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Bertero L, Dalla Dea G, Osella-Abate S, Botta C, Castellano I, Morra I, Pollo B, Calatozzolo C, Patriarca S, Mantovani C, Rudà R, Tardivo V, Zenga F, Garbossa D, Papotti M, Soffietti R, Ricardi U, Cassoni P. Prognostic Characterization of Higher-Grade Meningiomas: A Histopathological Score to Predict Progression and Outcome. J Neuropathol Exp Neurol 2020; 78:248-256. [PMID: 30689922 PMCID: PMC6380327 DOI: 10.1093/jnen/nly127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Higher-grade meningiomas (WHO grade II and III) represent a diagnostic and prognostic challenge. We assessed the pathological and molecular characteristics of 94 higher-grade meningiomas (85 grade II, 9 grade III) to identify novel prognostic parameters. Higher mitotic count (p = 0.018), diffuse (≥50%) prominent nucleoli (p < 0.001), and sheeting (p < 0.001) were associated with recurrence. Lower SSTR2a-positive cells median rate (p = 0.048) and TERT promoter mutations (p = 0.014) were associated with recurrence and patient death, respectively; further analyses did not identify other outcome associations. Presence of Ki67 hot spots was associated with a shorter progression-free survival (PFS), independently of WHO grade at multivariate analysis (HR = 3.35, p = 0.008). Necrosis was related to a poorer overall survival (OS) at univariate (focal: HR = 4.55, p = 0.041 and diffuse: HR = 7.38, p = 0.020) and Kaplan-Meier analyses. A prognostic score was designed based on previous results: Presence of diffuse (≥50%) prominent nucleoli (0/1 point), diffuse (≥50%) sheeting (0/1 point), focal (<50%) or diffuse (≥50%) necrosis (0/1/2 points), and Ki67 hot spots (0/1 point). A total score ≥4 predicted poorer PFS and OS by Kaplan-Meier (PFS: 1.7 vs 6.4 years, p < 0.001 and OS: 5.2 vs 10.8 years, p = 0.001) and multivariate (PFS: HR = 5.98, p < 0.001 and OS: HR = 2.99, p = 0.048) analyses. These results were confirmed in an independent series of 58 grade II meningiomas (PFS: HR = 7.22, p = 0.002 and OS: HR = 9.69, p = 0.003). These associations and the integrated score could complement WHO grading.
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Affiliation(s)
- Luca Bertero
- Pathology Unit, Department of Medical Sciences, University of Turin, Torino, Italy
| | - Giulia Dalla Dea
- Pathology Unit, Department of Medical Sciences, University of Turin, Torino, Italy
| | - Simona Osella-Abate
- Pathology Unit, Department of Medical Sciences, University of Turin, Torino, Italy
| | - Cristina Botta
- Pathology Unit, Department of Medical Sciences, University of Turin, Torino, Italy
| | - Isabella Castellano
- Pathology Unit, Department of Medical Sciences, University of Turin, Torino, Italy
| | - Isabella Morra
- Pathology Unit, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Bianca Pollo
- Neuropathology Unit, Fondazione IRCCS Istituto Neurologico "C. Besta," Milano, Italy
| | - Chiara Calatozzolo
- Neuropathology Unit, Fondazione IRCCS Istituto Neurologico "C. Besta," Milano, Italy
| | - Silvia Patriarca
- Piedmont Cancer Registry - CRPT, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Cristina Mantovani
- Radiation Oncology Unit, Department of Oncology, University of Turin, Torino, Italy
| | - Roberta Rudà
- Neuro-oncology Unit, Department of Neurosciences, University of Turin, Torino, Italy
| | - Valentina Tardivo
- Neurosurgery Unit, Department of Neurosciences, University of Turin, Torino, Italy
| | - Francesco Zenga
- Neurosurgery Unit, Department of Neurosciences, University of Turin, Torino, Italy
| | - Diego Garbossa
- Neurosurgery Unit, Department of Neurosciences, University of Turin, Torino, Italy
| | - Mauro Papotti
- Pathology Unit, Department of Oncology, University of Turin, Torino, Italy
| | - Riccardo Soffietti
- Neuro-oncology Unit, Department of Neurosciences, University of Turin, Torino, Italy
| | - Umberto Ricardi
- Radiation Oncology Unit, Department of Oncology, University of Turin, Torino, Italy
| | - Paola Cassoni
- Pathology Unit, Department of Medical Sciences, University of Turin, Torino, Italy
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Marchiò C, Mariani S, Bertero L, Di Bello C, Francia Di Celle P, Papotti M, Rudà R, Soffietti R, Cassoni P. Liquoral liquid biopsy in neoplastic meningitis enables molecular diagnosis and mutation tracking: a proof of concept. Neuro Oncol 2019; 19:451-453. [PMID: 27838647 PMCID: PMC5464358 DOI: 10.1093/neuonc/now244] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 09/29/2016] [Indexed: 11/12/2022] Open
Affiliation(s)
- Caterina Marchiò
- Department of Medical Sciences, University of Turin, Turin, Italy.,Pathology Division, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Sara Mariani
- Department of Medical Sciences, University of Turin, Turin, Italy.,Pathology Division, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Luca Bertero
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Cristiana Di Bello
- Pathology Division, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Paola Francia Di Celle
- Pathology Division, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Mauro Papotti
- Pathology Division, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy.,Department of Oncology, University of Turin, Turin, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy.,Department of Neurosciences, University of Turin, Turin, Italy
| | - Paola Cassoni
- Department of Medical Sciences, University of Turin, Turin, Italy.,Pathology Division, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
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Osella-Abate S, Bertero L, Senetta R, Mariani S, Lisa F, Coppola V, Metovic J, Pasini B, Puig S S, Fierro MT, Manrique-Silva E, Kumar R, Nagore E, Cassoni P, Ribero S. TERT Promoter Mutations are Associated with Visceral Spreading in Melanoma of the Trunk. Cancers (Basel) 2019; 11:E452. [PMID: 30934988 DOI: 10.3390/cancers11040452] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 03/19/2019] [Accepted: 03/28/2019] [Indexed: 12/27/2022] Open
Abstract
Survival predictions are currently determined on the basis of NRAS/BRAF mutations, even though TERT promoter mutations have been recently associated with a poor prognosis in stage I-II melanomas. Usually, it is not recommended to perform a mutational test on primary melanoma, as the results do not always reflect the mutational status of metastases. In particular, trunk melanomas have been reported to have an unfavourable prognosis. A series of 105 advanced melanoma patients were analysed by TERT promoter Sanger sequencing. Univariate/multivariate binary logistic regression models were performed using progression to a visceral site as the dependent variable and patient/tumour characteristics as covariates. Performance of the model was assessed in an external independent primary melanoma patients’ dataset. Male gender (odds ratio (OR), 344; 95% CI, 1.12–10.6; p = 0.031), AJCC (American Joint Committee on Cancer) classification (OR, 022; 95% CI, 0.07–0.67; p = 0.008), SLNB (Sentinel Lymph Node Biopsy) status (OR, 3.05; 95% CI, 1.06–8.78; p = 0.039) and TERT-mutated trunk lesions (OR, 3.78; 95% CI, 1.35–10.6; p = 0.011) were significantly associated with the risk of developing a visceral spreading as first site of progression using multivariate logistic regression analysis. These results were confirmed in the external validation control group. Therefore, in trunk primary melanomas, due to their high risk of progression to visceral sites, we encourage somatic TERT mutation analysis at diagnosis to identify those patients who would potentially benefit from a more intensive follow-up protocol and a prompt initiation of therapy.
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Osella-Abate S, Mereu E, Pellegrino E, Bergaggio E, Ribero S, Bertero L, Lisa F, Fierro MT, Giulio Papotti M, Piva R. ALK expression favorably impacts the prognosis of NRAS-mutated metastatic melanomas. Oncol Lett 2018; 16:7091-7096. [PMID: 30546443 PMCID: PMC6256323 DOI: 10.3892/ol.2018.9560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 08/31/2018] [Indexed: 02/03/2023] Open
Abstract
Recent studies reported the expression of anaplastic lymphoma kinase (ALK) in malignant melanomas. The aim of this study was to investigate whether ALK expression is associated with specific clinical and molecular characteristics of melanoma metastases, and to evaluate its correlation with survival outcomes. Seventy-one patients with metastatic melanoma were investigated. Clinical features and survival outcomes were analyzed and correlated to ALK expression, as detected by immunohistochemistry and reverse transcription-quantitative polymerase chain reaction, and to the mutational status of BRAF, KRAS, NRAS, and PIK3CA. No translocations or ALK alternative isoforms were identified. ALK expression was mainly detected in NRAS mutated metastatic lesions. Interestingly, among NRAS-mutated patients, ALK positive samples displayed a significantly more favorable outcome in terms of disease specific survival, as compared to ALK negative ones. In conclusion, we suggest that ALK positive/NRAS mutated metastases represent a specific subset of metastatic melanomas, associated with a better prognosis. Validation of these observations in larger cohorts could contribute to understand the molecular events cooperating to melanoma progression, in addition to open new perspectives in the clinical and therapeutic management of this subgroup of patients.
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Affiliation(s)
- Simona Osella-Abate
- Department of Medical Sciences, Pathology Unit, University of Torino, I-10126 Torino, Italy
| | - Elisabetta Mereu
- Department of Molecular Biotechnology and Health Sciences, Center for Experimental Research and Medical Studies, University of Torino, I-10126 Torino, Italy
| | - Elisa Pellegrino
- Department of Molecular Biotechnology and Health Sciences, Center for Experimental Research and Medical Studies, University of Torino, I-10126 Torino, Italy
| | - Elisa Bergaggio
- Department of Molecular Biotechnology and Health Sciences, Center for Experimental Research and Medical Studies, University of Torino, I-10126 Torino, Italy
| | - Simone Ribero
- Department of Medical Sciences, Dermatology Unit, University of Torino, I-10126 Torino, Italy
| | - Luca Bertero
- Department of Molecular Biotechnology and Health Sciences, Center for Experimental Research and Medical Studies, University of Torino, I-10126 Torino, Italy
| | - Francesco Lisa
- Department of Medical Sciences, Dermatology Unit, University of Torino, I-10126 Torino, Italy
| | - Maria Teresa Fierro
- Department of Medical Sciences, Dermatology Unit, University of Torino, I-10126 Torino, Italy
| | - Mauro Giulio Papotti
- Department of Oncology, Pathology Unit, University of Torino, I-10126 Torino, Italy
| | - Roberto Piva
- Department of Molecular Biotechnology and Health Sciences, Center for Experimental Research and Medical Studies, University of Torino, I-10126 Torino, Italy
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Bertero L, Anfossi V, Osella-Abate S, Disanto MG, Mantovani C, Zenga F, Rudà R, Garbossa D, Soffietti R, Ricardi U, Papotti M, Cassoni P. Pathological prognostic markers in central nervous system solitary fibrous tumour/hemangiopericytoma: Evidence from a small series. PLoS One 2018; 13:e0203570. [PMID: 30183767 PMCID: PMC6124774 DOI: 10.1371/journal.pone.0203570] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/01/2018] [Indexed: 12/16/2022] Open
Abstract
Background Primary central nervous system (CNS) solitary fibrous tumour/hemangiopericytoma (SFT/HPC) is a rare neoplasm and its classification criteria have been redefined by the latest WHO Classification of CNS Tumours. Outcome can vary significantly among patients, thus reliable prognostic markers are warranted. Methods Primary CNS SFT/HPC diagnosed at the Pathology Unit of our Institution between 2006 and 2016 were retrospectively collected. Tumour grade along with immunohistochemistry for Ki67, STAT6, PHH3, CD34 and Bcl-2 were assessed. TERT promoter status was evaluated by Sanger sequencing. Results Fifteen SFT/HPC were analysed: 9/15 (60%) female, median age at diagnosis 60 (range: 10–67). Six (40%) cases showed a SFT phenotype and mean H&E-mitotic count was 4.8/10 HPF. Tumour grade was I in 6, II in 4 and III in 5 cases. Mean PHH3-mitotic count was higher than H&E count (8.4 versus 4.8/10 HPF), but it would have determined a change in tumour grade in a sole case. Nuclear staining for STAT6 was present in 14/15 (93.3%). CD34 and Bcl-2 expression rates were lower in higher grade tumours. TERT promoter was mutated in two cases. Median follow up time was 2.4 years (6 months-7.4 years) and 5/15 (33%) patients developed local disease recurrence. Partial resection (p = 0.0185), higher WHO grade (p = 0.038), lower CD34 (p = 0.038) and Bcl-2 (p = 0.010) expressions were significantly associated with a poorer disease-free interval. Conclusions WHO grade is the main prognostic tool in CNS SFT/HPC, but it could be integrated by other markers, like CD34 and Bcl-2, in the clinical practice. The relevance of TERT promoter mutations in this subset of CNS tumours needs further evaluation.
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Affiliation(s)
- Luca Bertero
- Pathology Unit, Department of Medical Sciences, University of Turin, Turin, Italy
- * E-mail:
| | - Vittorio Anfossi
- Pathology Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Simona Osella-Abate
- Pathology Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Maria Giulia Disanto
- Pathology Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Cristina Mantovani
- Radiation Oncology Unit, Department of Oncology, University of Turin, Turin, Italy
| | - Francesco Zenga
- Neurosurgery Unit, Department of Neurosciences, University of Turin, Turin, Italy
| | - Roberta Rudà
- Neuro-oncology Unit, Department of Neurosciences, University of Turin, Turin, Italy
| | - Diego Garbossa
- Neurosurgery Unit, Department of Neurosciences, University of Turin, Turin, Italy
| | - Riccardo Soffietti
- Neuro-oncology Unit, Department of Neurosciences, University of Turin, Turin, Italy
| | - Umberto Ricardi
- Radiation Oncology Unit, Department of Oncology, University of Turin, Turin, Italy
| | - Mauro Papotti
- Pathology Unit, Department of Oncology, University of Turin, Turin, Italy
| | - Paola Cassoni
- Pathology Unit, Department of Medical Sciences, University of Turin, Turin, Italy
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Mariani S, Bertero L, Coppola V, Saracco G, Arezzo A, Francia Di Celle P, Metovic J, Marchiò C, Cassoni P. Awareness of mutational artefacts in suboptimal DNA samples: possible risk for therapeutic choices. Expert Rev Mol Diagn 2018; 18:467-475. [PMID: 29676606 DOI: 10.1080/14737159.2018.1468254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Technical biases due to PCR artefacts could represent an insidious obstacle for mutational analysis and precision medicine. METHODS The authors report a retrospective analysis by fast COLD-PCR and sequencing of 31 suboptimal tumor DNA samples obtained from FFPE tissues and liquid biopsies. RESULTS In FFPE tumor tissues and plasma liquid biopsies of patients with lung and colorectal adenocarcinoma, we observed a significant rate of artefactual KRAS mutations, unveiled by repeated analysis following UDG pretreatment as well as by simple repetition without UDG pretreatment step, thus suggesting a DNA damage different from cytosine deamination. UDG pretreatment was not only unnecessary to contrast artefacts occurrence, but also hampered the efficiency of mutational screening, reducing the analytical sensitivity. Taken individually or considered together, the reduced DNA input per reaction and UDG pretreatment limited the detection of 'real' mutated alleles, decreasing PCR sensitivity enough to hamper distinction between artefactual and true subclonal mutations of KRAS. CONCLUSIONS Careful validation of analytical sensitivities should always be carried out through standard controls, and strategies other than UDG pretreatment need to be identified to avoid both amplification of artefactual mutations and failure to identify real subclonal mutations.
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Affiliation(s)
- Sara Mariani
- a Department of Medical Sciences , University of Turin and Pathology Unit, Città della Salute e della Scienza Hospital , Torino , Italy
| | - Luca Bertero
- a Department of Medical Sciences , University of Turin and Pathology Unit, Città della Salute e della Scienza Hospital , Torino , Italy
| | - Vittoria Coppola
- a Department of Medical Sciences , University of Turin and Pathology Unit, Città della Salute e della Scienza Hospital , Torino , Italy
| | - Giorgio Saracco
- b Department of Medical Sciences , University of Turin and Gastroenterology Unit, Città della Salute e della Scienza Hospital , Torino , Italy
| | - Alberto Arezzo
- c Department of Surgical Sciences , University of Turin and Surgical Unit, Città della Salute e della Scienza Hospital , Torino , Italy
| | | | - Jasna Metovic
- a Department of Medical Sciences , University of Turin and Pathology Unit, Città della Salute e della Scienza Hospital , Torino , Italy
| | - Caterina Marchiò
- a Department of Medical Sciences , University of Turin and Pathology Unit, Città della Salute e della Scienza Hospital , Torino , Italy
| | - Paola Cassoni
- a Department of Medical Sciences , University of Turin and Pathology Unit, Città della Salute e della Scienza Hospital , Torino , Italy
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Mariani S, Bertero L, Osella-Abate S, Di Bello C, Francia di Celle P, Coppola V, Sapino A, Cassoni P, Marchiò C. Extreme assay sensitivity in molecular diagnostics further unveils intratumour heterogeneity in metastatic colorectal cancer as well as artifactual low-frequency mutations in the KRAS gene. Br J Cancer 2017; 117:358-366. [PMID: 28618430 PMCID: PMC5537488 DOI: 10.1038/bjc.2017.170] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 05/15/2017] [Accepted: 05/22/2017] [Indexed: 12/16/2022] Open
Abstract
Background: Gene mutations in the RAS family rule out metastatic colorectal carcinomas (mCRCs) from anti-EGFR therapies. Methods: We report a retrospective analysis by Sequenom Massarray and fast COLD-PCR followed by Sanger sequencing on 240 mCRCs. Results: By Sequenom, KRAS and NRAS exons 2-3-4 were mutated in 52.9% (127/240) of tumours, while BRAF codon 600 mutations reached 5% (12/240). Fast COLD-PCR found extra mutations at KRAS exon 2 in 15/166 (9%) of samples, previously diagnosed by Sequenom as wild-type or mutated at RAS (exons 3-4) or BRAF genes. After UDG digestion results were reproduced in 2/12 analysable subclonally mutated samples leading to a frequency of true subclonal KRAS mutations of 1.2% (2.1% of the previous Sequenom wild-type subgroup). In 10 out of 12 samples, the subclonal KRAS mutations disappeared (9 out of 12) or turned to a different sequence variant (1 out of 12). Conclusions: mCRC can harbour coexisting multiple gene mutations. High sensitivity assays allow the detection of a small subset of patients harbouring true subclonal KRAS mutations. However, DNA changes with mutant allele frequencies <3% detected in formalin-fixed paraffin-embedded samples may be artifactual in a non-negligible fraction of cases. UDG pre-treatment of DNA is mandatory to identify true DNA changes in archival samples and avoid misinterpretation due to artifacts.
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Affiliation(s)
- Sara Mariani
- Department of Medical Sciences, University of Turin, via Santena 7, Turin 10126, Italy
| | - Luca Bertero
- Department of Medical Sciences, University of Turin, via Santena 7, Turin 10126, Italy
| | - Simona Osella-Abate
- Department of Medical Sciences, University of Turin, via Santena 7, Turin 10126, Italy
| | - Cristiana Di Bello
- Department of Molecular Biotechnology and Health Sciences, University of Turin, via Nizza 52, Turin 10126, Italy
| | - Paola Francia di Celle
- Pathology Unit, Azienda Ospedaliera Universitaria Città della Salute e della Scienza, via Santena 7, Turin 10126, Italy
| | - Vittoria Coppola
- Department of Medical Sciences, University of Turin, via Santena 7, Turin 10126, Italy
| | - Anna Sapino
- Department of Medical Sciences, University of Turin, via Santena 7, Turin 10126, Italy
| | - Paola Cassoni
- Department of Medical Sciences, University of Turin, via Santena 7, Turin 10126, Italy.,Pathology Unit, Azienda Ospedaliera Universitaria Città della Salute e della Scienza, via Santena 7, Turin 10126, Italy
| | - Caterina Marchiò
- Department of Medical Sciences, University of Turin, via Santena 7, Turin 10126, Italy.,Pathology Unit, Azienda Ospedaliera Universitaria Città della Salute e della Scienza, via Santena 7, Turin 10126, Italy
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Abstract
INTRODUCTION Next-Generation-Sequencing (NGS) has enabled gene mutation profiling - cataloguing sequence variants and modifications in clinical assays encompassing tens to thousands of genes in tumors and in germlines. The clinical benefit of applying multi-gene NGS to diverse applications in various malignancies remains to be demonstrated. AREAS COVERED Applications of gene mutation profiling in oncology include screening cancer-prone families, classification of malignancies, treatment selection, and monitoring the response to treatment of solid tumors (the 'liquid biopsy'). Google Scholar was used to search PubMed for the period 2011-2016 using combinations of the following search terms: 'clinical utility', NGS, 'molecular diagnostics'. Expert commentary: Clinical studies are in progress pairing mutation profiling with streamlined new trial designs to speed identification of promising drug-target combinations and to see if genotype-informed treatment selection will improve outcome across a spectrum of histologies. The analytical advantages and falling cost of NGS make focused gene panels likely to become the dominant modality in molecular diagnostic testing even if trials eventually discourage use of large panels to test all malignancies.
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Affiliation(s)
- Loren Joseph
- a Department of Pathology, Beth Israel Deaconess Medical Center, Molecular Diagnostics Laboratory , Harvard Medical School , Boston , MA , USA
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