Extracellular Vesicle–Mediated O-GlcNAcase Transfer Drives Neuronal Necroptosis to Facilitate Gallbladder Cancer Perineural Invasion

Peripheral nerve invasion (PNI) is an early and decisive step in gallbladder cancer progression that strongly predicts poor postsurgical outcome. The tumor-neuron interactions that drive PNI could represent potential targets and biomarkers to improve treatment of gallbladder cancer. In this study, we demonstrated that gallbladder cancer provoked necroptosis of neurons to enable PNI. Gallbladder cancer cells transferred extracellular vesicles (EV) containing O-GlcNAcase (OGA) to neurons, which activated RIPK1-dependent necroptosis. Mechanistically, EV-derived OGA suppressed RIPK1 glycosylation while enhancing its phosphorylation, thereby activating the RIPK1/RIPK3/MLKL axis to trigger neuronal necroptosis. Subsequent neuronal release of HMGB1 engaged RAGE on gallbladder cancer cells, establishing a loop that accelerated PNI. Moreover, the RAGE antagonist FPS-ZM1 synergized with gemcitabine to suppress tumor progression. Collectively, these findings uncover an EV-mediated cross-talk between gallbladder cancer cells and neurons in which RIPK1-dependent necroptosis and its effector HMGB1 drive PNI, positioning the HMGB1-RAGE axis as a tractable therapeutic target. SIGNIFICANCE: Tumor-derived extracellular vesicles trigger neuronal necroptosis that fuels peripheral nerve invasion, creating a tumor-neuron signaling loop that could be leveraged for liquid biopsy and personalized therapy strategies in neurotropic cancers.