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Filipek-Gorzała J, Kwiecińska P, Szade A, Szade K. The dark side of stemness - the role of hematopoietic stem cells in development of blood malignancies. Front Oncol 2024; 14:1308709. [PMID: 38440231 PMCID: PMC10910019 DOI: 10.3389/fonc.2024.1308709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/02/2024] [Indexed: 03/06/2024] Open
Abstract
Hematopoietic stem cells (HSCs) produce all blood cells throughout the life of the organism. However, the high self-renewal and longevity of HSCs predispose them to accumulate mutations. The acquired mutations drive preleukemic clonal hematopoiesis, which is frequent among elderly people. The preleukemic state, although often asymptomatic, increases the risk of blood cancers. Nevertheless, the direct role of preleukemic HSCs is well-evidenced in adult myeloid leukemia (AML), while their contribution to other hematopoietic malignancies remains less understood. Here, we review the evidence supporting the role of preleukemic HSCs in different types of blood cancers, as well as present the alternative models of malignant evolution. Finally, we discuss the clinical importance of preleukemic HSCs in choosing the therapeutic strategies and provide the perspective on further studies on biology of preleukemic HSCs.
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Affiliation(s)
- Jadwiga Filipek-Gorzała
- Laboratory of Stem Cell Biology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
- Department of Medical Biotechnology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
- Doctoral School of Exact and Natural Sciences, Jagiellonian University, Krakow, Poland
| | - Patrycja Kwiecińska
- Laboratory of Stem Cell Biology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | - Agata Szade
- Department of Medical Biotechnology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | - Krzysztof Szade
- Laboratory of Stem Cell Biology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
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2
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Hasan T, Pasala AR, Hassan D, Hanotaux J, Allan DS, Maganti HB. Homing and Engraftment of Hematopoietic Stem Cells Following Transplantation: A Pre-Clinical Perspective. Curr Oncol 2024; 31:603-616. [PMID: 38392038 PMCID: PMC10888387 DOI: 10.3390/curroncol31020044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 02/24/2024] Open
Abstract
Hematopoietic stem-cell (HSC) transplantation (HSCT) is used to treat various hematologic disorders. Use of genetically modified mouse models of hematopoietic cell transplantation has been critical in our fundamental understanding of HSC biology and in developing approaches for human patients. Pre-clinical studies in animal models provide insight into the journey of transplanted HSCs from infusion to engraftment in bone-marrow (BM) niches. Various signaling molecules and growth factors secreted by HSCs and the niche microenvironment play critical roles in homing and engraftment of the transplanted cells. The sustained equilibrium of these chemical and biologic factors ensures that engrafted HSCs generate healthy and durable hematopoiesis. Transplanted healthy HSCs compete with residual host cells to repopulate stem-cell niches in the marrow. Stem-cell niches, in particular, can be altered by the effects of previous treatments, aging, and the paracrine effects of leukemic cells, which create inhospitable bone-marrow niches that are unfavorable for healthy hematopoiesis. More work to understand how stem-cell niches can be restored to favor normal hematopoiesis may be key to reducing leukemic relapses following transplant.
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Affiliation(s)
- Tanvir Hasan
- Canadian Blood Services, Stem Cells and Centre for Innovation, Ottawa, ON K1G 4J5, Canada; (T.H.); (A.R.P.); (D.H.); (J.H.)
| | - Ajay Ratan Pasala
- Canadian Blood Services, Stem Cells and Centre for Innovation, Ottawa, ON K1G 4J5, Canada; (T.H.); (A.R.P.); (D.H.); (J.H.)
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8L6, Canada
| | - Dhuha Hassan
- Canadian Blood Services, Stem Cells and Centre for Innovation, Ottawa, ON K1G 4J5, Canada; (T.H.); (A.R.P.); (D.H.); (J.H.)
| | - Justine Hanotaux
- Canadian Blood Services, Stem Cells and Centre for Innovation, Ottawa, ON K1G 4J5, Canada; (T.H.); (A.R.P.); (D.H.); (J.H.)
| | - David S. Allan
- Canadian Blood Services, Stem Cells and Centre for Innovation, Ottawa, ON K1G 4J5, Canada; (T.H.); (A.R.P.); (D.H.); (J.H.)
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8L6, Canada
- Clinical Epidemiology & Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, ON K1Y 4E9, Canada
| | - Harinad B. Maganti
- Canadian Blood Services, Stem Cells and Centre for Innovation, Ottawa, ON K1G 4J5, Canada; (T.H.); (A.R.P.); (D.H.); (J.H.)
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8L6, Canada
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3
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Lee M. Deep Learning Techniques with Genomic Data in Cancer Prognosis: A Comprehensive Review of the 2021-2023 Literature. BIOLOGY 2023; 12:893. [PMID: 37508326 PMCID: PMC10376033 DOI: 10.3390/biology12070893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 07/30/2023]
Abstract
Deep learning has brought about a significant transformation in machine learning, leading to an array of novel methodologies and consequently broadening its influence. The application of deep learning in various sectors, especially biomedical data analysis, has initiated a period filled with noteworthy scientific developments. This trend has majorly influenced cancer prognosis, where the interpretation of genomic data for survival analysis has become a central research focus. The capacity of deep learning to decode intricate patterns embedded within high-dimensional genomic data has provoked a paradigm shift in our understanding of cancer survival. Given the swift progression in this field, there is an urgent need for a comprehensive review that focuses on the most influential studies from 2021 to 2023. This review, through its careful selection and thorough exploration of dominant trends and methodologies, strives to fulfill this need. The paper aims to enhance our existing understanding of applications of deep learning in cancer survival analysis, while also highlighting promising directions for future research. This paper undertakes aims to enrich our existing grasp of the application of deep learning in cancer survival analysis, while concurrently shedding light on promising directions for future research in this vibrant and rapidly proliferating field.
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Affiliation(s)
- Minhyeok Lee
- School of Electrical and Electronics Engineering, Chung-Ang University, Seoul 06974, Republic of Korea
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4
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Andersson-Assarsson JC, van Deuren RC, Kristensson FM, Steehouwer M, Sjöholm K, Svensson PA, Pieterse M, Gilissen C, Taube M, Jacobson P, Perkins R, Brunner HG, Netea MG, Peltonen M, Carlsson B, Hoischen A, Carlsson LMS. Evolution of age-related mutation-driven clonal haematopoiesis over 20 years is associated with metabolic dysfunction in obesity. EBioMedicine 2023; 92:104621. [PMID: 37209535 DOI: 10.1016/j.ebiom.2023.104621] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Haematopoietic clones caused by somatic mutations with ≥2% variant allele frequency (VAF) increase with age and are linked to risk of haematological malignancies and cardiovascular disease. Recent observations suggest that smaller clones (VAF<2%) are also associated with adverse outcomes. Our aims were to determine the prevalence of clonal haematopoiesis driven by clones of variable sizes in individuals with obesity treated by usual care or bariatric surgery (a treatment that improves metabolic status), and to examine the expansion of clones in relation to age and metabolic dysregulation over up to 20 years. METHODS Clonal haematopoiesis-driver mutations (CHDMs) were identified in blood samples from participants of the Swedish Obese Subjects intervention study. Using an ultrasensitive assay, we analysed single-timepoint samples from 1050 individuals treated by usual care and 841 individuals who had undergone bariatric surgery, and multiple-timepoint samples taken over 20 years from a subset (n = 40) of the individuals treated by usual care. FINDINGS In this explorative study, prevalence of CHDMs was similar in the single-timepoint usual care and bariatric surgery groups (20.6% and 22.5%, respectively, P = 0.330), with VAF ranging from 0.01% to 31.15%. Clone sizes increased with age in individuals with obesity, but not in those who underwent bariatric surgery. In the multiple-timepoint analysis, VAF increased by on average 7% (range -4% to 24%) per year and rate of clone growth was negatively associated with HDL-cholesterol (R = -0.68, 1.74 E-04). INTERPRETATION Low HDL-C was associated with growth of haematopoietic clones in individuals with obesity treated by usual care. FUNDING The Swedish Research Council, The Swedish state under an agreement between the Swedish government and the county councils, the ALF (Avtal om Läkarutbildning och Forskning) agreement, The Swedish Heart-Lung Foundation, The Novo Nordisk Foundation, The European Research Council, The Netherlands Organisation for Scientific Research.
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Affiliation(s)
- Johanna C Andersson-Assarsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, SE-405 30, Sweden
| | - Rosanne C van Deuren
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands; Department of Internal Medicine, Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands; Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands; Radboud Expertise Center for Immunodeficiency and Autoinflammation and Radboud Center for Infectious Disease (RCI), Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands
| | - Felipe M Kristensson
- Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, SE-405 30, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, SE-413 45, Sweden
| | - Marloes Steehouwer
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands; Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands
| | - Kajsa Sjöholm
- Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, SE-405 30, Sweden
| | - Per-Arne Svensson
- Institute of Health and Care Sciences, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, SE-405 30, Sweden
| | - Marc Pieterse
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands
| | - Christian Gilissen
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands; Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands
| | - Magdalena Taube
- Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, SE-405 30, Sweden
| | - Peter Jacobson
- Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, SE-405 30, Sweden
| | - Rosie Perkins
- Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, SE-405 30, Sweden
| | - Han G Brunner
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands; Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, 6200 MD, the Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands; GROW School of Oncology and Developmental Biology, and MHeNs School of Mental Health and Neuroscience, Maastricht University, Maastricht, 6500 MD, the Netherlands
| | - Mihai G Netea
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands; Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands; Radboud Expertise Center for Immunodeficiency and Autoinflammation and Radboud Center for Infectious Disease (RCI), Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands; Department of Immunology and Metabolism, Life and Medical Sciences Institute (LIMES), University of Bonn, Bonn, 53115, Germany
| | - Markku Peltonen
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, SE-141 83, Sweden; Public Health Promotion Unit, National Institute for Health and Welfare, Helsinki, 00271, Finland
| | - Björn Carlsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, SE-405 30, Sweden; Translational Science and Experimental Medicine, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, SE-431 83, Sweden
| | - Alexander Hoischen
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands; Department of Internal Medicine, Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands; Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands; Radboud Expertise Center for Immunodeficiency and Autoinflammation and Radboud Center for Infectious Disease (RCI), Radboud University Medical Center, Nijmegen, 6525 GA, the Netherlands.
| | - Lena M S Carlsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, SE-405 30, Sweden.
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5
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Shevyrev D, Tereshchenko V, Berezina TN, Rybtsov S. Hematopoietic Stem Cells and the Immune System in Development and Aging. Int J Mol Sci 2023; 24:ijms24065862. [PMID: 36982935 PMCID: PMC10056303 DOI: 10.3390/ijms24065862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Hematopoietic stem cells (HSCs) support haematopoiesis throughout life and give rise to the whole variety of cells of the immune system. Developing in the early embryo, passing through the precursor stage, and maturing into the first HSCs, they undergo a fairly large number of divisions while maintaining a high regenerative potential due to high repair activity. This potential is greatly reduced in adult HSCs. They go into a state of dormancy and anaerobic metabolism to maintain their stemness throughout life. However, with age, changes occur in the pool of HSCs that negatively affect haematopoiesis and the effectiveness of immunity. Niche aging and accumulation of mutations with age reduces the ability of HSCs to self-renew and changes their differentiation potential. This is accompanied by a decrease in clonal diversity and a disturbance of lymphopoiesis (decrease in the formation of naive T- and B-cells) and the predominance of myeloid haematopoiesis. Aging also affects mature cells, regardless of HSC, therefore, phagocytic activity and the intensity of the oxidative burst decrease, and the efficiency of processing and presentation of antigens by myeloid cells is impaired. Aging cells of innate and adaptive immunity produce factors that form a chronic inflammatory background. All these processes have a serious negative impact on the protective properties of the immune system, increasing inflammation, the risk of developing autoimmune, oncological, and cardiovascular diseases with age. Understanding the mechanisms of reducing the regenerative potential in a comparative analysis of embryonic and aging HSCs, the features of inflammatory aging will allow us to get closer to deciphering the programs for the development, aging, regeneration and rejuvenation of HSCs and the immune system.
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Affiliation(s)
- Daniil Shevyrev
- Centre for Cell Technology and Immunology, Sirius University of Science and Technology, Sirius, 354340 Sochi, Russia
| | - Valeriy Tereshchenko
- Centre for Cell Technology and Immunology, Sirius University of Science and Technology, Sirius, 354340 Sochi, Russia
| | - Tatiana N Berezina
- Department of Scientific Basis of Extreme Psychology, Moscow State University of Psychology and Education, 127051 Moscow, Russia
| | - Stanislav Rybtsov
- Centre for Cell Technology and Immunology, Sirius University of Science and Technology, Sirius, 354340 Sochi, Russia
- Centre for Regenerative Medicine, University of Edinburgh, Edinburgh EH8 9YL, UK
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6
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Abstract
Mutations in genes that confer a selective advantage to hematopoietic stem cells (HSCs) drive clonal hematopoiesis (CH). While some CH drivers have been identified, the compendium of all genes able to drive CH upon mutations in HSCs remains incomplete. Exploiting signals of positive selection in blood somatic mutations may be an effective way to identify CH driver genes, analogously to cancer. Using the tumor sample in blood/tumor pairs as reference, we identify blood somatic mutations across more than 12,000 donors from two large cancer genomics cohorts. The application of IntOGen, a driver discovery pipeline, to both cohorts, and more than 24,000 targeted sequenced samples yields a list of close to 70 genes with signals of positive selection in CH, available at http://www.intogen.org/ch. This approach recovers known CH genes, and discovers other candidates. Identifying the genetic drivers of clonal haematopoiesis (CH) has been challenging due to their low frequencies and a lack of adequate tools. Here, the authors use a reverse calling to detect blood somatic mutations and the IntOGen pipeline to identify CH drivers in large cancer genomics data sets based on signals of positive selection.
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7
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Chan ICC, Wiley BJ, Bolton KL. What Clonal Hematopoiesis Can Teach Us About MDS. Front Oncol 2022; 12:794021. [PMID: 35211401 PMCID: PMC8861516 DOI: 10.3389/fonc.2022.794021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/11/2022] [Indexed: 11/25/2022] Open
Abstract
Clonal hematopoiesis (CH), defined as the clonal expansion of mutated hematopoietic stem and progenitor cells (HSPCs), is a common aging process. CH is a risk factor for the development of hematologic malignancies, most commonly myeloid neoplasms (MNs) including acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), and myeloproliferative neoplasm (MPN). Recent work has elucidated how the development and cellular fitness of CH is shaped by aging, environmental exposures, and the germline (inherited) genetic background of an individual. This in turn has provided valuable insights into the pathogenesis of MNs including MDS. Here, in this review, we discuss the genetic origins of CH, the environmental stressors that influence CH, and the implications of CH on health outcomes including MDS. Since MNs have shared risk factors and underlying biology, most of our discussion regarding the implications of CH surrounds MN in general rather than focusing specifically on MDS. We conclude with future directions and areas of investigation including how intervention studies of CH might inform future therapeutic approaches to MN including MDS.
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Affiliation(s)
- Irenaeus C C Chan
- Washington University School of Medicine, St. Louis, MO, United States
| | - Brian J Wiley
- Washington University School of Medicine, St. Louis, MO, United States
| | - Kelly L Bolton
- Washington University School of Medicine, St. Louis, MO, United States
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8
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Skead K, Ang Houle A, Abelson S, Agbessi M, Bruat V, Lin B, Soave D, Shlush L, Wright S, Dick J, Morris Q, Awadalla P. Interacting evolutionary pressures drive mutation dynamics and health outcomes in aging blood. Nat Commun 2021; 12:4921. [PMID: 34389724 PMCID: PMC8363714 DOI: 10.1038/s41467-021-25172-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/27/2021] [Indexed: 01/10/2023] Open
Abstract
Age-related clonal hematopoiesis (ARCH) is characterized by age-associated accumulation of somatic mutations in hematopoietic stem cells (HSCs) or their pluripotent descendants. HSCs harboring driver mutations will be positively selected and cells carrying these mutations will rise in frequency. While ARCH is a known risk factor for blood malignancies, such as Acute Myeloid Leukemia (AML), why some people who harbor ARCH driver mutations do not progress to AML remains unclear. Here, we model the interaction of positive and negative selection in deeply sequenced blood samples from individuals who subsequently progressed to AML, compared to healthy controls, using deep learning and population genetics. Our modeling allows us to discriminate amongst evolutionary classes with high accuracy and captures signatures of purifying selection in most individuals. Purifying selection, acting on benign or mildly damaging passenger mutations, appears to play a critical role in preventing disease-predisposing clones from rising to dominance and is associated with longer disease-free survival. Through exploring a range of evolutionary models, we show how different classes of selection shape clonal dynamics and health outcomes thus enabling us to better identify individuals at a high risk of malignancy.
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Affiliation(s)
- Kimberly Skead
- Ontario Institute for Cancer Research, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
- Vector Institute for Artificial Intelligence, Toronto, ON, Canada
| | - Armande Ang Houle
- Ontario Institute for Cancer Research, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Sagi Abelson
- Ontario Institute for Cancer Research, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | | | - Vanessa Bruat
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Boxi Lin
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - David Soave
- Ontario Institute for Cancer Research, Toronto, ON, Canada
- Department of Mathematics, Wilfrid Laurier University, Waterloo, ON, Canada
| | - Liran Shlush
- Department of Immunology, Weizmann Institute of Science, Rehovot, Israel
| | - Stephen Wright
- Department of Ecology and Evolutionary Biology, University of Toronto, Toronto, ON, Canada
| | - John Dick
- Ontario Institute for Cancer Research, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Quaid Morris
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada.
- Vector Institute for Artificial Intelligence, Toronto, ON, Canada.
- Computational and Systems Biology Program, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
| | - Philip Awadalla
- Ontario Institute for Cancer Research, Toronto, ON, Canada.
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada.
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
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