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Cancer immunotherapy is a transformative technology allowing for the elimination of malignant cells through immune system stimulation; however, the large-scale clinical application of adoptive cellular therapy technologies is limited due to difficulties in ex vivo immune cell engineering, high costs, and complicated manufacturing process. Recently, in vivo immune cell engineering was discovered as an emerging approach that allows for the genetic reprogramming of immune cells in patients, thus circumventing many problems inherent to traditional cellular therapy technologies. Breakthroughs in targeted drug delivery systems such as cell-penetrating peptides, antibody- and receptor-mediated delivery approaches, lipid nanoparticles (LNPs), polymeric drug carriers, and biomimetic delivery systems allow for the more effective selective delivery of messenger RNA (mRNA), clustered regularly interspaced short palindromic repeats (CRISPR)/Cas gene editing systems, proteins, and other types of cargo to the target immune cells. In vivo immune cell engineering allows for the efficient generation of chimeric antigen receptor T-cells (CAR-T), CAR- natural killer (NK) cells, engineered macrophages, dendritic cells, and other immune cell types; moreover, transient and permanent immune reprogramming is achievable via vivo technologies. The present review discusses the biological barriers limiting immune cell-targeted delivery, including biodistribution, cellular uptake, intracellular transport, and endosomal escape of delivered drugs, and reviews the latest advancements in targeted delivery technologies addressing these obstacles. We also address the latest applications of in vivo immune cell engineering in hematological malignancies and solid tumors, including mRNA therapeutics, CRISPR-based genome editing, and advanced programmable immunotherapy technologies. Furthermore, we discuss unresolved issues related to the specificity of targeting, efficiency of drug delivery, safety of treatment, manufacturing processes, and regulation of in vivo immune engineering technologies and outline future opportunities arising from the integration of nanomedicine, synthetic biology, genome engineering, and artificial intelligence-assisted materials science.

Abstract Aims Randomized trials comparing percutaneous left atrial appendage occlusion (LAAO) with oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation have yielded conflicting results across device generations and anticoagulant eras. This Bayesian meta-analysis of randomized trials aimed to compare LAAO vs. OAC for stroke or systemic embolism (SSE) and non-procedural clinically relevant bleeding (CRB). Methods and results We conducted a systematic search across five databases (PubMed, Embase, Scopus, Web of Science, and Cochrane CENTRAL) to identify randomized trials of LAAO vs. OAC. Primary outcomes of stroke or systemic embolism, non-procedural CRB and clinical benefit composite were estimated using a Bayesian hierarchical random effects model and findings confirmed across robust sensitivity and subgroup analyses. Posterior probabilities for superiority, non-inferiority and equivalence were estimated using clinically meaningful margins. Six randomized trials including 7004 participants in the intention-to-treat groups, were analysed. LAAO was not associated with lower SSE vs. OAC (pooled RR, 1.11; 95% CrI, 0.80–1.49), with a 74.6% posterior probability of favouring OAC. The posterior probability of crossing non-inferiority was P(HR < 1.4) of 89%. In contrast, LAAO reduced non-procedural CRB (pooled RR, 0.59; 95% CrI, 0.45–0.78). The net clinical benefit composite, pooling contemporary trials, demonstrated a pooled RR of 0.90 (95% CrI 0.51–1.50), with P(RR < 1) of 76%, with substantial heterogeneity for this outcome. Conclusion This Bayesian meta-analysis found no clear evidence supporting clinically meaningful non-inferiority of LAAO over OAC for stroke prevention. Despite reduced non-procedural bleeding, LAAO did not demonstrate a similar reduction in major bleeding.

Introduction Recent transcriptome analysis has demonstrated increased expression of Vascular Endothelial Growth Factor receptor-1 (VEGFR-1/FLT1) and in AD brain. Increased expression of VEGFR1 and its ligand VEGFB were associated with a more rapid rate of cognitive decline, providing evidence of a potential link between increased VEGFR-1 expression in AD pathogenesis. In this study, we explored the potential role of VEGFR-1 expression in neurons on AD pathology. Methods To confirm VEGFR1 expression in AD brains, we first performed immunostaining in AD brain sections (AD - Braak stage V-VI, and normal controls - Braak 0-II). And to determine a potential detrimental role of neuronal VEGFR1 expression on AD associated pathologies, we exposed SH-SY5Y human neuroblastoma cells and mouse primary neurons to either hypoxia conditions (1%O 2 ) or 5 μ Aβ1-42 oligomers or fibrils for 24, 28 and 72hrs. Results In this study, we found preferential staining of VEGFR-1 in the neuropil and neuronal cell bodies both in AD and Control hippocampus and increased VEGFR-1 immunoreactivity in dystrophic neuritic processes in the vicinity of Thio-S positive amyloid plaques in AD brains. And treatment of SH-SY5Y human neuroblastoma cell line and mouse primary neurons, with either hypoxia conditions or Aβ1-42 oligomers, resulted in increased VEGFR-1 expression and cleaved caspase 3 activation, leading to neuronal toxicities/cell death. Similarly, treatment with Aβ1-42 fibrils also increased VEGFR-1 and cleaved caspase 3 protein levels in the SH-SY5Y cells whereas treatment with Aβ1-42 monomers had no effect on VEGFR-1 expression. In addition, we show that over-expression of VEGFR-1 intracellular domains in SH-SY5Y cells directly induced neuronal toxicities and importantly, siRNA-mediated knockdown of VEGFR-1 in neurons prevented the hypoxia, Aβ1-42 oligomer and Aβ1-42 fibril-induced toxicities and cell death phenotypes. Treatment with either hypoxia or Aβ1-42 oligomers also reduced expression of cell survival genes including VEGFR-2 and Hippo pathway YAP1 and siRNA-mediated VEGFR-1 knockdown in the neurons normalized expression of both VEGFR-2 and YAP1. Using differential gene expression analysis, we demonstrated upregulation of several inflammatory/interferon-stimulated genes (ISGs) as well as increased expression of genes involved in activation of oxidative stress and cell death pathways in response to Aβ1-42 oligomers treatment in mouse primary neurons. And siRNA-mediated VEGFR-1 knockdown in the mouse primary neurons, reduced gene expression of both the ISGs and oxidative stress/cell death pathways in response to Aβ1-42 oligomer treatment. Discussion In summary, these results show that siRNA-mediated knockdown of VEGFR-1 in neurons significantly prevented hypoxia, Aβ1-42 oligomer and Aβ1-42 fibril-induced cellular toxicities and cell death phenotypes, indicating a potential detrimental role of aberrant VEGFR-1 expression and signaling in response to AD associated pathologies.

560 Background: Patients (pts) with early stage hormone receptor-positive, human epidermal growth factor receptor 2-negative (HR+/HER2-) breast cancer (BC) remain at both short and long term risk of recurrence. While clinico-pathological and gene-based biomarkers provide insight into early and late recurrence risk, additional prognostic tools are needed. We previously developed (Saha et al. Clin Cancer Res , 2025) a new breast MRI image-based artificial intelligence prognostic tool (TumorSight Risk) composed of both radiographic and clinical information. Here we sought to validate this tool in an independent cohort. Methods: In this multi-center, blinded, prospective/retrospective validation study, we sought to validate the 5-year recurrence-free survival (RFS) according to pre-defined risk scores (0-100) and categories (“high” or “low”) via pre-specified cutoff (≥47) for pts with HR+/HER2- BC. Kaplan-Meier and Cox regression analyses were then used to assess the unadjusted and adjusted association between risk category/score and the 5-year RFS. Results: 2,129 pts with HR+/HER2- BC diagnosed between January 1, 2010, and December 31, 2024, who underwent breast MRI prior to surgery (no neoadjuvant therapy) were included from four institutions. Median age was 57 years, 16% were Black, 15% had grade 3 disease, 93% were clinical T1 or T2, and 85%/15% were clinical N0/N1. At a median follow up of 6.24 years, the unadjusted hazard ratio (HR) for RFS comparing low (n=1808) and high risk (n=321) pts was 2.71 (95% CI = 1.95 – 3.76, p = 3x10 -9 ). The estimated 5 year RFS rate according to risk score (low and high) was 95.5% (95% CI: 94.63 – 96.3%) and 89.6% (95% CI = 86.4 – 92.6%) while the 10 year RFS estimates were 88.9% (95% CI = 86.5 - 90.9%) and 69.6% (95% CI = 59.1 – 77.9%). Univariate subgroup analysis demonstrated that the risk score was prognostic by age (< 50 vs. ≥50 years), pathologic nodal status, grade, and surgery type, regardless of chemo-, endocrine, or radiation therapy administration. The observed continuous risk score was strongly associated with risk of recurrence, with a 22% increase in relative risk per 10-unit change in risk score (0-100), translating to a 2.4% (95% CI = 1.2 – 4.5%) and 25.5% (95% CI = 15.4 – 40.4%) risk of recurrence at 5-years for pts at the lowest (0-9) versus highest (90-100) risk score. The prognostic association between risk score and RFS remained after adjusting for pathologic T- and N-stage, grade, age, race, and treatment (p = 0.002). Conclusions: TumorSight Risk is a new image-based biomarker for HR+/HER2- BC that provides prognostic information independent of standard clinico-pathological parameters. Given the ready availability of breast MRI in most pts with BC, TumorSight Risk may be a convenient tool for estimating risk for recurrence.

522 Background: Tumor-associated macrophages (TAMs) drive immune evasion and chemotherapy resistance in breast cancer through tumor microenvironment reprogramming. We developed a composite TAM score integrating transcriptional programs with spatial IHC polarization markers to stratify recurrence risk and enrich macrophage-modulating trials, hypothesizing it would improve prognostic accuracy in treatment-naïve disease and predict neoadjuvant chemotherapy (NACT) response. Methods: TAM score was derived from scRNA-seq atlases (n=4), filtering survival-associated genes in METABRIC/TCGA (n=2,509), and weighting IHC markers CD163/CD206 normalized to CD68/CSF1R via Cox coefficients. Validation: treatment-naïve invasive carcinomas (n=83; follow-up 57 months; 24 events). Primary endpoint: recurrence-free survival (RFS); multivariable Cox adjusted for age, tumor size, nodal status, grade, subtype, treatment. Predictive utility assessed in matched primary/post-NACT residual tumors (n=45) correlating TAM dynamics with RCB. Results: High TAM score (≥median) independently predicted worse RFS (HR 3.8, 95% CI 1.6-9.1, p<0.05) and outperformed CD163/CD68 alone (HR 2.1, p<0.05); 5-year RFS was 68% vs 91% (TAM-high vs TAM-low). Prognostic value persisted in node-negative (HR 4.2, p=0.02) and luminal B (HR 3.5, p=0.01) subsets. In the NACT cohort, baseline TAM score inversely correlated with pCR (12% vs 38%, p=0.04). Among residual disease (RCB-II/III, n=34), persistent TAM-high post-NACT identified 3-year RFS 52% vs 85% in TAM-low/normalized cases (HR 4.1, p=0.01), independent of RCB; CD163+/CD206+ expansion occurred in 76% of RCB-III vs 29% of RCB-I (p=0.008). Conclusions: This TAM score predicts recurrence from pre-treatment tissue and identifies macrophage-driven resistance persisting post-NACT, nominating TAM-high residual disease for macrophage-modulating trials. Translational evidence supports this: CSF1R inhibition reduced immunosuppressive TAMs, increased M1-like programs, decreased PD-L1/PD-L2, and enhanced anti-PD-1 efficacy preclinically with ex vivo confirmation. Early-phase data (rebastinib plus chemotherapy in HER2-negative metastatic disease) demonstrate feasibility, supporting prioritization of TAM-high patients with residual disease for trials combining TAM modulation with checkpoint therapy. TAM score performance in treatment-naïve and NACT cohorts. Endpoint TAM-High TAM-Low HR scores (95% CI) p-value Treatment Naïve cohort 5 year RFS (Overall) 68% 91% 3.8 (1.6-9.1) <0.05 RFS (node-negative) 4.0 0.02 RFS (luminal B)-- 3.5 0.01 CD163/CD68 alone 2.1 <0.05 NACT Cohort (n=45) Baseline pCR rate 12% 38%- 0.04 3-year RFS(RCB-II/III n=34) 52% 85% 4.1 0.01 CD163+/CD206+ expansion 76% (RCB-III) 29%(RCB-I)- 0.008

Background: The role of venous Doppler ultrasound in assessing venous congestion in the setting of post-lung transplantation surgery is unknown. We performed a feasibility study on the use of venous Doppler ultrasound in the immediate post-operative period after lung transplantation in a retrospective, single-center observational evaluation. Patients had at least two venous congestion Doppler ultrasound exams involving interrogation of IVC diameter, hepatic vein, portal vein and renal vein Doppler assessments. Results: A total of 9 patients were included in our study with a median age of 60 years, 66.7% being male, and a median BMI of 20.9. All patients had VExUS grade ≥1 on their first venous Doppler exam. All nine patients had a decrease in portal vein pulsatility from initial to final exams. Correlation between portal venous pulsatility and net fluid balance was not statistically significant R= 0.33 (P= 0.39). Other parameters, including VExUS grade, IVC diameter, HV and RV Doppler changes from initial to final ultrasound exams showed variable changes in the post-operative period. Conclusion: Venous congestion Doppler ultrasound assessments appear feasible in immediate postoperative lung transplant patients. A multitude of factors beyond fluid status likely affect waveforms.

Patients with advanced liver disease challenge anesthesiologists, especially those providing regional anesthesia for postoperative pain management. Coagulopathy, encephalopathy, sepsis and other comorbidities complicate care. Liver failure lowers albumin and α1-acid glycoprotein and slows hepatic clearance, increasing the unbound fraction and effective exposure to amide local anesthetics. Risks are magnified by acidosis, low cardiac output, low body mass index, sepsis, and concurrent renal dysfunction. Neuraxial options are often limited by coagulopathy and the risk of catastrophic neurologic complications while superficial, compressible peripheral blocks are generally considered safer than deep plexus targets. Safe practice includes the use of ultrasound guidance, incremental injection with frequent aspirations, avoidance of unnecessary high-dose multiple-site injections, and conservative dosing and infusion strategies. Regional anesthesia is feasible in patients with hepatic failure when dose and technique are adjusted to disease biology and when local anesthetic systemic toxicity (LAST) preparedness is routine. Catheters should run at lower concentrations and rates with scheduled reassessment and clearly communicated stop times. Teams should keep 20% lipid emulsion immediately available for treatment of neurologic or cardiovascular signs of LAST. We provide a practical pathway to select the block, choose the agent, and set doses that keep a reasonable safety margin for local anesthetics.

OBJECTIVE The objective was to evaluate the trajectories of hematoma resolution and functional improvement after middle meningeal artery embolization (MMAE) for chronic subdural hematoma (cSDH), model the temporal pattern of cSDH resolution, and identify factors associated with favorable outcomes. METHODS This real-world multicenter retrospective study included cSDH patients treated with MMAE at 24 centers between 2019 and 2024. Hematoma thickness was measured at baseline and at follow-up intervals (1–4 weeks, 1–3 months, 3–6 months, 6–12 months, and > 12 months after embolization). Resolution patterns were modeled using exponential decay functions. Modified Rankin Scale (mRS) scores assessed functional outcomes. Good functional outcome was defined as mRS score ≤ 2. Resolution patterns were modeled using exponential decay functions to estimate time to 50% and 80% reduction. Patients were categorized as complete resolution (≥ 99%) or by quartile of the remaining distribution (substantial [73%–98%], moderate [53%–73%], partial [27%–53%], minimal [< 27%]). The primary outcome was good functional status (mRS score ≤ 2). RESULTS The authors analyzed a total of 1781 patients with 2295 cSDHs who underwent MMAE. The mean ± SD age was 72.8 ± 12.4 years and 68.1% of patients were male. The initial mean hematoma thickness was 15.31 ± 6.53 mm, decreasing to 5.24 ± 5.91 mm at final follow-up (mean reduction 64.3% ± 42.1%). Resolution followed an exponential decay pattern, with an estimated time to 50% reduction of 1.8 months and to 80% reduction of 8.9 months. Complete resolution occurred in 1031 of 2224 patients (46.4%) with complete follow-up. The median (IQR) mRS score improved from 1 (0–3) at baseline to 0 (0–2) at > 12 months. Good functional outcomes were more common in patients with complete versus minimal resolution (68.9% vs 35.0%, p < 0.001). Achieving ≥ 73% resolution within 90 days was associated with better outcomes (good outcome in 76.9% of those with ≥ 73% resolution vs 67.3% in those without, p < 0.001). Neurological deterioration was the strongest predictor of lack of good outcome (23.7% in patients with neurological deterioration vs 82.4% without, p < 0.001). CONCLUSIONS After MMAE for cSDH, reduction in hematoma thickness follows a predictable exponential decay pattern. Greater extent (≥ 80%) and faster timing (within 90 days) of resolution are valuable prognostic indicators. Functional outcomes improve progressively through 6–12 months after the procedure. The relationship between resolution extent and functional outcomes provides quantitative benchmarks for evaluating treatment response.