Background: A substantial proportion of patients with chronic migraine (CM) with previous failures among oral standard-of-care migraine medications do not respond to monoclonal antibodies targeting the calcitonine gene related peptide pathway (CGRP-mAbs), leaving limited evidence-based options for subsequent preventive strategies. The present multicentre real-world study evaluated the effectiveness of onabotulinumtoxin-A (BoNT-A) in CM patients with previous CGRP-mAb failure and multiple prior oral preventive failures. Methods: This prospective, observational, non-randomized multicentre study enrolled patients with CM who had failed ≥3 classes of oral preventive treatments and ≥1 CGRP-mAb due to lack of efficacy or intolerance. Participants received BoNT-A according to the PREEMPT “follow-the-pain” paradigm every three months and were followed for 6 months. Co-primary outcomes were change in monthly headache days (MHD) after three and six months and ≥50% MHD responder rates at both time points. Results: Fifty-three patients were analysed (85% female, aged 48.5 ± 15.2 years, range 20–73). Compared to the baseline, at the third month and sixth month, MHD decreased from 22.83 (SD 6.74) to 15.38 (SD 7.91; p < 0.001) and 14.55 (SD 9.35; p < 0.001), respectively. The percentages of participants achieving the response status in MMD at the third month and sixth month were 30% and 45%, respectively. In the third and sixth months, 22 patients (41.5%) and 27 patients (50.9%), respectively, converted from chronic to episodic migraine, while the prevalence of medication-overuse headache decreased from 81.1% of patients at baseline to 45.3% and 43.4%, respectively. Migraine-related impact and disability scores improved over follow-up, alongside improvements in anxiety and depressive symptoms and in migraine-specific quality of life. Conclusions: The present findings support the use of BoNT-A in difficult-to-treat patients with CM following CGRP-mAb failure and provide further evidence that its therapeutic effects may rely on mechanisms that are at least partially distinct from, and potentially complementary to, those of CGRP-targeted therapies.

10503 Background: Emerging evidence suggests that BRCA -altered prostate cancer (PC) is not a unique molecular subtype. However, the prognostic and therapeutic relevance of specific pathogenic/likely pathogenic variant (PV) in metastatic PC (mPC) remains poorly defined. We investigated the impact of BRCA2 PV type and position on clinical outcomes across across different metastatic settings. Methods: This international, hospital-based cohort study (Jan 2020–Apr 2025) included mPC patients (pts) across 29 centers who underwent germline, somatic, and/or ctDNA BRCA testing. Analysis included three settings: 1) mHSPC (ADT+docetaxel vs. ADT+ARPi); 2) mCRPC (ARPi vs. taxanes); 3) mCRPC treated with PARP inhibitors (PARPi). Outcomes [Time on Treatment (ToT); Overall Survival (OS)] were analyzed by PV type (frameshift, missense, nonsense, splicing; indels, SNV, CNV) and position: 1) Functional Domains (FDs) (RAD51-BD [AA 900-2000] vs. DBD [AA 2459-3190] vs. Others); 2) The recently identified Prostate Cancer Cluster Regions (PCCR) (c.756-c.1000 and 3' of c.7914 vs. Others). Results: Of 2.119 pts included, 401 harbored Homologous Recombination Repair PVs. In the cohort of 1.411 mHSPC pts, BRCA2 -mutated (n = 201) showed significantly shorter OS vs. wild-type (mOS 63 vs 76 months; HR 1.2, p = 0.02), regardless of first-line therapy. Contrary to previous reports, BRCA2 -mutated mHSPC pts had superior ToT from ADT+ARPi vs. ADT+docetaxel (55 vs 15 mos; HR 3.5, p < 0.001). Within the BRCA2 subgroup, PV location was highly prognostic for OS. In mHSPC, PCCR-outside variants (c.756-c.1000/3'of c.7914) and non-FD variants (RAD51-BD/DBD-outside) were associated with shorter OS (PCCR: 57 vs 97 mos, HR 4.0, p = 0.006; FD: 47 vs 88 mos, HR 3.0, p < 0.001). Similar prognostic impacts were confirmed in 684 mCRPC pts (PCCR: 78.0 vs 38.0 mos, HR 3.3, p = 0.01; FD: 64.0 vs 34.0 mos, HR 2.7; p = 0.009). Among 201 pts treated with olaparib, those with RAD51-BD PVs achieved significantly longer ToT (20.0 vs 7.0 mos; p = 0.01) and longer OS. Furthermore, frameshift deletions were associated with shorter OS compared to other PV types (15.9 vs 26.0 mos; p = 0.04). Conclusions: This is the largest longitudinal study to demonstrate that BRCA2 PV type and location are critical determinants of survival and treatment response in mPC. Our findings identify a "high-risk" molecular subgroup (PCCR and RAD51-BD/DBD-outside and frameshift deletions) with significantly poorer outcomes. These results provide a rationale for refined risk-stratification and personalized treatment selection, including early PARPi integration, in BRCA2 -mutated patients.

This retrospective study assessed the impact of SARS-CoV-2 infection on patients with interstitial lung disease (ILD) at two tertiary centers in Southern Italy between January 2022 and December 2023. The cohort included 282 ILD patients (mean age 69.6 years; 54.9% male), with common diagnoses such as idiopathic pulmonary fibrosis (33.3%) and connective tissue disease-associated ILD (18.7%). SARS-CoV-2 infection occurred in 130 patients (46%), mostly with mild or asymptomatic cases. Pneumonia developed in 18 cases, with 72.2% requiring hospitalization and 5 COVID-19-related deaths. Patients with pneumonia had higher rates of ILD progression (27.7%) and incidental post-infection ILD diagnoses (22.2%) than those with mild infection. Vaccination rates were high, correlating with favorable outcomes in most cases. Importantly, pneumonia cases were often associated with incomplete vaccination or complex comorbidities. Differentiating COVID-19-related lung changes from ILD progression proved challenging, highlighting the importance of specialized radiologic assessment. Excluding COVID-related deaths, mortality rates were similar regardless of infection status, suggesting a degree of resilience among ILD patients. The study concludes that with high vaccine coverage and careful follow-up, most ILD patients had stable outcomes after SARS-CoV-2 infection. However, pneumonia remains a risk factor for adverse outcomes, underscoring the need for long-term, specialized ILD care.

Abstract Myelodysplastic syndromes (MDS) are clinically and biologically diverse disorders, emphasizing the need for personalized treatment approaches. The International Working Group for Prognostication of MDS (IWG_PM) recently introduced a molecular classification, referred to as the MDS taxonomy, that categorizes patients into 16 subgroups based on 21 gene mutations, 6 cytogenetic abnormalities, and loss of heterozygosity (LOH) at TP53 and TET2 loci. This study sought to validate and enhance the clinical relevance of the MDS taxonomy by analyzing a large retrospective cohort (n = 5136) and transcriptomic data from a prospective cohort (n = 477). The taxonomy successfully identified subgroups with distinct clinical characteristics and disease progression patterns. However, incorporating gene interactions from taxonomy subgroups did not improve the prognostic performance of the Molecular International Prognostic Scoring System (IPSS‐M). We further assessed whether the taxonomy could guide management in patients receiving disease‐modifying therapies. Except for the “TP53‐complex” subgroup, taxonomy classifications were not predictive of hypomethylating agent response or transplant outcomes. Nonetheless, they correlated with overall survival, suggesting that while both IPSS‐M and the taxonomy capture disease biology, other non‐genetic factors may influence treatment response. RNA sequencing confirmed the biological distinctiveness of the taxonomy groups. Transcriptomic profiling of CD34+ bone marrow cells revealed unique, homogeneous gene expression patterns, particularly within the AML‐like, biTET2, SF3B1, and TP53‐complex subgroups. Further integration of multi‐omics data may refine MDS classification, improving clinical decision‐making and guiding the development of targeted therapies.

Background Chronic low-grade inflammation is increasingly recognized as a key determinant of major adverse cardiovascular events (MACE), beyond traditional risk factors. However, the association of inflammatory biomarkers with hypertension-mediated organ damage (HMOD) and long-term MACE in subjects without established CV diseases remains incompletely defined. Methods We assessed a panel of inflammatory biomarkers, including high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), interleukin-18 (IL-18), osteoprotegerin, calprotectin, and tumor necrosis factor-α (TNF-α), in subjects without established CV diseases. Subclinical HMOD was evaluated at the vascular (pulse wave velocity, carotid intima–media thickness and carotid plaque), cardiac (left ventricular mass and function), and renal (estimated glomerular filtration rate) levels. Participants were prospectively followed for CV events and mortality. Results Among 804 participants (mean age 51.1 ± 13.0 years; 62.4% men), at multivariable analyses, we found a significant association between MACE and IL-6 (HR 1.519, 95% CI 1.086;2.124, p=0.015), hs-CRP (1.314, 1.035;1.668, p=0.025) and calprotectin (4.048, 1.058;15.493, p=0.041). Furthermore, a positive significant association was found for hs-CRP and calprotectin and carotid plaque and TNF-α and PWV (both continuous and categorical) while a negative association was found between IL-18 and ejection fraction. Conclusions In subjects without established CV diseases, IL-6, hs-CRP and calprotectin were independently associated with long-term MACE. Furthermore, some association were founded with HMOD suggesting a potential role of inflammation in their pathogenesis.

Background Diagnostic and Therapeutic Care Pathways (DTCPs) are clinical governance tools aimed at managing the care of specific patient populations through the coordinated application of standardized, evidence-based interventions by multidisciplinary teams. Their primary goal is to ensure equitable, timely, and cost-effective access to high-quality care. Materials and method A panel of recognized opinion leaders, endorsed by the Italian Association of Medical Oncology (AIOM), was convened to develop a consensus document defining the role of the medical oncologist within Multidisciplinary Oncology Groups (MOGs) and DTCPs. Employing the RAND/UCLA Appropriateness Method in its “consensus conference” format, the panel evaluated a series of statements derived from a review of the scientific literature and expert-generated Good Practice Points (GPPs). These statements addressed five key areas.1.Skills of the Oncologist in the diagnostic phase2.Follow up3.Palliative care4.Management of the diagnostic and therapeutic care pathway of the oncological patient5.Medical therapy.To further support each topic, illustrative case studies were presented. Results A total of 21 articles met the inclusion criteria, yielding 88 evidence-based recommendations. Additionally, panel members contributed 9 further GPPs based on clinical expertise. Of the 97 total recommendations, 95 received a relevance score above 7, while 2 scored between 4 and 6.9; none scored below 4. Conclusions This consensus effort and the resulting document represent a comprehensive evaluation of the available evidence regarding the role of medical oncologists within MOGs and DTCPs. The objective is to propose standardized criteria for the optimal management of cancer patients (pts) across all phases of care from initial diagnosis and staging to treatment, follow-up, and end-of-life support.

Objectives The APC I1307K variant is a known moderate-risk allele for colorectal cancer (CRC), especially among Ashkenazi Jewish (AJ) individuals. However, its role in other cancers, particularly in male breast cancer (MBC), remains unclear. This study aimed to evaluate whether APC I1307K contributes to MBC risk in the Italian (non-AJ) population.Methods A multicenter case-control study was conducted involving 1028 MBC cases and 2,126 geographically matched healthy male controls. Genotyping was performed via Next Generation Sequencing or TaqMan assays. Associations between APC I1307K and MBC risk were analyzed using logistic regression models, including multivariate adjustments for age, enrollment center, and BRCA1/2 status.Results The APC I1307K variant was detected in 4 MBC cases (0.4 %) and 5 controls (0.2 %). No statistically significant association with MBC risk was observed (multivariate odds ratio [OR]=3.7, 95 % CI: 0.8-17.0, p=0.09). Clinical-pathologic comparisons revealed no distinguishing features among variant carriers. None of the carriers harbored BRCA1/2 pathogenic variants (PVs) or had personal histories of CRC or familial adenomatous polyposis.Conclusions These findings suggest that APC I1307K does not confer a significant risk for MBC in the Italian population.

e17050 Background: 177Lu-PSMA-617 radioligand therapy (RLT) has demonstrated efficacy in metastatic castration-resistant prostate cancer (mCRPC), although clinical benefit remains heterogeneous. We hypothesize that loss of PTEN leads to the functional impairment of FANCD2 -mediated high-fidelity DNA damage repair (DDR). In this deficient landscape, mCRPC cells become hyper-dependent on POLQ , which governs the error-prone Microhomology-Mediated End Joining (MMEJ) pathway. This "pathway switching" may sensitize mCRPC cells to RLT-induced DDR. We investigated whether baseline clinical factors and cell-free nucleic acid (cfNA) molecular profiles could refine patient selection and predict biochemical response. Methods: Consecutive mCRPC, PSMA-positive, patients treated with 177Lu-PSMA-617 every 6 weeks, from May to October 2025, were included. Baseline clinical data [Body Mass Index (BMI) Neutrophil-to-Lymphocyte Ratio (NLR), NRS pain scale, and time to CRPC)] were collected. Liquid biopsies were obtained after 3 cycles. Gene expression of PTEN , POLQ , and FANCD2 was quantified via ddPCR from plasma-derived cfNA. Biochemical response (BR) was defined as a ≥50% PSA decline. Results: Among 31 evaluable patients, 16 were responders (R) and 15 non-responders (NR). R showed lower baseline BMI (25.2 vs 26.8 months), NLR (2.6 vs 3.5), and NRS (5 vs 7), with a significantly longer time to CRPC (23 vs 13). Liquid biopsy showed lower median cfDNA levels in R (0.35 vs 1.57 ng/µL). Notably, a distinct DDR signature was associated with BR: R exhibited significantly lower median expression of PTEN (11.74 vs 14.83; p = 0.005) and FANCD2 (2.99 vs 13.65; p = 0.03), while POLQ expression was markedly elevated or uniquely detectable in R (range 0–27.23) compared to NR (0–0.83). This molecular signature suggests that the downregulation of PTEN and FANCD2 induces a homologous recombination deficiency state, providing a compensatory activation of the error-prone POLQ -mediated MMEJ pathway. Conclusions: A cfNA profile characterized by reduced FANCD2/PTEN and increased POLQ expression identifies a "synthetic vulnerability" signature of high genomic instability where the loss of high-fidelity repair mechanisms renders the tumor highly susceptible to RLT. These findings support futher study of PTEN-FANCD2-POLQ axis as predictive biomarker in larger cohorts, and the development of combination strategies targeting the DDR axis.

Lung Cancer (LC) remains one of the leading causes of cancer death worldwide. Molecular profiling of mandatory testing biomarkers significantly meliorates clinical outcome of advanced stage LC patients while intercepting early-stage lesions represents an unmet need. Recent advances in treatments for early-stage LC patients lay the basis for accelerating molecular analysis of actionable drivers before metastatic stages. In this scenario, liquid biopsy emerged as an innovative tool to guide clinical decision-making processes of early-stage LC patients. In addition, digital pathology is pioneering an integrative path to optimize morpho-molecular analysis. Undoubtedly, the lack of standardized preanalytical procedures significantly reduces the clinical availability of these approaches. This review aims to explore critical gaps affecting the clinical implementation of these approaches able to improve the clinical outcome of early-stage LC patients.

Endometrial cancer (EC) is a gynecologic neoplasm with a constantly increasing incidence, especially in high-income countries. Obesity, diabetes, old age, and genetic predisposition account for the main risk factors. Genetic knowledge has steadily increased from the historical clinicopathological classification into two pathogenic types to the molecular subdivision into four groups, highlighting that EC is not a single entity, but rather the sum of different molecular diseases with different prognoses. About 5%–10% of ECs show a hereditary basis attributable to germline pathogenic variants (PVs) in different susceptibility genes, including MMR ( MLH1 , MSH2 , MSH6 , and PMS2 ), POLE/POLD1 , PTEN , BRCA1/2 , MUTYH , NTHL1 , STK11 , which confer an increased risk of developing an early onset EC. Lynch syndrome is the main inherited disorder predisposing to EC, followed by other hereditary conditions, including Cowden syndrome, polymerase proof-reading associated polyposis, NTHL1 -associated syndrome, hereditary breast and ovarian cancer syndrome, MUTYH -associated polyposis, and Peutz-Jeghers syndrome. Genetics has been shown to affect several aspects of disease, including carcinogenesis, onset age, clinicopathological features, prognosis, and therapy response. In this review, we will investigate the impact of germline PVs in different genes on genetic susceptibility to the development of inherited EC, discussing the potential cancer risk in mutation carriers as well as prognostic implications and current therapeutic approaches, also evaluating the possibility of carrying out a more extensive routine genetic analysis for EC women, in order to increase the diagnostic power, improve prevention and surveillance strategies in genetically predisposed subjects, and implement tailored therapies.

Lung Cancer (LC) continues to be the biggest cause of cancer-related deaths around the world, mostly because of delayed diagnosis. Even if tissue biopsies and circulating tumor DNA (ctDNA) tests have revolutionized clinical management of LC patients, their effectiveness is restricted in settings with lower tumor burden, molecular heterogeneity, and bias in sampling approaches. In this scenario, the epigenetic profiling of cell-free DNA (cfDNA) stands out as a promising, less invasive approach, accurately detect cancer traces. Evidence from stage I-II disease and CT-detected pulmonary nodules supports the diagnostic potential of cfDNA methylation, although further validation in prospective screening cohorts remains necessary. Beyond genomic alterations, cfDNA epigenetic changes, including DNA methylation, chromatin organization, nucleosome positioning, and fragmentation patterns, reflect multi-dimensional complexity of tumor biology. These properties convey both the functional status and the origin of the circulating DNA fragments, accelerating for tumor integrating genomic analysis. Within this group, DNA methylation is the biologically robust and clinically well-established epigenetic marker, as alterations in methylation linked to cancer often occur in the early stages of tumorigenesis and are commonly found across different cancer cell types. Here, we explored the biological and clinical relevance of the epigenetic landscape of cfDNA in LC patients, particularly focusing on DNA methylation-based biomarkers and their evolving applications towards early diagnosis and post-surgical monitoring of minimal residual disease (MRD). We aimed to comprehensively overview analytical approaches for cfDNA methylation analysis, including targeted and genome-wide profiling strategies, and discuss their integration with machine learning (ML) and multi-omics frameworks in order to improve diagnostic performance and clinical applicability in LC management.

Lung Cancer (LC) remains the leading cause of cancer-related mortality. While Tissue Biopsy (TB) remains the gold standard for molecular profiling, its invasiveness and inability to provide real-time monitoring have led to the adoption of Liquid Biopsy (LB) as a minimally invasive alternative. By analyzing different circulating analytes such as cell-free DNA (cfDNA), circulating tumor DNA (ctDNA), Circulating Tumor Cells (CTCs), Extracellular Vesicles (EVs), and Tumor-Educated Platelets (TEPs), LB offers a dynamic approach to assessing tumor heterogeneity, Minimal Residual Disease (MRD), and treatment resistance. Recent clinical trials have underscored their role in guiding therapy decisions and monitoring treatment response. In early-stage disease, several Randomized Clinical Trials (RCTs) have shown that ctDNA clearance predicts survival benefits in patients receiving neoadjuvant or perioperative Immune Checkpoint Inhibitors (ICIs). Additionally, adjuvant RCTs have confirmed the ctDNA prognostic role in post-surgical relapse risk assessment. Despite its transformative potential, challenges such as assay standardization, sensitivity limitations in early-stage disease, and regulatory barriers remain. As ongoing research continues to validate its clinical utility, LB is poised to become an indispensable tool in the precision management of LC.

Background Effective communication between clinicians and patients is vital in hematology for personalized treatment. However, traditional practice is time-consuming and prioritizes clinical data over patient-reported outcomes (PROs), limiting direct patient interaction. Existing speech-to-text AI-based solutions promise to solve these issues but still present significant barriers: these solutions are often costly due to reliance on third-party models, lack of specialization on specific medical domains, are not easy to install on-premise and integrated with hospital systems, raising privacy and compliance issues. To overcome these limitations, we have developed a hematology-tailored platform called Ambient AI. This work presents results of an ongoing prospective study, currently under validation with real patients. The aim is to assess the platform's ability to support medical documentation and optimize patient enrollment and management in clinical trials within a real-world hematology setting. Methods Ambient AI records, transcribes in real-time clinician-patient conversations and extracts clinical information while filtering out non-essential details. It leverages four key modules: real-time conversation transcription, an AI-powered system for generating medical reports, a clinical data extraction module for research dataset and a dedicated component for optimizing patient management in clinical trials. The platform generates structured medical reports for physician review, modification, and approval. Once validated, reports are saved, and intermediate data is deleted to ensure privacy and compliance. The platform integrates local AI models using speech-to-text technology and open-source large language models (LLM) fine-tuned for hematology. The validation framework assesses: 1) technological performance, using metrics as Jaccard Similarity (JS) for text accuracy and Word Mover Distance (WMD) for contextual understanding, and an LLM as a judge for expert assessment; 2) clinical fidelity and physician satisfaction; and 3) patient experience and engagement measured through surveys. Results A preliminary analysis of 100 simulated reports, using an open-source Gemma3 12B quantized model, showed that AI-assisted transcription improves documentation efficiency by reducing manual data entry. AI-generated reports had high clinical relevance, requiring minimal physician edits. Strong transcription accuracy (JS 0.85) and effective contextual interpretation (WMD 0.81) were observed. However, some medical terminology or sentences were not properly captured. To address this, the model was fine-tuned with domain knowledge, and a sample of 30 reports from the initial 100 was used for performance assessment. Results showed improved metrics (JS 0.88, WMD 0.73). For a final assessment, a team of five physicians was presented with transcribed text and two reports, and tasked with selecting the more appropriate. The fine-tuned model's report was preferred on average in 28 out of 30 instances (93.3%). The Ambient AI platform validation is currently undergoing at Humanitas Research Hospital, Italy, involving 1,000 patients. Early results indicate increased physician satisfaction, improved workflow efficiency, and enhanced patient engagement. Moreover, we developed an AI tool leveraging an LLM for automatic data extraction from medical records, enabling structured dataset generation for research. To optimize clinical trial management we implemented a module that: 1) automatically scans medical records to identify eligible patients for ongoing clinical trials; 2) reports and grades adverse events during trial visits according to international guidelines; 3) suggests potential drug modification schedules based on study protocols; and 4) generates automated patient visit reports for Clinical Research Organizations (CROs), reducing the need for in-person monitoring visits. Conclusion The Ambient AI platform aims to improve hematology workflows by enhancing communication, streamlining documentation, and integrating PROs into clinical practice. This fosters better doctor-patient interaction, a key aspect of patient-centered care, providing support and empowering individuals. Preliminary findings show its effectiveness in accurate data collection, with ongoing validation. The technology may also facilitate patient selection and management in clinical trials, supporting precision medicine.

Introduction:Evaluation of every breast cancer (BC) patient by multidisciplinary team and application of guidelines are very important to ensure the best treatment and achieve the best outcome. Methods:The multicenter prospective observational BRIDE study enrolled, from 01/2018 to 02/2021, 1633 BC patients from 19 Italian cancer centers. To evaluate the clinical and biopathological characteristics of BC patients with pathological stage I-II-III treated with surgery followed by adjuvant systemic therapy, type of therapies delivered, outcome and adherence to guidelines, an analysis of 1123 patients out of 1633 patients enrolled in BRIDE study was conducted. Results:The 1123 patients with stage I-II-III BC had a median age of 61.2 years (Q1-Q3: 50.6-71.7); 70.2% were postmenopausal, 92.1% had ECOG PS 0, 68.4% pT1 disease, 70.7% pN0, 91.7% pathological stage I-II; 68.9% underwent conservative breast surgery and 79.8% sentinel lymph node biopsy alone. According to phenotypic subgroup, 80.6% of patients had a HER2-negative/HR-positive, 10.4% HER2-positive/HR-positive, 6.4% triple negative and 2.6% HER2-positive/HR-negative BC. In clinical practice, the phenotypic tumoral subgroup influenced oncologists in the choice of the type of adjuvant systemic therapy (p<0.0001) according to ESMO and AIOM Guidelines. Adjuvant radiotherapy was administered to 85.5% patients undergoing breast-conserving surgery. At the median follow up of 41.4 months (Q1: 35.3 months - Q3: 57.9 months), the DFS at 48 months was 92.8%, with different rates in the phenotypic subgroups. The adherence to AIOM Guidelines in clinical practice was ≥ 70% for the four evaluated quality indicators of treatment process. Discussion:In patients with pathological stage I-II-III BC, the phenotypic subgroup influenced the oncologists' decision on the choice of type of adjuvant systemic therapy, as also indicated by international and national guidelines. In our patients, the DFS rate at 24 and 48 months after surgery was 95.4% and 92.8% respectively. The adherence to the AIOM Guidelines in clinical practice was high but having both quality indicators (shared at international and national level) to evaluate the quality of care in BC and standardized threshold levels to evaluate adherence to guidelines is very important today because this type of evaluation will increase in the coming years.

BACKGROUND 20% of prostate cancer (PC) patients harbor germinal or somatic alterations in homologous recombination repair (HRR) genes, including BRCA1/2. BRCA mutations represent predictive biomarkers for treatment with polyadenosine diphosphate-ribose inhibitors (PARPi). Olaparib has shown efficacy in metastatic castration-resistant PC (mCRPC) and is currently approved in Italy for mCRPC with BRCA1/2 mutations. National and international guidelines strongly recommend BRCA testing in PC. However, genetic testing presents challenges in clinical practice that may limit access to PARPi. METHODS we conducted a survey directed towards members of the Italian Association of Medical Oncology to highlight the level of implementation of national recommendations and issues associated with genetic testing. Through an anonymous questionnaire, the survey collected clinical data of PC patients undergoing BRCA testing and the main difficulties to face in conducting the analysis. RESULTS The survey was completed by 108 participants (5% of AIOM members). 52.8% of respondents test BRCA in all metastatic PC patients. If tissue analysis is invalid, only 17% use liquid biopsy, and 15.7% always consider a re-biopsy of a metastatic lesion. A quarter of respondents have to outsource genetic testing to another center and 17.6% have a split process between different institutions. Long timelines, lack of a predefined procedure, and unavailability of liquid biopsy represent the main issues based on respondents' opinions. CONCLUSIONS BRCA testing in PC still presents several difficulties in clinical practice that can limit access to PARPi treatment. Better implementation of molecular testing to identify BRCA-mutated patients is crucial for tailored treatment in mCRPC.

Background: Older women represent a significant and increasing population of patients with breast cancer, accounting for over 40% of new cases of breast cancer. However, this growing subgroup of patients is still underrepresented in clinical trials, and treatment is usually selected based on limited data from retrospective subgroup analyses. However, the ESMO guidelines for metastatic breast cancer (mBC) suggest that the management decision should not be based on age alone. Nab-paclitaxel (nab-P) was associated with improved efficacy and a better safety profile than solvent-based taxanes without steroid or antihistamine premedication, making this treatment appealing to elderly patients. Patients and methods: This is an observational, retrospective, multicenter study, evaluating the safety and activity of nab-paclitaxel (nab-P) in elderly patients (≥65 years old) with HER2-negative mBC from 11 Sicilian oncology centers. The primary endpoint of the study was the safety nab-P in elderly mBC patients; secondary endpoints included the overall response rate (ORR), progression-free survival (PFS), and overall survival (OS). Results: We included 70 patients, and all were evaluable for safety and efficacy. All patients had previously been pretreated with taxane-based chemotherapy in a (neo)-adjuvant or metastatic setting. One third of the patients received nab-P as a fourth line therapy. Most of the patients were treated with nab-P at doses of 260 mg/m2 3-weekly (87.1%), and 12.9% received a nab-P dose of 125 mg/m2 weekly. Patients' characteristics included a median age of 67 years (range 65-83 years), a median ECOG PS of 1 (range 0-2), and the following intrinsic molecular subtypes: Luminal A (18.8%), Luminal B HER-2 negative (62.5%), and triple negative (18.8%). Nab-P was administered for a median of six cycles (range 1-21), with 35.5% of patients experiencing a dose reduction, and 11.5% treatment discontinuation due to toxicity. Adverse events were mainly G2-G3 and occurred mostly in patients treated with 3-weekly nab-P (85.7%). The ORR was 31.3% (CR in 6.3% and PR in 25% of pts) and the DCR was 70.4%. Median PFS was 6 months (95% CI, 2-38), and median OS was 40.5 months (95% CI, 7-255). Conclusions: Our real-life study showed that nab-P is an effective, well-tolerated regimen in elderly mBC patients, including taxane-pretreated patients, and can be safely administered in elderly mBC patients.

Myelodysplastic Syndromes (MDS) present an increased risk of progression to Acute Myeloid Leukemia (AML). The complex interactions between neoplastic clone, bone marrow (BM) microenvironment and immune cells during disease evolution remain poorly understood. We used multi-omics single-cell approach to define patterns of clonal expansion and microenvironment shifts associated with MDS disease progression. We analyzed paired BM samples at diagnosis and at time of AML transformation from 20 MDS patients who had not received disease-modifying treatments before progression. Single-cell analysis was performed by CITE-seq, integrating transcriptomic and protein expression data from hematopoietic stem and progenitor cells (HSPC), myeloid, T and NK cells, in combination with single-cell genotyping (TAPESTRI). To study longitudinal dynamics of cell states, we projected each cell into gene expression space and quantified the fold-enrichment of transcriptionally similar cells between diagnosis and AML by k-nearest neighbor analysis. Differential gene/protein expression analyses were performed by linear mixed-effects models accounting for inter-patient variability. We identified two evolution patterns in HSPC compartment. In 9 patients (pts), progression was marked by emergence of novel HSPC clusters with leukemic stem cell (LSC)-like phenotype (absent/minimally detectable at diagnosis), showing upregulation of LSC markers (CD99, CD44) and immune evasion proteins (CD47, CD276) and downregulation of TGF-β and interferon (INF) response programs. In the remaining pts, progression was associated with expansion of a multipotent progenitor (MPP)-like population (already present at diagnosis). MPP-like cells exhibited increased activity of proliferative and INF-related inflammatory pathways, as well as downregulation of HLA molecules, suggesting the involvement of distinct immune escape mechanisms. Patients with NPM1, RUNX1, or TP53 mutations were more likely to show emergence of LSC-like clusters, whereas MDS with spliceosome gene mutations had heterogeneous patterns of HSPC evolution. Notably, pts showing LSC-like cluster emergence progressed more rapidly to AML (p=0.01). Considering BM microenvironment, across all pts, disease progression was associated with increased inflammatory monocytes (CD14⁺ CD86⁺ and high expression of INF-related genes) and neutrophils, suggesting that mature myeloid cells contribute to shape a pro-inflammatory marrow niche. Longitudinal analysis of immune cell states in all pts revealed widespread remodeling from diagnosis to evolution: 1) NK cells reduced their cytotoxic activity (GZMK/B-, PRF1-) and upregulated pro-inflammatory programs (NF-kb, IFN-γ); 2) T-regs acquired a highly immunosuppressive phenotype, with increased ICOS expression, downregulation of BACH2, and a switch to CD45RO⁺; 3) CD4⁺ effector memory T cells showed lower cytotoxic potential reducing GZMB/GZMK expression. Notably, in a subset of pts, small populations of these dysfunctional immune subsets—particularly highly suppressive T-regs—were already detectable at diagnosis and were associated with a shorter time to progression (p = 0.02). When comparing immunological changes based on the type of HSPC expansion, pts with LSC-like cluster displayed a more exhausted immune microenvironment, characterized by reduced frequencies of naïve T cells and increased terminally differentiated effector memory T cells, potentially supporting the selective advantage of LSC-like clones. Conversely, pts with MPP-like expansion showed increased IFN signaling across multiple immune cell populations. TP53-mutated MDS exhibited a distinct inflammatory signature, independent of IFN signaling, in both mature myeloid cells and T-regs. These myeloid cells showed HLA downregulation, while T-regs were enriched for a CD161⁺ subset with enhanced suppressive function—indicating a specific pattern of immune dysregulation driven by myeloid inflammation and impaired antigen presentation. MDS follow distinct evolutionary trajectories within the HSPC compartment. Consistent alterations in the BM microenvironment emerged as a potential common driver of disease progression. Early detection of rare, aberrant myeloid and immune cell populations at diagnosis may help identify pts at higher risk of rapid transformation to AML. TP53-mutated MDS exhibited a unique immunosuppressive profile, which may be a driver of their poor prognosis.