Abstract Ewing sarcoma is a rare, fusion-driven malignancy with poor prognosis in the metastatic setting, for which no established immunotherapeutic treatment is currently available. Fusion breakpoints are rational precision immunotherapy targets, yet clinical evidence of immunogenicity is scarce. We administered an off-the-shelf multi-peptide vaccine spanning the type 1 EWSR1–FLI1 breakpoint to a patient with high-burden metastatic Ewing sarcoma following multimodal therapy. Vaccinations were combined with GM-CSF and topical imiquimod. Longitudinal immune monitoring by in vitro peptide stimulation and intracellular cytokine staining revealed de novo polyfunctional CD4⁺ T-cell responses against all four fusion-derived peptides, first detectable by month 7 and persisting beyond two years. Treatment was well tolerated with only grade 1 local reactions. Durable disease stability was maintained for more than 26 months. These first-in-human data support the feasibility, safety, and immunogenicity of a fusion-derived peptide vaccine and warrant further evaluation of precision immunotherapy in sarcomas driven by recurrent gene fusions.

Background & Aims: Immunotherapy with atezolizumab and bevacizumab (a + b) has improved the prognosis of patients with unresectable hepatocellular carcinoma (HCC). However, the outcome for individual patients is highly variable. This study aimed to (i) develop and validate a prognostic prediction model to estimate individual prognosis and (ii) compare it with established models. Methods: In this multicenter retrospective study, patients with HCC undergoing first-line immunotherapy with a + b from 24 centers (Europe, USA) were included. Statistical analysis and reporting followed the TRIPOD guidelines. The primary objective was overall survival (OS). A Cox model was developed and externally validated. Results: In total, 683 patients were included (training: 526, validation: 157). The C-reactive protein, albumin, bilirubin, lymphocytes, ECOG performance status, and extrahepatic spread (CABLE score) remained significantly associated with OS in Cox regression analysis. In the training set, the CABLE score had a higher discriminatory accuracy relative to ALBI, EZ-ALBI, mALBI, CRAFITY, PNI, NLR, PLR, and GPS (time-dependent AUC 0.79 and C-index 0.75 (95% CI 0.71-0.78) at 12 months). In the external validation set, the discriminatory performance of the CABLE score was comparable to ALBI, EZ-ALBI, and mALBI, but on average higher than PNI, CRAFITY, NLR, PLR, and GPS. In patients with Child-Pugh A, the CABLE score outperformed ALBI, EZ-ALBI, and mALBI in the first 9 months. We provide a web-based calculator for the CABLE score to allow estimation of individual prognosis for these patients (http://shiny.imbei.uni-mainz.de:3838/CABLE_Score/). Conclusions: The CABLE score shows good discriminatory performance in assessing the individual prognosis of patients undergoing first-line immunotherapy with a + b. Further validation studies are needed to investigate its performance compared with the ALBI score, in particular in subgroup analysis. (c) 2024 The Author(s). Published by Elsevier B.V. on behalf of European Association for the Study of the Liver (EASL). This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Background:Outpatient treatments, including targeted therapies, in oncology are on the rise. The implementation of remote patient monitoring (RPM) between therapy sessions has the potential to enhance patient care and therapy outcomes in the future. Objective:This pilot study assessed the feasibility of a new, app-based RPM system (bwHealthApp) by capturing patient-reported outcomes (PROs) and vital parameters using a wrist- or in-ear wearable. The study examined adherence, acceptance, and satisfaction, as well as the differences between the two types of wearables. Methods:Outpatients with gastrointestinal cancer receiving systemic therapies were invited to use and evaluate the bwHealthApp system for 1 month. The system was set up as an Android smartphone app to assess electronic PROs (ePROs) and connect to wearables for continuous vital sign measurements. A wrist wearable (Beurer AS99) that measured activity and heart rate or an in-ear wearable (Cosinuss Two) that measured heart rate, oxygen saturation, and temperature was used. The data were synchronized remotely to a web client. Outpatients were randomly assigned to the wrist wearable (n=17) or in-ear wearable (n=14) group. At the beginning, middle, and end of the study, patients (N=31) completed questionnaires on various feasibility aspects. Adherence to ePRO completion; wearable use, acceptance, and satisfaction; wearable data quantity and quality; and differences between the wearables were evaluated. Results:The mean adherence to bwHealthApp including dropouts was 46% (449/971 days) for ePRO completion and 61% (593/971 days) for wearable use. The system was most frequently used during everyday activities. More than half of the participants were satisfied with bwHealthApp (18/30, 60%) and could imagine continued use (21/30, 70%). Notably, 70% (21/30) rated the system as easy to use. Participants recorded more than 20 million wearable measures; however, 29% (SD 22%, range 3%-76%) of temperature values and 33% (SD 25%, range 10%-92%) of oxygen saturation values were outside the physiological range. For heart rate, the mean proportion of excluded values was 10% (SD 11%, range 4%-48%; in-ear) and 11% (SD 8%, range 4%-33%; wrist). The frequency of use of the two wearables did not differ significantly (t29=1.81; P=.08). The wrist wearable scored significantly better than the in-ear wearable regarding wearing comfort (t28=-11.17; P=.03). Conclusions:This bwHealthApp pilot study demonstrates the feasibility of RPM via a mobile app and wearable devices during outpatient systemic cancer therapy, including targeted therapies. The adherence level was moderate, and patients were generally satisfied with the system, although the wrist wearable received a higher rating. The system's functionality may be enhanced through the integration of additional wearables. This pilot study serves as a foundational framework for long-term assessments examining RPM and clinical data to improve cancer treatments.

Background/Objectives: Fully personalized peptide vaccines targeting tumor-specific mutations are a promising treatment option for patients in an adjuvant but also advanced/metastatic disease situation in addition to non-personalized standard therapies. Here, we report a patient’s case with advanced metastatic colorectal cancer (mCRC) who was treated with a neoantigen-derived multi-peptide vaccine in addition to standard of care. Methods: Tumor-specific mutations were identified by whole exome and transcriptome sequencing. An individualized peptide vaccine was designed using an in-house developed epitope prediction and vaccine design platform. In this case, the vaccine consisted of 20 peptides targeting 18 distinct mutations. The vaccine was administered according to a prime-boost scheme for a total of 12 vaccinations. Vaccine immunogenicity was determined by stimulation of patient T cells with vaccinated peptides and subsequent intracellular cytokine staining (ICS). Tumor-infiltrating lymphocytes (TIL) were analyzed by ICS and T cell receptor beta chain (TCRβ) sequencing. Results: The patient survived for 41 months since initial diagnosis despite continuous disease progression under all therapeutic interventions. The vaccination induced multiple neoantigen-specific T cell responses in the patient without notable side effects. Two liver metastases were resected five months after the start of vaccination, and TIL were extracted and cultured. Analysis of TIL cultures revealed tumor infiltration by vaccine-induced neoantigen-specific T cells in only one of the metastases. TCRβ sequencing of neoantigen-specific T cells and tumor tissues supported this finding. Vaccine-targeted variants were reduced or absent in the metastasis with vaccine-specific T cell infiltration. Conclusions: This case demonstrates immunogenicity of a neoantigen-derived peptide vaccine and highlights tumor-infiltrating capabilities and potential cytotoxicity of vaccine-induced T cells in mCRC.

Background and Aims: Primary liver cancer, including hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), has low response rates to existing treatments, highlighting the urgent need for novel treatment options. Adenosine A3 receptor (ADORA3) signaling has emerged as a potential target. Namodenoson, an ADORA3 agonist, has shown promise in early clinical trials for HCC. However, further data are required to clarify ADORA3 expression patterns in liver cancer, mechanisms of action, and the potential for combination therapies to inform patient selection for future clinical trials. Methods: Patient-derived tissue microarrays and RNA-sequencing were employed to investigate ADORA3 expression. Cellular responses to ADORA3 stimulation and combination treatments were studied in HCC and CCA cell lines and patient-derived organoids (PDOs). Genome-wide RNA-Seq analysis, mRNA analysis, and DigiWest protein profiling were performed. Results: Tissue microarray analysis revealed higher ADORA3 expression in nonmalignant samples and a subset of tumors with weak or absent ADORA3 expression. This was supported by RNA sequencing data from The Cancer Genome Atlas and needle biopsy samples. Cell lines and PDOs exhibited antiproliferative effects with the ADORA3 agonist Namodenoson, confirmed by receptor dependency tests with specific antagonists and siRNA experiments. Genome-wide RNA-Seq analysis suggested chromatin remodeling events after ADORA3 stimulation. mRNA expression and DigiWest profiling identified downregulation of histone deacetylases and histone H3 modifications. Combination treatments with different ADORA3 agonists and histone deacetylase inhibitors significantly enhanced antiproliferative effects in almost all selected combinations, supported by investigations in PDOs. Conclusion: ADORA3 expression varies considerably in HCC or CCA, ranging from high to absent receptor detection. This observation might help to identify patients for clinical studies. Additionally, Namodenoson’s epigenetic modulating activity suggests epigenetic drugs as promising candidates for combination treatment.

Mobile monitoring of outpatients during cancer therapy becomes possible through technological advancements. This study leveraged a new remote patient monitoring app for in-between systemic therapy sessions. Patients' evaluation showed that the handling is feasible. Clinical implementation must consider an adaptive development cycle for reliable operations.

Einleitung Die häufigste postoperative Komplikation nach laparoskopischer Sleeve-Gastrektomie ist eine Klammernaht-Insuffizienz, welche typischerweise im Bereich des Hiss´schen Winkels auftritt. Diese sogenannte Staple-Line-Leak tritt in bis zu 2 % der Operationen auf. Die bariatrischen Patienten weisen häufig keine typische klinische Symptomatik auf, so die Diagnose erschwert sein kann. Bei dringendem Verdacht auf das Vorliegen einer Staple-Line-Leak kann eine diagnostische Re-Laparoskopie mit Lavage und Zieldrainage und eine simultane Endoskopie ggf. mit Etablierung einer endoskopischen Unterdrucktherapie erfolgen. Durch die Endoskopie kann aufgrund der Insufflation periprozedural, eine sichere Detektion möglicher, kleiner Leckagen sichergestellt werden.

Introduction: Laparoscopic sleeve gastrectomy is one of the most commonly performed bariatric procedures worldwide with good results, high patient acceptance, and low complication rates. The most relevant perioperative complication is the staple line leak. For the treatment of this complication, endoscopic negative pressure therapy has proven particularly effective. The correct time to start endoscopic negative pressure therapy has not been the subject of studies to date. Methods: Twelve patients were included in this retrospective data analysis over three years. Endoscopic negative pressure therapy was carried out using innovative open pore suction devices. Patients were treated with simultaneous surgery and endoscopy, so called rendezvous-procedure (Group A) or solely endoscopically, or in sequence surgically and endoscopically (Group B). Therapy data of the procedures and outcome measures, including duration of therapy, therapy success, and change of treatment strategy, were collected and analysed. Results: In each group, six patients were treated (mean age 52.96 years, 4 males, 8 females). Poor initial clinical situation, time span of endoscopic negative pressure therapy (Group A 31 days vs. Group B 18 days), and mean length of hospital stay (Group A 39.5 days vs. Group B 20.17 days) were higher in patients with rendezvous procedures. One patient in Group B died during the observation time. Discussion: Rendezvous procedures for patients with staple line leaks after sleeve gastrectomy is indicated for serious ill patients with perigastric abscesses and in need of laparoscopic lavage. The one-stage complication management with the rendezvous procedure seems not to result in an obvious advantage in the further outcome in patients with staple line leaks after laparoscopic sleeve gastrectomy.

Intrahepatic cholangiocarcinoma (iCCA) has emerged as a promising candidate for precision medicine, especially in the case of activating FGFR2 gene fusions. In addition to fusions, a considerable fraction of iCCA patients reveals FGFR2 mutations, which might lead to uncontrolled activation of the FGFR2 pathway but are mostly of unknown functional significance. A current challenge for molecular tumor boards (MTB) is to predict the functional consequences of such FGFR2 alterations to guide potential treatment decisions. We report two iCCA patients with extracellular and juxtamembrane FGFR2 mutations. After in silico investigation of the alterations and identification of activated FGFR2 downstream targets in tumor specimens by immunohistochemistry and transcriptome analysis, the MTB recommended treatment with an FGFR-inhibiting tyrosine kinase inhibitor. Both patients developed a rapidly detectable and prolonged partial response to treatment. These two cases suggest an approach to characterize further detected FGFR2 mutations in iCCA to enable patients´ selection for a successful application of the FGFR -inhibiting drugs.

Background: Microvessel density is an indicator of tumor-driven neoangiogenesis. Hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) have distinct vascular patterns, which are also reflected in their imaging characteristics. Since a significant proportion of HCC are treated without biopsy confirmation, it is essential to discriminate HCC and ICC radiologically. The aim of our study was therefore to compare microvessel density and expression of VEGFR-2 in HCC and ICC, since these data may ultimately help us to better understand their imaging characteristics. Whereas CD31 documents vessel density, VEGFR-2 expression is an indicator of tumor-related neoangiogenesis. Methods: CD31 and VEGFR-2 expressing microvessels were quantified on tissue microarrays of 95 resection specimens of HCC and 47 cases of ICC. Microvessel density was evaluated by counting immuno-reactive vascular structures both within the tumor and adjacent liver control tissue, respectively. Further 16 cases of ICC were immunostained for CD31 and VEGFR-2 on full sections. Results: The frequency of VEGFR-2 (46.2/HPF; range 0-150) and CD31 (61.2/HPF; range 2.6-140) expressing vascular structures was significantly increased in HCC compared to adjacent liver parenchyma (VEGFR-2 33.3/ HPF, range 0-87, CD31 21.4/HPF, range 0-78, both p < 0,001). ICC revealed significantly less VEGFR2-positive microvessels (15.4/HPF; range 2-77) compared to matched control tissue (42.3/HPF; range 4.6-109), whereas microvessel density with CD31 was comparable between ICC and adjacent liver (32.1/HPF; range 5.3-78 versus 28.0/HPF; range 5.3-57; p = 0.89). In ICC, the tumor-to-normal microvessel density ratio was 0.38 for VEGFR-2 and 1.24 for CD31. These ratios were nearly identical (VEGFR: 0.38; CD31: 0,97) for the 16 cases of ICC studied on whole sections, confirming the validity of the TMA approach. In contrast, ratios of VEGFR-2 and CD31 in HCC vs. adjacent liver were significantly higher (VEGFR: 2.23; CD31: 6.57). Expression of VEGFR-2 by tumor cells was not observed in any of the cases. Conclusions: HCC and ICC differ significantly in their microvessel density, confirming the hypovascular nature of ICC as compared to the hypervascularity of HCC. Of note, inverse tumor-to-normal ratios of microvascular VEGFR-2 expression between the two neoplasms indicate distinct features of neoangiogenesis. Whether these differences can be exploited for improvements in imaging of hepatic tumors and may play a role for antiangiogenic treatment strategies requires further studies.

BACKGROUND: Approximately half of the prostate carcinomas are characterized by a chromosomal rearrangement fusing the androgen-regulated gene TMPRSS2 to the oncogenic ETS transcription factor ERG. Aim of this study was to comprehensively analyze the role and impact of the ERG rearrangement and protein expression on the progression to castration-resistant (CR) disease.METHODS: We used a tissue microarray (TMA) constructed from 114 hormone naive (HN) and 117 CR PCs. We analyzed the ERG rearrangement status by fluorescence in situ hybridization and the expression profiles of ERG, androgen receptor (AR) and the proliferation marker Ki67 by immunohistochemistry.RESULTS: Nearly half of the PC tissue specimens (HN: 38%, CR: 46%) harbored a TMPRSS2-ERG gene fusion. HN PCs with positive translocation status showed increased tumor cell proliferation (P<0.05). As expected, TMPRSS2-ERG gene fusion was strongly associated with increased ERG protein expression in HN and CR PCs (both P<0.0001). Remarkably, the study revealed a subgroup (26%) of CR PCs with ERG rearrangement but without any detectable ERG protein expression. This subgroup showed significantly lower levels of AR protein expression and androgen-regulated serum PSA (both P<0.05).CONCLUSIONS: In this study, we identified a subgroup of ERG-rearranged CR PCs without detectable ERG protein expression. Our results suggest that this subgroup could represent CR PCs with a dispensed AR pathway. These tumors might represent a thus far unrecognized subset of patients with AR-independent CR PC who may not benefit from conventional therapy directed against the AR pathway.

The transcription factor SOX2 has been extensively studied for its role in embryonic stem cell self-renewal and pluripotency. More recent data suggest oncogenic functions of SOX2 and demonstrate expression in several carcinoma types, predominantly of squamous cell origin. The gene SOX2 is located at chromosome 3q26, a region that is frequently amplified in ovarian high-grade serous carcinoma. In this study, we correlate SOX2 protein expression and gene-amplification status in ovarian carcinomas with histopathologic criteria and disease outcome. A total of 215 cases of ovarian carcinomas (154 serous, 39 endometrioid, 11 clear cell, 5 mucinous, and 6 transitional cell carcinomas) were analyzed by immunohistochemistry in a tissue microarray for nuclear expression of SOX2. A total of 60.5% of all carcinomas showed SOX2 expression with no significant difference between the major histologic types. Interestingly, SOX2 expression was predominantly a feature of high-grade tumors (G1: 36.4%, G2: 55.6%, G3: 64.0%, P=0.040). In 21.2% of these cases, fluorescence in situ hybridization analysis detected low-level SOX2 gene amplification which was not significantly associated with SOX2 protein expression. However, survival analysis of Stage II to IV high-grade serous carcinomas revealed a favorable effect of SOX2 expression (median disease-free survival 27 vs. 21 mo, P=0.041; median overall survival 39 vs. 25 mo, P=0.062). Further studies are needed to explore whether expression of SOX2 has a specific role in prognosis and therapy response.

Castration‐resistant prostate cancer (CRPC) is the most aggressive form of prostate cancer (PCa) and remains a significant therapeutic challenge. The key to the development of novel therapeutic targets for CRPC is to decipher the molecular alterations underlying this lethal disease. The aim of our study was to identify therapeutic targets for CRPC by assessing somatic copy number alterations (SCNAs) by whole‐exome sequencing on five CRPC/normal paired formalin‐fixed paraffin‐embedded (FFPE) samples, using the SOLiD4 next‐generation sequencing (NGS) platform. Data were validated using fluorescence in situ hybridization (FISH) on a PCa progression cohort. PTK2 and YWHAZ amplification, mRNA and protein expression were determined in selected PCa cell lines. Effects of PTK2 inhibition using TAE226 inhibitor and YWHAZ knock‐down on cell proliferation and migration were tested in PC3 cells in vitro. In a larger validation cohort, the amplification frequency of YWHAZ was 3% in localized PCa and 48% in CRPC, whereas PTK2 was amplified in 1% of localized PCa and 35% in CRPC. YWHAZ knock‐down and PTK2 inhibition significantly affected cell proliferation and migration in the PC3 cells. Our findings suggest that inhibition of YWHAZ and PTK2 could delay the progression of the disease in CRPC patients harbouring amplification of the latter genes. Furthermore, our validated whole‐exome sequencing data show that FFPE tissue could be a promising alternative for SCNA screening using next‐generation sequencing technologies. Copyright © 2013 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

In systemic amyloidosis spontaneous rupture of the liver is a rare complication. Here we report on a patient with unrecognized systemic amyloidosis who presented to an outside hospital with unspecific abdominal pain. Under the signs of a hemorrhagic shock, distended abdomen and intraabdominal bleeding a laparotomy was performed. Due to uncontrollable hemorrhage of the ruptured right liver lobe a packing was performed. After being transferred to the reporting institution a CT scan was performed showing a grade IV laceration of the right liver. Therefore a transarterial embolization of the right hepatic artery was carried out. The following day an infection of the abdominal cavity and the abdominal wall with gas-producing bacteria was noticed and a relaparotomy, necrectomy and repacking due to diffuse bleeding were performed. The situation deteriorated and at the second relaparotomy the following day an almost completely necrotic liver was found. The patient deceased the following day. Life-threatening spontaneous liver rupture due to systemic amyloidosis might only successfully be cured by high urgency liver transplantation as presented in the literature. However, in two published cases interventional therapy by embolization of bleeding vessels has saved patients' life.