胆囊癌文献月评（202406期）

健康健康 2024-07-29 16:37 上海

栏目寄语

胆囊癌是胆道系统最常见的恶性肿瘤，具有症状隐匿、发展迅速、早期转移、预后极差的特点，被称为新的“癌中之王”。我国是胆囊癌的高发地区之一，发病率和病死率近年来都呈持续缓慢上升趋势。胆囊慢性炎症、胆囊结石、胆囊息肉等都是胆囊癌的危险因素，但是胆囊癌目前仍缺乏特异性和敏感性都较好的早期诊断手段，临床发现的胆囊癌多为中晚期。尽管医学科技不断发展，根治性手术切除仍是当前唯一可能治愈胆囊癌的手段，行之有效的系统性治疗方法依然还在不断探索寻找中。因此，深入开展胆囊癌的临床和基础研究能够帮助我们更好地应对此类恶性肿瘤。

上海交通大学医学院附属新华医院普外科肝胆胰中心长期以来致力于胆道疾病诊治难点的攻关，形成了普外科、上海市胆道疾病研究重点实验室、上海市胆道疾病研究中心、Ⅰ期临床研究病房等多位一体的转化医学研究体系。尤其在胆囊癌的基础和临床研究方面的科研水平位于国内外领先水准，相关成果发表SCI论文50余篇，其中包括NatureGenetics、GUT、Hepatology等国际顶尖学术期刊，并获得了包括科技部新药创制项目、国家自然科学基金重点项目、上海市启明星、浦江人才、上海市优秀学科带头人、上海市卫健委新优靑等在内的多项科研及人才项目。

本期关于胆囊癌的研究呈现了多个领域的新进展，涵盖了TOPAZ-1试验的最新总生存期数据，德国的NALIRICC试验研究结果，胆汁代谢指纹图谱在鉴别胆道良恶性疾病的价值，GPRC5A通过JAK2-STAT3-TNS4通路调控胆囊癌转移的分子机制，胆道恶性肿瘤免疫治疗中肠道菌群和代谢物临床反应特征，中性粒细胞在胆囊癌肝侵袭中的作用机制等方面。这些研究在不同层面上揭示了胆囊癌治疗的新可能性，进一步推动了胆囊癌临床和基础研究的发展。因此，我们特别鸣谢上海交通大学附属新华医院普外科宋晓玲医师，以及上海市胆道疾病研究重点实验室陈世礼研究员、刘诗蕾博士、赵成博士、汤秋义博士、孔磊博士做出的贡献！

欢迎各位同道与我们积极交流探讨，共同推动胆囊癌研究和诊治的进步！

龚伟

1.Durvalumab或安慰剂联合吉西他滨和顺铂治疗晚期胆道恶性肿瘤患者（TOPAZ-1）：一项随机三期研究的最新总生存期数据（IF:30.9）

Oh DY, He AR, Bouattour M, et al. Durvalumab or placebo plus gemcitabine and cisplatin in participants with advanced biliary tract cancer (TOPAZ-1): updated overall survival from a randomised phase 3 study. Lancet Gastroenterol Hepatol. 2024;9(8):694-704.

摘要：Background: In the preplanned interim analysis of the TOPAZ-1 study, durvalumab plus gemcitabine-cisplatin significantly improved overall survival versus placebo plus gemcitabine-cisplatin in participants with advanced biliary tract cancer. We aimed to report updated overall survival and safety data from TOPAZ-1 with additional follow-up and data maturity beyond the interim analysis.Methods: TOPAZ-1 was a phase 3, randomised, double-masked, placebo-controlled, global study done at 105 sites in 17 countries. Participants aged 18 years or older with unresectable, locally advanced, or metastatic biliary tract cancer were randomly assigned (1:1) to durvalumab plus gemcitabine-cisplatin or placebo plus gemcitabine-cisplatin using a computer-generated randomisation scheme, stratified by disease status and primary tumour location. Participants received durvalumab (1500 mg) or placebo on day 1 of each cycle every 3 weeks for up to eight cycles, plus gemcitabine (1000 mg/m2) and cisplatin (25 mg/m2) intravenously on days 1 and 8 of each cycle every 3 weeks for up to eight cycles, followed by durvalumab (1500 mg) or placebo monotherapy every 4 weeks until disease progression or other discontinuation criteria were met. Investigators and participants were masked to study treatment. The primary endpoint was overall survival. TOPAZ-1 met its primary endpoint at the preplanned interim analysis, and the study is active but no longer recruiting participants. Updated overall survival and safety data from TOPAZ-1, with additional follow-up (data cutoff Feb 25, 2022) and data maturity beyond the interim analysis, are reported here. Efficacy was assessed in the full analysis set (all randomly assigned participants). Safety was assessed in the safety analysis set (all participants who received at least one dose of study treatment). The TOPAZ-1 study is registered with ClinicalTrials.gov, NCT03875235.Findings: From April 16, 2019, to Dec 11, 2020, 914 participants were enrolled, 685 of whom were randomly assigned (341 to the durvalumab plus gemcitabine-cisplatin group and 344 to the placebo plus gemcitabine-cisplatin group). 345 (50%) participants were male and 340 (50%) were female. Median follow-up at the updated data cutoff was 23·4 months (95% CI 20·6-25·2) in the durvalumab plus gemcitabine-cisplatin group and 22·4 months (21·4-23·8) in the placebo plus gemcitabine-cisplatin group. At the updated data cutoff, 248 (73%) participants in the durvalumab plus gemcitabine-cisplatin group and 279 (81%) participants in the placebo plus gemcitabine-cisplatin group had died (median overall survival 12·9 months [95% CI 11·6-14·1] vs 11·3 months [10·1-12·5]; hazard ratio 0·76 [95% CI 0·64-0·91]). Kaplan-Meier-estimated 24-month overall survival rates were 23·6% (95% CI 18·7-28·9) in the durvalumab plus gemcitabine-cisplatin group and 11·5% (7·6-16·2) in the placebo plus gemcitabine-cisplatin group. Maximum grade 3 or 4 adverse events occurred in 250 (74%) of 338 participants in the durvalumab plus gemcitabine-cisplatin group and 257 (75%) of 342 in the placebo plus gemcitabine-cisplatin group. The most common maximum grade 3 or 4 treatment-related adverse events were decreased neutrophil count (70 [21%] vs 86 [25%]), anaemia (64 [19%] vs 64 [19%]), and neutropenia (63 [19%] vs 68 [20%]).

赵成博士（上海市胆道疾病研究重点实验室）：

TOPAZ-1是一项随机、双盲、全球性的III期研究，是全球第一个评估晚期胆道恶性肿瘤一线免疫疗法联合吉西他滨-顺铂（GemCis）的研究。该研究采用免疫检查点抑制剂度伐利尤单抗（Durvalumab）联合化疗GemCis方案，获得了OS/ PFS/ ORR“三阳性”的亮眼成绩。TOPAZ-1研究结果（包括不同亚组分析）先后发布于2022年多场重要国际会议，开启了免疫联合方案一线治疗的新时代。TOPAZ-1的主要终点是总生存期，在预先计划的中期分析中，TOPAZ-1达到了主要终点，目前该研究仍在进行，但不再招募参与者。本文报告了TOPAZ-1的最新总生存期和安全性数据，包括额外的随访数据（数据截止日期为2022年2月25日）。

从2019年4月16日到2020年12月11日，685人被随机分配至Durvalumab联合GemCis组（341人），安慰剂联合GemCis组 (344人）。更新数据截止时，中位随访时间为 23.4个月（95% CI 20.6-25.2），安慰剂联合GemCis组为22.4个月（21.4-23.8），安慰剂联合GemCis组为22.4个月（21.4-23.8）。在更新的数据截止日期， Durvalumab联合GemCis组的248 名（占73%）入组患者和安慰剂联合GemCis组的279名（占81%）入组患者死亡（中位总生存期为12.9个月[95% CI 11.6-14.1] vs 11.3 个月 [10.1-12.5]）。经Kaplan-Meier评估的24个月总生存率Durvalumab联合GemCis组为23.6%（95% CI 18.7-28.9），安慰剂联合GemCis组为11.5%（7.6-16.2）。在Durvalumab联合GemCis组中，有250人（74%）发生了最严重的3或4级不良事件；安慰剂联合GemCis组中，有257人（75%）发生了最严重的3或4级不良事件。最常见的3级或4级治疗相关不良事件是中性粒细胞计数减少（70 [21%] vs 86 [25%]）、贫血（64 [19%] vs 64 [19%]）。

对于预后极差和缺乏有效治疗的胆道恶性肿瘤来说，TOPAZ-1研究可谓是 “破冰之举”。作为首个且目前唯一获得“三阳”结果的研究，其不仅给晚期胆道癌的一线治疗带来了新的希望，同时也助推胆道恶性肿瘤的治疗进入免疫联合化疗的新时代。相信随着探索的不断深入，对各类胆道肿瘤生物学特性认识的进一步加深，新的突破指日可待！

2.纳米脂质体伊立替康和氟尿嘧啶加亚叶酸钙与氟尿嘧啶加亚叶酸钙在既往接受吉西他滨治疗的胆管癌和胆囊癌患者中的比较（AIO NALIRICC）：一项多中心、开放标签、随机、2期试验（IF:30.9）

Vogel A, Saborowski A, Wenzel P, et al. Nanoliposomal irinotecan and fluorouracil plus leucovorin versus fluorouracil plus leucovorin in patients with cholangiocarcinoma and gallbladder carcinoma previously treated with gemcitabine-based therapies (AIO NALIRICC): a multicentre, open-label, randomised, phase 2 trial. Lancet Gastroenterol Hepatol. 2024;9(8):734-744.

摘要：Background: There is an unmet need for effective therapies in pretreated advanced biliary tract cancer. We aimed to evaluate the efficacy of nanoliposomal irinotecan and fluorouracil plus leucovorin compared with fluorouracil plus leucovorin as second-line treatment for biliary tract cancer.Methods: NALIRICC was a multicentr, open-label, randomised, phase 2 trial done in 17 German centres for patients aged 18 years or older, with an Eastern Cooperative Oncology Group performance status of 0-1, metastatic biliary tract cancer, and progression on gemcitabine-based therapy. Patients were randomly assigned (1:1) to receive intravenous infusions of nanoliposomal irinotecan (70 mg/m2), fluorouracil (2400 mg/m2), and leucovorin (400 mg/m2) every 2 weeks (nanoliposomal irinotecan group) or fluorouracil (2400 mg/m2) plus leucovorin (400 mg/m2) every 2 weeks (control group). Randomisation was by permutated block randomisation in block sizes of four, stratified by primary tumour site. Investigator-assessed progression-free survival was the primary endpoint, which was evaluated in all randomly assigned patients. Secondary efficacy outcomes were overall survival, objective response rate, and quality of life. Safety was assessed in all randomly assigned patients who received at least one dose of the study treatment. Enrolment for this trial has been completed, and it is registered with ClinicalTrials.gov, NCT03043547.Finding: Between Dec 4, 2017, and Aug 2, 2021, 49 patients were randomly assigned to the nanoliposomal irinotecan group and 51 patients to the control group. Median age was 65 years (IQR 59-71); 45 (45%) of 100 patients were female. Median progression-free survival was 2·6 months (95% CI 1·7-3·6) in the nanoliposomal irinotecan group and 2·3 months (1·6-3·4) in the control group (hazard ratio [HR] 0·87 [0·56-1·35]). Median overall survival was 6·9 months (95% CI 5·3-10·6) in the nanoliposomal irinotecan group and 8·2 months (5·4-11·9) in the control group (HR 1·08 [0·68-1·72]). The objective response rate was 14% (95% CI 6-27; seven patients) in the nanoliposomal irinotecan group and 4% (1-14; two patients) in the control group. The most common grade 3 or worse adverse events in the nanoliposomal irinotecan group were neutropenia (eight [17%] of 48 vs none in the control group), diarrhoea (seven [15%] vs one [2%]), and nausea (four [8%] vs none). In the control group, the most common grade 3 or worse adverse events were cholangitis (four [8%] patients vs none in the nanoliposomal irinotecan group) and bile duct stenosis (four [8%] vs three [6%]). Treatment-related serious adverse events occurred in 16 (33%) patients in the nanoliposomal irinotecan group (grade 2-3 diarrhoea in five patients; one case each of abdominal infection, acute kidney injury, pancytopenia, increased blood bilirubin, colitis, dehydration, dyspnoea, infectious enterocolitis, ileus, oral mucositis, and nausea). One (2%) treatment-related serious adverse event occurred in the control group (worsening of general condition). Median duration until deterioration of global health status, characterised by the time from randomisation to the initial observation of a score decline exceeding 10 points, was 4·0 months (95% CI 2·2-not reached) in the nanoliposomal irinotecan group and 3·7 months (2·7-not reached) in the control group.

宋晓玲医师（上海交通大学附属新华医院普外科）：

NALIRICC是一项德国开展的多中心、开放标签、随机对照、II期临床研究，旨在评估伊立替康脂质体联合氟尿嘧啶和亚叶酸钙作为胆道恶性肿瘤二线治疗方案的疗效与安全性。该研究自2017年12月4日至2021年8月2日，共入组德国17家中心116位既往接受吉西他滨或含吉西他滨治疗失败的晚期胆道恶性肿瘤患者（其中筛败16名，肝内胆管癌64名，肝外胆管癌19名，胆囊癌17名；55名男性，45女性），入组患者随机分为：伊立替康脂质体联合氟尿嘧啶、亚叶酸钙治疗组（伊立替康脂质体70mg/m2，亚叶酸钙400mg/m2，氟尿嘧啶2400mg/m2,每两周为1周期）和氟尿嘧啶、亚叶酸钙治疗组（亚叶酸钙400mg/m2，氟尿嘧啶2400mg/m2,每两周为1周期）。其中49名被分配到伊立替康脂质体组，51例患者被随机分配到对照组，由于4例患者未开始治疗筛败，最终每组48例患者接受治疗。

研究结果显示：伊立替康组中位治疗时间为1.6个月(IQR为1.0 - 5.1)，对照组中位治疗时间为1.4个月(IQR为0.9-3.4)。伊立替康组的中位随访时间为5.9个月(IQR为2.7 -10.1)，对照组的中位随访时间为6.4个月(IQR为3.1-12.2)。伊立替康组vs对照组的中位PFS时间分别为2.6个月(95% CI 1.7-3.6) vs 2.3个月(95% CI 1.6-3.4)，HR 0.87，95% CI 0.56–1.35，p=0.52。伊立替康组vs对照组的6个月无进展生存率为23% (95% CI 10-35) vs 23%(95% CI 10-36)。ORR分别为14% (95% CI 6−27;7例患者) vs 4%(95% CI 1−14;2例患者)。对照组的中位OS略长于伊立替康脂质体组(8.2个月，95% CI 5.4-11.9 vs 6.9个月，5.3-10.6，HR 1.08)。

在安全性方面，在该研究中，伊立替康脂质体组报告了544例不良事件，其中293例与伊立替康脂质体相关。3级及以上不良事件中，伊立替康脂质体组34例（71%）患者共报告了95例不良事件，对照组24例患者(50%)共报告了57例，其中，伊立替康脂质体组严重不良反应27例（56%），对照组19例（40%）。伊立替康脂质体组不良反应最常见的为中性粒细胞减少（17%）、腹泻（15%）,对照组最常见的不良反应为胆管炎（8%）和胆管狭窄（8%）。

NALIRICC研究表明，在含吉西他滨治疗失败的胆道恶性肿瘤患者中，伊立替康脂质体联合氟尿嘧啶、亚叶酸钙的方案在PFS和OS方面并没有显著优于对照组且毒性更高。目前的NALIRICC研究结果并不支持伊立替康脂质体作为胆道恶性肿瘤的二线治疗方案。

3.胆汁代谢指纹图谱鉴别胆道恶性肿瘤和良性胆道疾病（IF:12.9）

Yang S, Fu J, Qin W, et al. Bile metabolic fingerprints distinguish biliary tract cancer from benign biliary diseases. Hepatology. Published online June 11, 2024.

摘要：Background and aims: Biliary tract cancers are aggressive gastrointestinal malignancies characterized by a dismal 5-year overall survival rate <20%. Current diagnostic modalities suffer from limitations regarding sensitivity and specificity. This study aimed to develop a bile metabolite-based platform for precise discrimination between malignant and benign biliary diseases.Approach and results: Samples were collected from 336 patients with biliary tract cancer or benign biliary diseases across 3 independent cohorts. Untargeted metabolic fingerprinting was performed on 300 bile samples using novel nanoparticle-enhanced laser desorption/ionization mass spectrometry. Subsequently, a diagnostic assay was developed based on the exploratory cohort using a selected bile metabolic biomarker panel, with performance evaluated in the validation cohort. Further external validation of disease-specific metabolites from bile samples was conducted in a prospective cohort (n = 36) using quantitative analysis. As a result, we established a novel bile-based assay, BileMet, for the rapid and precise detection of malignancies in the biliary tract system with an AUC of 0.891. We identified 6-metabolite biomarker candidates and discovered the critical role of the chenodeoxycholic acid glycine conjugate as a protective metabolite associated with biliary tract cancer.Conclusions: Our findings confirmed the improved diagnostic capabilities of BileMet assay in a clinical setting. If applied, the BileMet assay enables intraoperative testing and fast medical decision-making for cases with suspected malignancy where brush cytology detection fails to support malignancy, ultimately reducing the economic burden by over 90%.

陈世礼研究员（上海市胆道疾病研究重点实验室）：

胆道恶性肿瘤恶性程度较高，其5年生存率不足20%。当前胆道恶性肿瘤的诊断主要依赖放射成像、内窥镜检查、病理评估及血清肿瘤标志物CA19-9等。然而这些检查手段的灵敏度和特异性存在一定的局限性，难以早期诊断胆道恶性肿瘤，使得大部分的胆道恶性肿瘤患者到了晚期才被发现，从而错失了及早干预的机会。因而有必要发展早期诊断胆道恶性肿瘤的生物标志物。

胆汁作为与胆道组织直接接触的一种体液，包含了丰富的与胆道恶性肿瘤相关的生物分子。当前有一些基于胆汁中的基因或蛋白表达来诊断胆道恶性肿瘤的研究，然而作为生物体代谢终端产物的代谢物，目前很少有针对胆汁中代谢物的变化来诊断胆道恶性肿瘤的研究。仅有的几项基于胆汁中代谢物的研究也在诊断灵敏度、特异性及样本量等方面存在一些局限性。

为了克服以上局限，来自东方肝胆外科医院的王红阳院士团队和来自上海交通大学的钱昆教授团队及合作者在三个独立的队列中共采集了336名胆道恶性肿瘤和胆道良性疾病患者的胆汁样本。通过基于纳米粒子增强激光解吸/电离质谱的非靶向代谢组学方法分析了300例回顾性队列胆汁样本的代谢物轮廓，共检测到了130个胆汁代谢物。在探索队列中通过机器学习筛选出了6个胆汁代谢标志物（葡萄糖、甘氨鹅脱氧胆酸、乙酰乙酸、苯基乳酸、亚油酸、水杨酸）并构建了诊断模型BileMet，其最优AUC为0.891，在验证队列中此诊断模型的AUC为0.868，均优于肿瘤检测金标准的细胞刷检或非侵入式的血清肿瘤标志物CA19-9、CEA（AUC为0.667~0.838）。此外，BileMet也可较好的区分胆囊癌和胆囊良性疾病（AUC=0.951），胆管癌和胆管良性疾病（AUC=0.833），肝门部胆管癌和胆管良性疾病（AUC=0.855），远端胆管癌和胆管良性疾病（AUC=0.827）。

作者接着构建了这6个胆汁代谢标志物的靶向分析方法，并对36个前瞻性队列病人的胆汁样本进行了分析，结果显示其诊断AUC达到了0.912，表明所构建的胆汁代谢标志物诊断模型具有较好的胆道恶性肿瘤预测和诊断能力。在这6个胆汁代谢标志物中，甘氨鹅脱氧胆酸在胆道恶性肿瘤病人胆汁中的下调趋势最为明显，且在细胞实验中证实了其具有抑制胆道恶性肿瘤的功能，这也为今后开发针对甘氨鹅脱氧胆酸抗胆道肿瘤的治疗方法提供了研究基础。综上所述，本研究基于336个病人的大队列开发了诊断胆道恶性肿瘤的胆汁代谢物模型BileMet。所采用的纳米粒子增强激光解吸/电离质谱非靶向代谢组学方法实现了胆汁代谢物轮廓的系统描绘，且由于采取新的固相分离而无需色谱分离，样本处理简单仅需稀释即可，所需样本量也很少（仅需1.5微升），单个样本处理和分析可在半小时内完成。本研究所构建的胆汁代谢物模型BileMet用于诊断胆道恶性肿瘤的特异性和灵敏度均优于传统的细胞刷检或血清蛋白肿瘤标志物，且经过了回顾性及前瞻性队列病人验证。简单迅速的样本检测分析及高可信度的诊断能力和较低的检测成本使得BileMet不仅有望用于胆道恶性肿瘤病人的大规模筛查，还可用于辅助临床手术过程中的即时诊断决策。

4.GPRC5A 通过 JAK2-STAT3 通路上调 TNS4 促进胆囊癌转移（IF: 9.1）

Yang J, Li X, Chen S, et al. GPRC5A promotes gallbladder cancer metastasis by upregulating TNS4 via the JAK2-STAT3 pathway. Cancer Lett. Published online June 26, 2024.

摘要：Aberrant expression of G protein-coupled receptor class C group 5 member A (GPRC5A) has been reported in multiple cancers and is closely related to patient prognosis. However, the mechanistic role of GPRC5A in gallbladder cancer (GBC) remains unclear. Here, we determined tumor expression levels of GPRC5A and the molecular mechanisms by which GPRC5A regulates gallbladder cancer metastasis. We found that GPRC5A was significantly upregulated in GBC, correlating with poorer patient survival. Knocking down GPRC5A inhibited GBC cell metastasis both in vitro and in vivo. GRPRC5A knockdown resulted in downregulation of TNS4 expression through the JAK2-STAT3 axis. Clinically, GPRC5A expression positively correlated with TNS4. Finally, STAT3 bound to TNS4's promoter region, inducing its expression. Overall, GPRC5A showed high expression in GBC tissues, associated with poor patient prognosis. Our findings first demonstrate that the GPRC5A-JAK2-STAT3-TNS4 pathway promotes GBC cell metastasis, suggesting potential therapy targets

刘诗蕾博士（上海市胆道疾病研究重点实验室）：

这是一篇由上海交通大学医学院附属仁济医院刘颖斌教授团队于2024年6月在《Cancer Letters》上发表的研究论文。该项研究继续聚焦于刘颖斌教授的研究方向-胆囊癌，通过高通量的蛋白质组学质谱和转录组测序技术，筛选出了本项研究的主角—GPRC5A( G蛋白偶联受体家族C5组成员A，G protein-coupled receptor class C group 5 member A)。该项研究发现，与癌旁组织相比，GPRC5A的蛋白水平及RNA水平在胆囊癌组织中均呈显著高表达。同时，GPRC5A高表达与胆囊癌患者较短的总生存期以及肿瘤侵袭深度、发生淋巴结转移和较晚的TNM分期密切相关。随后，研究团队利用CCK-8、平板克隆、脾注射肝转移模型等实验证实了GPRC5A具有促进胆囊癌增殖、转移的能力。为了进一步探索GPRC5A调控胆囊癌进展的机制，研究团队通过转录组测序筛选出了在胆囊癌中与GPRC5A表达情况显著正相关的TNS4(张力蛋白4，Tensin 4)。接下来，研究团体通过一系列设计严谨的实验和参考既往相关研究的“干湿结合”，发现并验证了GPRC5A能激活JAK2-STAT3信号通路，并通过转录因子STAT3与TNS4启动子的结合，转录激活从而正向调节TNS4的表达，从而促进胆囊癌发生转移。这些发现为胆囊癌的诊断和治疗提供了新的思路和潜在靶点，具有重要的临床应用价值。

创新点

1.首次发现：本文首次报道了GPRC5A在胆囊癌中的高表达及其与不良预后的关联。

2.机制研究：揭示了GPRC5A通过JAK2-STAT3-TNS4通路调控胆囊癌转移的分子机制。

3.新靶基因：首次证明了TNS4是STAT3在胆囊癌中的新靶基因。

5.基于抗PD-1/PD-L1的胆道恶性肿瘤免疫治疗中肠道菌群和代谢物临床反应特征（IF：9.5）

Zhu C, Wang Y, Zhu R, et al. Gut microbiota and metabolites signatures of clinical response in anti-PD-1/PD-L1 based immunotherapy of biliary tract cancer. Biomark Res. 2024;12(1):56.

摘要：Background: Accumulating evidence suggests that the gut microbiota and metabolites can modulate tumor responses to immunotherapy; however, limited data has been reported on biliary tract cancer (BTC). This study used metagenomics and metabolomics to identify characteristics of the gut microbiome and metabolites in immunotherapy-treated BTC and their potential as prognostic and predictive biomarkers.Methods: This prospective cohort study enrolled 88 patients with BTC who received PD-1/PD-L1 inhibitors from November 2018 to May 2022. The microbiota and metabolites significantly enriched in different immunotherapy response groups were identified through metagenomics and LC-MS/MS. Associations between microbiota and metabolites, microbiota and clinical factors, and metabolites and clinical factors were explored.Results: Significantly different bacteria and their metabolites were both identified in the durable clinical benefit (DCB) and non-durable clinical benefit (NDB) groups. Of these, 20 bacteria and two metabolites were significantly associated with survival. Alistipes were positively correlated with survival, while Bacilli, Lactobacillales, and Pyrrolidine were negatively correlated with survival. Predictive models based on six bacteria, four metabolites, and the combination of three bacteria and two metabolites could all discriminated between patients in the DCB and NDB groups with high accuracy. Beta diversity between two groups was significantly different, and the composition varied with differences in the use of immunotherapy.Conclusions: Patients with BTC receiving immunotherapy have specific alterations in the interactions between microbiota and metabolites. These findings suggest that gut microbiota and metabolites are potential prognostic and predictive biomarkers for clinical outcomes of anti-PD-1/PD-L1-treated BTC.

汤秋义博士（上海市胆道疾病研究重点实验室）：

这是一项关于肠道菌群和代谢物与胆道恶性肿瘤免疫治疗反应性的相关性研究。文章通过宏基因组学和代谢组学的分析方法，深入挖掘了胆道恶性肿瘤患者接受免疫治疗后肠道菌群和代谢物的变化，并探讨了它们与治疗效果和生存的关系。

研究团队收集了215名胆道恶性肿瘤患者的肠道样本，根据严格的纳排标准最终纳入了88名患者。这些患者都接受了标准的抗PD-1/PD-L1治疗，并根据RECIST 1.1标准进行疗效评估。其中，持续临床获益组包括CR、PR或SD持续大于6个月的患者，非持续获益组包括PD或SD持续小于6个月的患者。通过高通量测序技术，对这些患者的肠道样本进行了宏基因组学分析，使用了MetaPhlAn和HUMAnN软件对数据进行注释和分析。此外，还利用LC-MS/MS技术对样本中的代谢物进行了分析。

研究发现免疫治疗后持续获益组和非持续获益组患者的肠道菌群和代谢物存在显著差异。菌群分析显示许多菌种的差异富集，如Escherichia coli在持续获益组明显增加，而非持续获益组中Faecali bacterium prausnitzii的富集程度最高。代谢物分析发现了24个在两组间差异显著的代谢物。这些菌群和代谢物与免疫治疗的生存获益呈现不同程度的关联。其中，Alistipes与生存预后呈显著正相关，而Bacilli、Lactobacillales和Pyrrolidine则与生存预后呈显著负相关。另外，研究还发现肠道菌群的多样性与免疫治疗的疗效之间存在关联，较高的多样性与良好的临床反应相关。

为了进一步研究肠道菌群和代谢物与治疗效果和生存之间的关联，研究团队建立了多个预测模型，利用不同菌群和代谢物组成来区分免疫治疗持续获益患者和非持续获益患者。这些模型显示出一定的预测价值。

研究存在一些不足之处。首先，研究样本量较小，样本数量的不足可能限制了结果的可靠性和推广性。进一步的大样本研究是必要的，以进一步验证和复制这些结果。其次，本研究是一个观察性研究，不能确定菌群和代谢物变化与免疫治疗效果之间的因果关系。因此，未来应该开展更多的实验和机制研究来解释这种关系。此外，尽管研究团队已经采取了一系列分析和控制措施来减少潜在的干扰因素，仍然存在一些临床因素的混淆，并可能对最终结果产生影响。更好的控制和考虑临床因素的影响能够更准确地解释肠道菌群和代谢物与治疗结果之间的关系。

总结起来，本文通过宏基因组学和代谢组学的方法，深入研究了胆道恶性肿瘤患者接受免疫治疗后肠道菌群和代谢物的变化，并探讨了它们与治疗效果和生存之间的关系。尽管研究发现了一些显著的差异，但仍然需要进一步的研究来验证和解释这些结果。

6.胆囊癌多模型分析揭示摄取 OxLDL 的中性粒细胞在促进肝脏侵袭的作用（IF：9.4）

Rao D, Li J, Zhang M, et al. Multi-model analysis of gallbladder cancer reveals the role of OxLDL-absorbing neutrophils in promoting liver invasion. Exp Hematol Oncol. 2024;13(1):58. Published 2024 May 31.

摘要：Background: Gallbladder cancer (GBC) is the most common and lethal malignancy of the biliary tract that lacks effective therapy. In many GBC cases, infiltration into adjacent organs or distant metastasis happened long before the diagnosis, especially the direct liver invasion, which is the most common and unfavorable way of spreading.Methods: Single-cell RNA sequencing (scRNA-seq), spatial transcriptomics (ST), proteomics, and multiplexed immunohistochemistry (mIHC) were performed on GBC across multiple tumor stages to characterize the tumor microenvironment (TME), focusing specifically on the preferential enrichment of neutrophils in GBC liver invasion (GBC-LI).Results: Multi-model Analysis reveals the immunosuppressive TME of GBC-LI that was characterized by the enrichment of neutrophils at the invasive front. We identified the context-dependent transcriptional states of neutrophils, with the Tumor-Modifying state being associated with oxidized low-density lipoprotein (oxLDL) metabolism. In vitro assays showed that the direct cell-cell contact between GBC cells and neutrophils led to the drastic increase in oxLDL uptake of neutrophils, which was primarily mediated by the elevated OLR1 on neutrophils. The oxLDL-absorbing neutrophils displayed a higher potential to promote tumor invasion while demonstrating lower cancer cytotoxicity. Finally, we identified a neutrophil-promoting niche at the invasive front of GBC-LI that constituted of KRT17+ GBC cells, neutrophils, and surrounding fibroblasts, which may help cultivate the oxLDL-absorbing neutrophils.Conclusions: Our study reveals the existence of a subset of pro-tumoral neutrophils with a unique ability to absorb oxLDL via OLR1, a phenomenon induced through cell-cell contact with KRT17+ GBC cells in GBC-LI.

孔磊博士（上海市胆道疾病研究重点实验室）：

胆囊癌（GBC）侵袭肝脏严重影响患者的预后，因此，阐明 GBC 肝侵袭的特征对于制定有效的治疗策略至关重要。在本研究中，复旦大学附属中山医院樊嘉院士、高强教授团队对来自15名GBC患者（GBC-Lo，Localized GBC，n=8；GBC-LI，GBC liver invasion，n=7）的38例样本（包括肿瘤、癌旁及血液样本）进行了单细胞RNA测序（scRNA-seq），同时结合空间转录组学（ST）、蛋白质组学和多重免疫组化（mIHC）分析，聚焦于GBC-LI的肿瘤微环境（TME），揭示了中性粒细胞在GBC-LI中的特异性富集及其免疫抑制特性。研究发现，中性粒细胞在不同组织环境中的转录状态不同，其中肿瘤相关中性粒细胞（Tumor-Modifying neutrophils）表现出氧化低密度脂蛋白（oxLDL）代谢相关基因的高表达。体外实验结果表明，GBC细胞与中性粒细胞的直接细胞-细胞接触显著增加了中性粒细胞对oxLDL的摄取，摄取oxLDL的中性粒细胞表现出更强的促肿瘤侵袭能力，同时其抗癌细胞毒性较低。进一步研究发现，中性粒细胞上OLR1（Oxidized Low-Density Lipoprotein Receptor 1）的表达升高主要介导这一过程，阻断OLR1可以显著减少oxLDL进入中性粒细胞，表明OLR1在中性粒细胞摄取oxLDL并促肿瘤侵袭中起关键作用。研究还发现，GBC-LI的侵袭前沿存在一个由KRT17阳性GBC细胞、中性粒细胞及周围成纤维细胞组成的中性粒细胞促进生态位，这一生态位可能有利于摄取oxLDL的中性粒细胞适应TME，进而促进肿瘤侵袭。然而，GBC-中性粒细胞接触以及oxLDL 摄取过程可能涉及比肿瘤表达KRT17 和中性粒细胞 OLR1 激活更复杂的机制，需要未来进一步地探索。中性粒细胞在适应胆囊癌肝脏侵袭的TME中表现出高度可塑性，为设计创新的免疫治疗策略开辟了新的途径。

综上，本研究通过scRNA-seq、ST、蛋白组学等多模式分析确定了一种新的肿瘤浸润中性粒细胞状态，其特点是 OLR1 介导的 oxLDL 摄取，揭示了中性粒细胞在GBC肝侵袭中的作用主要通过oxLDL代谢相关通路实现。此外，KRT17阳性的GBC细胞通过直接细胞接触诱导中性粒细胞摄取oxLDL，进一步促进肿瘤侵袭。本研究的发现为理解GBC的肿瘤微环境以早期识别和干预其侵袭行为提供了新的视角，并为未来开发针对中性粒细胞的治疗策略提供了理论基础和潜在靶点。

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上海交通大学附属新华医院普外科

上海交通大学医学院附属新华医院普外科创建于1958年，学科医、教、研水平居国内领先，以消化道肿瘤、器官移植、甲乳外科、微创外科为特色。普外科是卫生部国家临床重点专科，是卫生部首批批准的肝移植定点医院。2016年成立上海市胆道疾病研究中心。