Publications

OBJECTIVES: To evaluate the feasibility, safety, and technical performance of robot-assisted CT-guided cryoablation for pulmonary metastases.

MATERIALS AND METHODS: A single-centre IDEAL stage 2a prospective development study of 26 participants (median age 62 years, IQR 47-71; 14 men) who underwent 30 procedures targeting 37 lung metastases using a robotic navigation system. Median tumour diameter was 9.8 mm (IQR 5.1-12.8). All procedures were performed under general anaesthesia with high-frequency jet ventilation. Feasibility, safety, and technical performance (targeting accuracy, manipulations, radiation dose) were recorded.

RESULTS: Robotic guidance was successfully completed without conversion in 35/37 tumours (95%). One major complication occurred (3%, CTCAE grade 3 pneumothorax requiring 4 days of drainage); all others were grade 1-2. Pneumothoraces were managed by observation (n = 7) or prophylactic intraprocedural chest drain insertion (n = 11). No bronchopleural fistulas were observed. Median hospital stay was 1 night (IQR 1-2). A total of 54 cryoprobes were used. Median Euclidean targeting error on first insertion was 6.1 mm (IQR 2.9-9.7) and lateral error 4.2 mm (IQR 2.2-6.5). The median number of manipulations per probe was 1 (IQR 0-2.5), with one-third requiring no adjustment. Once integrated into the workflow, the "chopstick" technique was frequently applied, supporting conformal ablation. Median total procedure time was 66.5 min (IQR 56.6-92.8). Twelve-month local tumour progression-free survival was 97%.

CONCLUSION: Robot-assisted CT-guided cryoablation of pulmonary metastases was feasible, safe, and accurate, achieving high targeting precision with minimal cryoprobe manipulation. These findings support evaluation in prospective comparative trials.

KEY POINTS: Question Robotic-assisted CT-guided cryoablation of lung metastases is feasible and safe, achieving high targeting accuracy and minimal probe manipulation, even in anatomically challenging cases. Findings Robotic trajectory planning supported complex multiprobe configurations. Procedural refinements-including patient positioning, probe selection, and adoption of "chopstick" configurations-were introduced to address bleeding risk and optimise energy delivery. Clinical relevance Robot-assisted navigation is particularly advantageous in cryoablation, enabling minimal manipulations and accurate probe placement despite the often-necessary complex trajectories.

Apolipoprotein E (APOE) ε4 is the strongest genetic risk factor for Alzheimer's disease (AD). However, it is known that other pathways independent of APOE also play a role in AD. Disentangling APOE-dependent and independent effects is instrumental for understanding the biology of AD. We conducted an APOE-stratified multi-omic analysis in multiple large datasets to identify AD-associated plasma proteins and metabolites. More than 64% of the identified proteins were not found in non-APOE stratified studies, and 17% of the proteins showed APOE-specific trends. Mitochondrial dysfunction was associated in AD independently of APOE and was accompanied by disruptions in glucose and lipid metabolism and cell death and increased in inflammatory signaling activation. Lipid upregulation was found in AD cases when compared with controls with the same APOE genotype, indicating that additional factors beyond APOE affect lipid regulation and AD risk. These findings may be informative in guiding the development of effective medications for AD.

GGGGCC (G4C2) repeat expansion in C9ORF72 is the most common genetic cause of amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD). Toxicity is thought to result from the accumulation of either repeat RNAs and/or dipeptide repeat proteins (DPRs) translated from repeat-containing transcripts through repeat-associated non-AUG (RAN) translation. To disentangle RNA from DPR toxicity, we mutated a CUG codon predominantly used to initiate DPR translation from all three reading frames. This mutation disrupted DPR synthesis while preserving the expression of repeat-containing RNAs. Despite the accumulation of RNA foci, behavioral deficits and pathological abnormalities, including p-TDP-43 inclusions, STING activation, motor neuron loss, neuroinflammation, and increased plasma neurofilament concentration, were alleviated in C9ORF72 mice. Base editing of the CUG codon also improved molecular phenotypes and survival in patient induced pluripotent stem cell-derived neurons, which highlights the potential of therapeutically targeting DPR production rather than repeat RNAs.

Priming rare subdominant precursor B cells in germinal centers (GCs) is a central goal of vaccination to generate broadly neutralizing antibodies (bnAbs) against HIV. Multivalent immunogen display on protein nanoparticle scaffolds can promote such responses, but it also generates scaffold-specific B cells that could theoretically limit bnAb precursor expansion in GCs. We rationally designed DNA origami-based virus-like particles (DNA-VLPs) displaying a germline-targeting HIV envelope protein immunogen, which elicited no scaffold-specific antibody responses. Compared with a state-of-the-art clinical protein nanoparticle, these DNA-VLPs increased the expansion of epitope-specific GC B cells relative to off-target B cells and enhanced expansion of bnAb-lineage B cells in a humanized mouse model of CD4 binding site priming. Thus, minimizing off-target responses enhances bnAb priming and indicates that DNA-VLPs are a promising vaccine platform.

Estrogen receptor (ER) positive breast cancer is the most prevalent subtype, commonly responsive to endocrine therapies. Immune checkpoint inhibitors (ICIs) have limited efficacy in ER-positive disease, highlighting the need for the development of combination immunotherapies for these patients. We previously established that nitroso-N-methylurea-induced mammary tumors in outbred Sprague-Dawley rats mimic immune evasive mechanisms and the heterogeneity of ICI response observed in patients. We identified a "luminal growing" gene signature in ER-positive tumors, which correlated with tumor growth and immune-related differences. Here, we evaluated targeting candidates from this signature KMT5B/C and IKBKE using inhibitors A-196 and IKBKEi respectively, alongside anti-estrogen (fulvestrant) and a TGFβ blocking antibody (NIS793), both individually and in combination with αPD-L1, within this rat model. Fulvestrant emerged as the most effective treatment, inducing regression of most existing tumors and reducing on-treatment tumor burden when combined with αPD-L1. A-196, while ineffective as a monotherapy, demonstrated enhanced response when combined with αPD-L1. Comprehensive tumor profiling through polychromatic flow cytometry and single-cell RNA sequencing revealed that A-196 induced a luminal-to-basal shift in tumor epithelial cells, enhancing antigen presentation, whereas epithelial-to-mesenchymal transition was linked to fulvestrant resistance. Our findings underscore the value of the rat mammary tumor model for preclinical studies in ER-positive breast cancer and advocate for the further validation and potential clinical development of KMT5B/C inhibitors to enhance the efficacy and broaden the applicability of ICI therapy in cancer patients.

Tumor-associated neutrophils (TANs) are abundant across cancers, yet their phenotypic diversity and functional states remain poorly defined. Here, we introduce a cell-type probability classifier that recovers low-transcript neutrophils from scRNAseq datasets, enabling pan-cancer analyses of TAN heterogeneity. Across >190 human and murine tumors, we identify a conserved differentiation trajectory that culminates in a terminal CCL3hi state. This state exhibits pro-tumor transcriptional programs, including those involved in hypoxic adaptation and senescence. Consistently, CCL3hi TANs are enriched in hypoxic tumor niches in both humans and mice. Through mechanistic perturbations of neutrophil-derived CCL3 in mice, we show that it sustains TAN survival in hypoxic tumor regions via CCR1-dependent signaling. These findings establish CCL3 as a conserved marker and functional driver of pro-tumor neutrophils in growing tumors, and provide a scalable framework for dissecting neutrophil biology across cancer types.

Carotid sinus hypersensitivity (CSH) is commonly associated with elderly patients and underlying cardiovascular conditions. We present a rare case of cardiac arrest in a young, healthy female, occurring immediately after a jaw thrust maneuver during mask ventilation, due to carotid sinus compression and subsequent vagal stimulation. This case highlights the need to consider CSH as a cause of sudden intraoperative cardiac arrest, even in young patients without risk factors.

Peer support is an effective strategy to promote self-management behaviors and improve well-being in those with cardiometabolic disease, including type 2 diabetes mellitus (T2DM). There is limited knowledge about stakeholder perceptions regarding peer support programs in low- and middle-income countries (LMICs). The study assessed stakeholders' awareness and understanding of peer support initiatives for T2DM, and explored their perceived barriers and readiness for implementation. A cross-sectional, self-administered online survey with branching logic was distributed to stakeholders across macro- (health policy), meso (tertiary hospital), and micro (community) levels of LMIC healthcare systems from June 1 to December 15, 2023. Quantitative data were analyzed descriptively; qualitative data underwent thematic content analysis. A total of 69 respondents from 25 LMICs participated in the survey. Due to branching logic and response attrition, 53 surveys (77%) had complete responses. Most respondents were medical doctors (n = 35, 50.7%) and a large proportion worked in tertiary hospitals (n = 27, 39.1%). Thirty-nine respondents (56.5%) were aware of peer support; among the 38 respondents with complete data, 29 (76%) reported active involvement in T2DM peer support initiatives. Of 15 responses to open-ended questionnaires regarding barriers to T2DM peer support, 9 (60%) cited concerns about limited resources and lack of funding. Local leadership (mean ± standard deviation: 3.4 ± 1.2), resource allocation (2.7 ± 1.4), and sustainability planning (2.7 ± 1.4) showed the highest perceived readiness on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Stakeholders in LMICs demonstrate awareness and active involvement in T2DM peer support programs. While limited resources and funding remain significant barriers, local leadership, resource allocation, and sustainability planning showed the highest perceived readiness, indicating promising foundations for implementation. Strengthening these areas through targeted support could facilitate the expansion and sustainability of peer support initiatives in resource-constrained settings.