lipids, beyond affecting local tumor metabolism, can precondition and reprogram immune cells, reshaping the TME and ultimately influencing tumor fate and cancer progression. This review summarizes how these systemic lipid alterations affect key immune populations, including CD8⁺ T cells, regulatory T cells (Tregs), natural killer cells (NKs), myeloid-derived suppressor cells (MDSCs), tumor-associated macrophages (TAMs), and dendritic cells (DCs), through mechanisms involving lipid uptake, peroxidation, and altered signaling pathways. Understanding the interplay between systemic lipid metabolism and local immune reprogramming may inform personalized strategies to improve cancer immunotherapy treatment outcomes.
The treatment of non-small cell lung cancer (NSCLC), a disease known for its aggressiveness and significant global impact, has substantially improved in recent decades. A notable shift from cytotoxic chemotherapy to more personalized approaches, such as targeted therapies and immunotherapies, has led to improved outcomes for some patients. However, the emergence of resistance remains a major challenge in clinical practice, highlighting the inherent adaptability of cancer cells. This adaptability extends beyond genetic and epigenetic changes within malignant cells, as the bidirectional crosstalk with the tumor microenvironment (TME) also plays a crucial role. This complex ecosystem, consisting of various cellular components (e.g., fibroblasts, endothelial cells, immune cells), extracellular matrix elements, and soluble factors, significantly influences tumor progression, metastasis, and treatment response. Therefore, a comprehensive understanding of how the TME evolves under the selective pressures of different therapies is essential for developing more durable and effective treatment strategies for NSCLC.
Obesity is an established risk factor for at least thirteen cancer types, yet the mechanisms by which the gut microbiota participates in obesity-related tumorigenesis remain incompletely understood. In this review, we summarize the role of the gut microbiota in the four core oncogenic pathways of obesity including metabolic reprogramming, the obesity-related secretome, hormonal dysregulation,and immune modulation. Mechanistically, microbial activity shapes these processes primarily through the production of metabolites, disruption of the intestinal barrier, and stimulation of innate immunity via microbe-associated molecular patterns, ultimately contributing to chronic low-gradeinflammation and impaired antitumor immune surveillance. Nevertheless, many outstanding questions remain. Microbial signals are not uniformly tumor-promoting, in obesity- related liver cancer models, short-chain fatty acid-producing taxa can suppress pro-tumor inflammation. In terms of cancer type, the evidence for mechanistic involvement is strongest for colorectal and liver cancers, owing to the gut-liver axis and direct epithelial exposure, whereas causal inferences for other cancer types remain limited. Moreover, the role of intratumoral microbiota remains uncertain due to low microbial biomass and potential sequencing contamination. Key translational challenges include confounding factors such as diet and co-treatments, inconsistencies in obesity phenotyping across studies, and platform-dependent variability in microbial biomarkers. Nonetheless, microbial interventions aimed at targeting obesity-related cancer development and progression represent a promising avenue for future therapeutic strategies.
Chronic lymphocytic leukemia (CLL) is a paradigmatic malignancy driven by intraclonal diversity and dynamic evolutionary processes. High-resolution genomic profiling has demonstrated that CLL progression rarely follows a linear trajectory; rather, it is characterized by a complex and evolving (sub)clonal architecture shaped by intrinsic biological features and extrinsic factors, including therapeutic pressure. Recurrent genetic alterations affect key signaling pathways and cellular processes, including B-cell receptor and NF-κB signaling, DNA damage response, RNA processing, and apoptosis. Many of these lesions arise as subclonal events and subsequently expand, thereby influencing disease progression, therapeutic resistance, and transformation. Over the past decade, the treatment paradigm in CLL has shifted from chemoimmunotherapy to targeted agents, resulting in substantial clinical benefit. Nevertheless, the emergence of therapeutic resistance remains a major challenge. In this review, we summarize current knowledge of clonal evolution and resistance mechanisms in CLL. Resistance to chemoimmunotherapy is frequently driven by genetic lesions, such as TP53 aberrations, and by expansion of resistant microclones. In contrast, targeted therapies select for distinct resistance mechanisms, such as BTK and PLCG2 mutations in patients treated with BTK inhibitors, as well as activation of alternative survival pathways. We further discuss emerging technologies, including single-cell sequencing and integrative multi-omics approaches. Finally, we highlight the need for future studies addressing resistance in evolving clinical contexts, such as combination targeted therapies, bispecific antibodies, and CAR T-cell therapy. Taken together, a deeper understanding of clonal evolution is central to the development of personalized therapeutic strategies and to improving long-term outcomes for patients with CLL.
Differentiating multiple primary lung carcinomas (MPLCs) from intrapulmonary metastases (IPMs) remains a critical challenge in the management of patients with multiple non-small cell lung carcinomas (NSCLCs). Although the clinical presentation of MPLCs and IPMs often appears similar, they represent biologically distinct evolutionary processes. In the genomics era, molecular pathology has provided new tools to address this diagnostic challenge in clinical practice. Simultaneously, a multitude of genome research studies have elucidated the evolutionary dynamics underlying tumor initiation, progression, and metastatic divergence which provide a mechanistic framework and underpinning for unambiguous clonality diagnostics. In this review, we aim to bridge the gap between tumor evolution and the dilemma of clonality diagnostics in NSCLC. We first revisit historical approaches to clonality diagnostics from today’s genomic perspective. We then systematically discuss how evolutionary principles of oncogenesis are reflected across established and emerging diagnostic approaches, including histomorphology, somatic mutation profiling, fusion detection, copy number aberration analysis, transcriptomics, and methylation testing. Finally, we discuss the limitations and potential opportunities of these approaches in current and future clinical practice.We show that the conceptual integration of tumor evolution into clonality diagnostics is essential for accurate staging and treatment selection to ultimately improve outcomes for patients with multiple lung carcinomas.
Sarcomas and carcinomas represent approximately 1% and 80% of all cancer diagnoses, respectively. Despite their very different prevalence, both tumor types share a critical dependence on mitochondrial functions for metabolic adaptation, survival and progression. Mitochondria act as cellular powerhouses by generating ATP through oxidative phosphorylation; however, their roles extend far beyond energy production. These organelles are central hubs of biosynthetic and catabolic pathways, including the tricarboxylic acid cycle, glutaminolysis, lipid metabolism, branched-chain amino acid catabolism and gluconeogenesis. Moreover, they play a key role in regulating various forms of programmed cell death, such as apoptosis, necroptosis, ferroptosis and pyroptosis. In this review, we provide a comprehensive overview on the contribution of mitochondria to tumor cell metabolism specifically in sarcomas and carcinomas. We describe how mitochondrial DNA-encoded proteins influence tumorigenesis and how mitochondria support cancer stem cell maintenance. We also discuss the therapeutic potential of targeting mitochondrial pathways, highlighting clinical trials and emerging strategies. The available evidence suggests that sarcoma cells might be more responsive to mitochondrial-targeted therapies due to their higher mitochondrial content and activity compared with carcinomas. Lastly, we bring some evidence of the involvement of mitochondria in the tumor microenvironment and discuss the implication of this finding for cancer immunotherapy. Altogether, these insights emphasize the importance of mitochondria as central regulators of cancer cell fate and promising therapeutic targets.
Oxysterols are enzymatically or non-enzymatically generated cholesterol derivatives that act as metabolic messengers at the interface of lipid homeostasis, nuclear receptor signaling, oxidative stress, and immunity. Their structural diversity endows them with highly selective biological activities: some function as ligands for LXRα/β, ERα, or GR; others regulate sterol trafficking, autophagy, redox equilibrium, and membrane organization. In cancer, this versatility translates into a dualistic influence on tumor biology. The oxysterol dendrogenin A activates differentiation programs, antioxidant defenses, and immunogenic pathways, whereas 27-hydroxycholesterol and oncosterone promote proliferation, endocrine resistance, and immune escape. The 5,6-epoxycholestanol pathway exemplifies this metabolic bifurcation: the same precursor may be routed toward dendrogenin A, supporting anticancer immunity, or toward OCDO, a glucocorticoid-like oncometabolite that suppresses cytotoxic lymphocytes and enhances tumor survival. A third axis, governed by CYP27A1, introduces additional complexity by hydroxylating the oncogenic oxysterol OCDO into an antiproliferative metabolite. These interlocking routes form a sterol-centered signaling network that integrates metabolic state with tumor progression and immune surveillance. Understanding how tumors rewire oxysterol metabolism, and how these lipid signals shape cellular plasticity and the tumor microenvironment, offers a promising framework for identifying metabolic vulnerabilities and designing sterol-based therapeutic strategies.
