Jamal, Fares

The role of circulating tumor DNA (ctDNA) in gastroesophageal adenocarcinoma (GEA) has expanded in recent years. In resectable disease, postoperative ctDNA is able to detect patients at highest risk of recurrence months before scans. Tumor-informed assays provide the best sensitivity and emerging methylation assays are useful when tissue is scarce. In metastatic GEA, baseline ctDNA burden correlates with prognosis, and a decrease in ctDNA level after treatment initiation reflects therapeutic response. It can also uncover actionable targets, including ERBB2, FGFR2, and MSI-H, and detect resistance that can arise after starting treatment. Limitations include variable assay performance, low shedding in some tumors, clonal hematopoiesis confounding, and a lack of randomized data showing that ctDNA-guided changes improve outcomes. Ongoing trials are testing MRD-guided escalation/de-escalation and ctDNA-directed biomarker therapy. In this review, we evaluate the role of ctDNA in GEA cancers over recent years.

Background: Cardiac amyloidosis (CA) patients with reduced left ventricular ejection fraction (EF) are at increased risk for mortality. The benefit of cardiac resynchronization therapy (CRT) in terms of mortality reduction has not been established in this population. Aim: To evaluate the survival benefit of CRT, either CRT-D or CRT-P, in a large cohort of patients with cardiac amyloidosis and reduced EF. Methods: We retrospectively analyzed patients with confirmed CA and reduced EF (<40%) between 2009 and 2023 across Mayo Clinic sites. Patients were stratified into three groups: no device, CRT with pacemaker function (CRT-P), and CRT with defibrillator function (CRT-D). CRT devices were indicated for low ejection fraction less than 40% and patients who had chronic heart failure with a wide QRS. Kaplan-Meier survival estimates were generated, and log-rank tests were used for comparison. A secondary analysis was conducted combining CRT-P and CRT-D versus no device (EF <40%), and a tertiary analysis compared CRT-P versus CRT-D. Results: Among 184 patients [36 AL (20%), 148 ATTR (80%)], 38 (19%) had no cardiac device and EF <40%, 20 (11%) received CRT-P, and 116 (63%) received CRT-D. The median follow-up was 3.4 years (1.7, 5.0). The probability of survival was significantly higher in the CRT group compared to the no device-EF<40 group (Log Rank p=0.013; figure B). Among patients receiving CRT, there was no significant difference in all-cause mortality between those receiving CRT-P and those receiving CRT-D (Log Rank p=0.5; figure C). Conclusion: In patients with cardiac amyloidosis and reduced EF, CRT is associated with significantly improved survival compared to no device. No mortality difference was observed between CRT-P and CRT-D. Prospective studies are warranted.

ABSTRACT Sjögren's syndrome (SS) is a chronic autoimmune disorder characterized by lymphocytic infiltration and destruction of exocrine glands, commonly involving the salivary and lacrimal glands, leading to dry mouth and eyes. While SS primarily affects the upper gastrointestinal tract, this case presents a rare small intestine involvement. This patient was diagnosed with SS in 2018 with positive antinuclear antibodies (ANA), rheumatoid factor (RF), SSA antibodies, and salivary lip gland biopsy. By 2021, she developed unusual cyclic episodes of nausea, vomiting, and poor oral intake, resulting in significant weight loss and recurrent hospitalizations. She had frequent hospitalizations due to her recurrent symptoms. Evaluations included esophagogastroduodenoscopy (EGD) and colonoscopy, but pathology was nondiagnostic. Several abdominal and pelvic computed tomography (CT) scans demonstrated bladder edema, pancolitis, and terminal ileitis with mucosal hyperenhancement of the bowel and moderate ascites, likely inflammatory. Her gastric emptying study showed hypermotility. Multiple teams, including Rheumatology, Allergy/Immunology, Gastroenterology, Hematology, and Surgery, were involved. C1 esterase antigen was normal, ruling out hereditary angioedema. PET‐CT scan did not show lymphadenopathy or significant inflammation. Full biopsy for definitive diagnosis was deferred due to concerns of decreased healing with an edematous intestine. She was trialed on Icatibant without benefit. Differentials included lupus peritonitis, protein‐losing enteropathy, and SS intestinal lymphoma. She was discharged on a trial of empiric high‐dose steroids with Rheumatology follow‐up. Symptoms recurred with steroid tapering. Her complement levels decreased with flares and increased with treatment. Rituximab was added, leading to steady clinical improvement and reduced hospitalizations. Bowel involvement has been predominantly described in lupus, often referred to as lupus enteritis or bowel vasculitis. To our knowledge, this represents the first reported case of Sjögren's syndrome. Bowel biopsies are not typically subjected to routine immunohistochemical staining. Consequently, standard testing may be limited in detecting autoimmune processes. This case highlights the diagnostic challenges of SS‐related gastrointestinal manifestations and underscores the importance of considering autoimmune enteropathy, particularly in patients who respond to immunosuppressive therapy.

Acute severe ulcerative colitis (ASUC) is a medical emergency affecting up to 25% of patients with ulcerative colitis (UC), with colectomy required in approximately 25–30% of cases during the initial admission. Intravenous corticosteroids remain the first-line therapy, though one-third of patients do not respond, necessitating rescue with infliximab or calcineurin inhibitors, which are both supported by randomized trials and guideline recommendations. Comparative studies and meta-analyses have shown similar efficacy between these agents, while sequential use is associated with higher adverse event rates and should be restricted to specialized centers. Recent data have refined infliximab use, with the PREDICT-UC trial showing no superiority of intensified dosing over standard regimens. Emerging therapies are under investigation: vedolizumab has been used as maintenance following calcineurin induction; ustekinumab has shown benefits in retrospective UC cohorts, particularly after cyclosporine; and Janus kinase (JAK) inhibitors represent the most recent addition. The randomized TACOS trial and the prospective TRIUMPH study demonstrated an improved short-term response with tofacitinib in steroid-refractory ASUC, and real-world reports suggest promising outcomes with upadacitinib. While infliximab and cyclosporine remain as standard rescue therapies, ongoing trials with novel agents are likely to broaden treatment options. This review summarizes the clinical features, initial management, and the role of advanced therapies in ASUC.

Primary biliary cholangitis (PBC) is a chronic autoimmune liver disease marked by cholestasis and progressive fibrosis. While ursodeoxycholic acid (UDCA) remains the first-line therapy, approximately 30–40% of patients have an inadequate biochemical response, increasing the risk of disease progression. Obeticholic acid (OCA), a potent farnesoid X receptor (FXR) agonist, was the first second-line agent approved by the only Food and Drug Administration (FDA) and has demonstrated moderate biochemical efficacy but limited tolerability due to dose-dependent pruritus and safety concerns in cirrhosis. Fenofibrate, a peroxisome proliferator-activated receptor alpha (PPAR-α) agonist, showed substantial alkaline phosphatase (ALP) reductions when added to UDCA, although its long-term benefit remains unconfirmed in large-scale trials and its use remains off-label in the United States, unlike FDA-approved agents. Seladelpar, a selective peroxisome proliferator-activated receptor delta (PPAR-δ) agonist, and elafibranor, a dual PPAR-α/δ agonist, have both recently received FDA accelerated approval after demonstrating significant improvements in ALP, biochemical response rates, and pruritus relief in phase 3 trials. This review summarizes these second-line therapies’ mechanisms, efficacy, safety, and limitations emphasizing the need for individualized treatment decisions and ongoing research into long-term clinical outcomes.

Metabolic dysfunction-associated steatotic liver disease (MASLD) and its progressive form, metabolic dysfunction-associated steatohepatitis (MASH), are among the most prevalent causes of chronic liver disease worldwide, closely linked to the global rise in overweight and obesity, type 2 diabetes, and metabolic syndrome. Until recently, treatment options were limited to lifestyle interventions, with no approved pharmacologic therapies. Resmetirom, a liver-directed, selective thyroid hormone receptor beta (THR-β) agonist, is a promising disease-modifying agent that targets hepatic lipid metabolism, inflammation, and fibrosis. Clinical trials, including the pivotal phase 3 MAESTRO-NASH and MAESTRO-NAFLD-1 trials, have demonstrated significant improvements in liver fat reduction, lipid profiles, histological endpoints, and health-related quality of life, with a favorable safety profile. In March 2024, the FDA granted accelerated approval of resmetirom for adults with MASH and moderate-to-advanced fibrosis, marking a significant milestone in MASLD treatment. This review discusses the mechanistic rationale, preclinical data, and pivotal clinical trial outcomes supporting resmetirom’s role in MASLD/MASH management, while outlining ongoing research needs, including long-term safety, pediatric evaluation, and biomarker development for optimized patient selection.

Abstract Biliary tract cancer (BTC) remains among the most challenging malignancies with a poor prognosis and limited treatment options, particularly in pretreated patients. As most patients experience disease progression after first-line treatment, effective second-line and subsequent treatments are required. Although the addition of modified FOLFOX (fluorouracil, leucovorin, and oxaliplatin) to active symptom control improved the overall survival of patients with progressing advanced BTC despite gemcitabine plus cisplatin treatment, its efficacy was modest. Moreover, most clinical trials demonstrated modest efficacy of molecular-targeted agents for molecularly unselected pretreated advanced BTC. Patients with advanced BTC carry a relatively high druggable genetic alteration rate and have shown promising responses to molecular-matched therapies targeting gene alterations such as FGFR2 fusions/rearrangements, IDH1 mutation, and HER2 overexpression/amplification. Additionally, tumor-agnostic approaches, including BRAF V600E, NTRK fusion, and RET fusion, have expanded the treatment options for some patients. Immune checkpoint inhibitors have shown limited efficacy as mono- or combination therapy in patients with pretreated advanced BTC. Therefore, developmental efforts have shifted to immune checkpoint inhibitor and other combinations such as vascular endothelial growth factor receptor inhibitors or radiation. In addition to refining combination strategies to enhance the therapeutic potential of immune checkpoint inhibitor, future research should focus on elucidating the tumor microenvironment. This review delineates the evolution of systemic therapies in patients with pretreated advanced BTC. By examining past developments and recent advances through prospective trials, it highlights novel approaches that may improve outcomes in this challenging disease.

820 Background: The number of FDA-approved anticancer drugs have increased in recent years with a more use of surrogate endpoints. However, it is unclear whether the same trend applies to GI cancers. Therefore, we aimed to evaluate the trend in FDA-approved GI cancer drugs over the past two decades and the associated clinical benefit. Methods: The FDA’s online database was searched for drugs approved for GI cancers from 2006 until 2024. Primary and secondary endpoints along with trial characteristics were extracted. ESMO Magnitude of Clinical Benefit Scale (ESMO-MCBS) was assessed by two blinded investigators with a third resolving disagreements. We divided the study into period A (01/2006-12/2014) and period B (01/2015-08/2024). Results: Since 2006, FDA approved 62 regimens for GI cancer based on 70 trials, mostly (n= 45;72.6%) in period B. Most trials (n=44) were phase III with only 26 phase II: 22 single arm, and 4 randomized. All the 22 single-arm phase II trials were approved in period B with two randomized phase II trials approved in each period. Approvals based on phase III trials dropped by 33.5% (from n=15 to n=29) between the two periods. Half (n=34) of the approvals were based on overall survival (OS) benefit, while the use of objective response rate (ORR) as an endpoint has increased from 11.8% (n=2) in period A to 45.3% (n=24) in period B. Quality of life (QoL) was assessed only in 27% of the studies and found benefit only in 22.7%. The mean gain in OS was similar across both periods; 2.3 months [1.2-4.7]. Out of the 19 accelerated approvals, 17 were in period B, of which 23% (4/17) were based on secondary endpoint, 18% (3/17) were withdrawn, and 59% (10/17) received full approval. Substantial clinical benefit (ESMO score 4-5) was seen in 11.8% of the trials in period A and 19.6% in period B, with 17.4% overall from 2006-2024. Conclusions: Despite rising FDA approvals for GI cancer drugs since 2006, only 17.4% demonstrated substantial clinical benefit based on ESMO-MCBS. Recent approvals rely more on single-arm phase II studies and ORR, often without OS or QoL benefit. These trends underscore the need for more rigorous clinical trials that prioritize meaningful endpoint to ensure that new therapies provide real clinical value to the patient.

451 Background: Perioperative chemotherapy with surgery is the standard of care for patients (pts) with resectable gastric or gastroesophageal junction adenocarcinoma (GEA). However, recent studies have shown more favorable responses after neoadjuvant immunotherapy (NIO) in patients with mismatch repair deficient (dMMR) cancers. Herein, we present the outcomes of 10 cases with dMMR GEA. Methods: We retrospectively reviewed patients with GEA at Mayo Clinic Arizona who met the following criteria: have dMMR disease by IHC, nonmetastatic operable disease, and received NIO +/- chemotherapy. Patient demographics, disease characteristics, and clinical outcomes were extracted. The primary endpoint was clinical complete response (cCR) in patients treated with non-operative management (NOM) defined as complete radiological response and no residual disease on endoscopic ultrasound (EUS) and biopsy. Results: 10 pts with dMMR GEA with a median age of 70 (43-85) were identified. 6 pts had T2N0, 1 had T4N0, 3 had N+ disease. 8 pts received NIO monotherapy upfront, 1 received NIO after progressing on chemotherapy, and 1 concurrently with chemotherapy. No grade 3/4 toxicities were reported, however, 2 pts discontinued therapy due to arthralgia and colitis. After NIO, 9/10 pts had significant or complete resolution of FGD avidity on PET/CT, while 1/10 had stable disease. 3/10 pts underwent surgical resection, with 2 achieving pathological complete response (pCR) and the third showing T1N0 disease with no recurrence 1 year after surgery. Notably, one of the pts with pCR passed away due to surgical complications. 7/10 patients had NOM, of whom, 4 had cCR and 3 had radiological response only, as no EUS data was available. 4/7 NOM pts had follow up data at 6 months with no evidence of progression, of whom one pt remained progression-free at 33 months. ctDNA testing was performed in 6/10 pts: 2 had undetectable ctDNA at baseline, while 3 became MRD-negative after NIO, consistent with radiological and/or pathological response, and 1 had persistent ctDNA both before and after NIO, despite cCR. Conclusions: This study demonstrates exceptional and prolonged response, along with good tolerability to NIO in pts with dMMR GEA, supporting the feasibility of non-operative management in such patients.