Brassica napus BnaA09.MYB52 enhances seed coat mucilage accumulation and tolerance to osmotic stress during seed germination in Arabidopsis thaliana

Seed coat mucilage plays an important role in promoting seed germination under adversity. Previous studies have shown that Arabidopsis thaliana MYB52 (AtMYB52) can positively regulate seed coat mucilage accumulation. However, the role of Brassica napus MYB52 (BnaMYB52) in accumulation of seed coat mucilage and tolerance to osmotic stress during seed germination remains largely unknown. We cloned the BnaA09.MYB52 coding domain sequence from B. napus cv ZS11, identified its conserved protein domains and elucidated its relationship with homologues from a range of plant species. Transgenic plants overexpressing BnaA09.MYB52 in the A. thaliana myb52-1 mutant were generated through Agrobacterium-mediated transformation and used to assess the possible roles of BnaA09.MYB52 in accumulation of seed coat mucilage and tolerance to osmotic stress during seed germination. Subcellular localization and transcriptional activity assays demonstrated that BnaA09.MYB52 functions as a transcription factor. RT-qPCR results indicate that BnaA09.MYB52 is predominantly expressed in roots and developing seeds of B. napus cv ZS11. Introduction of BnaA09.MYB52 into myb52-1 restored thinner seed coat mucilage in this mutant to levels in the wild type. Consistently, expression levels of three key genes participating in mucilage formation in developing seeds of myb52-1 were also restored to wild type levels by overexpressing BnaA09.MYB52. Furthermore, BnaA09.MYB52 was induced by osmotic stress during seed germination in B. napus, and ectopic expression of BnaA09.MYB52 successfully corrected sensitivity of the myb52-1 mutant to osmotic stress during seed germination. These findings enhance our understanding of the functions of BnaA09.MYB52 and provide a novel strategy for future B. napus breeding.

Clinical value of FAT1 mutations to indicate the immune response in colorectal cancer patients

Immunotherapy is currently approved for CRC whose tumors have high MSI-H. To find additional biomarkers for immunotherapy in CRC, targeted sequencing was performed on tumor tissues from a discovery cohort of 161 CRC patients. Validation cohorts from the cBioPortal were also used for survival and tumor cell infiltration analyses. The FAT1-mutated CRC group often co-occurred with MSI events and displayed a higher tumor mutational burden compared to the FAT1 wild-type CRC. Overall survival was higher in patients with FAT1 mutations than in patients with wild type FAT1. The altered PI3K-AKT pathway and immune pathways were enriched in the FAT1-mutated CRC. A higher infiltration rate of immune cells including CD4+ T cells, CD8+ T cells, macrophages M1 and regulatory T cells were also observed in the colorectal tumors with FAT1 mutation compared to tumors with wild type FAT1. The results showed that CRC patients with FAT1 mutations exhibited an immunotherapy-favorable profile.

Is polyethylene glycol loxenatide 100 μg the preferred glucagon-like peptide-1 receptor agonist for type 2 diabetes mellitus? A meta-analysis and trial sequential analysis

OBJECTIVE

This study aimed to systematically evaluate the efficacy, safety and optimal dose of polyethylene glycol loxenatide (PEX168) for treating type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

Clinical trials of PEX168 for T2DM were identified in 8 databases, with a build time limit of January 2023. Included studies were subjected to meta-analysis and trial sequential analysis (TSA).

RESULTS

On the efficacy endpoint, the meta-analysis showed that PEX168 100 μg significantly reduced 0.86% glycated hemoglobin type A1c (HbA1c) (MD -0.86, 95% CI -1.02 - -0.70,  p<0.00001), 1.11 mmol/L fasting plasma glucose (FPG) (MD -1.11, 95% CI -1.49 - -0.74, p<0.00001) and 1.91 mmol/L 2h postprandial glucose (PPG) (MD -1.91, 95% CI -3.35 - -0.46, p=0.01) compared with placebo. The TSA showed that all these benefits were conclusive. On safety endpoints, total adverse events (AEs), gastrointestinal (GI) AEs, serious AEs, and hypoglycemia were comparable to placebo for PEX168 100 μg (p>0.05). In the dose comparison, the HbA1c, FPG, and 2h PPG of PEX168 200 μg were comparable to 100 μg (p>0.05), while GI AEs were significantly higher than 100 μg (RR=2.84, 95% CI 1.64-4.93,  p=0.0002).

CONCLUSIONS

PEX168 100 μg can significantly lower blood glucose and does not increase the risk of total AEs, GI AEs, and hypoglycemia, which may be a preferred glucagon-like peptide-1 receptor agonist for type 2 diabetes mellitus.

[Association between remnant cholesterol levels and incident diabetic retinopathy in middle-aged and older patients with diabetes]

Objective: To investigate the association between remnant cholesterol (RC) and the risk of diabetic retinopathy (DR) in middle-aged and older individuals with diabetes. Methods: Based on the Shanghai Nicheng Cohort Study database, the data of 1 255 individuals with diabetes aged 55-70 years at baseline (2013-2014) with complete fundus photographs and serum cholesterol data in Nicheng, Shanghai, were analyzed. Multinomial logistic regression models were used to evaluate risk ratios (RRs) and their 95% confidence intervals (CIs) between baseline RC level and incident DR. Results: The median age of the subjects was 61.9 years, and 60.4% were women. After a 4.6-year follow-up, 79 (6.3%) patients developed DR, including 50 (4.0%) mild non-proliferative DR and 29 (2.3%) referable DR (RDR). Multivariable logistic regression showed that each mmol/L increase of RC was associated with a 40% higher risk of RDR (RR=1.40, 95%CI 1.03-1.90). Compared with the lowest tertile of RC (<0.63 mmol/L), the risk of RDR in the highest tertile (≥0.85 mmol/L) increased by 4.59 times (RR=5.59, 95%CI 1.51-20.73). Conclusion: The RC level may help identify individuals at high risk of incident RDR in middle-aged and older Chinese adults with diabetes.

A Phase II Study of Osimertinib in Patients with Advanced-Stage Non-Small Cell Lung Cancer following Prior Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitor (EGFR TKI) Therapy with EGFR and T790M Mutations Detected in Plasma Circulating Tumour DNA (PLASMA Study)

Epidermal growth factor receptor (EGFR) T790M mutations drive resistance in 50% of patients with advanced non-small cell lung cancer (NSCLC) who progress on first/second generation (1G/2G) EGFR tyrosine kinase inhibitors (TKIs) and are sensitive to Osimertinib. Tissue sampling is the gold-standard modality of T790M testing, but it is invasive. We evaluated the efficacy of Osimertinib in patients with EGFR mutant NSCLC and T790M in circulating tumour DNA (ctDNA). PLASMA is a prospective, open-label, multicentre single-arm Phase II study. Patients with advanced NSCLC harbouring sensitizing EGFR and T790M mutations in plasma at progression from ≥one 1G/2G TKI were treated with 80 mg of Osimertinib daily until progression. The primary endpoint was the objective response rate (ORR); the secondary endpoints included progression-free survival (PFS), overall survival (OS), disease control rate (DCR) and toxicities. Plasma next-generation sequencing was performed to determine Osimertinib resistance mechanisms and assess serial ctDNA. A total of 110 patients from eight centres in five countries were enrolled from 2017 to 2019. The median follow-up duration was 2.64 (IQR 2.44-3.12) years. The ORR was 50.9% (95% CI 41.2-60.6) and the DCR was 84.5% (95% CI 76.4-90.7). Median PFS was 7.4 (95% CI 6.0-9.3) months; median OS was 1.63 (95% CI 1.35-2.16) years. Of all of the patients, 76% had treatment-related adverse events (TRAEs), most commonly paronychia (22.7%); 11% experienced ≥ Grade 3 TRAEs. The ctDNA baseline load and dynamics were prognostic. Osimertinib is active in NSCLC harbouring sensitizing EGFR and T790M mutations in ctDNA testing post 1G/2G TKIs.

High Dose Hyperfractionated Thoracic Radiotherapy vs. Standard Dose for Limited Stage Small-Cell Lung Cancer: A Multicenter, Open-Label Randomized, Phase 3 Trial

PURPOSE/OBJECTIVE(S)

Limited stage small-cell lung cancer (LS-SCLC) is associated with poor prognosis. We aimed to assess the efficacy and safety of high-dose, hyperfractionated thoracic radiotherapy of 54 Gy in 30 fractions compared with standard dose (45 Gy in 30 fractions) as a first-line treatment for LS-SCLC.

MATERIALS/METHODS

The study was an open-label, randomized, phase 3 trial, done at 16 public hospitals in China. Key inclusion criteria were patients aged 18-70 years, with previously histologically or cytologically confirmed LS-SCLC, previously untreated or received 1-2 courses of intravenous cisplatin (75 mg/m²of body-surface area, on day 1 or divided into two days of each cycle) or carboplatin (area under the curve of 5 mg/mL per min, day 1 of each cycle)and intravenous etoposide (100 mg/m²of body-surface area, on days 1-3 of each cycle), and an Eastern Cooperative Oncology Group (ECOG) performance status of 0-1.Eligible patients were randomly assigned (1:1) to receive volumetric-modulated arc radiotherapy (VMAT) of 45 Gy in 30 fractions or the simultaneous integrated boost VMAT (SIB-VMAT) of 54 Gy in 30 fractions to the primary lung tumor and lymph node metastases starting 0-42 days after the first chemotherapy course. Both groups of patients received thoracic radiotherapy twice per day and 10 fractions per week. Prophylactic cranial radiation (PCI, 25 Gy in 10 fractions) was implemented to patients with responsive disease. The primary endpoint was overall survival. Safety was analyzed in the as-treated population.

RESULTS

Between June 30, 2017, and April 6, 2021, 224 eligible patients were enrolled and randomly assigned to 54 Gy (n = 108) or 45 Gy (n = 116). Median follow-up for the primary analysis was 45 months (IQR 41-48). Median overall survival was significantly improved in the 54 Gy group (62.4 months) compared with the 45 Gy group (43.1 months; p = 0.001). Median progression-free survival was significantly improved in the 54 Gy group (30.5 months) compared with the 45 Gy group (16.7 months; p = 0.044). The most common grade 3-4 adverse events were neutropenia (30 [28%] of 108 patients in the 54 Gy group vs 27 [23%] of 116 patients in the 45 Gy group), neutropenic infections (6 [6%] vs 2 [2%]), thrombocytopenia (13 [12%] vs 12 [10%]), anemia (6 [6%] vs 4 [3%]), and esophagitis (1 [1%] vs 3 [3%]). Treatment-related serious adverse events occurred in 9 [8%] patients in the 54 Gy group and 16 [14%] patients in the 45 Gy group. There were one treatment-related deaths in 54 Gy group (myocardial infarction).

CONCLUSION

Compared with standard thoracic radiotherapy dose of 45 Gy, the high dose of 54 Gy improved overall survival and progression-free survival without increasing toxicities in patients with LS-SCLC, supporting twice-daily hyperfractionated thoracic radiotherapy of 54 Gy with concurrent chemotherapy is an alternative treatment option for LS-SCLC. This study is complete and registered with ClinicalTrials.gov, NCT03214003.

Clinical and molecular characteristics of kinase domain duplications across diverse cancer types in the Chinese population

BACKGROUND

Kinase domain duplications (KDDs) have recently been recognized as oncogenic mutations and possible association with drug resistance in cancers.

METHOD

Here, targeted sequencing was performed with the tumor tissue and/or plasma from 65 cancer patients with KDDs.

RESULT

Intact KDDs were identified in approximately 0.1% of the total population across multiple cancer types. EGFR KDD was first identified in colorectal cancer and breast cancer, whereas FGFR2 KDD was first identified in gastric cancer. Tumors with EGFR KDD displayed lower concurrent TP53 gene alterations (p = 0.03) and slightly higher chromosome instability (p = 0.27) compared to tumors with non-EGFR-KDDs. Immune pathway analysis further revealed the enrichment of the cytokine receptors pathway (93%) in the KDD carriers. Hyperprogression-related gene mutations were identified in four cases.

CONCLUSION

Collectively, our data revealed the genomic features of KDD alterations in a multi-cancer cohort, providing more information for the potential treatment application in the KDD carriers.

Clinical Outcome-Related Cancer Pathways and Mutational Signatures in Patients With Unresectable Esophageal Squamous Cell Carcinoma Treated With Chemoradiotherapy

PURPOSE

Definitive chemoradiotherapy (dCRT) is a standard-of-care for locally advanced unresectable esophageal squamous cell carcinoma (ESCC). However, even in individuals treated with the same dCRT regimen, differences in the local control rate and radiation-induced thoracic toxicity exist (radiation-induced esophagitis [RIE]).

METHODS AND MATERIALS

Here, we describe a comprehensive genomic evaluation of pretreatment tumor tissue samples from 183 patients with ESCC using targeted sequencing of 474 cancer-related genes. The association between endpoints (progression-free survival [PFS], overall survival, locoregional relapse-free survival, distant metastasis-free survival), toxicity (RIE) and genomic features, including altered pathways and the mutational signature, was analyzed. An independent cohort of 84 stage II-III patients with ESCC was used for validation.

RESULTS

Gene alterations in the cell cycle pathway were identified in 87% of cases. Other frequently altered pathways included PI3K-AKT (45.9%), NOTCH (38.3%), NRF2 (36.6%), RKT-RAS (28.4%), and homologous recombination repair (HRR; 20.2%). HRR pathway alterations correlated with shortened PFS (mutation vs wild-type: 9.00 vs 14.40 months, hazard ratio, 2.10; 95% confidence interval, 1.29-3.44), while altered RTK-RAS pathways were correlated with worse overall survival in patients with ESCC treated with chemoradiotherapy (mutation vs wild-type: 23.70 vs 33.50 months; hazard ratio, 1.65; 95% confidence interval, 1.01-2.69). Furthermore, enrichment of apolipoprotein B mRNA editing enzyme, catalytic polypeptide (APOBEC) signatures (signatures 2 and 13) was identified in ESCC tumors with altered HRR pathways. High APOBEC signatures and an altered HRR pathway were correlated with poor prognoses in dCRT-treated ESCC. Moreover, the APOBEC signature and/or the presence of HRR pathway alterations were associated with poor PFS and overall survival, which was validated in an independent whole exome sequence cohort. Notably, the altered HRR pathway was also associated with high-grade RIE toxicity in patients with ESCC.

CONCLUSIONS

Collectively, our results support the use of comprehensive genomic profiling to guide treatment and minimize RIE in patients with ESCC.

Pan-cancer molecular analysis of EGFR large fragment deletion in the Asian population

BACKGROUND

Large fragment deletion (LFD) of EGFR was associated with carcinogenesis in many types of cancers. However, the molecular features of EGFR-LFD have not been studied in the Asian cancer population.

METHOD

Here we retrospectively analyzed the targeted sequencing data from a large cancer database.

RESULTS

EGFR-LFD was detected at a frequency of 0.03% with EGFRvIII being the most frequently observed LFD. TERTp variants were identified in 60% of the cases. TP53 alterations (33%) were mutually exclusive with TERTp variants and coexisted with EGFR-LFD in lung cancer and colorectal cancer. EGFR amplification (67%) and chromosome 10p deletion (53%) were the most focal-level and arm-level CNV in this cohort. EGFR exon2-17 skipping was found in the tumor tissue of one patient after progressing on osimertinib.

CONCLUSION

Our study provided valuable insights into the distribution and molecular characteristics of EGFR-LFD, hoping to shed light on the treatment management for EGFR-LFD carriers.

Assessing the Readiness for Implementing the World Health Organization's ICOPE Approach in Hong Kong: Perspectives from Social Care and Policy Stakeholders

Although integrated care has been considered a key strategy in reforming health systems around the world, it seems hard to realise in practice, particularly in the part of medical social integration. Worse still, little is known about the capacity of social care professionals who implement it, or their perceived roles and responsibilities, as well as the barriers and facilitators that stakeholders from the health and social sectors identify as factors affecting the ICOPE implementation process. Therefore, the present study was performed to probe into these issues. Data were collected from an online survey based on the WHO ICOPE scorecard (N = 34), and focus groups with policy makers, managers, health and social care professionals (N = 47). Inductive analyses were performed in accordance with the service and system levels within the WHO ICOPE implementation framework. While the findings from the scorecard survey highlight the gap in actualizing the ICOPE approach within the existing social services and care structures, we found support for a model of integrated care underpinned by the WHO ICOPE approach. Factors that may hinder and facilitate ICOPE implementation include workforce capacity-building, coordinated networks and partnerships, and financial mechanisms. This finding can help inform subsequent actions that further support health and social care advancement and collaboration, and the implementation of the ICOPE approach.

A Dyadic Cooking-Based Intervention for Improving Subjective Health and Well-Being of Older Adults with Subjective Cognitive Decline and Their Caregivers: A Randomized Controlled Trial

OBJECTIVES

Evidence on the effectiveness of cooking activities as a well-being promotion intervention for older adults with subjective cognitive decline (SCD) and their caregivers is scarce. In view of this, a randomized controlled trial was conducted to examine whether a dyadic cooking-based intervention can improve the subjective health and well-being of older adults with SCD and their caregivers, as well as the cooking competence of the former group.

DESIGN

Randomized controlled trial.

SETTING

Community.

PARTICIPANTS

Sixty pairs of community-dwelling older adults aged 60 years or above with SCD (mean age = 78.4 years) and their caregivers (mean age = 65.3 years) were randomly assigned to the intervention group (N = 30 pairs) and the wait-list control group (N = 30 pairs).

INTERVENTION

The intervention was an innovative 5-week (two hours per week) dyadic cooking-based intervention employing procedural learning methods specifically adapted for older adults with SCD.

MEASUREMENTS

The outcome measures included 1) a well-being index composed by four indicators: life satisfaction, feeling of happiness, sense of purpose and meaning in life, and perceived health, and 2) cooking competence.

RESULTS

For both older adults with SCD and their caregivers, the increases in the well-being index were significantly greater in the intervention group than in the control group (β = 0.508, 95% CI [0.036, 0.980]). For older adults with SCD, the increases in the cooking competence score were significantly greater in the intervention group than in the control group (β = 1.629, 95% CI [0.165, 3.071]).

CONCLUSION

The dyadic cooking-based intervention resulted in improvements in the cooking competence and well-being of older adults with SCD, as well as the well-being of caregivers.

Trajectories of Intrinsic Capacity: Determinants and Associations with Disability

OBJECTIVES

Intrinsic capacity (IC) declines progressively with age, thereby increasing the risk of disability. However, it is less known whether IC trajectories are associated with disability. This study aims to identify the different patterns of IC trajectories in older people, and examine their determinants and associations with Instrumental Activities of Daily Living (IADL).

DESIGN

Cohort study.

SETTING

Community centres in different regions in Hong Kong.

PARTICIPANTS AND MEASUREMENTS

Longitudinal data from community-dwelling older people aged 60 years or above (n = 1371) collected between 2016 and 2021 was analysed. Their mean age was 74.5 years, and 78.7% of them were female. Repeated measurements of a set of 14 self-reported items were used to generate IC scores at four time points using a bi-factor model. Latent class growth analysis was performed to identify classes with distinct IC trajectories. The association between class membership and IADL disability was then examined using logistic regression.

RESULTS

Three distinct IC trajectories were identified. The 1st class included those with the highest level of baseline IC and the least declining trajectory, whereas the 3rd class was composed by those with the lowest level of baseline IC and the most declining trajectory. Older age, female gender, lower perceived financial adequacy, living in public or subsidized housing, and chronic diseases were associated with the 3rd class. After adjusting for demographic factors, socioeconomic status, and the number of chronic diseases, the 1st class was more likely to preserve IADL when compared against the 2nd class, with OR being 3.179 (95% CI: 2.152-4.793), whereas for the 3rd class, the OR was 0.253 (95% CI: 0.178-0.359).

CONCLUSION

Monitoring IC trajectories is of relevance to clinical practice, as it helps shift the focus from treating acute episodes of illness to preserving the functional ability of older people.

Moving towards the ICOPE Approach: Evaluation of Community-Based Intervention Activities on Improving Intrinsic Capacity

OBJECTIVES

Different types of community-based intervention activities may have differential effects in improving the intrinsic capacity (IC) of older people. This study aims to (i) identify subgroups of older people based on their IC impairments, (ii) examine the differential associations between different types of activity participations and change in IC across subgroups, and (iii) assess whether the activity participation patterns of older people align with the way that would benefit them the most.

METHODS

Participants were community-dwelling older people aged 60 years or above. They were screened for IC impairments at baseline, and their participation records of different types (cognitive, physical, nutritional, mental, and social) of intervention activities were collected for one year. An aggregated IC score was created based on four IC domains including cognitive (self-rated memory), locomotor (self-rated difficulties in walking), vitality (self-rated weight loss), and psychological (subjective well-being). Cluster analysis was used to group homogenous participants. Mixed-effects regression was used to examine the associations between activity counts (i.e., number of sessions participated) and change in IC. Activity participation patterns were also compared across subgroups.

RESULTS

Data were obtained from 7,357 participants (mean age = 74.72 years). Four clusters were identified, including those who were relatively robust (cluster 1, N = 4,380, 59.5%), those who had cognitive decline (cluster 2, N = 2,134, 29.0%), those who had impaired mobility and vitality (cluster 3, N = 319, 4.3%), and those with poor psychological well-being (cluster 4, N = 524, 7.1%). Overall, activity count was associated with IC improvement (β = 0.073, 95% CI [0.037, 0.108]). However, as regards the cluster-specific results, different types of activities were associated with IC improvement for different specific clusters. For instance, cognitive activity count was associated with IC improvement only for cluster 2 (β = 0.491, 95% CI [0.258, 0.732]). Notably, none of the activity types were associated with IC improvement for cluster 1. Regarding the activity participation patterns, there were no significant differences across the four clusters (Wilk's Λ = 0.997, F = 1.400, p = .138).

CONCLUSIONS AND IMPLICATIONS

IC improvement depended on the activity types and IC status of older people. In view of this, a people-centred and targeted approach should be adopted to maximize the overall benefits of intervention activities.

Comprehensive genomic profiling of colorectal cancer patients reveals differences in mutational landscapes among clinical and pathological subgroups

With the widespread of colonoscopy, colorectal cancer remains to be one of the most detrimental types of cancer. Though there were multiple studies investigating the genomic landscape of colorectal cancer, a comprehensive analysis uncovering the differences between various types of colorectal cancer is still lacking. In our study, we performed genomic analysis on 133 patients with colorectal cancer. Mutated FAT1 and PKHD1 and altered Hippo pathway genes were found to be enriched in early-onset colorectal cancer. APOBEC signature was prevalent in microsatellite stable (MSS) patients and was related to lymph node metastasis. ZNF217 mutations were significantly associated with early-stage colorectal cancer. In all, this study represents a comprehensive genomic analysis uncovering potential molecular mechanisms underneath different subgroups of colorectal cancer thus providing new targets for precision treatment development.

Lactation time influences the composition of Bifidobacterium and Lactobacillus at species level in human breast milk

Human breast milk is a source of microorganisms for infants that play an important role in building infant gut health and immunity. The bacterial composition in human breast milk is influenced by lactation time. This study aimed to investigate the influence of lactation time on bacteria in breast milk at the genus level and the species levels of Bifidobacterium and Lactobacillus on days 2-4, 8, 14, and 30. Eighteen individuals were recruited and 60 milk samples were collected. The 16S rRNA gene, and the bifidobacterial groEL and lactobacilli groEL genes were used for amplicon sequencing. The results revealed that the alpha diversities of colostrum and transition 1 (day 8) milk were lower than that of transition 2 (day 14) and mature milk. PCoA analysis showed that bacterial composition in colostrum and transition 1 milk differed from transition 2 and mature milk. A lower relative abundance of Blautia was found in colostrum and transition 1 milk compared with mature milk and lower abundances of Ruminococcus, Dorea, and Escherichia-Shigella were found in transition 1 compared with mature milk. Bifidobacterium ruminantium, Limosilactobacillus mucosae, and Ligilactobacillus ruminis were the predominant species across all four lactation stages, while Bifidobacterium bifidum was lower in transition 1, and Bifidobacterium pseudocatenulatum and Bifidobacterium pseudolongum were higher in transition 1 milk. This study indicated that the bacterial composition in colostrum was more similar to that of transition 1 milk, whereas the bacterial community in transition 2 milk was similar to that of mature milk which suggests that bacterial composition in human breast milk shows stage-specific signatures even within a short period at both genus level and Bifidobacterium and Lactobacillus species levels, providing insights into probiotic supplementation for the nursing mother.

Prognostic value of baseline genetic features and newly identified TP53 mutations in advanced breast cancer

Approximately 30% of breast cancer (BC) patients suffer from disease relapse after definitive treatment. Monitoring BC at baseline and disease progression using comprehensive genomic profiling would facilitate the prediction of prognosis. We retrospectively studied 101 BC patients ultimately experiencing relapse and/or metastases. The baseline and circulating tumor DNA‐monitoring cohorts included patients with baseline tumor tissue and serial plasma samples, respectively. Samples were analyzed with targeted next‐generation sequencing of 425 cancer‐relevant genes. Of 35 patients in the baseline cohort, patients with TP53 mutations (P < 0.01), or CTCF/GNAS mutations (P < 0.01) displayed inferior disease‐free survival, and patients harboring TP53 (P = 0.06) or NOTCH1 (P = 0.06) mutations showed relatively poor overall survival (OS), compared to patients with wild‐type counterparts. Of the 59 patients with serial plasma samples, 11 patients who were newly detected with TP53 mutations had worse OS than patients whose TP53 mutational status remained negative (P < 0.01). These results indicate that an inferior prognosis of advanced breast cancer was potentially associated with baseline TP53, CTCF, and NOTCH1 alterations. Newly identified TP53 mutations after relapse and/or metastasis was another potential prognostic biomarker of poor prognosis.

POS0744 SYSTEMIC LUPUS ERYTHEMATOSUS WITH ACTIVE MUSCULOSKELETAL SYMPTOMS: PATIENT REPORTED SYMPTOM IMPACT, TREATMENT PATTERNS AND SATISFACTION WITH CURRENT THERAPY OPTIONS

Background

Musculoskeletal (MSK) symptoms affect 50-95% of patients with SLE over their disease course negatively impacting functioning, and quality of life (QoL).1 In SLE-UPDATE, a US, cross-sectional, non-interventional online survey of adults with SLE, over half of the participants reported active MSK symptoms, including pain or swelling in the joints (53%) and stiffness (57%).2 The present study evaluated the sub-group of participants with ‘currently active’ MSK symptoms.

Objectives

To describe the self-reported disease burden, treatment patterns, and satisfaction with therapies in patients with SLE, comparing those with versus without active MSK symptoms.

Methods

This secondary analysis of SLE-UPDATE survey data stratified participants into active or non-active MSK group. Participants currently experiencing pain or swelling and/or stiffness in their joints and had a Joint Pain NRS > 4 were in the “active MSK group”. All remaining participants were in the “non-active MSK group”. Analysis comprised descriptive statistics, mean (standard deviation [SD]) for continuous variables, and frequency (percentage [%]) for categorical variables. Two-sample t-test to compare mean scores and chi-squared testing to compare proportions were used.

Results

Of the survey participants, 285 were in the active MSK group and 215 in the non-active MSK group. The active MSK group was older (44.3 vs. 40.2 years, <0.001) and had a longer time since diagnosis (12.6 vs. 9.2 years, <0.001). More people in the MSK group had fibromyalgia (FM) (45 vs 12%, <0.0001), worse pain, fatigue, and QoL (Table 1) suggestive of Type 2 non-inflammatory SLE symptoms. Fewer in the MSK group were employed full-time (36.5 vs. 62.8%) and more were on permanent disability (27.0 vs. 6.5%). More participants in the active MSK group negatively assessed their general health (fair or poor) over the last month (53.4 vs. 20.4%). The active MSK group self-reported more “flares” over the prior 3 months; with 44.9 vs 41.9% reporting 1-3 flares, 15.1 vs 5.1% reporting 4-6 flares, and 8.1 vs 2.3% reporting > 7 flares.

Table 1.

Patient Reported Outcomes

Active MSKNon-Active MSKFMNon-FMFMNon-FMN=129N=156N=26N=189Worst Pain NRS, Mean (SD)6.5 (1.7)*4.8 (2.6)6.9 (1.6)*6.2 (1.8)4.0 (2.2)4.9 (2.6)~Worst Joint Pain NRS, Mean (SD)6.7 (1.7)*4.5 (2.6)7.1 (1.6)*6.5 (1.6)3.5 (2.0)4.6 (2.6)*FACIT Fatigue Score, Mean (SD)19.1 (10.8)*28.1 (11.6)15.4 (9.5)*22.1 (10.9)25.7 (13.8)28.4 (11.3)~LupusPRO HRQoL Score (SD)48.9 (20.2)*64.1 (23.0)45.5 (18.1)*51.7 (21.4)63.0 (23.9)64.3 (22.9)~

NRS: 0 (none)-10 (worst imaginable); FACIT Fatigue: 0-52, higher= less fatigue; LupusPRO: 0-100, higher= better QoL; *p < 0.05; ~ Not significant

The active MSK group used more anti-malarials (50.9 vs. 30.7%), immunosuppressants (37.2 vs. 26.5%), including methotrexate (12.6 vs 3.3%), narcotic analgesics (18.6 vs. 10.2%), and topicals for joint pain (30.5 vs. 10.2%). Interestingly, treatment goals of greatest importance in both groups were reduction in fatigue and pain, but pain reduction had higher importance in active MSK group (rated very important by 26.7 vs. 18.1%). Lower proportions in the active MSK group were satisfied with steroids (58.0 vs. 77.8% <0.01), immunosuppressants (65.1 vs. 80.7% <0.05), methotrexate (47.2 vs. 85.7% =0.061), and belimumab (80 vs. 95.5%=0.102).

Conclusion

Reduction of pain and fatigue was the main treatment goal of patients with SLE whether they had active or non-active MSK symptoms. Patients with active MSK symptoms had higher pain and fatigue, lower QoL, and less satisfaction with current therapies compared to SLE patients without active MSK symptoms, driven only in part by co-morbid FM. Findings from these analyses suggest there are unmet needs to better understand MSK manifestations, their overlap with Type 2 SLE symptoms, align patient/physician priorities, and improve therapies for MSK symptoms for patients with SLE.

References

[1]Mahmoud K. Curr Opin Rheumatol 2017;29:486-492

[2]Birt J. Rheum Ther 2021;8:1189-1205

Acknowledgements

The authors would like to thank the Lupus Foundation of America for their support with the design of the survey.

Disclosure of Interests

Diane L Kamen: None declared, Julie Birt Shareholder of: Shareholder of Eli Lilly & Company, Employee of: Employee of Eli Lilly & Company, Monica Hadi Grant/research support from: Evidera received funding to conduct this research, Elizabeth Gibbons Grant/research support from: Evidera received funding to conduct this research, Don Bushnell Grant/research support from: Evidera has received funding for the conduct of this research, Ren Yu Grant/research support from: Evidera has received funding to conduct this research, Laure Delbecque Shareholder of: Shareholder of Eli Lilly, Employee of: Employee of Eli Lilly, Kirstin Griffing Shareholder of: Eli Lilly & Company shareholder, Employee of: Eli Lilly & Company paid employee, Anca Askanase Grant/research support from: Investigator for GSK, AZ, Pfizer, Idorsia, Eli Lilly

FAT1 mutations in colorectal cancer patients are associated with the therapeutic benefit of immunotherapy

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Background: Immunotherapy is one of the main treatment modalities for advanced colorectal cancer. Although microsatellite instability (MSI) is widely applied as an effective immune efficacy prediction biomarker in clinical practice, the majority of the colorectal patients are microsatellite stable (MSS). This study is designed to identify new biomarkers for immune efficacy in colorectal cancer. Methods: Targeted sequencing with a 425 gene panel was performed with the tumor tissues from a total of 161 colorectal cancer (CRC) patients (discovery cohort) for mutation analysis. The association between FAT1 mutations and immunotherapy markers MSI and TMB was investigated using an external database of 727 CRC patients from cBioportal (validation cohort). Results: The discovery cohort consisted of 95(59%) males and 66(41%) females with a median age of 59 years old. There were 2(1.2%) stage II, 5(3.1%) stage III, 24(14.9%) stage IV, and 130(80.8%) unknown stage patients. The majority of the discovery cohort was MSS (154, 95.7%), which was similar to the validation cohort (518, 71.2%). FAT1 mutations were present around similar ratios in both discovery cohort (12.4%) and validation cohort (11.6%). In both cohorts, the co-occurrence analysis revealed that MSI events were often co-occurred with FAT1 mutations and patients with FAT1 mutations had a higher mutational load compared to the FAT1 wild-type patients. Analysis with survival data from the validation cohort showed that OS was significantly higher in patients with FAT1-mutated tumors than in ones with FAT1 wild-type. Compared to the FAT1 wild-type tumors, the higher infiltration rate of immune cell identified in the colorectal tumors with FAT1 mutation may also explain the good immune efficacy of patients with FAT1 mutation. Conclusions: Colorectal cancer patients with FAT1 mutations may benefit from immunotherapy. The increased immunogenicity in patients with FAT1 mutations may be due to increased immune cell infiltration.

Molecular landscape and therapeutic alterations in Asian soft-tissue sarcoma patients

Background

Soft‐tissue sarcoma (STS) is a rare solid malignant tumor with numerous histologic subtypes. Current studies on targeted therapy for STS are in preclinical and early‐phase trials. Genomic differences largely influence the prognosis of patients even with the same subtype. To investigate the genomic alterations (GAs) and the potential of targeted therapy in STS, we analyzed the genomic landscape, the therapeutic GAs, and biomarkers of immunotherapy in Chinese STS patients.

Methods

Targeted sequencing covering 425 genes was performed, from which we obtained the results of tissue samples from 351 Chinese STS patients of all ages covering different histologic subtypes. Bioinformatics analysis of altered genes with nonsynonymous mutations, copy‐number variations, and gene fusions were performed. OncoKB therapeutic GAs and relevant biomarkers including TMB, MSI, and HRD were further examined for potential targeted therapy.

Results

In total, 2743 GAs were identified in 330 genes with a median of 6 (1–38) per case. The top 11 frequently altered genes were: TP53, MCL1, MDM2, CDK4, MYC, CDKN2A, GNAS, RB1, ATRX, CDKN2B, and FGFR1. OncoKB defined therapeutic GAs were found in 23 genes in 43% of the patients. In general, 9.4% of the patients had high‐TMB, 2.8% had MSI, and 13.7% had HRD. A significant difference in the percentage of patients with OncoKB therapeutic GAs were observed between the most frequent two subtypes, leiomyosarcoma and liposarcoma. Altogether, 54% of the patients had the potential to respond to a targeted therapy.

Conclusion

This study indicated the potential efficacy of targeted therapy on many STS patients, and also provided insight for novel precision therapy. The clinical efficacy of combining targeted therapy and immunotherapy can be further investigated.

Pathway-Based Analysis Revealed the Role of Keap1-Nrf2 Pathway and PI3K-Akt Pathway in Chinese Esophageal Squamous Cell Carcinoma Patients With Definitive Chemoradiotherapy

Esophageal squamous cell carcinoma (ESCC) is the major type of EC in China. Chemoradiotherapy is a standard definitive treatment for early-stage EC and significantly improves local control and overall survival for late-stage patients. However, chemoradiotherapy resistance, which limits therapeutic efficacy and treatment-induced toxicity, is still a leading problem for treatment break. To optimize the selection of ESCC patients for chemoradiotherapy, we retrospectively analyzed the clinical features and genome landscape of a Chinese ESCC cohort of 58 patients. TP53 was the most frequent mutation gene, followed by NOTCH1. Frequently, copy number variants were found in MCL1 (24/58, 41.4%), FGF19 (23/58, 39.7%), CCND1 (22/58, 37.9%), and MYC (20/58, 34.5%). YAP1 and SOX2 amplifications were mutually exclusive in this cohort. Using univariate and multivariate analyses, the YAP1 variant and BRIP1 mutant were identified as adverse factors for OS. Patients with PI3K-Akt pathway alterations displayed longer PFS and OS than patients with an intact PI3K-Akt pathway. On the contrary, two patients with Keap1-Nrf2 pathway alterations displayed significantly shortened PFS and OS, which may be associated with dCRT resistance. Our data highlighted the prognostic value of aberrant cancer pathways in ESCC patients, which may provide guidance for better chemoradiotherapy management.

Pathway-Based Analysis Revealed the Role of Keap1-Nrf2 Pathway and PI3K-Akt Pathway in Chinese Esophageal Squamous Cell Carcinoma Patients With Definitive Chemoradiotherapy

Esophageal squamous cell carcinoma (ESCC) is the major type of EC in China. Chemoradiotherapy is a standard definitive treatment for early-stage EC and significantly improves local control and overall survival for late-stage patients. However, chemoradiotherapy resistance, which limits therapeutic efficacy and treatment-induced toxicity, is still a leading problem for treatment break. To optimize the selection of ESCC patients for chemoradiotherapy, we retrospectively analyzed the clinical features and genome landscape of a Chinese ESCC cohort of 58 patients. TP53 was the most frequent mutation gene, followed by NOTCH1. Frequently, copy number variants were found in MCL1 (24/58, 41.4%), FGF19 (23/58, 39.7%), CCND1 (22/58, 37.9%), and MYC (20/58, 34.5%). YAP1 and SOX2 amplifications were mutually exclusive in this cohort. Using univariate and multivariate analyses, the YAP1 variant and BRIP1 mutant were identified as adverse factors for OS. Patients with PI3K-Akt pathway alterations displayed longer PFS and OS than patients with an intact PI3K-Akt pathway. On the contrary, two patients with Keap1-Nrf2 pathway alterations displayed significantly shortened PFS and OS, which may be associated with dCRT resistance. Our data highlighted the prognostic value of aberrant cancer pathways in ESCC patients, which may provide guidance for better chemoradiotherapy management.

Altered Signaling Pathways Revealed by Comprehensive Genomic Profiling in Patients With Unknown Primary Tumors

Purpose

Carcinoma of unknown primary (CUP) is a clinically aggressive disorder with early tumor dissemination. Identifying molecular traits of CUP can be not only beneficial for a better therapeutic approach but also potentially valuable for patients with general metastatic dissemination.

Patients and Methods

We retrospectively investigated a total of 35 unique CUP cases. Tumor tissue samples were available in 26 patients, and plasma samples were available in 22 patients. Targeted sequencing was performed with a panel of 416 pan cancer-related genes.

Results

A genomic landscape of the CUP cohort showed that TP53 mutation was the most frequently observed mutation while MYC amplification was the most common CNV. Aberrant TP53, RTK-RAS, and PI3K signaling pathways were also prevalent, identified in more than half of the cases with tumor tissue. Around 58% of the CUP cases harbored homologous recombinant repair (HRR) pathway gene alterations. The tumor mutational load of CUP patients with altered HRR pathway displayed a significant increase than that of patients with intact HRR. Clinically actionable mutations were identified in eight patients, which may benefit from targeted therapies. Eight patients were treated with platinum-based chemotherapy, showing different responses, HRR, and LOH status.

Conclusion

Collectively, our data have provided much-need insights into the treatment options for patients diagnosed with CUP in the era of precision medicine.

Application of Metagenomic Next-Generation Sequencing in the Etiological Diagnosis of Infective Endocarditis During the Perioperative Period of Cardiac Surgery: A Prospective Cohort Study

Objective

The present study aimed to prospectively evaluate the role of metagenomic next-generation sequencing (mNGS) in the etiological diagnosis of patients with perioperative infective endocarditis (IE).

Methods

From May 1st, 2019 to December 31st, 2020, a total of 99 patients with IE were enrolled in the present study according to the modified Duke criteria, etiological, and pathological results. 11 non-IE patients undergoing heart valve surgery in the same period were selected as the control group. A blood culture test was performed immediately after admission, and the valves harvested operatively were examined by blood culture and mNGS.

Results

In the IE group, there were 29 cases (29.3%) with positive blood culture, 16 cases (16.2%) with positive valve culture, and 85 cases (85.9%) with positive valve mNGS. Compared to culture-based detection, mNGS achieved better performance with a sensitivity, specificity, area under the curve (AUC) of 0.859, 0.727, and 0.793, respectively. The combined approach using culture and mNGS further improved the diagnostic accuracy (sensitivity 89.9%, specificity 72.7%, AUC 0.813). Preoperative white blood cell (P = 0.029) and neutrophils (P = 0.046) were identified as independent factors affecting the detection rate of mNGS. In the mNGS-positive group, 95 strains of pathogens were found and 10 cases were identified with mixed infection. There were 72 gram-positive bacteria and 14 gram-negative bacteria. mNGS positive group displayed higher species richness than mNGS negative group with enrichment of Streptococcus sanguis, Streptococcus buccalis, and Streptococcus griseus. Proteobacteria and Actinomycetes were enriched in mNGS negative group. Notably, six patients showed disconcordant results between culture and mNGS. Rothia aeria was identified in the blood culture, valve culture, and valve mNGS in one patient. Bartonella Quintana and Coxiella burnetii, which were fastidious intracellular bacteria, were found in two blood and valve culture-negative cases.

Conclusions

mNGS outperformed the conventional culture method and displayed high accuracy in detecting pathogens in IE patients. This study provided support for the use of mNGS in the etiological diagnosis of IE.

Rapid subcutaneous progression after immunotherapy in pretreated patients with metastatic carcinoma: two case reports

There is heterogeneity in cancer patients' responses to immune checkpoint inhibitors (ICIs), including hyperprogression, which is very rapid tumor progression following immunotherapy, and pseudoprogression, which is an initial increase followed by a decrease in tumor burden or in the number of tumor lesions. This heterogeneity complicates clinical decisions because either premature withdrawal of the treatment or prolonged ineffective treatment harms patients. We presented two patients treated with ICIs with heterogeneous responses. One patient had Merkel cell carcinoma in the right thigh, and the other had nasopharyngeal squamous carcinoma. The first patient was treated with sintilimab and the second with sintilimab combined with abraxane. In the first patient, subcutaneous lesions grew substantially after the first cycle of treatment with sintilimab. In the second patient, subcutaneous lesions grew gradually after the second cycle of treatment with sintilimab combined with abraxane. In both cases, biopsy examination confirmed that newly emerged lesions were metastases of the primary tumor. These two cases remind clinicians that when subcutaneous nodules appear after treatment with ICIs, pathological biopsy is needed to determine the nature-pseudoprogression or rapid progression-of the disease course.

[Associations between gene polymorphisms of signal transducer and activator of transcription 3 and the susceptibility to hepatitis B virus related liver cirrhosis]

To investigate the associations between gene polymorphisms of signal transducer and activator of transcription 3 (STAT3) and liver cirrhosis (LC) after hepatitis B virus (HBV) infection. A case-control study was conducted in 243 patients with hepatitis B cirrhosis (HBV-LC, case group) and 486 HBV-infected subjects without LC (non-LC, control group) collected from January 2018 to September 2020 at the Changsha Central Hospital Affiliated to Nanhua University. Three single nucleotide polymorphisms (SNPs) of STAT3 gene, including rs4796793C>G, rs2293152C>G, and rs1053004T>C were selected through literature and biological information database, and the genotypes were detected by real-time fluorescent quantitative PCR (RFQ-PCR). The distribution differences of STAT3 SNPs genotypes between the two groups were compared using Chi-square test and haplotype analysis was conducted by Shesis online. The proportion of HBV C genotype in HBV-LC patients was significantly higher than that in the control group (80.91% vs. 70.79%, χ²=7.109, P=0.008), while the logarithm of ALT was significantly lower than that of the control group (1.78±0.43 vs. 1.95±0.54, t=3.801, P=0.000). The genotypes distributions of rs4796793, rs2293152, and rs1053004 were not significantly different between HBV-LC and non-LC in overall analysis and stratified analysis by gender (χ²=2.610, 1.505, 0.586, 2.653, 2.685, 1.583, 0.351, 5.388, 0.339, respectively, P>0.05 for each). Among the subjects infected with HBV genotype C, rs1053004 CC (vs. TT) significantly increased the risk of HBV-LC [odds ratio (OR) = 1.40, 95% confidence interval (CI): 1.03-1.91]. Among the HBV-infected subjects with HBeAg negative, rs4796793 GG genotype (vs. CC) and G allele (vs. C) significantly increased the risks of HBV-LC (OR = 2.17, 95%CI: 1.11-4.23; OR = 1.45, 95%CI: 1.06-1.97, respectively). Haplotypes analysis showed that the frequency of haplotype C-G-T composed of rs4796793, rs2293152, and rs1053004 was significantly lower in HBV-LC than that in the control group (non-LC) (27.3% vs. 35.6%, χ²=9.949, P = 0.001). The correlation between STAT3 and HBV-LC is different in HBV-infected subjects with different infection status. The HBV-infected subjects carrying haplotype rs4796793C-rs2293152G-rs1053004T of STAT3 gene have significantly decreased risk of LC.

Clinical utility of cerebrospinal fluid-derived circular RNAs in lung adenocarcinoma patients with brain metastases

Background

Free circular RNAs(circRNAs) escaping from primary lesion of cancer to brain are strictly regulated by blood–brain barrier and therefore cerebrospinal fluid (CSF) circRNAs have potential advantage in exploring biomarkers and mechanism of brain metastasis in lung cancer.

Methods

We collected paired cerebrospinal fluid, plasma and tumor tissues from 21 lung adenocarcinoma (ADC) patients with brain metastases (BM) and performed RNA sequencing.

Results

Compared to tumor tissue and plasma, circRNAs in CSF were characterized by lower number of spieces but higher abundance. Notably, CSF-circRNAs displayed high heterogeneity among different BM lung ADC patients. A total of 60 CSF-circRNAs was identified and associated with shorten overall survival. The circRNA-miRNA-mRNA network analysis revealed that the 60 CSF-circRNAs involved in cancer-associated pathways, and five of them showed strong association with WNT signaling pathway. Validation by RT-PCR of CSF and in vitro experiments of the five candidate circRNAs support their potential roles in cell proliferation and invasion.

Conclusions

In summary, our results depicted the heterogenous CSF-circRNAs profiles among BM lung ADC and implied that CSF-circRNAs may be promising prognosis-related biomarkers.

Real-world circulating tumor DNA analysis depicts resistance mechanism and clonal evolution in ALK inhibitor-treated lung adenocarcinoma patients

Background

Sequential treatment with different generations of anaplastic lymphoma kinase (ALK) inhibitors have been widely applied to ALK-positive lung cancer; however, resistance mutations inevitably developed. Further characterization of ALK resistance mutations may provide key guidance to subsequent therapies. Here we explored the emergence of secondary ALK mutations during sequential ALK tyrosine kinase inhibitor (TKI) treatment in a real-world study of Chinese lung adenocarcinoma (ADC) patients.

Methods

A clinical-genomic database was queried for lung ADC patients with at least one ALK inhibitor treatment and at least one plasma sample collected following ALK inhibitor treatment. Targeted genome profiling was performed with a 139-gene panel in baseline tumor tissue and serial plasma samples of patients.

Results

A total of 116 patients met inclusion criteria. ALK G1202R was more common in patients with echinoderm microtubule-associated protein-like 4 (EML4)-ALK v3 fusion, whereas ALK L1196M was more common in v1. TP53 mutant patients were significantly associated with harboring multiple ALK resistance mutations (P = 0.03) and v3+/TP53 mutant patients had the highest rate of multiple ALK resistance mutations. The sequential use of ALK TKI led to an increased incidence of concurrent ALK mutations along the lines of therapies. Alectinib had a lower rate (9%) harboring ALK resistance mutation as first-line ALK TKI compared with crizotinib (36%). ALK compound mutations identified included ALK D1203N/L1196M, ALK G1202R/L1196M, and ALK G1202R/F1174C, which may be lorlatinib resistant. Using paired pretreatment and post-treatment samples, we identified several ALK-independent resistance-related genetic alterations, including PTPRD and CNKN2A/B loss, MYC, MYCN and KRAS amplification, and EGFR^19del.

Conclusions

Sequential postprogression plasma profiling revealed that increased lines of ALK inhibitors can accelerate the accumulation of ALK resistance mutations and may lead to treatment-refractory compound ALK mutations. The selection for optimal first-line TKI is very important to achieve a more efficacious long-term strategy and prevent the emergence of on-target resistance, which may provide guidance for clinical decision making.

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ALK resistance mutations were differentially enriched in the setting of EML4-ALK v1/v3 and TP53 status.

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Serial liquid biopsies NGS depicted accumulation of multiple ALK secondary mutations during sequential ALK treatments.

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Several lorlatinib-resistant ALK compound mutations and ALK-independent resistance genetic alterations were identified.

Prognostic Implications of Six Altered Genes in Asian Non-Surgical Esophageal Carcinoma Patients Treated with Chemoradiotherapy

Background

Esophageal cancer (EC), especially esophageal squamous cell carcinoma, remained as one of the most aggressive tumors in China with a five-year survival rate of around 40%. Molecular characteristics through next-generation sequencing are becoming an emerging method in identifying prognostic biomarkers for better treatment management for EC patients.

Methods

Targeted next-generation sequencing using a 422-gene pan-cancer panel was performed with tumor tissue samples from a total of 69 Asian non-surgical esophageal carcinoma patients (AEC) treated with chemoradiotherapy. A TCGA cohort of 143 EC patients and another Asian ESCC cohort of 47 patients were employed for validation.

Results

In the AEC cohort, alterations in TP53 (94.2%) and NOTCH1 (55.1%) were the two most frequently observed alterations, whereas in the TCGA cohort, only TP53 alterations were observed at a high ratio (85.3%). Co-amplifications of FGF19 and CCND1 were found at a similar ratio in both cohorts. Multiple alterations in the DNA damage pathway were identified but not associated with overall survival in AEC. Using univariate and multivariate Cox regression analyses, six gene alterations including YAP1 amplification, RB1 alteration, BAP1 mutation, MYC amplification, WRN mutation, and BRIP1 mutation were identified as adverse prognostic factors in the AEC cohort. A Cox proportional hazard model based on the six prognosis-related genes was constructed and showed the ability in distinguishing EC patients with poorer disease outcomes in AEC and two validation cohorts.

Conclusion

Six gene alterations were found to be potential unfavorable prognostic markers that might provide guidance in the treatment management for EC patients.

Dietary Patterns and Intrinsic Capacity in Community-Dwelling Older Adults: A Cross-Sectional Study

OBJECTIVES

Few studies have investigated the link between diet and intrinsic capacity (IC), and the potential sex difference in such association. This study examined the association between dietary patterns and IC and its sub-domains in Chinese community-dwelling older adults.

DESIGN

Cross-sectional analysis using baseline data from the MrOs and MsOs study.

SETTING

Community.

PARTICIPANTS

Chinese community-dwelling older adults aged ≥65 years in Hong Kong.

MEASUREMENTS

Dietary intake was assessed using a validated food frequency questionnaire and priori and posteriori dietary pattern scores were generated. IC including measures of cognitive, locomotor, vitality, sensory and psychological domains was assessed. Multiple logistic regression was performed to examine the associations between dietary pattern scores and the likelihood of greater IC and sub-domain scores with adjustment for sociodemographic and lifestyle factors.

RESULTS

Data of 3730 participants (aged 72.2±5.0 years, 50.4% men) was available. In men, higher Diet Quality Index-International (DQI-I) and Okinawan diet scores, and lower "meat-fish" pattern scores were associated with greater IC. A higher DQI-I score was associated with greater locomotion, whereas higher "snacks-drinks-milk products" pattern score was associated with a greater sensory function. In women, none of the dietary pattern scores was associated with IC. Higher DQI-I score, Mediterranean-DASH Intervention for Neurodegenerative Delay Diet (MIND) score and "vegetables-fruits" pattern score were associated with greater psychological function.

CONCLUSION

Various dietary patterns were associated with greater IC and its sub-domains in Chinese community-dwelling older adults, and more associations were observed in men than women. Strategies to improve diet and IC should take sex differences into account.

Towards Healthy Ageing: Using the Concept of Intrinsic Capacity in Frailty Prevention

OBJECTIVES

To examine whether intrinsic capacity (IC) could predict frailty, whether declines in specific domains of IC could lead to frailty, and whether different combinations of domains could represent different risks of developing frailty.

SETTING

Community.

PARTICIPANTS

Chinese people aged 65 years and older.

MEASUREMENTS

Using data from a prospective cohort study, we derived a summary score for IC and scores for the five domains (cognitive, locomotor, vitality, sensory, psychological) for each participant at baseline. Frailty was assessed according to the Fried's frailty phenotype at baseline, 2- and 4-year follow-ups. Participants were classified as frail if they had ≥3 of the following criteria: weight loss, self-rated exhaustion, weakness, slow walking speed, and low physical activity.

RESULTS

Four thousand participants were interviewed at baseline. Overall mean age was 72.5 years; 50% were women. Between baseline and the 2-year follow-up, 5.7% of non-frail participants developed frailty; between 2- and 4-year follow-ups, 5.7% of non-frail participants developed frailty. The average annual incidence rate of frailty was 2.9%. Higher scores on IC at baseline were associated with a lower risk of incident frailty at both follow-ups (year 2, odds ratio (OR)=0.64, 95% confidence interval (CI)=0.59-0.71); year 4, OR=0.64, 95%CI=0.58-0.71) after adjustment for age, sex, educational level, and chronic diseases. Across the five domains, vitality was the strongest predictor of incident frailty at each follow-up (year 2, OR=0.33, 95%CI=0.24-0.45; year 4, OR=0.33, 95%CI=0.23-0.46). Compared to other combinations of any two domains, having 'high' scores on both vitality and locomotor domains was associated with the lowest risk of incident frailty (year 2, OR=0.11, 95%CI=0.06-0.22, area under the curve (AUC)=0.770; year 4, OR=0.18, 95%CI=0.10-0.32, AUC=0.782).

CONCLUSION

This study provides evidence that IC was independently associated with incident frailty. It also finds that vitality was the domain most strongly associated with incident frailty. Finally, it suggests that optimizing multiple domains of IC, particularly vitality and locomotor, may prevent frailty.

[Differential diagnosis of pure ground glass nodules in lung with spectral CT imaging]

Objective: To evaluate the differential diagnostic performance of quantitative parameters derived from the spectral CT imagingin pure ground-glass nodules. Methods: A total of 44 patients with pure ground glass nodules underwent chest energy spectrum CT and with known subsequently pathological findings in the Imaging Department of the Second Affiliated Hospital of Soochow University from August 2017 to September 2019 were retrospectively analyzed. Among them, there are 18 males and 26 females, aged from 26 to 79 (51±12) years. They were divided into as the inflammatory group (n=12), pre-invasive adenocarcinoma group (n=17) and invasive adenocarcinoma group (n=15). The aforementioned three groups were further reclassified as non-invasive adenocarcinoma group (inflammatory lesion+pre-invasive lesion) and invasive adenocarcinoma group in order to evaluating the values of water concentration (WC) for the determination of adenocarcinoma infiltration status. The values of WC derived from the arterial and venous phase of the lesion, iodine concentration (IC), standardized iodine concentration (NIC) were measured respectively.The slope of the energy spectral curve (K_40-70KeV) derived from the arterial and venous phase of the lesion was also calculated. One-way ANOVA analysis was performed to compare the differences of the three groups and the multiple comparison method was used for further comparing. Intraclass correlation efficient (ICC) was used to assess the consistency of the three times of measurements. The area under curve(AUC) of Receiver Operating Characteristic (ROC) was conducted to evaluate the diagnostic performance of water based values. Results: The values of WC in the arterial and venous phases were significantly different. As in the inflammatory group, the pre-invasive lesion group and the invasive adenocarcinoma group, the values of WC was (291.95±58.66) mg/cm³, (297.61±63.96) mg/cm³and (374.52±60.62) mg/cm³ of the arterial phase, and (277.07±33.78) mg/cm³, (291.74±50.49) mg/cm³ and (373.33±75.12) mg/cm³ of the venous phase, respectively(all P<0.05). Further comparison demonstrated that no significant difference was observed for the values of WC derived from the arterial phases and venous phases between the inflammatory lesion group and the pre-invasive lesion group (all P>0.05).There were an significant differences between the invasive adenocarcinoma group, the inflammatory lesion group and the pre-invasive lesion group (all P<0.05). The values of WC derived from the venous phase achieved the largest AUC (0.770) for differentiating invasive adenocarcinoma from non-invasive adenocarcinoma (inflammatory lesions+pre-invasive lesions) in the pure ground glass nodules. The sensitivity and specificity were 66.67% and 93.10%, respectively, when using 349.31 mg/cm³ as the optimal threshold. The slope of the spectral curve and iodine-related parameters (IC, NIC) derived from arterial or venous phases among the three groups were not significantly different (all P>0.05). Conclusion: The values of WC derived from the spectral CT can better distinguish inflammatory, pre-invasive lesions and invasive adenocarcinoma, which is helpful for the qualitative analysis for pure ground glass nodules.

[Correlation study between changes in intestinal microflora structure and immune indexes in newly treated patients with pulmonary tuberculosis]

To explore the correlation between the changes of the intestinal flora of newly treated pulmonary tuberculosis patients and the immune indicators of the body, and to provide a reference for the prevention and treatment of pulmonary tuberculosis. A single-center and case-control study was adopted. From October 2020 to April 2021, 43 patients with newly diagnosed tuberculosis in the Department of Tuberculosis, Affiliated Changsha Central Hospital,University of South China were selected as the control group. 43 cases of newly treated pulmonary tuberculosis (PTB), 43 healthy control (HC) during the same period, collected fresh feces and whole blood of subjects, and used Illumina Hiseq high-throughput sequencing technology to analyze 16S of all microorganisms in feces The V4 region of rRNA was amplified and sequenced, and the structure of the intestinal flora was analyzed by QIIME software. Use flow cytometry to determine the subject's immune indicators (CD3⁺, CD4⁺, CD8⁺, CD4⁺CD25⁺CD127^-Treg, CD14⁺CD16⁺, CD14⁺CD16^-), and analyze the changes in intestinal flora and immune function in newly treated pulmonary tuberculosis patients Inherent connection. The χ² test, t test, and Wilcox rank sum test were used to analyze the differences in age, gender, α diversity, and relative abundance of the two groups of people. Compared with the HC group, the alpha diversity of the intestinal flora in the PTB group decreased (shannon index: t=3.906, P=0.000 2; simpson index: Z=553, P=0.004 7; chao1 index: t=5.395, P=0.000 0). β diversity analysis showed that there were significant differences in the structure of the intestinal flora between the two groups (P=0.000). Species difference analysis showed that at the phylum level, the relative abundance of Firmicutes in the PTB group was significantly lower than that in the HC group (Z=486.0, P=0.000 5). At the genus level, there are 15 different bacterial genera between the two groups. In the PTB group, bifidobacterium, enterococcus, lactobacillus, anaerostipes, the relative abundance of the above 5 genera of veillonella is higher than that of the HC group (P<0.05); Butyricimonas, clostridium, and broutella (blautia), coprococcus, dorea, lachnospira, roseburia, faecalibacterium, ruminococcus, the relative abundance of 10 bacterial genera including dialister was lower than that of the HC group (P<0.05). Comparison of immune indexes between groups showed that CD14⁺CD16⁺monocytes (%) in the PTB group were higher than those in the HC group (t=2.456, P=0.001 6<0.05), while CD14⁺CD16^-monocytes (%) were lower than HC (t=-4.368, P=0.000<0.05), while the differences in CD3⁺, CD4⁺, CD8⁺, CD4⁺/CD8⁺and Treg (CD4⁺CD25⁺CD127^-) were not statistically significant (P>0.05). Spearman correlation analysis showed that Firmicutes in the PTB group was negatively correlated with CD4⁺/CD8⁺, CD14⁺CD16⁺(r=-0.218, P=0.048; r=-0.245, P=0.025), and positively correlated with CD14⁺CD16^-Correlation (r=0.250, P=0.022); At the genus level, Faecalis is positively correlated with CD4⁺/CD8⁺and CD4⁺(r=0.250, P=0.023; r=0.258, P=0.019); Rosella and CD3⁺, CD8⁺and CD14⁺CD16^-are positively correlated (r=0.27, P=0.024; r=0.219, P=0.046; r=0.027, P=0.039), and negatively correlated with CD14⁺CD16⁺(r=-0.280, P= 0.01). Changes in the structure of the intestinal flora of newly treated pulmonary tuberculosis patients may be one of the influencing factors of the immune function of the body. Targeted optimization of the structure of the intestinal flora and improvement of the body's immunity may be used as an effective auxiliary treatment for pulmonary tuberculosis.

Hypocomplementemia (C3) as an independent predictor for children with acute post-streptococcal glomerulonephritis: a long-term observation

OBJECTIVE

The aim of this study was to examine the altering patterns in clinical characteristics and severity of acute post-streptococcal glomerulonephritis (APSGN) in children.

PATIENTS AND METHODS

We analyzed the medical records of 119 children who were diagnosed with APSGN from 1987 to 2018, retrospectively. The patients were divided into two groups: Group I (n=72, before 1998) and Group II (n=47, after 1998). Clinical, radiologic, and laboratory findings were compared between the two groups.

RESULTS

The clinical manifestations, including vomiting (20.8% vs. 4.3%, p=0.014), oliguria (40.3% vs. 19.1%, p=0.016), and generalized edema (86.1% vs. 63.8%, p=0.005), were statistically less frequent since 1998. Pulmonary edema on chest X-ray (22.7% vs. 4.4%, p=0.014) was less frequent in Group II than in Group I. The level of BUN (23.3±19.3 vs. 18.8±11.2, p=0.009) was lower in Group II than in Group I, while that of creatinine was not significantly different between the two groups. C3 level was an independent factor for predicting the development of edema (odds ratio [OR]: 1.034, 95% CI: 1.010-1.060, p=0.006) and acute nephritic symptoms (≥2) (OR: 0.974, 95% CI: 0.952-0996, p=0.020). It was also negatively correlated with an increasing number of acute nephritic symptoms, including oliguria and edema, in patients with APSGN (R=-0.182, p=0.048).

CONCLUSIONS

This study demonstrated that APSGN had favorable clinical manifestations and severity over the past 30 years. The monitoring of C3 levels can be used to assess the disease severity and risk of complications, including edema and oliguria, which are decreasing in South Korean children.

Genomic Profiling Reveals the Molecular Landscape of Gastrointestinal Tract Cancers in Chinese Patients

Gastrointestinal tract cancers have high incidence and mortality in China, but their molecular characteristics have not been fully investigated. We sequenced 432 tumor samples from the colorectum, stomach, pancreas, gallbladder, and biliary tract to investigate cancer-related mutations and detail the landscape of microsatellite instability (MSI), tumor mutation burden (TMB), and chromosomal instability (CIN). We observed the highest TMB in colorectal and gastric cancers and the lowest TMB in gastrointestinal stromal tumors (GISTs). Twenty-four hyper-mutated tumors were identified only in colorectal and gastric cancers, with a significant enrichment of mutations in the polymerase genes (POLE, POLD1, and POLH) and mismatch repair (MMR) genes. Additionally, CIN preferentially occurred in colorectal and gastric cancers, while pancreatic, gallbladder, and biliary duct cancers had a much lower CIN. High CIN was correlated with a higher prevalence of malfunctions in chromosome segregation and cell cycle genes, including the copy number loss of WRN, NAT1, NF2, and BUB1B, and the copy number gain of MYC, ERBB2, EGFR, and CDK6. In addition, TP53 mutations were more abundant in high-CIN tumors, while PIK3CA mutations were more frequent in low-CIN tumors. In colorectal and gastric cancers, tumors with MSI demonstrated much fewer copy number changes than microsatellite stable (MSS) tumors. In colorectal and gastric cancers, the molecular characteristics of tumors revealed the mutational diversity between the different anatomical origins of tumors. This study provides novel insights into the molecular landscape of Chinese gastrointestinal cancers and the genetic differences between tumor locations, which could be useful for future clinical patient stratification and targeted interventions.

Genetic Profiling of Cell-Free DNA From Pleural Effusion in Advanced Lung Cancer as a Surrogate for Tumor Tissue and Revealed Additional Clinical Actionable Targets

BACKGROUND

Pleural effusion (PE) has been one of the promising sources of liquid biopsy in advanced lung cancer patients. However, its clinical utility is not widely accepted due to the lack of full estimation of its potential versus routine clinical samples.

METHOD

A total of 164 advanced lung cancer patients were enrolled with 164 matched tumor tissue and PE-cfDNA, 153 accompanied plasma and 63 ¹PE-sDNA.

RESULT

PE-cfDNA displayed significantly higher median mutant allele frequency and an overall mutation concordance rate of 65% to tissue, which was higher than PE-sDNA (43%) and plasma-cfDNA (43%). The discrepancies between PE-cfDNA and tumor tissue were high in several genes, including SMARCA4, PIK3CA, ERBB2, KM T2A, ALK and NF1. For clinically actionable mutations, the concordance rate between PE-cfDNA and tumor tissue is 87%. Eleven patients were identified with actionable mutations in PE-cfDNA and four patients benefited from PE-cfDNA-guided targeted. Meanwhile, PE-cfDNA recapitulated mutations of diverse tissue origins and provided more mutational information under the circumstance that tumor tissue or tumor tissue of different origins were unavailable. The combination of tumor tissue and PE-cfDNA profiling increased positive detection rates of patients compared to tumor tissue alone. Our finding highlighted the importance of PE-cfDNA in the optimal selection of patients for targeted therapy.

CONCLUSION

The PE-cfDNA-based liquid biopsy displays better performance in the characterization of gene alterations than PE-sDNA and plasma-cfDNA. PE-cfDNA together with tumor tissue profiling optimizes comprehensively genomic profiling of lung cancer patients, which might be important for selecting patients for better treatment management.

Abstract 2166: The prevalence and molecular characteristics of EGFRlarge fragment deletion in Asian cancer population by comprehensive genome profiling

Background: Large fragment deletion(LFD) of EGFR was associated with carcinogenesis in many types of cancers, especially in glioblastoma. Overall, there are five major types of EGFR large fragment deletion across EGFR extracellular region and carboxyl terminal domain which were originally discovered in gliomas. The prevalence and molecular feature of EGFR-LFD have not been studied in Asian Cancer population.

Method: We retrospectively reviewed records of 66,500 Asian cancer patients who underwent genetic testing using capture-based targeted NGS between January 2014 to May 2020 at hospitals across China. Five to ten mL peripheral blood was collected from each patient in EDTA-coated tubes. Plasma was extracted within 2 hours of blood collection and shipped to the central testing laboratory. Formalin-fixed paraffin-embedded (FFPE) tumor tissue blocks/sections or fresh tumor tissues were obtained from the hospitals, with confirmation by the pathologists for diagnosis and tumor purity. Mean sequencing depths of tumor tissue and plasma were 500X and 3000X respectively.

Result: Our finding showed that EGFR-LFD was detected at a frequency of 0.03%, of which the most frequent was EGFRvIII in glioblastoma. In this EGFR-LFD cohort, there were 9 males(53%), 7 females(41%) and one unknown sex type with a median age of 54 years old, ranging from 42 to 85 years old. Interestingly, novel EGFR-LFDs spanning exon2-7 were identified in unreported cancer type including deletions of EGFR exon2-11(1case, lung cancer), exon2-15(1case, lung cancer), exon2-17(2 cases, lung cancer and colorectal cancer), exon2-28(1 case, cholangiocarcinoma). TERT promoter(TERTp) variants(60%) showed highest frequency in EGFR-LFD carriers, consisting of 6 cases of −124C&gt;T and 2cases of −146C&gt;T in glioblastoma(7) and melanoma(1). Concurrent EGFR amplification was identified in 67% of EGF-LFD cohort including glioblastoma(6), colorectal cancer(3), unknown(1). Over half of EGFR-LFD carriers harbored deletion on both arms of chromosome 10.

Conclusion: Our study provided valuable insights into the distribution and molecular characteristics of EGFR-LFD by employing a large Asian Cancer cohort, hoping to shed lights on the treatment management for Asian EGFR-LFD carriers.

Citation Format: Ruoying Yu, Qiuxiang Ou, Hua Bao, Xue Wu, Yang Shao. The prevalence and molecular characteristics of EGFRlarge fragment deletion in Asian cancer population by comprehensive genome profiling [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2166.

Assessing alfalfa (Medicago sativa L.) tolerance to salinity at seedling stage and screening of the salinity tolerance traits

Salt is among the most harmful agents that negatively influences crop yield. Alfalfa is an important perennial forage crop that exhibits wide cultivar variations in salt tolerance. Developing salt-tolerant alfalfa plants is a promising way to utilize salinized land. A comprehensive method was developed to achieve reliable and effective evaluation of alfalfa salt resistance. This included principal components, membership functions and cluster and stepwise regression analyses. These were used to analyse the salt tolerance coefficients of 14 traits and to evaluate 20 diverse alfalfa cultivars at the seedling stage. The various morphological root parameters of six alfalfa cultivars with contrasting salt tolerance were also tested by a scanning apparatus. According to the comprehensive evaluation value (D value), one highly salt-tolerant, two salt-tolerant, four moderately salt-tolerant and 13 salt-sensitive alfalfa cultivars were screened. A mathematical equation for the evaluation of alfalfa salt tolerance was established: D' = -0.126 + 0.667SFW + 0.377SDW + 1.089K⁺ /Na⁺  + 0.172SFW/RFW (R²  = 0.988; average forecast accuracy of 96.95%), where four indices were closely related to the salt tolerance: shoot fresh weight, ratio of shoot fresh weight to root fresh weight, shoot dry weight and ratio of K⁺ to Na⁺ in the shoot. We also found that SSA correlated strongly with SFW, SDW, K⁺ /Na⁺ , D values, while SRV correlated obviously with SFW, SFW/RFW and D values after 150 mm NaCl treatment. In conclusion, the SFW, K⁺ /Na⁺ , SDW, SFW/RFW, SSA and SRV could be used as indicators of salt tolerance in alfalfa seedlings grown under 150 mm NaCl treatment.

Correlation of plasma exosomal microRNAs with the efficacy of immunotherapy in EGFR / ALK wild-type advanced non-small cell lung cancer

Background

Immunotherapy has become an important treatment option for patients with advanced non-small cell lung cancer (NSCLC). At present, none of these existing biomarkers can effectively stratify true responders and there is an urgent need for identifying novel biomarkers. Exosomes derived from the serum of patients with cancer have been proven to be reliable markers for cancer diagnosis. Here, we explored the possibility of using plasma-derived exosomal microRNAs as potential biomarkers for optimal selection of patients with advanced EGFR/ALK negative NSCLC to immunotherapy.

Methods

From June 2017 to February 2019, 30 patients with advanced EGFR/ALK wild-type (WT) NSCLC who received PD-1/PD-L1 inhibitors were enrolled. The efficacy evaluation was conducted after every three cycles of treatment according to RECIST 1.1. Plasma samples of these patients were collected before the administration of PD-1/PD-L1 inhibitors as baseline, and after every three cycles if the patients achieved partial response (PR) or complete response. Plasma from seven healthy individuals was also collected as normal control. Exosomes were prepared by ultracentrifugation followed by total RNA extraction, and exosome-derived miRNAs were profiled using small RNA next-generation sequencing followed by differential expression analysis.

Results

In order to identify biomarker for better response, all five patients who achieved PR and four patients with progressive disease (PD) at efficacy evaluation were included for differential expression analysis. Based on unsupervised hierarchical clustering, exosomal miRNA expression profile was significantly altered in patients with NSCLC compared with normal controls with a total of 155 differentially expressed exosomal miRNAs. Interestingly, hsa-miR-320d, hsa-miR-320c, and hsa-miR-320b were identified significantly upregulated in the PD groups compared with the PR group at baseline before the treatment. In addition, we identified that hsa-miR-125b-5p, a T-cell suppressor, showed a trend of increased expression in the PD group at baseline and was significantly downregulated in the post-treatment plasma exosomes compared with pre-treatment samples of the PR patients.

Conclusion

Patients with NSCLC represent unique plasma exosomal miRNA profiles. Hsa-miR-320d, hsa-miR-320c, and hsa-miR-320b were identified as potential biomarkers for predicting the efficacy of immunotherapy in advanced NSCLCs. When T-cell suppressor hsa-miR-125b-5p was downregulated during the treatment, the patients may obtain increased T-cell function and respond well to immunotherapy.

Circulating tumor DNA to investigate resistance mechanism and clone evolution of ALK TKI treated lung adenocarcinoma

3011

Background: Sequential treatment with first-, second-generation ALK TKI followed by third-generation TKI (lorlatinib) have been widely applied to ALK-positive lung cancer. However, acquired resistance is often driven by secondary ALK mutations, which are needed to be further explored. Circulating tumor DNA, a non-invasive approach, can detect tumor-derived DNA from multiple metastatic sites and has become a promising strategy for assessing the genetic evolution of tumors and analyzing TKI resistance. Methods: Post-progression plasma specimens were collected and sequenced with a targeted gene panel from a total of 116 patients underwent ALK TKI treatment with from February 2014 to April 2020. The ALK TKIs administrated in this cohort included crizotinib (first-generation), ceritinib (second-generation), alectinib (second-generation), brigatinib (second-generation), ensartinib (second-generation) and lorlatinib (third-generation). Results: In this ALK-positive lung adenocarcinoma cohort, 49.1% were female and the rest were male with a median age of 52 (range 20 to 79). More than half of patients received more than one line of ALK TKI treatment. The most frequent ALK fusion type is EML4-ALK including EML4-ALK v1(E13; A20, 37/116, 31.9%) and EML4-ALKv3(E6a/b; A20, 49/116, 42.2%). TP53 (29.1%, 41/141) was the most frequently mutated gene other than ALK. Frequently identified secondary mutations in patients progressing on ALK inhibitors were ALK mutations L1196M and G1202R. ALK G1202R was more common in patient with v3 fusion than in v1 (25.8% vs 0%; P<.001) while ALK L1196M was more common in v1 than in v3 (20.8% vs 3.2%; P=.005). Meanwhile, G1202R was identified at higher ratio in patients progressed on second-generation ALK TKI than first- and third-generation ALK TKI (11.3% vs 0% and 9.1%) whereas L1196M was more found in patients progressed on first-generation ALK TKI (9.1% vs 1.9% and 4.5%). Other identified secondary mutations were ALK F1174C/V/L, E1210K/Q, D1269A, D1203N and L1122M/V. Compound ALK mutations (≥2 concurrent ALK mutations) were more common in patients relapsed on third-generation ALK TKI lorlatinib (36.4%) compared to first- (12.1%) and second-generation (20.8%) ALK TKIs. Using serial plasma specimens, clone evolution analysis showed that five patients developed compound ALK mutations after sequential ALK TKI treatments and two novel ALK compound lorlatinib-resistant mutations D1203N+I1171N and F1174C+G1202R were identified. Conclusions: Genotyping of sequential post-progression plasma specimens reveals that treatment with sequential first-, second-, and third-generation ALK inhibitors can accelerate the accumulation of ALK resistance mutations and may lead to treatment-refractory compound ALK mutations. The selection for optimal first-line TKI is very important to achieve a more efficacious long-term strategy and prevent the emergence of on-target resistance.