Background: Liver metastasis represents the most common distant dissemination in gastric cancer (GC) but persists as a challenging condition to manage, and its driving molecular mechanisms remain poorly understood. This study aimed to uncover the key regulatory drivers of GC liver metastasis and explore their potential as therapeutic targets. Methods: Herein, we employed a multifaceted approach combining single-cell RNA sequencing, bulk transcriptomics, epigenomics analyses of GC primary tumors and normal adjacent tissues, paired liver metastasis, and circulating tumor cells, alongside in vitro and in vivo experimental validation, to investigate how metastatic GC cells spread to and adapt within the liver microenvironment. Results: We discovered that GC cells undergoing liver metastasis transcriptionally reprogrammed into a high plasticity state. This plasticity was mediated by the transcription factor CCAAT enhancer-binding protein beta (CEBPB), which activated liver metastasis-associated genes through enhancer reprogramming. Notably, CEBPB-driven reprogramming enhanced the metastatic potential of GC cells and enabled them to evade immune surveillance via interactions between cluster of differentiation 155 (CD155) and T cell immunoreceptor with Ig and ITIM domains (TIGIT). Blocking the CD155-TIGIT interplay inhibited liver metastasis and restored T cell cytotoxicity. Conclusions: Our study identifies CEBPB-mediated transcriptional and epigenetic reprogramming as a fundamental driver of GC liver metastasis. Our findings underscore the CEBPB/CD155/TIGIT axis as a promising therapeutic target for liver-metastatic GC.

BackgroundAdenocarcinoma of the esophagogastric junction (AEG) is increasingly recognized as a distinct gastrointestinal tumor type with a poor prognosis. However, the mechanisms driving AEG progression, particularly the interplay between metabolic reprogramming and the immune microenvironment, remain poorly understood.MethodsWe integrated multi-omics to profile the tumor microenvironment and metabolic reprogramming of AEG. Tumor tissues and paired normal adjacent tissues from AEG patients were subjected to single-cell RNA sequencing (N=11), spatial transcriptomics (N=4), and metabolomics analysis (N=26). Molecular experiments and animal models were used for validation.ResultsOur analysis revealed an AEG-specific malignant subtype originating from the esophagogastric junction, characterized by heightened proliferation and poor differentiation. These malignant cells exhibited metabolic reprogramming marked by hyperactivation of the glutamine-arginine-spermine axis with concomitant spermine accumulation. Spermine was found to drive the polarization of tumor-associated macrophages into an APOE+ immunosuppressive phenotype, thereby modulating the tumor immune microenvironment. Mechanistically, spermine promoted the phosphorylation of STAT3, thereby enhancing its binding affinity to the APOE promoter region and leading to enhanced transcriptional activation of APOE.ConclusionThis study identified AEG-like malignant cells as a high-risk subtype, revealed the metabolic-immune crosstalk driven by the spermine-STAT3-APOE axis in AEG progression, and provided potential targets for AEG metabolic intervention and immunotherapy.

Locally advanced rectal cancer (LARC) presents significant treatment challenges, particularly in microsatellite stable (MSS) patients, who often show limited response to immunotherapy. In these cases, neoadjuvant chemoradiotherapy (neoCRT) followed by surgery remains the recommended approach. However, the response to neoCRT varies significantly among LARC patients. In this study, the role of the tumor microenvironment (TME) is explored, focusing on early-stage exhausted T cells (early-Tex) and tertiary lymphoid structures (TLS), in predicting neoCRT response in MSS LARC. Through multi-omics analyses, it is found that immune features of the TME, rather than mutational status, are more closely associated with treatment response. Within the TME, it is observed that early-Tex cells, a subset with both similarities and distinct differences compared to previously described precursor exhausted T (Tpex) cells, are enriched in responders and correlated with favorable treatment outcomes. Additionally, it is identified that TLSs are more abundant, activated, and mature in responders compared to non-responders. LAMP3⁺ dendritic cells (DCs) play a pivotal role in suppressing TLS formation, with IRF8 as a key transcriptional regulator, which may ultimately affect therapeutic response. These findings suggest early-Tex cells and modulation of TLS by LAMP3⁺ DCs can serve as indicators for optimizing neoCRT in MSS LARC.

The efficacy of immune checkpoint inhibitors (ICIs) in microsatellite stable colorectal cancer (MSS CRC) remains limited, highlighting an urgent need for predictive biomarkers. Through multi-omics analysis, we identified two novel MSS CRC subtypes, termed DUB-H and DUB-L. The DUB-L subtype exhibited an inflamed tumor immune microenvironment, a superior response to immune therapy, and better recurrence-free survival (RFS) compared to DUB-H. The classifier gene USP7 was selected as a gene of interest due to its specific expression profile, which is highly expressed in MSS CRC but not in microsatellite instability-high (MSI-H) tumors, and strongly correlated with suppressed immune infiltration. Large-scale clinical analyses confirmed associations between high USP7 expression, microsatellite stability, specific consensus molecular subtypes (CMS), and unfavorable prognosis. Single-cell analysis and multiplex immunofluorescence validated an immune-desert phenotype in USP7-high MSS tumors. Mechanistically, USP7 knockdown in MSS CRC cells enhances the secretion of T-cell-recruiting chemokines (CXCL9/10/11), promoting CD8⁺ T cell recruitment and cytotoxicity in vitro. In vivo experiments demonstrated that USP7 blockade enhanced the efficacy of anti-PD-1 treatment in MSS CRC models by remodeling the tumor immune microenvironment, increasing infiltration and function of CD8⁺ T and NK cells. Consistently, low USP7 expression is associated with a better response to anti-PD-1 therapy. Overall, we propose a novel DUB-based classification system for MSS CRC and demonstrate that targeting USP7 may overcome immunotherapy resistance by converting immunologically “cold” tumors into “hot” ones.

BACKGROUND:Gastric cancer (GC) is highly heterogeneous, and current prognostic models fail to fully capture tumor immune characteristics, limiting personalized treatment. This study introduces the Tumor Immune Environment Score (TIES), an immune-based prognostic model designed to enhance risk stratification and predict response to immunotherapy. METHODS:Transcriptomic and clinical data from seven GC cohorts, comprising a total of 1487 patients, were analyzed. The training cohort included GSE15459, GSE62254, GSE84433, and GSE13861, while the validation cohort comprised GSE26899, GSE26901, and TCGA-STAD. Immune-related gene signatures were quantified using ssGSEA and subsequently analyzed via LASSO and Cox regression. Clinical applicability was quantified using decision-curve analysis (DCA) and reclassification metrics (category-free NRI/IDI) for TIES versus TIES + pathological stage. Immunotherapy response was assessed using data from GSE183924, and its associations with immune characteristics, molecular alterations, and drug sensitivity were investigated. For experimental confirmation, we established a 12-gene RT-qPCR panel in 30 institutional GC specimens and computed a weighted qPCR surrogate (qTIES). RESULTS:A high TIES was associated with worse OS (HR = 2.44, p < 0.001) and DFS (HR = 2.25, p < 0.001). TIES was an independent prognostic factor and demonstrated superior predictive accuracy compared to TNM staging (AUC = 0.75-0.79 vs. 0.61-0.64, p < 0.001). Integrating clinical-pathological features with TIES significantly enhanced predictive performance (AUC = 0.75-0.78 vs. 0.61-0.63, p < 0.01). A low TIES was indicative of an immune-inflamed subtype, characterized by a higher TMB (p < 0.01) and a greater likelihood of response to immunotherapy (HR = 0.24, p = 0.014). TIES outperformed TIDE in predicting immunotherapy outcomes, achieving a higher OS C-index (0.780 vs. 0.743) and DFS C-index (0.664 vs. 0.610). At 3 years, TIES + stage yielded a greater net benefit than TIES alone across clinically relevant thresholds (DCA) and improved NRI/IDI.The qPCR panel reproduced axis biology (CSR/TGF-βincreased with NK/Th2 decreased), correlated with pathological stage, stratified OS/DFS by Kaplan-Meier, and showed 3-year discrimination. CONCLUSION:TIES represents a robust immune-based prognostic tool for GC, facilitating improved risk stratification and immunotherapy response prediction. Its integration into clinical practice, particularly in combination with clinical-pathological features, may enhance personalized treatment strategies and improve patient outcomes.

BACKGROUND:The advent of ultrasonic scalpels has remarkably advanced minimally invasive surgery; however, the Chinese market's reliance on imports highlights the urgent need for a cost-effective, efficient, and domestically produced surgical scalpel. This study aimed to compare SanAgileTMSA01 with the Johnson & Johnson GEN11, and HAR36 surgical devices. RESEARCH DESIGN AND METHODS:In total, 152 participants requiring urological or general laparoscopic surgery were randomly and equally divided between the two hospitals and randomized to the test and control groups. Clinical outcomes, adverse event rates, intraoperative bleeding, and surgery duration were compared between the two devices. RESULTS:The clinical application rate of both devices was 100%. There were no significant differences between the two groups in intraoperative bleeding, surgery duration, and incidence of adverse events. In the test group, five device-related adverse events occurred (6.58%), compared to two (2.63%) in the control group (no significant difference). The device-related adverse events did not result in any sequelae. CONCLUSIONS:The clinical performance of the SanAgileTMSA01 was comparable to that of the Johnson & Johnson GEN11 and HAR36. The SanAgileTMSA01 device may serve as a viable alternative ultrasonic surgical tool, thereby providing clinicians with additional options. TRIAL REGISTRATION:Registration number of Shanghai Medical Equipment Preparation 20,190,114.

While whole genome sequencing (WGS) of cell-free DNA (cfDNA) holds enormous promise for molecular residual disease (MRD) detection, its performance is limited by WGS error rate. Here we introduce AccuScan, an efficient cfDNA WGS technology that enables genome-wide error correction at single read level, achieving an error rate of 4.2×10 -7 , which is about two orders of magnitude lower than a read-centric de-noising method. When applied to MRD detection, AccuScan demonstrated analytical sensitivity down to 10 -6 circulating tumor allele fraction at 99% sample level specificity. In colorectal cancer, AccuScan showed 90% landmark sensitivity for predicting relapse. It also showed robust MRD performance with esophageal cancer using samples collected as early as 1 week after surgery, and predictive value for immunotherapy monitoring with melanoma patients. Overall, AccuScan provides a highly accurate WGS solution for MRD, empowering circulating tumor DNA detection at parts per million range without high sample input nor personalized reagents. One Sentence Summary:AccuScan showed remarkable ultra-low limit of detection with a short turnaround time, low sample requirement and a simple workflow for MRD detection.

Postoperative gastrointestinal disorder (POGD) was a common complication after surgery under anesthesia. Strategies in combination with Traditional Chinese Medicine and Western medicine showed some distinct effects but standardized clinical practice guidelines were not available. Thus, a multidisciplinary expert team from various professional bodies including the Perioperative and Anesthesia Professional Committees of the Chinese Association of Integrative Medicine (CAIM), jointly with Gansu Province Clinical Research Center of Integrative Anesthesiology/Anesthesia and Pain Medical Center of Gansu Provincial Hospital of Traditional Chinese Medicine and WHO Collaborating Center for Guideline Implementation and Knowledge Translation/Chinese Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Center/Gansu Provincial Center for Medical Guideline Industry Technology/Evidence-based Medicine Center of Lanzhou University, was established to develop evidence-based guidelines. Clinical questions (7 background and 12 clinical questions) were identified through literature reviews and expert consensus meetings. Based on systematic reviews/meta-analyses, evidence quality was analyzed and the advantages and disadvantages of interventional measures were weighed with input from patients' preferences. Finally, 20 recommendations were developed through the Delphi-based consensus meetings. These recommendations included disease definitions, etiologies, pathogenesis, syndrome differentiation, diagnosis, and perioperative prevention and treatment.

The presence of malignant ascites in colorectal cancer (CRC) patients is associated with a poor prognosis, a high risk of recurrence, and resistance to chemotherapy and immune therapy [1-3]. Understanding the complex interactions among different kinds of cells and the ecosystem of peritoneal metastasized colorectal cancer (pmCRC) ascites may provide insights into effective treatment strategies. We profiled the single-cell transcriptomes of 96,065 cells from ascites samples of 12 treatment-naïve patients with pmCRC using the 10× single-cell RNA-sequencing (scRNA-seq) (Supplementary Figure S1A, Supplementary Table S1). Eleven major cell types were identified by characteristic canonical cell markers, including epithelial cells, endothelial cells, fibroblasts, T cells, B cells, monocytes, macrophages, plasma cells, natural killer (NK) cells, dendritic cells (DCs), and mast cells (Figure 1A-B). The main cellular components of pmCRC ascites are T cells (40,095; 41.7%), macrophages (28,487; 29.7%), and fibroblasts (5,932; 6.2%). Compared with primary CRC, which showed 14.8% epithelial cells [4], only 0.3% (291) epithelial cells were found in the ascites. The low percentage of epithelial cells in pmCRC ascites was consistent with the scRNA-seq studies of another tumor ascites [5-7]. Single-cell transcriptomic landscape of malignant ascites of metastatic CRC. (A) The UMAP plot shows 11 major cell types in pmCRC ascites, color-coded by cell types. (B) The fraction of each major cell type across 12 patients between PD and SD patients shows heterogeneous (left panel). The fraction of each patient across 11 cell type populations shows heterogeneous (right panel). (C) Differential gene expression of fibroblasts between PD and SD patients. (D) Differential gene expression reveals significantly up-regulated and down-regulated genes in 11 cell types between PD and SD patients. (E) Comparison of cell abundance between primary tumor and ascites. Macrophages are significantly more abundant in ascites than in primary tumors. The data of primary tumor were cited from Khailq et al. (2022) Genome Biology (https://doi.org/10.1186/s13059-022-02677-z) (F) Circle plots show the cellular interaction network of 11 cell types in pmCRC ascites. Fibroblasts and macrophages were the core of the cellular interaction network (Edge width represents the numbers of interactions and node size represents the abundance of cell populations. The round loops along with cell type represent the interactions within the same cell type.). (G) Dot plots show communication probability of the interactions between cell populations in pmCRC ascites (The dot size is proportional to the contribution score computed from pattern recognition analysis.). (H) The box plots show CD74, LGALS9 and both were highly expressed in metastatic patients of TCGA COAD & READ patients. The Kaplan-Meier overall survival curves of CD74, LGALS9, CD44 and ITGAX using TCGA COAD & READ patients. High score, n = 151; low score, n = 452. (I) UMAP plot of fibroblasts are grouped into 7 cell sub-clusters and indicated by color. (J) UMAPs show the expression levels of eCAFs scores and apCAFs scores in fibroblasts. Violin plots show the expression levels of eCAFs scores and apCAFs scores in fibroblasts sub-clusters. (K) UMAP plot of macrophages are grouped into 8 cell sub-clusters and indicated by color. (L) UMAPs and violin plots show the M1/M2 score in macrophages sub-clusters. (M) Violin plots show the upregulations of multiple immunosuppressive markers, HAVCR2, LGALS9, LAIR1, VSIR and cancer-promoting M2-like macrophage marker (CD163). (N) UMAPs show the enriched expression for PDCD1, TIGIT and TREM2. (O) UMAP plot of T cells are grouped into 11 cell sub-clusters and indicated by color. (P) UMAPs and violin plots show the enrichment of the proliferation score, CD8+ T cells cytotoxicity score and CD8+ T cells exhausted score in T cells sub-clusters. (Q) The single cell transcriptomics landscape of pmCRC ascites. (R) Drug repurposing using the transcriptomes data of macrophages in pmCRC ascites, shows 10 best drug candidates. Abbreviations: apCAF, antigen-presenting cancer-associated fibroblast; CRC, colorectal cancer; eCAF, extracellular matrix cancer-associated fibroblast; HAVCR2, hepatitis A virus cellular receptor 2; ITGAX, integrin alpha X; LAIR1, leukocyte-associated immunoglobulin-like receptor 1; LGALS9, recombinant human galectin-9; PD, progressive disease; PDCD1, programmed cell death 1; pmCRC, peritoneal metastasized colorectal cancer; SD, stable disease; TIGIT, T cell immune receptor with Ig and ITIM domains; TREM2, triggering receptor expressed on myeloid cells 2; UMAP, uniform manifold approximation and projection; VSIR, V-set immunoregulatory receptor. We classified the 12 patients into 2 groups according to their treatment response as follows: 8 patients (P02, P03, P04, P07, P08, P09, P11, and P12) had stable disease (SD), while 4 (P01, P05, P06, and P10) had progressive disease (PD). Single-cell transcriptomic analyses have revealed high heterogeneity of cell composition in 12 patients. The SD group exhibited a higher proportion of fibroblasts and epithelial cells (Figure 1B). Remarkably, fibroblasts had significantly different expression characteristics between the 2 groups (Figure 1C), and the top five upregulated/downregulated genes were visualized in 11 cell types (Figure 1D). We also found a significant increase in the frequency of macrophages in pmCRC ascites compared with the primary tumors [4] (Figure 1E). It hinted that significant inter-patient variability in the composition and functional programs of pmCRC ascites cells under different disease states. To comprehensively study the cellular interactions within the pmCRC ascites ecosystem, we predicted cell-cell communication networks using CellChat. Overall, we identified 44 significant ligand-receptor pair interactions. Although T cells were the most abundant cell population (41.7%) in pmCRC ascites, fibroblasts and macrophages were the core of the cellular interaction network (Figure 1F), suggesting their important roles in recruiting and cross-talking with diverse cells in the pmCRC ascites ecosystem. The result of cellular communications suggested that there was a complex interplay between various signaling molecule. Macrophage migration inhibitory factor (MIF), annexin, complement, and C-C chemokine ligand (CCL) were the most active outgoing/incoming signaling molecules in CRC ascites (Supplementary Figure S1B). Fibroblasts directly contacted with different types of cells via ligand-receptor interactions of the MIF-(CD74 + C-X-C chemokine receptor type 4 [CXCR4]) and MIF-(CD74 + CD44) axes and C3-(integrin alpha X [ITGAX] + integrin subunit beta 2 [ITGB2]) (Figure 1G). Notably, macrophage populations were more likely to interact with other cells through the adhesive ligand-receptor pairs galectin-9 (LGALS9)-CD44 and LGALS9-CD45, which were not observed in other cell populations (Figure 1G). CD74, LGALS9 were significantly associated with metastasis in The Cancer Genome Atlas (TCGA) CRC cohorts. We also found CD44 and ITGAX were survival (Figure 1H; CD44 and ITGAX showed no significant differential expression between metastatic and non-metastatic patients, so data are not shown). These results indicated that the entire cellular interaction network of pmCRC ascites contributed to establishing an immunosuppressive and metastatic microenvironment. We observed that the abundance of fibroblasts in pmCRC ascites samples was significantly greater in SD patients than in PD patients (Figure 1B). The fibroblasts were partitioned into 7 distinct clusters (C0-C6) based on unsupervised clustering (Figure 1I). All sub-clusters of cancer-associated fibroblasts (CAfs) showed a high expression of extracellular matrix cancer-associated fibroblasts (eCAFs) signature (Figure 1J), while inflammatory CAF (iCAF), myofibroblast CAF (myCAF), matrix CAF (mCAF), and vascular CAF (vCAF) only presented in a small fraction of fibroblasts (Supplementary Figure S1C), supporting the role of eCAFs in enhancing the metastatic potential of pmCRC. A higher abundance of antigen-presenting cancer-associated fibroblasts (apCAFs) was observed in the PD cohort (n = 310) than in the SD cohort (n = 93) (Wilcoxon test, P = 0.049). These results indicated that the CAFs in pmCRC ascites have bidirectional associations with immune regulation function, serving as a favorable candidate for CRC treatment. Differentially expressed genes and gene ontology (GO) analyses showed that the "cell-cell adhesion", "inflammatory response", and "cytokine production" were differentially enriched between primary tumors and ascites (Supplementary Figure S1D), which implied that the liquid state of ascites changed the functions of the fibroblast populations. Macrophages were significantly enriched in pmCRC ascites and categorized into 8 sub-clusters (C0-C7) (Figure 1K). Using the previously defined "M1" and "M2" signatures, C2 showed an "M1-like" pattern, and C5 showed "M2-like" patterns. We also identified a small sub-cluster of C5 co-expressed both "M1" and "M2" gene signatures (Figure 1L), which have been reported in previous studies on solid tumors [8]. We next examined the expression of a series of the previously reported immunosuppressive genes (leukocyte-associated immunoglobulin-like receptor 1 [LAIR1], hepatitis A virus cellular receptor 2 [HAVCR2; also known as T cell immunoglobulin and mucin domain-containing protein 3], LGALS9, and V-set immunoregulatory receptor [VSIR]) in macrophage sub-clusters. Because the expression pattern of the "M2" marker gene CD163 perfectly coincided with that of LAIR1 in all sub-clusters (Figure 1M), we postulated that the immunosuppressive function of tumor-associated macrophages (TAMs) might be exerted via LAIR1. Two other immunosuppressive genes, T cell immune receptor with Ig and ITIM domains (TIGIT) and programmed cell death 1 (PDCD1), were also identified highly expressed in C5. C4 highly expressed the key immunosuppressive phenotypic marker triggering receptor expressed on myeloid cells 2 (TREM2) (Figure 1N). In summary, the majority of macrophages in pmCRC ascites exhibited high immunosuppressive features. We identified 11 sub-clusters of T cells according to the expression of their respective markers, including CD4+ T cells (C1, C4, C5, and C6) and CD8+ T cells (C0, C2, C3, C7, C8, C9, and C10) (Figure 1O). Most CD8+ effector memory cells re-expressing CD45RA T (Temra/Teff) cells (C8) were from patient 5 (P05), and CD8+ effector memory T (Tem) cells (C7) were mostly from patient 8 (P08); the remaining 10 patients exhibited high heterogeneity in 11 T-cell sub-clusters (Supplementary Figure S1E-F). Importantly, CD8+ tissue-resident memory (Trm) cells (C7), which were reported to be associated with forming a tertiary lymphoid structure (TLS) [9], were less abundant in SD patients (P03, P08, P09, P11, and P12). We also observed that all sub-clusters expressed ferritin light chain (FTL) (Supplementary Figure S1G), which was reported to regulate chemoresistance and metastasis in CRC [10]. We calculated the cytotoxicity, proliferation, and exhaustion signatures for all CD8+ T-cell sub-clusters (Figure 1P). Only one sub-cluster of CD8+ T cells was not show exhaustion signature (C10). Clusters 9 and 10 exhibited slightly higher proliferation, which could recruit cytotoxic T cells. The abundance of C9 and C10 was low, suggesting that T cells may play a minor role in the immune microenvironment of ascites and may work synergistically with other cell populations. Moreover, we predicted immunomodulatory drugs targeting macrophages, where gene sets were extracted from the macrophages of the pmCRC ascites data (Figure 1Q). In conclusion, we found that T cells, fibroblasts, and macrophages exhibited immunosuppressive features in pmCRC ascites (Figure 1R). The cellular landscape of pmCRC ascites has the significant indication of patients' immune status, providing insights for prognosis and therapy selection. Haiyang Zhou made contributions to the conceptualization, funding acquisition, investigation, resource acquisition, and writing original draft. Jiahui Yin made contributions to the data curation, formal analysis, and software analysis. Anqi Wang made contributions to the formal analysis, investigation, and resource acquisition. Xiaomao Yin made contributions to the formal analysis. Taojun Jin made contributions to the formal analysis and visualization. Kai Xu made contributions to the resource acquisition and supervision. Lin Zhu made contributions to the investigation and resource acquisition. Jiexuan Wang made contributions to the investigation and resources acquisition. Wenqiang Wang made contributions to the resource acquisition. Wei Zhang made contributions to the resource acquisition. Xinxiang Li made contributions to the conceptualization, visualization, and writing – review & editing. Zhiqian Hu made contributions to the funding acquisition, visualization, and writing – review & editing. Xinxing Li made contributions to the investigation, resource acquisition, visualization, writing – original draft, and writing – review & editing. All authors read and approved the final manuscript. We would like to thank Prof. Weiping Chen (Zhejiang Cancer Hospital) for English language editing. The authors declare that they have no competing interests. The authors gratefully acknowledge the financial support from the National Key R&D Program of China (No. 2019YFA0110601), National Natural Science Foundation of China (No. 81571827), Natural Science Foundation Project of Shanghai Science and Technology Commission (SKW2030), Excellent Discipline Reserve Talent Plan of Tongji Hospital Affiliated to Tongji University (HBRC2014), Clinical research Project of Tongji Hospital Affiliated to Tongji University (ITJ-ZD-2104), Key talent introduction project of Tongji Hospital Affiliated to Tongji University (RCQD2102), Talent project of Tongji Hospital Affiliated to Tongji University (GJPY2111), and Shanghai Tongji Hospital special disease database construction project (TJ-DB-2105). All the investigation protocols were approved by the Institutional Ethics Committees of Shanghai Changzheng Hospital and Shanghai Tongji Hospital (SBKT-2022-155). All subjects provided informed consent to participate in the study and approved the use of their biological samples for analysis. All experiments were performed following institutional guidelines, in compliance with relevant laws. Data sharing mechanisms will ensure that the rights and privacy of individuals participating in research will be guaranteed. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Background: Right hemicolectomy is the standard treatment for right-sided colon cancer. There is variation in the technical aspects of performing right hemicolectomy as well as in short-term outcomes. It is therefore necessary to explore best clinical practice following right hemicolectomy in expert centres.Methods: This snapshot study of right hemicolectomy for colon cancer in China was a prospective, multicentre cohort study in which 52 tertiary hospitals participated. Eligible patients with stage I-III right-sided colon cancer who underwent elective right hemicolectomy were consecutively enrolled in all centres over 10 months. The primary endpoint was the incidence of postoperative 30-day anastomotic leak.Results: Of the 1854 patients, 89.9 per cent underwent laparoscopic surgery and 52.3 per cent underwent D3 lymph node dissection. The overall 30-day morbidity and mortality were 11.7 and 0.2 per cent, respectively. The 30-day anastomotic leak rate was 1.4 per cent. In multivariate analysis, ASA grade > II (P < 0.001), intraoperative blood loss > 50 ml (P = 0.044) and D3 lymph node dissection (P = 0.008) were identified as independent risk factors for postoperative morbidity. Extracorporeal side-to-side anastomosis (P = 0.031), intraoperative blood loss > 50 ml (P = 0.004) and neoadjuvant chemotherapy (P = 0.004) were identified as independent risk factors for anastomotic leak.Conclusion: In high-volume expert centres in China, laparoscopic resection with D3 lymph node dissection was performed in most patients with right-sided colon cancer, and overall postoperative morbidity and mortality was low. Further studies are needed to explore the optimal technique for right hemicolectomy in order to improve outcomes further.

BACKGROUND:Venous thromboembolism (VTE) is a common and serious complication after colorectal cancer (CRC) surgery. Few large-sample studies have reported VTE incidence and management status after CRC surgery in China. This study aimed to investigate the incidence and prevention of VTE in Chinese patients after CRC surgery, identify risk factors for developing VTE, and construct a new scoring system for clinical decision-making and care planning. METHODS:Participants were recruited from 46 centers in 17 provinces in China. Patients were followed up for 1 month postoperatively. The study period was from May 2021 to May 2022. The Caprini score risk stratification and VTE prevention and incidence were recorded. The predictors of the occurrence of VTE after surgery were identified by multivariate logistic regression analysis, and a prediction model (CRC-VTE score) was developed. RESULTS:A total of 1836 patients were analyzed. The postoperative Caprini scores ranged from 1 to 16 points, with a median of 6 points. Of these, 10.1% were classified as low risk (0-2 points), 7.4% as moderate risk (3-4 points), and 82.5% as high risk (≥5 points). Among these patients, 1210 (65.9%) received pharmacological prophylaxis, and 1061 (57.8%) received mechanical prophylaxis. The incidence of short-term VTE events after CRC surgery was 11.2% (95% CI 9.8-12.7), including deep venous thrombosis (DVT) (11.0%, 95% CI 9.6-12.5) and pulmonary embolism (PE) (0.2%, 95% CI 0-0.5). Multifactorial analysis showed that age (≥70 years), history of varicose veins in the lower extremities, cardiac insufficiency, female sex, preoperative bowel obstruction, preoperative bloody/tarry stool, and anesthesia time at least 180 min were independent risk factors for postoperative VTE. The CRC-VTE model was developed from these seven factors and had good VTE predictive performance ( C -statistic 0.72, 95% CI 0.68-0.76). CONCLUSIONS:This study provided a national perspective on the incidence and prevention of VTE after CRC surgery in China. The study offers guidance for VTE prevention in patients after CRC surgery. A practical CRC-VTE risk predictive model was proposed.

Background:Diversion colitis (DC) is nonspecific inflammation of the distal intestinal mucosa following disruption of colonic continuity with colonic dysfunction. The colonscopic score is a good tool for differentiating the severity of patients with DC. At present, no studies have analyzed the pathogenesis of DC from the perspective of the diversity and and differences of intestinal flora. Methods:Retrospective study: Clinical information were collected from patients with low rectal cancer admitted to the Department of Anorectal Surgery, Changzheng Hospital, from April 2017 to April 2019. These patients underwent laparoscopic low anterior resection (LAR) combined with terminal ileum enterostomy (dual-chamber). We used chi-square test to comparethe clinical baseline information, clinical symptoms, and colonscopic characteristics between different severity of DC. Propsective oberservational study: We recruited 40 patients with laparoscopic anterior low resection combined with terminal ileum enterostomy and they were further classified into mild group and severe group according to the scores of colonscopic examinations for DC. 16s-rDNA sequencing was carried out to analyze the diversity and and differences of intestinal flora in the intestinal lavage fluid of the two groups. Results:In retrospective study, we found that age, BMI, history of diabetes, and symptoms associated with the stoma state were the independent risk factors that affect DC severity (P<0.05). Meanwhile, age, BMI, history of diabetes and colonscopic score were found to be independent risk factors affecting the severity of diarrhea after ileostomy closure surgery(P<0.05), which was consistent with our results of differentiating the severity of DC under endoscopy; In propsective oberservational study, 40 patients with low rectal cancer recruited by sample size calculation, 23 were in the mild group and 17 in the severe group. The results of 16s-rDNA sequencing showed that intestinal flora with high enrichment values primarily consisted of Bifidobacteriales and Prevotella in mild group, whereas that in the severe group consisted of Providencia and Dorea. The functional predictions on such two types of intestinal flora were mainly focused on lipid synthesis, glycan synthesis, metabolism, and amino acid metabolism pathways. Conclusion:After ileostomy closure surgery, a series of severe clinical symptoms might appear in DC patients. There are significant differences in local and systemic inflammatory responses, composition of intestinal flora between DC patients with different colonscopic scores, which provide a basis for the clinical interventional treatment for DC in patients with permanent stoma.

BACKGROUND & AIMS:Aberrant epigenetic events mediated by histone methyltransferases and demethylases contribute to malignant progression of colorectal cancer (CRC). However, the role of the histone demethylase ubiquitously transcribed tetratricopeptide repeat on chromosome X (UTX) in CRC remains poorly understood.METHODS:UTX conditional knockout mice and UTX-silenced MC38 cells were used to investigate UTX function in tumorigenesis and development of CRC. We performed time of flight mass cytometry to clarify the functional role of UTX in remodeling immune microenvironment of CRC. To investigate metabolic interaction between myeloid-derived suppressor cells (MDSCs) and CRC, we analyzed metabolomics data to identify metabolites secreted by UTX-deficient cancer cells and taken up by MDSCs.RESULTS:We unraveled a tyrosine-mediated metabolic symbiosis between MDSC and UTX-deficient CRC. Loss of UTX in CRC resulted in methylation of phenylalanine hydroxylase, preventing its degradation and subsequently increasing tyrosine synthesis and secretion. Tyrosine taken up by MDSCs was metabolized to homogentisic acid by hydroxyphenylpyruvate dioxygenase. Homogentisic acid modified protein inhibitor of activated STAT3 via carbonylation of Cys 176, and relieved the inhibitory effect of protein inhibitor of activated STAT3 on signal transducer and activator of transcription 5 transcriptional activity. This in turn, promoted MDSC survival and accumulation, enabling CRC cells to acquire invasive and metastatic traits.CONCLUSIONS:Collectively, these findings highlight hydroxyphenylpyruvate dioxygenase as a metabolic checkpoint to restrict immunosuppressive MDSCs and to counteract malignant progression of UTX-deficient CRC.

Objective:To analyze the predictive value of tumor budding grade on the risk of lymph node metastasis and its correlation with prognosis in patients with colorectal cancer(CRC).Methods:A total of 212 CRC patients who underwent laparotomy or laparoscopic surgery in our hospital from April 2012 to December 2019 were enrolled. The predictive efficacy of tumor budding grade (TBG) for the risk of lymph node metastasis was analyzed with receiver operating characteristic, and the cutoff value was determined. The correlation between TBG and prognosis was analyzed with Kaplan-Meier survival curve. The risk factors of lymph node metastasis and affecting factors of overall survival (OS) were analyzed with Cox model. Results:Tumor budding was present in 140 of 212 CRC patients, accounting for 66.04%, and tumor budding had a high power to predict the risk of lymph node metastasis, with an area under the cure of 0.757. The number of budding 4 was selected as the cutoff value, when tumor budding predicted lymph node metastasis with a sensitivity of 0.640 and a specificity of 0.780. In patients with high tumor budding≥4, the lymph node metastasis rate was significantly higher than that in patients with low budding group( P<0.05), and the survival time was shorter than that in the low budding group( P<0.05), and tumor budding≥4 was an independent risk factor for the development of lymph node metastasis and affecting factors of OS( P<0.05). Conclusion:TBG is a useful indicator for predicting the risk of lymph node metastasis in CRC patients and is closely related to prognosis, which can provide a reference for treatment selection and prognosis of CRC.

Main point:Our retrospective analysis of a large number of cases found in patients with primary colorectal cancer (CRC) carrying positive HBsAg inhibited the occurrence of synchronous liver metastases (SLM). However, liver cirrhosis caused by non-HBV factors promoted the occurrence of SLM.Objectives:This study aimed to investigate the effect of HBV on the occurrence of synchronous liver metastases (SLM) of colorectal cancer (CRC).Methods:Univariate and multivariate analyses were used to analyze the influence of clinical parameters on the occurrence of SLM.Results:A total of 6, 020 patients with primary CRC were included in our study, of which 449 patients carrying HBsAg(+) accounted for 7.46%. 44 cases of SLM occurred in the HBsAg(+) group, accounting for 9.80%, which was much lower than 13.6% (758/5571) in the HBsAg(-) group (X=5.214, P=0.022). Among CRC patients with HBsAg(-), the incidence of SLM was 24.9% and 14.9% in the group with high APRI and FIB-4 levels, respectively, which were significantly higher than that in the compared groups (12.3% and 12.5%, all P<0.05). Compared with the control group, female patients, late-onset patients, and HBV-infective patients had lower risks of SLM (HR=0.737, 95%CI: 0.614-0.883, P<0.001; HR=0.752, 95%CI: 0.603-0.943, P=0.013; HR=0.682, 95%CI: 0.473-0.961, P=0.034).Conclusions:The carriage of HBsAg(+) status inhibited the occurrence of SLM from CRC. HBV-causing liver cirrhosis did not further influence the occurrence of SLM, whereas non-HBV-factor cirrhosis promoted the occurrence of SLM. Nevertheless, this still required prospective data validation.

AbstractBackground and AimsThe annual incidence of early‐onset colorectal cancer (EOCRC) is increasing at an alarming rate. The prognosis of EOCRC remains controversial, and whether the early onset is a risk factor for colorectal cancer remains unclear.MethodsWe searched four electronic bibliographic databases from database inception to April 25, 2022 for studies that included both early‐ and later‐onset patients and performed a prognostic analysis. Random‐effects models were used to summarize the prognostic information extracted by the investigators, including overall survival (OS), cancer‐special survival (CSS), and disease‐free survival (DFS). Network meta‐analysis (NMA) was used to compare patients' long‐term prognoses in different age subgroups.ResultsAfter 694 reports were screened, 13 studies were included in the final analysis, with a total of 448,781 CRC cases. In the meta‐analysis of the 5‐year OS, EOCRC had a better prognosis compared to LOCRC (hazard ratio [HR] 0.87, 95% confidence interval [CI], 0.74–0.99; relative risk [RR] 0.83, 95% CI, 0.78–0.89). No difference in prognosis was found between the two groups in terms of 5‐year CSS (RR 0.99, 95% CI, 0.93–1.05), 5‐year DFS (RR 0.90, 95% CI, 0.74–1.09), and short‐term OS. In the NMA, patients aged <30 years had the worst outcome (surface under the cumulative ranking curve [SUCRA], 15.8%) in 5‐year OS; consistent results were observed in the analysis of 5‐year CSS (<30 years, SUCRA 4.5%), but the difference was not statistically significant.ConclusionAlthough patients with early‐onset CRC had better OS than those with later‐onset CRC, there was no difference in the CSS. Meanwhile, the trend for survival was worse in younger patients, especially in those ages 18–29 years. Thus, more attention should be paid to early diagnosis and treatment of EOCRC.Systematic Review and Meta‐Analysis RegistrationThe systematic review and Meta‐analysis protocol was registered with PROSPERO (registration number CRD42022334697).

Objectives: Cancer morbidity and mortality can be reduced if the cancer is detected early. Cell-free DNA (cfDNA) fragmentomics emerged as a novel epigenetic biomarker for early cancer detection, however, it is still at its infancy and requires technical improvement. We sought to apply a single-strand DNA sequencing technology, for measuring genetic and fragmentomic features of cfDNA and evaluate the performance in detecting multiple cancers.Methods: Blood samples of 364 patients from six cancer types (colorectal, esophageal, gastric, liver, lung, and ovarian cancers) and 675 healthy individuals were included in this study. Circulating tumor DNA mutations, cfDNA fragmentomic features and a set of protein biomarkers were assayed. Sensitivity and specificity were reported by cancer types and stages.Results: Circular Ligation Amplification and sequencing (CLAmp-seq), a single-strand DNA sequencing technology, yielded a population of ultra-short fragments (<100 bp) than double-strand DNA preparation protocols and reveals a more significant size difference between cancer and healthy cfDNA fragments (25.84 bp vs. 16.05 bp). Analysis of the subnucleosomal peaks in ultra-short cfDNA fragments indicates that these peaks are regulatory element "footprints" and correlates with gene expression and cancer stages. At 98 % specificity, a prediction model using ctDNA mutations alone showed an overall sensitivity of 46 %; sensitivity reaches 60 % when protein is added, sensitivity further increases to 66 % when fragmentomics is also integrated. More improvements observed for samples representing earlier cancer stages than later ones.Conclusions: These results suggest synergistic properties of protein, genetic and fragmentomics features in the identification of early-stage cancers.

BACKGROUND:We aimed to evaluate whether extracellular vesicles (EV)-derived microRNAs (miRNAs) can be used as biomarkers for advanced adenoma (AA) and colorectal cancer (CRC).METHODS:We detected the changes in the plasma EV-delivered miRNA profiles in healthy donor (HD), AA patient, and I-II stage CRC patient groups using miRNA deep sequencing assay. We performed the TaqMan miRNA assay using 173 plasma samples (two independent cohorts) from HDs, AA patients, and CRC patients to identify the candidate miRNA(s). The accuracy of candidate miRNA(s) in diagnosing AA and CRC was determined using the area under the receiver-operating characteristic curve (AUC) values. Logistic regression analysis was performed to evaluate the association of candidate miRNA(s) as an independent factor for the diagnosis of AA and CRC. The role of candidate miRNA(s) in the malignant progression of CRC was explored using functional assays.RESULTS:We screened and identified four prospective EV-delivered miRNAs, including miR-185-5p, which were significantly upregulated or downregulated in AA vs. HD and CRC vs. AA groups. In two independent cohorts, miR-185-5p was the best potential biomarker with the AUCs of 0.737 (Cohort I) and 0.720 (Cohort II) for AA vs. HD diagnosis, 0.887 (Cohort I) and 0.803 (Cohort II) for CRC vs. HD diagnosis, and 0.700 (Cohort I) and 0.631 (Cohort II) for CRC vs. AA diagnosis. Finally, we demonstrated that the upregulated expression of miR-185-5p promoted the malignant progression of CRC.CONCLUSION:EV-delivered miR-185-5p in the plasma of patients is a promising diagnostic biomarker for colorectal AA and CRC. Trial registration The study protocol was approved by the Ethics Committee of Changzheng Hospital, Naval Medical University, China (Ethics No. 2022SL005, Registration No. of China Clinical Trial Registration Center: ChiCTR220061592).