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Li Y, Sui S, Goel A. Extracellular vesicles associated microRNAs: Their biology and clinical significance as biomarkers in gastrointestinal cancers. Semin Cancer Biol 2024; 99:5-23. [PMID: 38341121 DOI: 10.1016/j.semcancer.2024.02.001] [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: 10/13/2023] [Revised: 01/26/2024] [Accepted: 02/04/2024] [Indexed: 02/12/2024]
Abstract
Gastrointestinal (GI) cancers, including colorectal, gastric, esophageal, pancreatic, and liver, are associated with high mortality and morbidity rates worldwide. One of the underlying reasons for the poor survival outcomes in patients with these malignancies is late disease detection, typically when the tumor has already advanced and potentially spread to distant organs. Increasing evidence indicates that earlier detection of these cancers is associated with improved survival outcomes and, in some cases, allows curative treatments. Consequently, there is a growing interest in the development of molecular biomarkers that offer promise for screening, diagnosis, treatment selection, response assessment, and predicting the prognosis of these cancers. Extracellular vesicles (EVs) are membranous vesicles released from cells containing a repertoire of biological molecules, including nucleic acids, proteins, lipids, and carbohydrates. MicroRNAs (miRNAs) are the most extensively studied non-coding RNAs, and the deregulation of miRNA levels is a feature of cancer cells. EVs miRNAs can serve as messengers for facilitating interactions between tumor cells and the cellular milieu, including immune cells, endothelial cells, and other tumor cells. Furthermore, recent years have witnessed considerable technological advances that have permitted in-depth sequence profiling of these small non-coding RNAs within EVs for their development as promising cancer biomarkers -particularly non-invasive, liquid biopsy markers in various cancers, including GI cancers. Herein, we summarize and discuss the roles of EV-associated miRNAs as they play a seminal role in GI cancer progression, as well as their promising translational and clinical potential as cancer biomarkers as we usher into the area of precision oncology.
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Affiliation(s)
- Yuan Li
- Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope, Biomedical Research Center, Monrovia, CA, USA; Department of Clinical Laboratory, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China
| | - Silei Sui
- Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope, Biomedical Research Center, Monrovia, CA, USA; Department of Oncology, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ajay Goel
- Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope, Biomedical Research Center, Monrovia, CA, USA.
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Cheung AHK, Wong KY, Chiang CH, Liu X, Zhang Y, Hui CHL, Chen B, Wang Y, Chow C, Kang W, To KF. Interpretation of Lung Cancer Plasma EGFR Mutation Tests in the Clinical Setting. Am J Clin Pathol 2023; 159:181-191. [PMID: 36573768 DOI: 10.1093/ajcp/aqac149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/26/2022] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Comprehensive data synthesis of the clinical parameters that affect plasma EGFR mutation test results in non-small cell lung carcinoma is lacking. Although individual studies have suggested a variety of patient characteristics that can affect diagnostic accuracy, no unified conclusion has been reached. METHODS We analyzed 170 plasma EGFR mutation tests performed between 2015 and 2021 at our institution and carried out a systematic review and meta-analysis to identify clinical and imaging features that correlate with plasma EGFR mutation test sensitivity. RESULTS Data synthesis from 14 studies of 2,576 patients revealed that patients with stage IV disease had a significantly lower false-negative rate than those with stage I through III disease. For our institutional cohort, which consisted of 75 paired plasma and tissue tests that were assessable for diagnostic accuracy, the overall sensitivity was 70.59% (95% confidence interval, 56.17%-82.51%). Patients who had distant metastases and more suspicious lymph nodes on imaging findings correlated with a low false-negative rate. CONCLUSIONS While interpreting plasma EGFR mutation results, extra caution should be exercised for patients with early-stage, localized disease to accommodate the possibility of false-negative results. These meta-analyses and clinical data may enable clinicians to make evidence-based judgments for individual patients.
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Affiliation(s)
- Alvin Ho-Kwan Cheung
- Department of Anatomical and Cellular Pathology, State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kit-Yee Wong
- Department of Anatomical and Cellular Pathology, State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | | | - Xiaoli Liu
- Department of Anatomical and Cellular Pathology, State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yihan Zhang
- Department of Anatomical and Cellular Pathology, State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Chris Ho-Lam Hui
- Department of Anatomical and Cellular Pathology, State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Bonan Chen
- Department of Anatomical and Cellular Pathology, State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yifei Wang
- Department of Anatomical and Cellular Pathology, State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Chit Chow
- Department of Anatomical and Cellular Pathology, State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Wei Kang
- Department of Anatomical and Cellular Pathology, State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ka-Fai To
- Department of Anatomical and Cellular Pathology, State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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Sánchez-Herrero E, Serna-Blasco R, Robado de Lope L, González-Rumayor V, Romero A, Provencio M. Circulating Tumor DNA as a Cancer Biomarker: An Overview of Biological Features and Factors That may Impact on ctDNA Analysis. Front Oncol 2022; 12:943253. [PMID: 35936733 PMCID: PMC9350013 DOI: 10.3389/fonc.2022.943253] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 06/16/2022] [Indexed: 11/13/2022] Open
Abstract
Cancer cells release nucleic acids, freely or associated with other structures such as vesicles into body fluids, including blood. Among these nucleic acids, circulating tumor DNA (ctDNA) has emerged as a minimally invasive biomarker for tumor molecular profiling. However, certain biological characteristics of ctDNA are still unknown. Here, we provide an overview of the current knowledge about ctDNA biological features, including size and structure as well as the mechanisms of ctDNA shedding and clearance, and the physio-pathological factors that determine ctDNA levels. A better understanding of ctDNA biology is essential for the development of new methods that enable the analysis of ctDNA.
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Affiliation(s)
- Estela Sánchez-Herrero
- Liquid Biopsy Laboratory. Biomedical Sciences Research Institute Puerta de Hierro-Majadahonda, Majadahonda, Spain
- +D Department, Atrys Health, Barcelona, Spain
| | - Roberto Serna-Blasco
- Liquid Biopsy Laboratory. Biomedical Sciences Research Institute Puerta de Hierro-Majadahonda, Majadahonda, Spain
| | - Lucia Robado de Lope
- Liquid Biopsy Laboratory. Biomedical Sciences Research Institute Puerta de Hierro-Majadahonda, Majadahonda, Spain
| | | | - Atocha Romero
- Liquid Biopsy Laboratory. Biomedical Sciences Research Institute Puerta de Hierro-Majadahonda, Majadahonda, Spain
- Medical Oncology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
- *Correspondence: Atocha Romero, ; orcid.org/0000-0002-1634-7397
| | - Mariano Provencio
- Liquid Biopsy Laboratory. Biomedical Sciences Research Institute Puerta de Hierro-Majadahonda, Majadahonda, Spain
- Medical Oncology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
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Temraz S, Nasr R, Mukherji D, Kreidieh F, Shamseddine A. Liquid Biopsy Derived Circulating Tumor Cells and Circulating Tumor DNA as Novel Biomarkers in Hepatocellular Carcinoma. Expert Rev Mol Diagn 2022; 22:507-518. [PMID: 35758097 DOI: 10.1080/14737159.2022.2094706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The diagnosis of hepatocellular carcinoma (HCC) is made at a relatively advanced stage resulting in poor prognosis. Alpha-fetoprotein and liver ultrasound have limited accuracy as biomarkers in HCC. Liver biopsy provides information on tumor biology; however, it is invasive and holds high threat of tumor seeding. Thus, more accurate and less invasive approaches are needed. AREAS COVERED Highly sensitive liquid biopsy assays have made possible the detection and analysis of cells or organelles such as circulating tumor cells (CTCs), circulating tumor DNA (ctDNA), and tumor-derived exosomes. Here, we focus on CTCs and ctDNA components of liquid biopsy and their clinical application as diagnostic, prognostic and predictive biomarkers in HCC. Unlike tissue biopsy, liquid biopsy involves attaining a sample at several time frames in an easy and a non-invasive manner. They have been efficacious in detecting and classifying cancer, in predicting treatment response, in monitoring disease relapse and in identifying mechanisms of resistance to targeted therapies. EXPERT OPINION Although interesting and highly promising, liquid biopsy techniques still have many obstacles to overcome before their wide spread clinical application sees the light. It is expected that these techniques will be incorporated into traditional methodologies for better diagnostic, predictive and prognostic results.
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Affiliation(s)
- Sally Temraz
- Department of internal medicine, Hematology/Oncology division, American University of Beirut Medical Center, Riad El Solh, Beirut, Lebanon
| | - Rihab Nasr
- Department of Anatomy, Cell Biology and Physiology, American University of Beirut Medical Center, Riad El Solh, Beirut, Lebanon
| | - Deborah Mukherji
- Department of internal medicine, Hematology/Oncology division, American University of Beirut Medical Center, Riad El Solh, Beirut, Lebanon
| | - Firas Kreidieh
- Department of internal medicine, Hematology/Oncology division, American University of Beirut Medical Center, Riad El Solh, Beirut, Lebanon
| | - Ali Shamseddine
- Department of internal medicine, Hematology/Oncology division, American University of Beirut Medical Center, Riad El Solh, Beirut, Lebanon
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Determination of MYD88L265P mutation fraction in IgM monoclonal gammopathies. Blood Adv 2021; 6:189-199. [PMID: 34788399 PMCID: PMC8753203 DOI: 10.1182/bloodadvances.2021005354] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/27/2021] [Indexed: 11/29/2022] Open
Abstract
Quantitative evaluation of the tumor load in patients with IgM monoclonal gammopathies in tDNA and cfDNA samples.
We describe a novel method for the detection of MYD88L265P mutation using a competitive allele-specific polymerase chain reaction (Cast-PCR) assay. This assay has a sensitivity of 1 × 10−3, is applicable in reactions containing very low amounts of DNA (as low as 20 pg), and allowed the detection of MYD88L265P somatic mutation in both tumor-derived DNA (tDNA) and cell-free DNA (cfDNA). In addition, using the Cast-PCR assay, we were able to determine the mutation allele fraction (MAF) in each tested sample. We then analyzed baseline tDNA and cfDNA samples from 163 patients (53 with immunoglobulin M monoclonal gammopathy of undetermined significance and 110 with Waldenström’s macroglobulinemia [WM], of whom 54 were asymptomatic and 56 were symptomatic) and also in sequential samples of 37 patients. MAF in both cfDNA and tDNA was higher among patients with symptomatic compared with asymptomatic WM and in those with asymptomatic WM compared with those with immunoglobulin M (IgM) monoclonal gammopathy of undetermined significance. In addition, the evaluation of sequential samples showed that MAF decreased after treatment, whereas it increased in patients who relapsed or progressed to symptomatic WM. Thus, Cast-PCR is a highly sensitive, cost-effective diagnostic tool for MYD88L265P detection, applicable in both tDNA and cfDNA samples, that also provides a quantitative evaluation of the tumor load in patients with IgM monoclonal gammopathies.
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Maggi R, Breitschwerdt EB, Qurollo B, Miller JC. Development of a Multiplex Droplet Digital PCR Assay for the Detection of Babesia, Bartonella, and Borrelia Species. Pathogens 2021; 10:pathogens10111462. [PMID: 34832618 PMCID: PMC8620149 DOI: 10.3390/pathogens10111462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 11/16/2022] Open
Abstract
We describe the development, optimization, and validation of a multiplex droplet digital PCR (ddPCR) assay for the simultaneous detection of Babesia, Bartonella, and Borrelia spp. DNA from several sample matrices, including clinical blood samples from animals and humans, vectors, in-vitro infected human and animal cell lines, and tissues obtained from animal models (infected with Bartonella and/or B. burgdorferi). The multiplex ddPCR assay was able to detect 31 Bartonella, 13 Borrelia, and 24 Babesia species, including Theileria equi, T. cervi, and Cytauxzoon felis. No amplification of Treponema or Leptospira spp. was observed. Sensitivity of 0.2-5 genome equivalent DNA copies per microliter was achieved for different members of the Bartonella and Borrelia genus, depending on the species or matrix type (water or spiked blood DNA) tested. The ddPCR assay facilitated the simultaneous detection of co-infections with two and three vector-borne pathogens comprising four different genera (Babesia, Bartonella, Borrelia, and Theileria) from clinical and other sample sources.
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Affiliation(s)
- Ricardo Maggi
- Department of Clinical Sciences, The Comparative Medicine Institute, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC 27607, USA; (E.B.B.); (B.Q.)
- Galaxy Diagnostics, Inc., 6 Davis Drive, Suite 201, Research Triangle Park, NC 27709, USA;
- Correspondence:
| | - Edward B. Breitschwerdt
- Department of Clinical Sciences, The Comparative Medicine Institute, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC 27607, USA; (E.B.B.); (B.Q.)
- Galaxy Diagnostics, Inc., 6 Davis Drive, Suite 201, Research Triangle Park, NC 27709, USA;
| | - Barbara Qurollo
- Department of Clinical Sciences, The Comparative Medicine Institute, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC 27607, USA; (E.B.B.); (B.Q.)
| | - Jennifer C. Miller
- Galaxy Diagnostics, Inc., 6 Davis Drive, Suite 201, Research Triangle Park, NC 27709, USA;
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Stitz R, Buder A, Silye R, Baumgartner B, Pühringer F, Filipits M, Oberndorfer E, Heitzer E. Validation of a next-generation sequencing assay for the detection of EGFR mutations in cell-free circulating tumor DNA. Exp Mol Pathol 2021; 123:104685. [PMID: 34560086 DOI: 10.1016/j.yexmp.2021.104685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/06/2021] [Accepted: 09/17/2021] [Indexed: 11/27/2022]
Abstract
Detection of EGFR mutations from blood plasma represents a gentle, non-invasive alternative to rebiopsy and can therefore be used for therapy monitoring of non-small-cell lung cancer (NSCLC) patients. The aim of this project was to investigate whether the Reveal ctDNA™ 28 NGS assay (ArcherDX, Boulder, CO), has a comparable sensitivity and specificity to droplet digital PCR (ddPCR, gold-standard) and is therefore suitable for therapy monitoring of progressing lung cancer patients. First, we validated the NGS assay with a commercially available reference material (SeraCare, Massachusetts, US). Using an input of 22 ng, a sensitivity of 96% and a specificity of 100% could be achieved for variant allele frequencies (VAF) of 0.5%. For variants at a VAF of 0.1% the sensitivity was substantially reduced. Next, 28 plasma samples from 16 patients were analyzed and results were compared to existing ddPCR data. This comparative analysis of patient samples revealed a concordance of 91% between NGS and ddPCR. These results confirm that the Reveal ctDNA™ 28 NGS assay can be used for therapy monitoring of patients under TKI therapy. However, due to the slightly superior sensitivity of ddPCR, a combination of NGS (with broad coverage of a large number of genomic loci) and ddPCR (with targeted highly sensitive detection of specific mutations) might be the ideal approach.
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Affiliation(s)
- Regina Stitz
- Institute of Pathology, Salzkammergutklinikum Vöcklabruck, Vöcklabruck, Austria
| | - Anna Buder
- Institute of Cancer Research, Department of Medicine I, Comprehensive Cancer Center, Medical Center of Vienna, Vienna, Austria
| | - Rene Silye
- Institute of Pathology, Salzkammergutklinikum Vöcklabruck, Vöcklabruck, Austria
| | - Bernhard Baumgartner
- Department of Pulmonary Medicine, Salzkammergutklinikum Vöcklabruck, Vöcklabruck, Austria
| | - Franz Pühringer
- Institute of Pathology, Salzkammergutklinikum Vöcklabruck, Vöcklabruck, Austria
| | - Martin Filipits
- Institute of Cancer Research, Department of Medicine I, Comprehensive Cancer Center, Medical Center of Vienna, Vienna, Austria
| | - Eva Oberndorfer
- Institute of Pathology, Salzkammergutklinikum Vöcklabruck, Vöcklabruck, Austria
| | - Ellen Heitzer
- Institute of Human Genetics, Diagnostic and Research Center for Molecular BioMedicine, Medical University of Graz, Graz, Austria.
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Wen T, Zhang X, Lippuner C, Schiff M, Stuber F. Development and Evaluation of a Droplet Digital PCR Assay for 8p23 β-Defensin Cluster Copy Number Determination. Mol Diagn Ther 2021; 25:607-615. [PMID: 34327613 PMCID: PMC8320422 DOI: 10.1007/s40291-021-00546-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2021] [Indexed: 12/01/2022]
Abstract
Introduction It has been proposed that the copy number (CN) variation (CNV) in β-defensin genes (DEFB) on human chromosome 8p23 determines phenotypic differences in inflammatory diseases. However, no method for accurate and easy DEFB CN quantification is yet available. Objective Droplet digital polymerase chain reaction (ddPCR) is a novel method for CNV quantification and has been used for genes such as CCL4L, CCL3L1, AMY1, and HER2. However, to date, no ddPCR assay has been available for DEFB CN determination. In the present study, we aimed to develop and evaluate such a ddPCR assay. Methods The assay was designed using DEFB4 and RPP30 as the target and the reference gene, respectively. To evaluate the assay, 283 DNA samples with known CNs previously determined using the multiple ligation-dependent probe amplification (MLPA) method, the current gold standard, were used as standards. To discover the optimal DNA template amount, we tested 80 to 2.5 ng DNA by a serial of one to two dilutions of eight samples. To evaluate the reproducibility of the assay, 31 samples were repeated to calculate the intra- and inter-assay variations. To further validate the reliability of the assay, the CNs of all 283 samples were determined using ddPCR. To compare results with those using quantitative PCR (qPCR), DEFB CNs for 48 samples were determined using qPCR with the same primers and probes. Results In a one-dimensional plot, the positive and negative droplets were clearly separated in both DEFB4 and RPP30 detection channels. In a two-dimensional plot, four populations of droplets were observed. The 20 ng template DNA proved optimal, with either high (80 ng) or low (10, 5, 2.5 ng) template input leading to ambiguous or inaccurate results. For the 31 standard samples, DEFB CNs were accurately determined with small intra- and inter-assay variations (coefficient of variation < 0.04 for both). In the validation cohort, ddPCR provided the correct CN for all 283 samples with high confidence. qPCR measurements for the 48 samples produced noisy data with high uncertainty and low accuracy. Conclusions ddPCR is an accurate, reproducible, easy-to-use, cheap, high-throughput method for DEFB CN determination. ddPCR could be applied to DEFB CN quantification in large-scale case–control studies. Supplementary Information The online version contains supplementary material available at 10.1007/s40291-021-00546-2.
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Affiliation(s)
- Tingting Wen
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xianghong Zhang
- Department of Cardiac Intensive Care Unit, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Heath, Hangzhou, Zhejiang, China.
| | - Christoph Lippuner
- Department of Anesthesiology and Pain Medicine, Bern University Hospital, Inselspital, Bern, Switzerland
| | - Marcel Schiff
- Department of Anesthesiology and Pain Medicine, Bern University Hospital, Inselspital, Bern, Switzerland
| | - Frank Stuber
- Department of Anesthesiology and Pain Medicine, Bern University Hospital, Inselspital, Bern, Switzerland
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Li Y, Zheng Y, Wu L, Li J, Ji J, Yu Q, Dai W, Feng J, Wu J, Guo C. Current status of ctDNA in precision oncology for hepatocellular carcinoma. J Exp Clin Cancer Res 2021; 40:140. [PMID: 33902698 PMCID: PMC8074474 DOI: 10.1186/s13046-021-01940-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 04/06/2021] [Indexed: 01/12/2023] Open
Abstract
The conventional method used to obtain a tumor biopsy for hepatocellular carcinoma (HCC) is invasive and does not evaluate dynamic cancer progression or assess tumor heterogeneity. It is thus imperative to create a novel non-invasive diagnostic technique for improvement in cancer screening, diagnosis, treatment selection, response assessment, and predicting prognosis for HCC. Circulating tumor DNA (ctDNA) is a non-invasive liquid biopsy method that reveals cancer-specific genetic and epigenetic aberrations. Owing to the development of technology in next-generation sequencing and PCR-based assays, the detection and quantification of ctDNA have greatly improved. In this publication, we provide an overview of current technologies used to detect ctDNA, the ctDNA markers utilized, and recent advances regarding the multiple clinical applications in the field of precision medicine for HCC.
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Affiliation(s)
- Yan Li
- Department of Gastroenterology, Putuo People's Hospital, Tongji University School of Medicine, number 1291, Jiangning road, Putuo, Shanghai, 200060, China
- Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Number 301, Middle Yanchang road, Jing'an, Shanghai, 200072, China
| | - Yuanyuan Zheng
- Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Number 301, Middle Yanchang road, Jing'an, Shanghai, 200072, China
| | - Liwei Wu
- Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Number 301, Middle Yanchang road, Jing'an, Shanghai, 200072, China
| | - Jingjing Li
- Department of Gastroenterology, Putuo People's Hospital, Tongji University School of Medicine, number 1291, Jiangning road, Putuo, Shanghai, 200060, China
- Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Number 301, Middle Yanchang road, Jing'an, Shanghai, 200072, China
| | - Jie Ji
- Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Number 301, Middle Yanchang road, Jing'an, Shanghai, 200072, China
| | - Qiang Yu
- Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Number 301, Middle Yanchang road, Jing'an, Shanghai, 200072, China
| | - Weiqi Dai
- Department of Gastroenterology, Putuo People's Hospital, Tongji University School of Medicine, number 1291, Jiangning road, Putuo, Shanghai, 200060, China
- Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Number 301, Middle Yanchang road, Jing'an, Shanghai, 200072, China
| | - Jiao Feng
- Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Number 301, Middle Yanchang road, Jing'an, Shanghai, 200072, China.
| | - Jianye Wu
- Department of Gastroenterology, Putuo People's Hospital, Tongji University School of Medicine, number 1291, Jiangning road, Putuo, Shanghai, 200060, China.
| | - Chuanyong Guo
- Department of Gastroenterology, Putuo People's Hospital, Tongji University School of Medicine, number 1291, Jiangning road, Putuo, Shanghai, 200060, China.
- Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Number 301, Middle Yanchang road, Jing'an, Shanghai, 200072, China.
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Vessies DCL, Linders TC, Lanfermeijer M, Ramkisoensing KL, van der Noort V, Schouten RD, Meijer GA, van den Heuvel MM, Monkhorst K, van den Broek D. An Automated Correction Algorithm (ALPACA) for ddPCR Data Using Adaptive Limit of Blank and Correction of False Positive Events Improves Specificity of Mutation Detection. Clin Chem 2021; 67:959-967. [PMID: 33842952 DOI: 10.1093/clinchem/hvab040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/17/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Bio-Rad droplet-digital PCR is a highly sensitive method that can be used to detect tumor mutations in circulating cell-free DNA (cfDNA) of patients with cancer. Correct interpretation of ddPCR results is important for optimal sensitivity and specificity. Despite its widespread use, no standardized method to interpret ddPCR data is available, nor have technical artifacts affecting ddPCR results been widely studied. METHODS False positive rates were determined for 6 ddPCR assays at variable amounts of input DNA, revealing polymerase induced false positive events (PIFs) and other false positives. An in silico correction algorithm, known as the adaptive LoB and PIFs: an automated correction algorithm (ALPACA), was developed to remove PIFs and apply an adaptive limit of blank (LoB) to individual samples. Performance of ALPACA was compared to a standard strategy (no PIF correction and static LoB = 3) using data from commercial reference DNA, healthy volunteer cfDNA, and cfDNA from a real-life cohort of 209 patients with stage IV nonsmall cell lung cancer (NSCLC) whose tumor and cfDNA had been molecularly profiled. RESULTS Applying ALPACA reduced false positive results in healthy cfDNA compared to the standard strategy (specificity 98 vs 88%, P = 10-5) and stage IV NSCLC patient cfDNA (99 vs 93%, P = 10-11), while not affecting sensitivity in commercial reference DNA (70 vs 68% P = 0.77) or patient cfDNA (82 vs 88%, P = 0.13). Overall accuracy in patient samples was improved (98 vs 92%, P = 10-7). CONCLUSIONS Correction of PIFs and application of an adaptive LoB increases specificity without a loss of sensitivity in ddPCR, leading to a higher accuracy in a real-life cohort of patients with stage IV NSCLC.
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Affiliation(s)
- Daan C L Vessies
- Department of Laboratory Medicine, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Theodora C Linders
- Department of Laboratory Medicine, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Mirthe Lanfermeijer
- Department of Laboratory Medicine, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | | | - Robert D Schouten
- Department of Pulmonology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Gerrit A Meijer
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Kim Monkhorst
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Daan van den Broek
- Department of Laboratory Medicine, Netherlands Cancer Institute, Amsterdam, the Netherlands
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Jean-Baptiste SR, Feigenberg SJ, Dorsey JF, Kao GD. Personal and Prognostic: Tissue and Liquid Biomarkers of Radiotherapeutic Response in Non-Small Cell Lung Cancer. Semin Radiat Oncol 2021; 31:149-154. [PMID: 33610272 PMCID: PMC9889131 DOI: 10.1016/j.semradonc.2020.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Recent treatment advances have improved outcomes for patients with non-small cell lung cancer (NSCLC), often utilizing tumor molecular characterization to identify targetable mutations. This is further enhanced by advancements in "liquid biopsies", using peripheral blood for noninvasive, serial sampling of tumor biology. While tumor genomic alterations have established therapeutic implications in metastatic NSCLC, research is also ongoing to develop applications for tissue and liquid biomarkers in earlier stage disease, such as patients treated with radiation for early stage or locoregional NSCLC.
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Affiliation(s)
- Samuel R. Jean-Baptiste
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania
| | - Steven J. Feigenberg
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania
| | - Jay F. Dorsey
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania,Corresponding Authors: Gary D. Kao, MD, Ph.D.: , Perelman Center for Advanced Medicine, Bldg 421 SCTR 8-134, 3400 Civic Center Blvd., University of Pennsylvania, Philadelphia, PA 19104, Office: 215-573-2285, Jay F. Dorsey, MD, Ph.D.: , Perelman Center for Advanced Medicine, Bldg 421 SCTR 8-135, 3400 Civic Center Blvd, Philadelphia, PA 19104, Office: (215) 662-2428, Fax: (215) 349-5445
| | - Gary D. Kao
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania,Corresponding Authors: Gary D. Kao, MD, Ph.D.: , Perelman Center for Advanced Medicine, Bldg 421 SCTR 8-134, 3400 Civic Center Blvd., University of Pennsylvania, Philadelphia, PA 19104, Office: 215-573-2285, Jay F. Dorsey, MD, Ph.D.: , Perelman Center for Advanced Medicine, Bldg 421 SCTR 8-135, 3400 Civic Center Blvd, Philadelphia, PA 19104, Office: (215) 662-2428, Fax: (215) 349-5445
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12
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González de Aledo-Castillo JM, Arcocha A, Victoria I, Martinez-Puchol AI, Sánchez C, Jares P, Rodríguez GF, Viñolas N, Reyes R, Reguart N, Puig-Butillé JA. Molecular characterization of advanced non-small cell lung cancer patients by cfDNA analysis: experience from routine laboratory practice. J Thorac Dis 2021; 13:1658-1670. [PMID: 33841957 PMCID: PMC8024825 DOI: 10.21037/jtd-20-3142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 01/20/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Analysis of circulating free DNA (cfDNA) by the real-time PCR cobas® EGFR Mutation Test v2 (cobas® EGFR Test) is a diagnostic approach used in clinical practice for the characterization of advanced non-small cell lung cancer (NSCLC) patients. The test additionally outputs a semiquantitative index (SQI) which reflects the proportion of mutated versus wild-type copies of the EGFR gene in cfDNA with potential use as a biomarker. CfDNA concentration and cfDNA fragmentation pattern have also shown potential utility as biomarkers for cancer patients. We evaluated the implementation of EGFR testing and cfDNA related parameters in NSCLC patients in routine clinical setting as biomarkers for disease stage and diagnosis. METHODS A prospective cohort of 173 locally advanced or metastatic NSCLC TKI-naïve patients analyzed by the cobas® EGFR Test were included in the study. Reproducibility of the test was assessed in 56 patients. The concentration of cfDNA and fragment size pattern was measured using fluorometry and microchip electrophoresis respectively. RESULTS The test showed high diagnostic accuracy when compared to the gold standard of biopsy tumor tissue testing. The SQI value showed a moderate reproducibility (r2=0.70) and did not correlate with cfDNA concentration (r2=0.17, P=0.28) or disease stage (stage III patients SQI =9.1±3.1 and stage IV patients SQI =11.5±4.8, P=0.41). We found differences in SQI values according to the type of EGFR mutation (Ex19Del mutations, SQI =13.6; p.L858R, SQI =8.88; P=0.001). Stage IV patients had higher concentrations of cfDNA (P<0.0001) and higher fractions of cfDNA 100-250 base pairs (bp) fragments (P=0.01) compared to stage III patients. From the ROC curve analysis, cfDNA concentration showed higher AUC compared to cfDNA 100-250 bp fragments (0.86 vs. 0.71). We obtained a cut-off value for cfDNA concentration of 20.3 ng/mL with 72.3% sensitivity and 95% specificity for predicting disease stage in TKI-naïve advanced NSCLC patients. CONCLUSIONS The study indicates that cfDNA analysis in plasma for EGFR testing by RT-PCR is an accurate and fast method to initially stratify NSCLC patients in a real-world clinical setting. However, the SQI has limited clinical value. The cfDNA concentration and fragmentation pattern have clear potential clinical utility for tumor staging in NSCLC patients.
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Affiliation(s)
| | - Ainara Arcocha
- Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain
- Medical Oncology Department, Hospital Clínic, Barcelona, Spain
| | - Iván Victoria
- Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain
- Medical Oncology Department, Hospital Clínic, Barcelona, Spain
| | | | | | - Pedro Jares
- Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain
- Molecular Biology CORE, Hospital Clínic, Barcelona, Spain
- Pathology Department, Hospital Clínic, Barcelona, Spain
| | | | - Núria Viñolas
- Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain
- Medical Oncology Department, Hospital Clínic, Barcelona, Spain
| | - Roxana Reyes
- Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain
- Medical Oncology Department, Hospital Clínic, Barcelona, Spain
| | - Noemí Reguart
- Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain
- Medical Oncology Department, Hospital Clínic, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Joan Antón Puig-Butillé
- Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain
- Molecular Biology CORE, Hospital Clínic, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
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13
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Zhou S, Huang R, Cao Y. Detection of epidermal growth factor receptor mutations in peripheral blood circulating tumor DNA in patients with advanced non-small cell lung cancer: A PRISMA-compliant meta-analysis and systematic review. Medicine (Baltimore) 2020; 99:e21965. [PMID: 33019389 PMCID: PMC7535563 DOI: 10.1097/md.0000000000021965] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The epidermal growth factor receptor (EGFR) mutation status related to the treatment approach for advanced non-small cell lung cancer (NSCLC) patients. This study aimed to evaluate the diagnostic accuracy of peripheral blood circulating tumor DNA (ctDNA) in EGFR mutated advanced NSCLC patients. METHOD The related database was systematically searched with keywords until January 19, 2020. Studies contained the histopathological and cytological advanced NSCLC samples were included, and the diagnostic data were recorded for calculating sensitivity and specificity. I statistics were used for detecting heterogeneity across studies, and the meta-regression was performed to seek the source of heterogeneity. RESULT A total of 32 studies with 4527 advanced NSCLC patients were included in our meta-analysis. Among them, 87% of the patients were diagnosed as stage IV. The pooled sensitivity of peripheral blood ctDNA was 0.70 (95% CI: 0.63-0.75, I = 81.76) and the pooled specificity was 0.98 (95% CI: 0.96-0.99, I = 88.33). The meta-regression showed that the prospective study design and the ARMS detection method were the main source of heterogeneity for sensitivity (P < .05), and the publication country (Asia or non-Asia) was the main source of heterogeneity for specificity (P < .01). CONCLUSION ctDNA biopsy has high specificity and diagnostic accuracy in detection of EGFR mutation in advanced NSCLC patients. When the ctDNA gene test result is negative, we should fully consider the risk of missed diagnosis, and further tissue biopsy is still needed to undertake.
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Affiliation(s)
- Shunkai Zhou
- Department of Thoracic Surgery, 900 Hospital of the Joint Logistics Team, Fuzhou
| | - Rongzhi Huang
- Department of Cardiothoracic Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou
| | - Yunpeng Cao
- Department of Thoracic Surgery, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, Fujian, China
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14
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Establishment and validation of a novel droplet digital PCR assay for ultrasensitive detection and dynamic monitoring of EGFR mutations in peripheral blood samples of non-small-cell lung cancer patients. Clin Chim Acta 2020; 510:88-96. [PMID: 32645388 DOI: 10.1016/j.cca.2020.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/03/2020] [Accepted: 07/02/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Droplet digital PCR (ddPCR)-based blood detection of EGFR mutations plays significant roles in the individualized therapy of non-small-cell lung cancer (NSCLC) patients. However, a standard assay that is approved by health authorities is still lacking. Additionally, the proper application of this method in clinical settings also needs further investigation. METHODS The performance of a newly established ddPCR assay was first evaluated using reference samples and then validated by comparing this method with the amplification refractory mutation system (ARMS) using cell-free DNA (cfDNA) in patients' peripheral blood. Further, the correlation between dynamic quantification of EGFR mutation in the patients and their clinical outcome of tyrosine kinase inhibitors (TKIs) therapy was investigated. RESULTS A total of 77 patients were included, with 50 in the test group and 27 in the validation group. According to the results of the reference samples and the blood samples in the test group, the cut-off value for patient detection was proposed as mutation rate ≥ 0.1% (total copy number of cfDNA ≥ 1000) or at least one copy of mutation DNA was detected (total copy number of cfDNA < 1000). With this criterion, superior sensitivity of our assay to that of ARMS was observed (P = 0.002 for Ex19Del & L858R and P < 0.001 for T790M). The dynamic quantification of EGFR mutations during TKI therapy indicated that an increase in mutation abundance was correlated with resistance, while a decline was associated with response. Notably, a rebound in mutation abundance during chemotherapy may indicate a desirable chance for TKI re-treatment. CONCLUSION The novel ddPCR assay showed superior sensitivity in the detection of EGFR mutation in blood. The dynamic quantification of EGFR mutations by this assay would greatly facilitate the administration of TKI therapy, including the monitoring of resistance and response, as well as cohort screening for retreatment.
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15
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The Validity and Predictive Value of Blood-Based Biomarkers in Prediction of Response in the Treatment of Metastatic Non-Small Cell Lung Cancer: A Systematic Review. Cancers (Basel) 2020; 12:cancers12051120. [PMID: 32365836 PMCID: PMC7280996 DOI: 10.3390/cancers12051120] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/21/2020] [Accepted: 04/27/2020] [Indexed: 12/11/2022] Open
Abstract
With the introduction of targeted therapies and immunotherapy, molecular diagnostics gained a more profound role in the management of non-small cell lung cancer (NSCLC). This study aimed to systematically search for studies reporting on the use of liquid biopsies (LB), the correlation between LBs and tissue biopsies, and finally the predictive value in the management of NSCLC. A systematic literature search was performed, including results published after 1 January 2014. Articles studying the predictive value or validity of a LB were included. The search (up to 1 September 2019) retrieved 1704 articles, 1323 articles were excluded after title and abstract screening. Remaining articles were assessed for eligibility by full-text review. After full-text review, 64 articles investigating the predictive value and 78 articles describing the validity were included. The majority of studies investigated the predictive value of LBs in relation to therapies targeting the epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) receptor (n = 38). Of studies describing the validity of a biomarker, 55 articles report on one or more EGFR mutations. Although a variety of blood-based biomarkers are currently under investigation, most studies evaluated the validity of LBs to determine EGFR mutation status and the subsequent targeting of EGFR tyrosine kinase inhibitors based on the mutation status found in LBs of NSCLC patients.
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16
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McNulty SN, Mann PR, Robinson JA, Duncavage EJ, Pfeifer JD. Impact of Reducing DNA Input on Next-Generation Sequencing Library Complexity and Variant Detection. J Mol Diagn 2020; 22:720-727. [PMID: 32142899 DOI: 10.1016/j.jmoldx.2020.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 01/07/2020] [Accepted: 02/20/2020] [Indexed: 12/23/2022] Open
Abstract
PCR amplification, a key step in next-generation sequencing (NGS) library construction, can generate an unlimited amount of product from limited input; however, it cannot create more information than was present in the original template. Thus, NGS libraries can be made from very little DNA, but reducing the input may compromise assay sensitivity in ways that are difficult to ascertain unless library complexity (ie, the number of unique DNA molecules represented in the library) and depth of coverage with unique sequence reads (those derived from input DNA molecules) versus duplicate sequence reads (those resulting from overamplification of particular molecules) are discretely measured. A series of experiments was performed to explore the impact of low DNA input on an amplicon-based NGS assay using unique molecular identifiers to track unique versus duplicate reads. At high sequencing depths, unique and total (unique plus duplicate) read coverage are not well correlated, so increasing the number of sequenced reads does not necessarily improve sensitivity. Unique coverage depth tends to improve with more input, but improvements are not consistent. Fluctuations in library complexity complicated variant detection using both standardized and clinical specimens, often resulting in technical replicates with vastly different estimates of variant allelic fraction. In conclusion, depth of coverage with unique reads must be tracked in clinical NGS to ensure that sensitivity and accuracy are maintained.
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Affiliation(s)
- Samantha N McNulty
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri.
| | - Patrick R Mann
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Joshua A Robinson
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Eric J Duncavage
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - John D Pfeifer
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
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17
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Li C, He Q, Liang H, Cheng B, Li J, Xiong S, Zhao Y, Guo M, Liu Z, He J, Liang W. Diagnostic Accuracy of Droplet Digital PCR and Amplification Refractory Mutation System PCR for Detecting EGFR Mutation in Cell-Free DNA of Lung Cancer: A Meta-Analysis. Front Oncol 2020; 10:290. [PMID: 32195189 PMCID: PMC7063461 DOI: 10.3389/fonc.2020.00290] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 02/19/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Epidermal growth factor receptor (EGFR) mutation testing in plasma cell-free DNA (cfDNA) from advanced lung cancer patients is an emerging clinical tool. This meta-analysis was designed to determine the diagnostic accuracy of two common PCR systems, droplet digital PCR (ddPCR) and amplification refractory mutation system PCR (ARMS-PCR), for detecting EGFR mutation in cfDNA. Materials and methods: A systematic search was carried out based on PubMed, Web of science, Embase and the Cochrane library. Data from eligible studies were extracted and pooled to calculate the sensitivity, specificity, diagnostic odds ratio (DOR), area under the summary receiver-operating characteristic curve (AUROC), using tissue biopsy results as the standard method. Subgroup analyses were performed regarding EGFR mutation type, tumor stage, and EGFR-TKI treatment. Results: Twenty-five studies involving 4,881 cases were included. The plasma testing sensitivity, specificity, DOR, and AUROC, compared with the matched tumor tissues, were 72.1%, 95.6%, 38.5, 0.89 for ddPCR, and 65.3%, 98.2%, 52.8, 0.71 for ARMS-PCR, respectively, through indirect comparison, significant differences were found in sensitivity (P = 0.003) and specificity (P = 0.007). Furthermore, significant difference was found in sensitivity between tumor stage subgroups (IIIB–IV subgroup vs. IA–IV subgroup) in ARMS-PCR (73.7 vs. 64.2%, P = 0.008), but not in ddPCR (72.5 vs. 71.2%, P = 0.756). Conclusions: This study demonstrates that ddPCR and ARMS-PCR have a high specificity with a practical sensitivity for detecting EGFR mutation in cfDNA, which supports their application as a supplement or a conditional-alternative to tissue biopsy in clinical practice for genotyping. It seems that ddPCR has a higher sensitivity than ARMS-PCR, especially in early stages.
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Affiliation(s)
- Caichen Li
- China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qihua He
- China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Hengrui Liang
- China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Bo Cheng
- China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jianfu Li
- China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shan Xiong
- China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yi Zhao
- China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Minzhang Guo
- China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhichao Liu
- China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jianxing He
- China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wenhua Liang
- China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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18
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Chai SY, Peng R, Zhang R, Zhou L, Pillay N, Tay KH, Badrick T, Li J, Horan MP. External Quality Assurance of Current Technology for the Testing of Cancer-Associated Circulating Free DNA Variants. Pathol Oncol Res 2019; 26:1595-1603. [PMID: 31487000 DOI: 10.1007/s12253-019-00744-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 08/29/2019] [Indexed: 02/07/2023]
Abstract
Liquid biopsy testing is rapidly emerging as a diagnostic means of identifying circulating free DNA (cfDNA) disease-associated variants. However, the reporting of cfDNA variants remains inconsistent due in part to the application of multiple testing pipelines which raise uncertainty about current cfDNA detection efficiency. External quality assurance (EQA) programs are required to monitor, evaluate and help improve laboratory performance for cfDNA variant detection and in clinical interpretation. This study therefore evaluated the performance of diagnostic laboratories currently performing cfDNA testing in China, Australia and New Zealand. A total of 89 laboratories participated in this EQA program. Reference testing material comprised of cfDNA manufactured to contain six different genotypes in four different genes (EGFR, KRAS, BRAF, NRAS). The predicted genotypic variant allelic frequencies ranged between 0.5% - 2.5%. Proficiency testing used a z-score on the laboratory consensus allelic frequency data to compare laboratory performance for the detection of the different genotypes. Allelic frequency genotyping data were received from 88 of the 89 laboratories. Next generation sequencing and digital PCR testing platforms were primarily used by participants in this pilot EQA. The average consensus data for each cfDNA genotype identified allelic frequencies ranging between 0.39% - 4.4%. Z-score proficiency testing found that >92% of clinical laboratories were concordant for detecting the cfDNA variants. The data from this pilot study suggest that current cfDNA testing platforms can detect cfDNA allelic frequency variants from 0.39% and above with high levels of confidence. In addition, these data highlight the importance of laboratories enrolling on EQA programs so that proficiency in cfDNA diagnostic testing can be determined and potential sources of error identified and addressed.
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Affiliation(s)
- Sze Yee Chai
- RCPAQAP Molecular Genetics, St Leonard's, Sydney, Australia
| | - Rongxue Peng
- National Center for Clinical Laboratories, Beijing Hospital, National Center of Gerontology, Beijing, P R China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, P R China
| | - Rui Zhang
- National Center for Clinical Laboratories, Beijing Hospital, National Center of Gerontology, Beijing, P R China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, P R China
| | - Li Zhou
- National Center for Clinical Laboratories, Beijing Hospital, National Center of Gerontology, Beijing, P R China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, P R China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, P R China
| | | | - Kwang Hong Tay
- RCPAQAP Molecular Genetics, St Leonard's, Sydney, Australia
| | - Tony Badrick
- RCPAQAP Molecular Genetics, St Leonard's, Sydney, Australia
| | - Jinming Li
- National Center for Clinical Laboratories, Beijing Hospital, National Center of Gerontology, Beijing, P R China. .,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, P R China. .,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, P R China.
| | - Martin P Horan
- RCPAQAP Molecular Genetics, St Leonard's, Sydney, Australia.
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19
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Guo QM, Wang L, Yu WJ, Qiao LH, Zhao MN, Hu XM, Sun YM, Ni S, Xu YH, Lou JT. Detection of Plasma EGFR Mutations in NSCLC Patients with a Validated ddPCR Lung cfDNA Assay. J Cancer 2019; 10:4341-4349. [PMID: 31413754 PMCID: PMC6691702 DOI: 10.7150/jca.31326] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 05/09/2019] [Indexed: 12/22/2022] Open
Abstract
Purpose: The clinical utility of cell-free DNA (cfDNA) to assess EGFR mutations is increasing. However, there are limited studies determining their clinical validity and utility. The value of cfDNA assays in cancer management remains controversial. Methods: In this study, we first evaluated the analytical performance of the ddPCR Lung cfDNA Assay. We next analyzed the concordance of the results with tissue amplification refractory mutation system PCR (ARMS-PCR) and plasma next-generation sequencing (NGS) genotyping. Finally, we assessed its clinical utility by exploring the association of cfDNA EGFR mutations with metastatic sites and the efficacy of EGFR-TKIs treatment. Results: The ddPCR Lung cfDNA Assay demonstrated a limit of blank of 1 droplet per reaction, an analytical specificity of 100%, and detection limit of 0.05%, 0.05%, and 0.1% for E746_A750del, L858R, and T790M, respectively. With tissue ARMS-PCR as a standard for comparison, the clinical sensitivity and specificity of ddPCR were 62.5% (15/24) and 100% (82/82) for E746_A750del, and 75.0% (15/20) and 94.2% (81/86) for L858R, respectively. The ddPCR showed high concordance with NGS in determining cfDNA EGFR mutations. Patients with bone and/or brain metastasis showed a higher detection rate and mutant abundance of cfDNA EGFR mutations compared to those with other sites of metastasis. Moreover, EGFR-TKIs treatment was effective in patients with sensitive EGFR mutations in either plasma cfDNA or tumor tissue-derived DNA. Conclusions: We validated in this study that the ddPCR Lung cfDNA Assay is reliable for detection of EGFR mutations in lung cancers, in terms of analytical performance, clinical validity and utility.
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Affiliation(s)
- Qiao-mei Guo
- Department of Laboratory Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Lin Wang
- Department of Laboratory Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wen-jun Yu
- Department of Laboratory Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Li-hua Qiao
- Department of Laboratory Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ming-na Zhao
- Department of Laboratory Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao-meng Hu
- Department of Laboratory Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ya-meng Sun
- Bio-Chain Biological Technology Co., Ltd, Shanghai, China
| | - Sheng Ni
- Bio-Chain Biological Technology Co., Ltd, Shanghai, China
| | - Yun-hua Xu
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jia-tao Lou
- Department of Laboratory Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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20
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Jiang XW, Liu W, Zhu XY, Xu XX. Evaluation of EGFR mutations in NSCLC with highly sensitive droplet digital PCR assays. Mol Med Rep 2019; 20:593-603. [PMID: 31115577 PMCID: PMC6580028 DOI: 10.3892/mmr.2019.10259] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 02/21/2019] [Indexed: 01/10/2023] Open
Abstract
Targeted drugs have been widely used in the treatment of patients with lung cancer, particularly for those with non-small cell lung cancer (NSCLC). Plasma cell-free DNA is an emerging clinical tool for the detection of epidermal growth factor receptor (EGFR) gene mutation in patients with lung cancer. Detection of circulating tumor (ct) DNA by droplet digital PCR (ddPCR) is a highly sensitive and minimally invasive alternative for the assessment and management of cancer. In the present study, four ddPCR systems were developed to detect the 19DELs, L858R, T790M and C797S mutations of the EGFR gene in plasma ctDNA samples, and all exhibited higher sensitivity compared with the amplification refractory mutation system (ARMS)-PCR assays. The results revealed that the sensitivity of the ddPCR assays for the four major types of EGFR mutant reached 0.04%. In total, 50 plasma ctDNA samples were collected from patients with NSCLC to detect the 19DELs, L858R, T790M and C797S mutations by ddPCR and ARMS-PCR. All the mutations except for C797S were detected and the concordance rates between ddPCR and ARMS-PCR were 96% (19DELs), 98% (L858R) and 100% (T790M). The fraction of EGFR mutation ranged from 0.43 to 68.07% using the ddPCR method. Therefore, the present study suggests that the four ddPCR testing systems could be used for early detection of EGFR mutations in plasma samples, so that patients can better select the targeted drugs according to the EGFR mutation.
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Affiliation(s)
- Xi-Wen Jiang
- Da An Gene Co., Ltd. of Sun Yat‑sen University, Guangzhou, Guangdong 510665, P.R. China
| | - Wei Liu
- Lu He Hospital Capital Medical University Beijing China, Beijing 100069, P.R. China
| | - Xiao-Ya Zhu
- Da An Gene Co., Ltd. of Sun Yat‑sen University, Guangzhou, Guangdong 510665, P.R. China
| | - Xiao-Xie Xu
- Da An Gene Co., Ltd. of Sun Yat‑sen University, Guangzhou, Guangdong 510665, P.R. China
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21
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Pratt ED, Cowan RW, Manning SL, Qiao E, Cameron H, Schradle K, Simeone DM, Zhen DB. Multiplex Enrichment and Detection of Rare KRAS Mutations in Liquid Biopsy Samples using Digital Droplet Pre-Amplification. Anal Chem 2019; 91:7516-7523. [DOI: 10.1021/acs.analchem.8b01605] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Erica D. Pratt
- Ahmed Center for Pancreatic Cancer Research, Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Robert W. Cowan
- Ahmed Center for Pancreatic Cancer Research, Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Sara L. Manning
- Ahmed Center for Pancreatic Cancer Research, Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
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22
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Castellanos-Rizaldos E, Zhang X, Tadigotla VR, Grimm DG, Karlovich C, Raez LE, Skog JK. Exosome-based detection of activating and resistance EGFR mutations from plasma of non-small cell lung cancer patients. Oncotarget 2019; 10:2911-2920. [PMID: 31080561 PMCID: PMC6499599 DOI: 10.18632/oncotarget.26885] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 04/07/2019] [Indexed: 12/26/2022] Open
Abstract
Non-small cell lung cancer (NSCLC) is the most prevalent form of lung cancer and its molecular landscape has been extensively studied. The most common genetic alterations in NSCLC are mutations within the epidermal growth factor receptor (EGFR) gene, with frequencies between 10-40%. There are several molecular targeted therapies for patients harboring these mutations. Liquid biopsies constitute a flexible approach to monitor these mutations in real time as opposed to tissue biopsies that represent a single snap-shot in time. However, interrogating cell free DNA (cfDNA) has inherent biological limitations, especially at early or localized disease stages, where there is not enough tumor material released into the patient’s circulation. We developed a qPCR- based test (ExoDx EGFR) that interrogates mutations within EGFR using Exosomal RNA/DNA and cfDNA (ExoNA) derived from plasma in a cohort of 110 NSCLC patients. The performance of the assay yielded an overall sensitivity of 90% for L858R, 83% for T790M and 73% for exon 19 indels with specificities of 100%, 100%, and 96% respectively. In a subcohort of patients with extrathoracic disease (M1b and MX) the sensitivities were 92% (L858R), 95% (T790M), and 86% (exon 19 indels) with specificity of 100%, 100% and 94% respectively.
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Affiliation(s)
| | - Xuan Zhang
- Exosome Diagnostics, a Bio-Techne brand, Waltham, Massachusetts, USA
| | | | - Dominik G Grimm
- Exosome Diagnostics, a Bio-Techne brand, Martinsried, Germany
| | - Chris Karlovich
- Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Luis E Raez
- Memorial Cancer Institute, Memorial Health Care System, Florida International University, Florida, USA
| | - Johan K Skog
- Exosome Diagnostics, a Bio-Techne brand, Waltham, Massachusetts, USA
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23
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Shi Y, Cao T, Sun Y, Xia J, Wang P, Ma J. Nitidine Chloride inhibits cell proliferation and invasion via downregulation of YAP expression in prostate cancer cells. Am J Transl Res 2019; 11:709-720. [PMID: 30899373 PMCID: PMC6413267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 12/24/2018] [Indexed: 06/09/2023]
Abstract
Nitidine chloride (NC) exhibits tumor suppressive function in a variety of human cancers. However, the molecular mechanism of NC-triggered anti-cancer activity has not been fully elucidated. In the present study, we aim to investigate the anti-tumor molecular basis of NC in prostate cancer cells. Multiple approaches including MTT, FACS, wound healing assay, Transwell invasion assay, Transfection, and Western blotting were performed. We found that NC inhibited cell growth and induced apoptosis in prostate cancer cells. Moreover, NC suppressed cell migration and invasion in prostate cancer cells. Notably, we found that NC decreased the expression of YAP oncoprotein in prostate cancer cells. Downregulation of YAP enhanced the anti-tumor function mediated by NC in prostate cancer cells. On the contrary, upregulation of YAP abrogated the anti-cancer activity of NC treatment in prostate cancer cells. Our findings indicate that NC could be useful as a YAP inhibitor for the treatment of prostate cancer cells.
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Affiliation(s)
- Ying Shi
- Department of Biochemistry and Molecular Biology, School of Laboratory Medicine, Bengbu Medical CollegeBengbu 233030, Anhui, China
| | - Tong Cao
- Department of Clinical Laboratory, The First Affiliated Hospital of Bengbu Medical CollegeBengbu 233004, Anhui, China
| | - Yu Sun
- Department of Biochemistry and Molecular Biology, School of Laboratory Medicine, Bengbu Medical CollegeBengbu 233030, Anhui, China
| | - Jun Xia
- Department of Biochemistry and Molecular Biology, School of Laboratory Medicine, Bengbu Medical CollegeBengbu 233030, Anhui, China
| | - Peter Wang
- Department of Biochemistry and Molecular Biology, School of Laboratory Medicine, Bengbu Medical CollegeBengbu 233030, Anhui, China
| | - Jia Ma
- Department of Biochemistry and Molecular Biology, School of Laboratory Medicine, Bengbu Medical CollegeBengbu 233030, Anhui, China
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24
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Franczak C, Filhine-Tresarrieu P, Gilson P, Merlin JL, Au L, Harlé A. Technical considerations for circulating tumor DNA detection in oncology. Expert Rev Mol Diagn 2019; 19:121-135. [DOI: 10.1080/14737159.2019.1568873] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Claire Franczak
- Service de Biopathologie, Institut de Cancérologie de Lorraine, Vandoeuvre les Nancy, France
| | | | - Pauline Gilson
- Service de Biopathologie, Institut de Cancérologie de Lorraine, Université de Lorraine, CNRS UMR 7039 CRAN, Nancy, France
| | - Jean-Louis Merlin
- Service de Biopathologie, Institut de Cancérologie de Lorraine, Université de Lorraine, CNRS UMR 7039 CRAN, Nancy, France
| | - Lewis Au
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - Alexandre Harlé
- Service de Biopathologie, Institut de Cancérologie de Lorraine, Université de Lorraine, CNRS UMR 7039 CRAN, Nancy, France
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25
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Yang K, Li J, Zhao J, Ren P, Wang Z, Wei B, Dong B, Sun R, Wang X, Groen HJM, Ma J, Guo Y. Developing Ultrasensitive Library-Aliquot-Based Droplet Digital PCR for Detecting T790M in Plasma-Circulating Tumor DNA of Non-small-Cell-Lung-Cancer Patients. Anal Chem 2018; 90:11203-11209. [PMID: 30156405 DOI: 10.1021/acs.analchem.8b01776] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A T790M secondary mutation in epidermal-growth-factor receptor (EGFR) is the most well-established EGFR-tyrosine-kinase-inhibitor (TKI) resistance marker in non-small-cell lung cancer (NSCLC). The current methods to rapidly and accurately detect T790M in clinical practice are not satisfactory because of several obstacles, including the unavailability of tumor-tissue rebiopsies and the low DNA copy number of T790M in circulating tumor DNA (ctDNA). Here, we develop library-aliquot-based droplet digital PCR (LAB-ddPCR) to increase detection sensitivity without affecting accuracy. This new LAB-ddPCR method is performed using aliquots of the ctDNA precapture next-generation-sequencing (NGS) library, in which the isolated ctDNA was amplified and enriched. We show that the LAB-ddPCR can precisely distinguish between T790M wild-type and mutation alleles without introducing extra false-positive signals. In a cohort of 70 post-TKI NSCLC patients, the LAB-ddPCR identified 41 T790M-positive cases (sensitivity 58.57%), but ddPCR only detected T790M in 27 cases (sensitivity 38.57%). Taking the ARMS-PCR result from matched tumor rebiopsies into consideration, the LAB-ddPCR method is better than ddPCR. In conclusion, the LAB-ddPCR ctDNA test offers a feasible and flexible option for the rapid and accurate detection of the T790M secondary mutation, which is helpful in dynamically monitoring drug response and disease progression throughout the therapeutic regimen.
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Affiliation(s)
- Ke Yang
- Department of Molecular Pathology , The Affiliated Cancer Hospital of Zhengzhou University , 127 Dongming Road , Zhengzhou 450003 , China
| | - Jun Li
- Department of Molecular Pathology , The Affiliated Cancer Hospital of Zhengzhou University , 127 Dongming Road , Zhengzhou 450003 , China
| | - Jiuzhou Zhao
- Department of Molecular Pathology , The Affiliated Cancer Hospital of Zhengzhou University , 127 Dongming Road , Zhengzhou 450003 , China
| | - Pengfei Ren
- Department of Molecular Pathology , The Affiliated Cancer Hospital of Zhengzhou University , 127 Dongming Road , Zhengzhou 450003 , China
| | - Zhizhong Wang
- Department of Molecular Pathology , The Affiliated Cancer Hospital of Zhengzhou University , 127 Dongming Road , Zhengzhou 450003 , China
| | - Bing Wei
- Department of Molecular Pathology , The Affiliated Cancer Hospital of Zhengzhou University , 127 Dongming Road , Zhengzhou 450003 , China
| | - Bing Dong
- Department of Molecular Pathology , The Affiliated Cancer Hospital of Zhengzhou University , 127 Dongming Road , Zhengzhou 450003 , China
| | - Rui Sun
- Department of Molecular Pathology , The Affiliated Cancer Hospital of Zhengzhou University , 127 Dongming Road , Zhengzhou 450003 , China
| | - Xiaoyan Wang
- Department of Molecular Pathology , The Affiliated Cancer Hospital of Zhengzhou University , 127 Dongming Road , Zhengzhou 450003 , China
| | - Harry J M Groen
- Department of Pulmonary Diseases , University of Groningen and University Medical Center Groningen , Groningen 9700 RB , The Netherlands
| | - Jie Ma
- Department of Molecular Pathology , The Affiliated Cancer Hospital of Zhengzhou University , 127 Dongming Road , Zhengzhou 450003 , China
| | - Yongjun Guo
- Department of Molecular Pathology , The Affiliated Cancer Hospital of Zhengzhou University , 127 Dongming Road , Zhengzhou 450003 , China
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26
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Lee E, Lee KJ, Park H, Chung JY, Lee MN, Chang MH, Yoo J, Lee H, Kong SY, Eom HS. Clinical Implications of Quantitative JAK2 V617F Analysis using Droplet Digital PCR in Myeloproliferative Neoplasms. Ann Lab Med 2018; 38:147-154. [PMID: 29214759 PMCID: PMC5736674 DOI: 10.3343/alm.2018.38.2.147] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 06/18/2017] [Accepted: 09/27/2017] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND JAK2 V617F is the most common mutation in myeloproliferative neoplasms (MPNs) and is a major diagnostic criterion. Mutation quantification is useful for classifying patients with MPN into subgroups and for prognostic prediction. Droplet digital PCR (ddPCR) can provide accurate and reproducible quantitative analysis of DNA. This study was designed to verify the correlation of ddPCR with pyrosequencing results in the diagnosis of MPN and to investigate clinical implications of the mutational burden. METHODS Peripheral blood or bone marrow samples were obtained from 56 patients newly diagnosed with MPN or previously diagnosed with MPN but not yet indicated for JAK2 inhibitor treatment between 2012 and 2016. The JAK2 V617F mutation was detected by pyrosequencing as a diagnostic work-up. The same samples were used for ddPCR to determine the correlation between assays and establish a detection sensitivity cut-off. Clinical and hematologic aspects were reviewed. RESULTS Forty-two (75%) and 46 (82.1%) patients were positive for JAK2 V617F by pyrosequencing and ddPCR, respectively. The mean mutated allele frequency at diagnosis was 37.5±30.1% and was 40.7±31.2% with ddPCR, representing a strong correlation (r=0.9712, P<0.001). Follow-up samples were available for 12 patients, including eight that were JAK2 V617F-positive. Of these, mutational burden reduction after treatment was observed in six patients (75%), consistent with trends of hematologic improvement. CONCLUSIONS Quantitative analysis of the JAK2 V617F mutation using ddPCR was highly correlated with pyrosequencing data and may reflect the clinical response to treatment.
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Affiliation(s)
- Eunyoung Lee
- Center for Hematologic Malignancy, National Cancer Center, Goyang, Korea
| | - Kyoung Joo Lee
- Department of System Cancer Science, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea
| | - Hyein Park
- Department of System Cancer Science, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea
| | - Jin Young Chung
- Center for Hematologic Malignancy, National Cancer Center, Goyang, Korea
| | - Mi Na Lee
- Green Cross Laboratories, Yongin, Korea
| | - Myung Hee Chang
- Division of Oncology-Hematology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jongha Yoo
- Department of Laboratory Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Hyewon Lee
- Center for Hematologic Malignancy, National Cancer Center, Goyang, Korea
| | - Sun Young Kong
- Center for Hematologic Malignancy, National Cancer Center, Goyang, Korea.,Department of System Cancer Science, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea.,Department of Laboratory Medicine, National Cancer Center, Goyang, Korea.
| | - Hyeon Seok Eom
- Center for Hematologic Malignancy, National Cancer Center, Goyang, Korea.,Department of System Cancer Science, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea.
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27
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Kageyama SI, Nihei K, Karasawa K, Sawada T, Koizumi F, Yamaguchi S, Kato S, Hojo H, Motegi A, Tsuchihara K, Akimoto T. Radiotherapy increases plasma levels of tumoral cell-free DNA in non-small cell lung cancer patients. Oncotarget 2018; 9:19368-19378. [PMID: 29721209 PMCID: PMC5922403 DOI: 10.18632/oncotarget.25053] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 03/21/2018] [Indexed: 12/20/2022] Open
Abstract
We investigated the plasma levels of tumor-specific cell-free DNA (cfDNA) in 17 stage I–II (early) and IV (advanced) non-small cell lung cancer (NSCLC) patients who underwent radiotherapy. Digital polymerase chain reaction (PCR) and targeted sequencing showed that total and tumor-specific cfDNA levels increased in response to radiotherapy in both early- and advanced-stage NSCLC patients. We detected high copy numbers of epidermal growth factor receptor mutations (L858R and T790M) in the cfDNA samples from stage IV NSCLC patients who underwent stereotactic body radiation therapy to treat brain metastasis related to tyrosine kinase inhibitor (TKI) treatment failure. In conclusion, our study demonstrates that radiotherapy increases tumoral cfDNA levels in the plasma and shows potential to serve as an indicator for diagnosing drug-resistant tumor-related gene mutations in early-stage NSCLC patients or those undergoing molecular targeted therapy.
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Affiliation(s)
| | - Keiji Nihei
- National Cancer Center Hospital East, Kashiwa, Chiba 277-8577, Japan
| | | | - Takeshi Sawada
- National Cancer Center Hospital East, Kashiwa, Chiba 277-8577, Japan
| | - Fumiaki Koizumi
- National Cancer Center Hospital East, Kashiwa, Chiba 277-8577, Japan
| | - Shigeo Yamaguchi
- National Cancer Center Hospital East, Kashiwa, Chiba 277-8577, Japan
| | - Shunsuke Kato
- National Cancer Center Hospital East, Kashiwa, Chiba 277-8577, Japan
| | - Hidehiro Hojo
- National Cancer Center Hospital East, Kashiwa, Chiba 277-8577, Japan
| | - Atsuhi Motegi
- National Cancer Center Hospital East, Kashiwa, Chiba 277-8577, Japan
| | | | - Tetsuo Akimoto
- National Cancer Center Hospital East, Kashiwa, Chiba 277-8577, Japan
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28
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Abraham J, Singh S, Joshi S. Liquid biopsy - emergence of a new era in personalized cancer care. ACTA ACUST UNITED AC 2018. [DOI: 10.1186/s41241-018-0053-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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29
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Zhang X, Chang N, Yang G, Zhang Y, Ye M, Cao J, Xiong J, Han Z, Wu S, Shang L, Zhang J. A comparison of ARMS-Plus and droplet digital PCR for detecting EGFR activating mutations in plasma. Oncotarget 2017; 8:112014-112023. [PMID: 29340107 PMCID: PMC5762375 DOI: 10.18632/oncotarget.22997] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 06/02/2017] [Indexed: 12/02/2022] Open
Abstract
In this study, we introduce a novel amplification refractory mutation system (ARMS)-based assay, namely ARMS-Plus, for the detection of epidermal growth factor receptor (EGFR) mutations in plasma samples. We evaluated the performance of ARMS-Plus in comparison with droplet digital PCR (ddPCR) and assessed the significance of plasma EGFR mutations in predicting efficacy of EGFR-tyrosine kinase inhibitor (TKI) regimen. A total of 122 advanced non-small cell lung cancer (NSCLC) patients were enrolled in this study. The tumor tissue samples from these patients were evaluated by conventional ARMS PCR method to confirm their EGFR mutation status. For the 116 plasma samples analyzed by ARMS-Plus, the sensitivity, specificity, and concordance rate were 77.27% (34/44), 97.22% (70/72), and 89.66% (104/116; κ=0.77, P<0.0001), respectively. Among the 71 plasma samples analyzed by both ARMS-Plus and ddPCR, ARMS-Plus showed a higher sensitivity than ddPCR (83.33% versus 70.83%). The presence of EGFR activating mutations in plasma was not associated with the response to EGFR-TKI, although further validation with a larger cohort is required to confirm the correlation. Collectively, the performance of ARMS-Plus and ddPCR are comparable. ARMS-Plus could be a potential alternative to tissue genotyping for the detection of plasma EGFR mutations in NSCLC patients.
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Affiliation(s)
- Xinxin Zhang
- Department of Pulmonary Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ning Chang
- Department of Pulmonary Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Guohua Yang
- Research and Development Department, GenoSaber Biotech Co. Ltd., Shanghai, China
| | - Yong Zhang
- Department of Pulmonary Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Mingxiang Ye
- Department of Pulmonary Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jing Cao
- Department of Pulmonary Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jie Xiong
- Department of Pulmonary Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zhiping Han
- Department of Pulmonary Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Shuo Wu
- Department of Pulmonary Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Lei Shang
- Department of Health Statistics, School of Preventive Medicine, Fourth Military Medical University, Xi'an, China
| | - Jian Zhang
- Department of Pulmonary Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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30
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Bouhlel L, Hofman V, Maschi C, Ilié M, Allégra M, Marquette CH, Audigier-Valette C, Thariat J, Hofman P. The liquid biopsy: a tool for a combined diagnostic and theranostic approach for care of a patient with late-stage lung carcinoma presenting with bilateral ocular metastases. Expert Rev Anticancer Ther 2017; 17:1087-1092. [PMID: 29069959 DOI: 10.1080/14737140.2017.1398089] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Liquid biopsies (LB) are used routinely in clinical practice in two situations for late stage non-small-cell lung cancer (NSCLC) patients, (i) at the initial diagnosis when looking for activating mutations in EGFR in the absence of analyzable tissue DNA and, (ii) during tumor progression on a tyrosine kinase inhibitor treatment to look for the resistance mutation T790M in EGFR. LB is not presently recommended in daily practice for the diagnosis of NSCLC. Areas covered: We report the diagnosis of a NSCLC in a patient with bilateral ocular metastases after detection of a deletion in exon 19 of EGFR when using plasma DNA. Without histological analysis, the origin of the primary ocular metastasis was uncertain. In this context, a LB showing an activating mutation in EGFR and circulating tumor cells positive for TTF1 led to the diagnosis of NSCLC and targeted therapy. Expert commentary: When no tumor tissue sample is available a LB can be used to diagnose for metastatic NSCLC, when a mutation in EGFR is identified. While a tissue biopsy is the gold standard approach for the diagnosis of a NSCLC and for identification of activating mutations, LB can exceptionally provide both a diagnosis of the primitive tumor and indicate appropriate therapy based on a molecular analysis.
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Affiliation(s)
- Linda Bouhlel
- a Department of Oncology , Antoine Lacassagne Comprehensive Cancer Centre , Nice , France
| | - Véronique Hofman
- b FHU OncoAge, Laboratory of Clinical and Experimental Pathology , CHU of Nice , Nice , France.,c Hospital-Integrated Biobank (BB-0033-00025) , CHU of Nice , Nice , France
| | - Célia Maschi
- d Department of Ophtalmology , CHU of Nice , Nice , France
| | - Marius Ilié
- b FHU OncoAge, Laboratory of Clinical and Experimental Pathology , CHU of Nice , Nice , France.,c Hospital-Integrated Biobank (BB-0033-00025) , CHU of Nice , Nice , France
| | - Maryline Allégra
- b FHU OncoAge, Laboratory of Clinical and Experimental Pathology , CHU of Nice , Nice , France.,c Hospital-Integrated Biobank (BB-0033-00025) , CHU of Nice , Nice , France
| | | | | | - Juliette Thariat
- g Radiation Oncology Department , Antoine Lacassagne Comprehensive Cancer Center , Nice , France
| | - Paul Hofman
- b FHU OncoAge, Laboratory of Clinical and Experimental Pathology , CHU of Nice , Nice , France.,c Hospital-Integrated Biobank (BB-0033-00025) , CHU of Nice , Nice , France
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31
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Mehrotra M, Singh RR, Loghavi S, Duose DY, Barkoh BA, Behrens C, Patel KP, Routbort MJ, Kopetz S, Broaddus RR, Medeiros LJ, Wistuba II, Luthra R. Detection of somatic mutations in cell-free DNA in plasma and correlation with overall survival in patients with solid tumors. Oncotarget 2017. [PMID: 29535804 PMCID: PMC5828199 DOI: 10.18632/oncotarget.21982] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
A suitable clinical-grade platform is required for detection of somatic mutations with high sensitivity in cell-free DNA (cfDNA) of patients with solid tumors. In this study, we evaluated in parallel ultra-deep NGS with MassARRAY and allele-specific droplet digital PCR (ddPCR) for cfDNA genotyping and correlated cfDNA yield and mutation status with overall survival (OS) of patients. We assessed plasma samples from 46 patients with various advanced metastatic solid tumors and known mutations by deep sequencing using an Ampliseq cancer hotspot panel V2 on Ion Proton. A subset of these samples with DNA availability was tested by ddPCR and UltraSEEK MassARRAY for mutation detection in 5 genes (IDH1, PIK3CA, KRAS, BRAF, and NRAS). Sixty one of 104 expected tissue mutations and 6 additional mutations not present in the tissue were detected in cfDNA. ddPCR and MassARRAY showed 83% and 77% concordance with NGS for mutation detection with 100% and 79% sensitivity, respectively. The median OS of patients with lower cfDNA yield (74 vs 50 months; P < 0.03) and cfDNA negative for mutations (74.2 vs 53 months; p < 0.04) was significantly longer than in patients with higher cfDNA yield and positive for mutations. A limit-of-detection of 0.1% was demonstrated for ddPCR and MassARRAY platforms using a serially diluted positive cfDNA sample. The MassARRAY and ddPCR systems enable fast and cost-effective genotyping for a targeted set of mutations and can be used for single gene testing to guide response to chemotherapy or for orthogonal validation of NGS results.
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Affiliation(s)
- Meenakshi Mehrotra
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rajesh R Singh
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Dzifa Yawa Duose
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bedia A Barkoh
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carmen Behrens
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Keyur P Patel
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark J Routbort
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Scott Kopetz
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Russell R Broaddus
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - L Jeffrey Medeiros
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ignacio I Wistuba
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rajyalakshmi Luthra
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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32
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Yang Y, Shen X, Li R, Shen J, Zhang H, Yu L, Liu B, Wang L. The detection and significance of EGFR and BRAF in cell-free DNA of peripheral blood in NSCLC. Oncotarget 2017; 8:49773-49782. [PMID: 28572536 PMCID: PMC5564806 DOI: 10.18632/oncotarget.17937] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 05/04/2017] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE Although driver mutation status is crucial to targeted therapy decision-making in non-small cell lung cancer (NSCLC), due to unavailable or inadequate biopsies, there are still many patients with unknown mutation status. A promising way to solve this problem is liquid biopsy, such as cell-free DNA (cfDNA) in peripheral blood. Additionally, due to the little amount of cfDNA, detecting methods with high sensitivity, specificity and economy are required in clinical practice. Here, we explored the feasibility of Competitive Allele-Specific TaqMan® PCR (CastPCR) detecting driver mutations in cfDNA from plasma in lung adenocarcinoma patients. RESULTS Sensitivity, specificity, concordance, PPV and NPV of CastPCR detecting EGFR mutations in cfDNA was 56.4% (31/55), 94.2% (49/52), 74.8% (80/107), 91.2% (31/34) and 67.1% (49/73), respectively. Notably, specificity and PPV for p.T790M both reached 100.0%. For BRAF detection, it was 28.6% (2/7), 93.0% (93/100), 88.8% (95/107), 22.2% (2/9) and 94.9% (93/98), respectively. MATERIALS AND METHODS Plasma specimens of 107 lung adenocarcinoma patients and their matched tumor formalin fixed paraffin embedded (FFPE) samples were analyzed. CastPCR was used to detect EGFR (c.2235_2249del, c.2236_2250del, c.2369C>T p.T790M, c.2573T>G p.L858R) and BRAF (c.1406G>C p.G469A, c.1799T>A p.V600E, c.1781A>G p.D594G) mutations. Mutation results of tumor tissue was set as gold standard, and the sensitivity, specificity, concordance, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each mutation. CONCLUSIONS For patients whose tumor tissue is unavailable or inadequate, EGFR mutation detection in cfDNA with CastPCR could be first choice. Mutation positive results may provide reference for further clinical medication. While negative results indicate that detection in tissue should be considered as the following step. In this way, tumor tissue could be economized to the maximum extent and the risk of repeated percutaneous transthoracic lung biopsy could also be lowered to the maximum extent. For BRAF detection in cfDNA, CastPCR is a specific method while the sensitivity needs further exploration.
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Affiliation(s)
- Yang Yang
- The Comprehensive Cancer Center of Drum Tower Hospital, Nanjing University Medical School and Clinical Cancer Institute of Nanjing University, Nanjing 210008, PR China
- Nanjing Xianlin Drum Tower Hospital, Nanjing 210046, PR China
| | - Xiaoyan Shen
- The Comprehensive Cancer Center of Drum Tower Hospital, Nanjing University Medical School and Clinical Cancer Institute of Nanjing University, Nanjing 210008, PR China
| | - Rutian Li
- The Comprehensive Cancer Center of Drum Tower Hospital, Nanjing University Medical School and Clinical Cancer Institute of Nanjing University, Nanjing 210008, PR China
| | - Jie Shen
- The Comprehensive Cancer Center of Drum Tower Hospital, Nanjing University Medical School and Clinical Cancer Institute of Nanjing University, Nanjing 210008, PR China
| | - Hang Zhang
- The Comprehensive Cancer Center of Drum Tower Hospital, Nanjing University Medical School and Clinical Cancer Institute of Nanjing University, Nanjing 210008, PR China
| | - Lixia Yu
- The Comprehensive Cancer Center of Drum Tower Hospital, Nanjing University Medical School and Clinical Cancer Institute of Nanjing University, Nanjing 210008, PR China
| | - Baorui Liu
- The Comprehensive Cancer Center of Drum Tower Hospital, Nanjing University Medical School and Clinical Cancer Institute of Nanjing University, Nanjing 210008, PR China
| | - Lifeng Wang
- The Comprehensive Cancer Center of Drum Tower Hospital, Nanjing University Medical School and Clinical Cancer Institute of Nanjing University, Nanjing 210008, PR China
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Gu J, Zang W, Liu B, Li L, Huang L, Li S, Rao G, Yu Y, Zhou Y. Evaluation of digital PCR for detecting low-level EGFR mutations in advanced lung adenocarcinoma patients: a cross-platform comparison study. Oncotarget 2017; 8:67810-67820. [PMID: 28978074 PMCID: PMC5620214 DOI: 10.18632/oncotarget.18866] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 06/02/2017] [Indexed: 01/28/2023] Open
Abstract
Emerging evidence has indicated that circulating tumor DNA (ctDNA) from plasma could be used to analyze EGFR mutation status for NSCLC patients; however, due to the low level of ctDNA in plasma, highly sensitive approaches are required to detect low frequency mutations. In addition, the cutoff for the mutation abundance that can be detected in tumor tissue but cannot be detected in matched ctDNA is still unknown. To assess a highly sensitive method, we evaluated the use of digital PCR in the detection of EGFR mutations in tumor tissue from 47 advanced lung adenocarcinoma patients through comparison with NGS and ARMS. We determined the degree of concordance between tumor tissue DNA and paired ctDNA and analyzed the mutation abundance relationship between them. Digital PCR and Proton had a high sensitivity (96.00% vs. 100%) compared with that of ARMS in the detection of mutations in tumor tissue. Digital PCR outperformed Proton in identifying more low abundance mutations. The ctDNA detection rate of digital PCR was 87.50% in paired tumor tissue with a mutation abundance above 5% and 7.59% in paired tumor tissue with a mutation abundance below 5%. When the DNA mutation abundance of tumor tissue was above 3.81%, it could identify mutations in paired ctDNA with a high sensitivity. Digital PCR will help identify alternative methods for detecting low abundance mutations in tumor tissue DNA and plasma ctDNA.
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Affiliation(s)
- Jincui Gu
- Department of Respiratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wanchun Zang
- Novogene Bioinformatics Institute, Beijing, China
| | - Bing Liu
- Novogene Bioinformatics Institute, Beijing, China
| | - Lei Li
- Novogene Bioinformatics Institute, Beijing, China
| | - Lixia Huang
- Department of Respiratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shaoli Li
- Department of Respiratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Guanhua Rao
- Novogene Bioinformatics Institute, Beijing, China
| | - Yang Yu
- Novogene Bioinformatics Institute, Beijing, China
| | - Yanbin Zhou
- Department of Respiratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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