Rondell P. Graham

Aberrant epigenetic regulation is a central driver of tumorigenesis, and the reversibility of epigenetic modifications underscores their potential as therapeutic targets. Epigenetic factors often function in a highly context-dependent manner, necessitating rigorous study of their dynamic and complex roles. In this study, we uncovered an intricate regulation of tumor development and plasticity by the KDM6 family of histone demethylases in pancreatic ductal adenocarcinoma (PDAC), a disease with sustained high mortality and limited treatment options. Temporally resolving KRAS-driven tumor development revealed a switch from tumor-suppressive to oncogenic functions for KDM6B, with implications for tumor aggressiveness in rodents and patients. These oncogenic functions were mediated by regulation of NOTCH signaling, a pathway known to promote PDAC tumorigenesis. Concurrent elimination of KDM6A and KDM6B led to profound phenotypic changes resembling sarcomatoid carcinomas, a rare, poorly characterized subtype of human PDAC. These tumors exhibited altered oncogenic networks, including NOTCH and c-Jun N-terminal kinase signaling, that may support the development of therapies tailored to molecular subtypes. Given the critical and distinct activities of KDM6 histone demethylases during PDAC development, targeting KDM6 activities may be beneficial in the right cellular and temporal context. Significance: Histone demethylases KDM6A and KDM6B dynamically modulate pancreatic cancer development, aggressiveness, and plasticity by altering NOTCH signaling, providing a rationale for developing selective KDM6 inhibitors.

Gallbladder adenocarcinoma (GBCa) and extrahepatic bile duct cholangiocarcinoma (ECCa) are aggressive malignancies. For unresectable, locally advanced, or metastatic disease, systemic therapy is the only treatment option. Survival rates remain dismal, thus a better understanding of their molecular biology and study of potential targeted therapies are important unmet needs. The tissue agnostic approval of HER2-targeted therapy for medications such as trastuzumab-deruxtecan (T-DXd) for tumors with strong (3+) HER2 expression by immunohistochemistry has motivated interest in HER2 expression among these tumor types. We sought to study the frequency and clinicopathologic features of HER2 expression in GBCa and ECCa. A 14-year retrospective analysis was performed on GBCa and ECCa, including metastatic cases. HER2 immunohistochemistry (Ventana, clone 4B5) was performed on eligible cases and interpreted using the CAP/ASCO gastroesophageal adenocarcinoma scoring guidelines. Clinicopathologic features were assessed with respect to HER2 immunoreactivity, and HER2 scoring agreement was calculated using weighted kappa statistics. There were 59 total cases (GBCa n = 43, ECCa n = 16), with five cases demonstrating strong (3+) HER2 reactivity (8.5%), 22 cases showing 1 + or 2 + immunoreactivity (37.3%), and 32 with a score of 0 (54.2%). HER2 score was higher in metastases compared to corresponding primaries in 7/18 events (38.9%). Among factors considered, histologic grade differed most significantly by HER2 score, with negative cases more likely to be poorly differentiated (p = 0.006). HER2 status was not significantly associated with clinical outcomes (3-year PFS, all-cause mortality). The study describes the frequency and clinicopathologic correlates of HER2 expression in gallbladder adenocarcinoma and extrahepatic cholangiocarcinoma.

Aims: Despite its clinical importance, histological steatosis assessment remains poorly standardized and highly variable among pathologists. We examined determinants of this variability by comparing pathologist estimates with quantitative artificial intelligence (AI) based measurements. Methods and Results: Ten experienced liver pathologists from four institutions evaluated a limited set of 20 permanent H&E‐stained whole‐slide images (WSIs) from metabolic dysfunction‐associated steatotic liver disease (MASLD) cases (10 core biopsies, 7 wedge biopsies and 3 resections) and 6 additional 500 × 500‐μm image fields from separate permanent H&E‐stained cases selected to represent varying droplet compositions. The WSIs spanned the full spectrum of steatosis severity. Assessments used four phases: default method, steatosis proportionate area (SPA), percentage of hepatocytes containing fat (%HCF) and Banff large‐droplet criteria. Image fields were also assessed using no size cut‐off or cut‐offs based on hepatocyte, nuclear or 2–3× nuclear size. AI models quantified SPA, %HCF and droplet size for comparison with pathologists' assessments. Pathologists differed substantially in terminology, droplet‐size definitions and quantification methods. Method choice (SPA vs. %HCF) was a major determinant of estimate dispersion and discrepancy from AI measurements. Visual estimates exceeded AI quantification by 1.4–3.6×. Pathologists' SPA estimates were increasingly higher than the corresponding AI measurements with increasing burden of droplets with area below 50 μm ² , whereas, in exploratory analysis, %HCF estimates remained relatively stable relative to the corresponding AI measurements. Mixed‐effects calibration equations were derived to relate visual and digital assessment scales. Conclusion: Steatosis assessment lacks standardized terminology and measurement practices. SPA and %HCF are conceptually distinct, and their interchangeable use amplifies discrepancies, particularly in small‐droplet‐rich cases. These findings support standardized, AI‐compatible quantification; the exploratory conversion equations require independent validation before clinical application.

Introduction: Optimal treatment following first-line immunotherapy for advanced hepatocellular carcinoma (HCC) remains uncertain. This study evaluated futibatinib, a pan-FGFR inhibitor, combined with pembrolizumab in previously treated patients with FGF19-expressing HCC. Methods: Eligible patients were ≥18 years old with advanced HCC, prior systemic therapy, Child-Pugh A-B7 liver function, ECOG 0-2, and FGF19 overexpression. Patients received futibatinib 20 mg orally daily plus pembrolizumab 200 mg intravenously every 3 weeks. The primary endpoint was progression-free survival at 6 months (PFS6). Secondary endpoints included overall survival (OS), objective response rate (ORR), quality of life, and safety. Results: Between August 2021 and March 2024, 14 patients enrolled and 13 were evaluable. Median age was 72 years (range, 60-87), 53.8% were male, 92.3% had Child-Pugh A liver function, and all had received prior immunotherapy. Median progression-free survival was 15 weeks (95% CI, 9.0-NE), with a PFS6 rate of 23.1% (95% CI, 8.6-62.3%). ORR was 0% (95% CI, 0-24.7%), while stable disease was observed in 53.9% of patients. Median OS was 55.7 weeks (95% CI, 47.3-NE). Grade ≥3 adverse events occurred in 69.2% of patients, and grade ≥4 adverse events in 15.4%. One grade 5 event (acute-on-chronic kidney injury) was deemed unrelated to treatment. Common adverse events included hyperphosphatemia, fatigue, diarrhea, elevated transaminases, dry eye, nail changes, rash, and oral mucositis. Conclusions: Futibatinib plus pembrolizumab demonstrated an acceptable safety profile but did not meet efficacy thresholds supporting further study in FGF19-expressing HCC. Effective post-immunotherapy treatment strategies remain an unmet need.

Background: Societal guidance recommends sequential noninvasive testing for metabolic dysfunction–associated steatotic liver disease (MASLD), using Fibrosis-4 (FIB-4) ≥1.3 as a gatekeeper before second-line assessment with the Enhanced Liver Fibrosis (ELF) score (<7.7 as a rule-out). The impact of this pathway design on the detection of fibrotic MASH remains uncertain. We aimed to evaluate the performance of guideline-endorsed sequential testing and to determine optimized ELF thresholds within alternative strategies. Methods: In this prospective study, patients with or at risk for MASLD underwent FIB-4, ELF testing, magnetic resonance elastography (MRE), and liver biopsy within 1 month. Fibrotic MASLD was defined as fibrosis stage ≥2 on histology or liver stiffness ≥3.1 kPa on MRE. Diagnostic performance of ELF was assessed, and sequential (ELF applied after FIB-4 ≥1.3) and concurrent (either test positive) testing strategies were compared. Results: Among 186 participants (median age 51 years; 69% women), fibrotic MASLD was present in 71 (38%). ELF demonstrated AUROC 0.77 (95% CI 0.70–0.84); the cohort-derived cutoff was 9.4 (80% sensitivity, 65% specificity). Lower cutoffs (8.7 and 7.7) increased sensitivity (≥90% and 100%) but low specificity (34% and 4%). FIB-4 ≥1.3 showed limited sensitivity (57%), resulting in 43% of fibrotic MASH cases being excluded from second-line testing. Sequential application of ELF, therefore, failed to overcome this sensitivity ceiling. A concurrent strategy using FIB-4 ≥1.3 or ELF ≥9.4 improved sensitivity to 87% with 64% specificity. Conclusions: Sequential FIB-4–based testing substantially limits the detection of fibrotic MASLD due to gatekeeping sensitivity constraints. Concurrent first-line testing with FIB-4 and ELF improves case identification, underscoring the importance of pathway design in optimizing noninvasive fibrosis assessment.

Correlation of intratumoral immune infiltration in dMMR CRCs estimated by MCP-counter and CIBERSORT.

Purpose:Immune checkpoint blockade (ICB) induces frequent and durable responses in metastatic deficient DNA mismatch repair (dMMR) colorectal cancer, yet substantial molecular heterogeneity and resistance remain. We sought to identify candidate tumor- and immune-related biomarkers associated with clinical outcomes following anti–PD-1 therapy.Experimental Design:Consecutive patients with metastatic dMMR colorectal cancer (N = 39) treated with anti–PD-1 therapy underwent tumor profiling using a validated immune-enhanced exome and transcriptome platform. Microsatellite instability (MSI) burden was quantified as the percentage of unstable microsatellite loci using MSIsensor-pro. Associations with objective response were evaluated, and progression-free survival (PFS) and overall survival (OS) were analyzed using Cox proportional hazards models.Results:Higher MSI burden was associated with improved objective response (P = 0.018) and survival. The dichotomized MSI level (Q2–4 vs. Q1) was associated with longer PFS [hazard ratio (HR), 0.18; 95% confidence interval (CI), 0.06–0.56; P = 0.003] and OS (HR, 0.20; 95% CI, 0.07–0.58; P = 0.003), with similar results when modeled continuously. MSI burden correlated with neoantigen clonality but not burden (R = 0.53, P = 0.01). Responders exhibited significantly greater T-cell receptor repertoire diversity; both T- and B-cell receptor diversities were associated with survival. Although human leukocyte antigen (HLA) A, HLA-B, and HLA-C expression was not prognostic, the HLA-B*07:02 allele was associated with the best overall response. In contrast, overexpression of immune exhaustion–related genes and cytotoxic T-cell and natural killer cell exhaustion phenotypes were associated with ICB resistance and poorer prognosis.Conclusions:Integrated exome/transcriptome profiling with MSI quantification identified MSI burden and adaptive immune repertoire diversity as potential correlates of response and survival following ICB. These findings suggest a mechanistic link among genomic instability, antigen recognition diversity, and immunotherapy benefit.

Alpha smooth muscle actin (ACTA2) and fibronectin (FN1) gene expression in relationship to response and survival.

Percent unstable microsatelite (MSI) loci in dMMR CRCs among patient subgroups in relationship to clinical outcome.