Therapeutic strategy for cervical gastric-type adenocarcinoma by targeting CLU to relieve CLU-associated stress and sensitize chemotherapy

Objectives: Gastric-type adenocarcinoma (GAS), an aggressive subtype of non-human papillomavirus (HPV)-associated (NHPVA) cervical adenocarcinomas (ADC), remains a treatment-refractory disease with poor prognosis. This study aims to explore the oncogenic mechanism and efficacious therapeutic target of GAS. Methods: We included 19 NHPVA and 153 HPVA ADC patients from our center to investigate clinicopathological features. We collected 3 GAS and 2 usual-type endocervical adenocarcinomas (UEA) for single-cell RNA sequencing and T-cell receptor sequencing. We conducted immunohistochemical staining of 25 GAS and 25 UEA samples and multicolor immunohistochemical staining of 2 GAS samples for validation. We explored the efficacy of anti-clusterin (OGX-011) and/or cisplatin (DDP) for GAS based on GAS-derived tumoroids. Results: Based on clinical data, we clinicopathologically verified the malignancy of GAS. Through single-cell RNA sequencing, we delineated key cell subtypes including GAS epithelial cells, "GAS-enriched fibroblasts", "GAS-associated γδT cells", and CD8+ exhausted T cells enduring heat stress and contributing to GAS aggressive phenotype. Regarding validation, we verified clusterin (CLU)-associated heat stress, highlighted the potential role of CLU-associated stress in promoting immune escape, and established a four-gene signature (CLU, PDGFB, TIGIT, and C3) indicating poor prognosis of GAS induced by CLU-associated stress and immune escape. Based on GAS-derived tumoroids retaining the histological features, CLU-associated stress, and genetic profile of parental tumor, we validated the anti-tumor and sensitizing DDP efficacy of targeting CLU. Conclusion: CLU-associated heat stress of key cell subtypes contributed to the malignant GAS microenvironment. Additionally, we pioneeringly constructed GAS-derived tumoroids and suggested that combining CLU-targeted treatment and DDP could improve the therapeutic efficacy for GAS.