Genomics Flashcards

1
Q

What is adjusted rand index?

A

Adjusted Rand index: A measure of the similarity between two data clusterings, adjusted for chance grouping of the elements.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is CoC analysis?

A

Cluster of clusters (CoC) analysis: A method of obtaining clusters (e.g., of patient samples) that represent a consensus among the individual data types (in this study, we incorporated DNA methylation, DNA copy number, mRNA expression, and microRNA expression into the analysis).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is a DM-BER?

A

Double-minute chromosome–breakpoint-enriched region (DM-BER): As detected by whole-exome and whole-genome sequencing, highly amplified gene regions that are connected by DNA rearrangement breakpoints and allow cancer cells to maintain high levels of oncogene amplification.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Define exon

A

The portion of a gene that encodes amino acids to form a protein.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Define fusion transcript

A

A transcript composed of parts of two separate genes joined together by a chromosomal rearrangement, in some cases with functional consequences for oncogenesis, therapy, or both.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is methylation?

A

The attachment of methyl groups to DNA at cytosine bases. Methylation is correlated with reduced transcription of the gene immediately downstream of the methylated site.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Define microRNA

A

A short regulatory form of RNA that binds to a target RNA and generally suppresses its translation by ribosomes.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is meant by ‘molecular subtype’

A

Molecular subtype: Subgroup of a tumor type based on molecular characteristics (rather than, e.g., histologic or clinical features); in this study, a molecular subtype is one of three classes based on IDH mutation and 1p/19q codeletion status.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Define mutation frequency

A

Mutation frequency: The number of mutations detected per megabase of DNA.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is meant by ‘significantly mutated gene’?

A

Significantly mutated gene: A gene with a greater number of mutations than expected on the basis of the background mutation rate, which suggests a role in oncogenesis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Sanger sequencing: how does the classical chain-termination method work?

A

Method of DNA sequencing based on the selective incorporation of chain-terminating dideoxynucleotides by DNA polymerase during in vitro DNA replication. The classical chain-termination method requires a single-stranded DNA template, a DNA primer, a DNA polymerase, normal deoxynucleotidetriphosphates (dNTPs), and modified di-deoxynucleotidetriphosphates (ddNTPs), the latter of which terminate DNA strand elongation. These chain-terminating nucleotides lack a 3’-OH group required for the formation of a phosphodiester bond between two nucleotides, causing DNA polymerase to cease extension of DNA when a modified ddNTP is incorporated. The ddNTPs may be radioactively or fluorescently labeled for detection in automated sequencing machines. The DNA sample is divided into four separate sequencing reactions, containing all four of the standard deoxynucleotides (dATP, dGTP, dCTP and dTTP) and the DNA polymerase. To each reaction is added only one of the four dideoxynucleotides (ddATP, ddGTP, ddCTP, or ddTTP), while the four other nucleotides are ordinary ones. The dideoxynucleotide is added in approximately 100-fold excess of the corresponding deoxynucleotide(e.g. 0.5mM ddATP : 0.005mM dATP) allowing for enough fragments to be produced while still transcribing the complete sequence. Following rounds of template DNA extension from the bound primer, the resulting DNA fragments are heat denatured and separated by size using gel electrophoresis. In the original publication of 1977,[2] the formation of base-paired loops of ssDNA was a cause of serious difficulty in resolving bands at some locations. This is frequently performed using a denaturing polyacrylamide-urea gel with each of the four reactions run in one of four individual lanes (lanes A, T, G, C). The DNA bands may then be visualized by autoradiography or UV light and the DNA sequence can be directly read off the X-ray film or gel image. In the image on the right, X-ray film was exposed to the gel, and the dark bands correspond to DNA fragments of different lengths. A dark band in a lane indicates a DNA fragment that is the result of chain termination after incorporation of a dideoxynucleotide (ddATP, ddGTP, ddCTP, or ddTTP). The relative positions of the different bands among the four lanes, from bottom to top, are then used to read the DNA sequence.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

In which instances is Sanger sequencing still often useful?

A

Sanger method remains in wide use, for smaller-scale projects, validation of Next-Gen results and for obtaining especially long contiguous DNA sequence reads (>500 nucleotides).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Limitations of chain-termination methods of Sanger sequencing?

A

Limitations include non-specific binding of the primer to the DNA, affecting accurate read-out of the DNA sequence, and DNA secondary structures affecting the fidelity of the sequence.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Describe two technical variations of chain-termination sequencing.

A

Technical variations of chain-termination sequencing include tagging with nucleotides containing radioactive phosphorus for radiolabelling, or using a primer labeled at the 5’ end with a fluorescent dye. Dye-primer sequencing facilitates reading in an optical system for faster and more economical analysis and automation. The later development by Leroy Hood and coworkers of fluorescently labeled ddNTPs and primers set the stage for automated, high-throughput DNA sequencing.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What does CRISPR stand for?

A

Clustered regularly interspaced short palindromic repeats Fifty years ago, microbiologists sparked the recombinant-DNA revolution with the discovery that bacteria have innate immune systems based on restriction enzymes. These enzymes bind and cut invading viral genomes at specific short sequences, and scientists rapidly repurposed them to cut and paste DNA in vitro — transforming biologic science and giving rise to the biotechnology industry. Ten years ago, microbiologists discovered that bacteria also harbor adaptive immune systems, and subsequent progress has been breathtakingly rapid.1 Between 2005 and 2009, microbial genetic studies conducted by the laboratories of Mojica, Jansen, Koonin, Horvath, van der Oost, Sontheimer, Marraffini, and others revealed that bacteria have a programmable mechanism that directs nucleases, such as Cas9, to bind and cut invading DNA that matches “guide RNAs” encoded in specific bacterial genome regions containing clustered regularly interspaced short palindromic repeats (CRISPR).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

How might CRISPR technology be applied to HIV?

A

To treat HIV infection, physicians might edit a patient’s immune cells to delete the CCR5 gene, conferring the resistance to HIV carried by the 1% of the U.S. population lacking functional copies of this gene. To treat progressive blindness caused by dominant forms of retinitis pigmentosa, they might inactivate the mutant allele in retinal cells. To prevent MIs that kill patients with homozygous familial hypercholesterolemia, they might edit liver cells to restore a functional copy of the gene encoding low-density lipoprotein receptors. Editing of blood stem cells might cure sickle cell anemia and hemophilia. These goals will require overcoming serious technical challenges (such as avoiding “off-target” edits elsewhere in the genome, which might give rise to cancer), but they pose no unique ethical issues because they affect only a patient’s own somatic cells.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Describe four central issues with human germline editing using CRISPR-Cas9 technology.

A
  1. Technical issues: whether genome editing can be performed with sufficient precision to permit scientists to responsibly contemplate creating genetically modified babies. Currently, the technology is far from ready: Liang and colleagues recently applied genome editing to human tripronuclear zygotes (abnormal products of in vitro fertilization [IVF] that are incapable of developing in vivo) and documented problems including incomplete editing, inaccurate editing, and off-target mutations. Even with improved accuracy, the process is unlikely to be risk-free. 2. Do compelling medical needs outweigh the risks both from inaccurate editing and from unanticipated effects of the intended edits. Various potential applications must be considered. 3. Who has the right to decide? Can parents consent for future generations? Some people will argue that parents should have unfettered autonomy — that modifying one’s progeny is akin to using PGD to avoid genetic diseases or choosing sperm donors on the basis of intellectual or athletic prowess. Yet parental autonomy must be weighed against the interests of future generations who cannot consent to the genetic modifications their flesh will be heir to. 4. Morality — what’s right and wrong and how we ought to live as a society. Authorizing scientists to make permanent changes to the DNA of our species is a decision that should require broad societal understanding and consent. It has been only about a decade since we first read the human genome. We should exercise great caution before we begin to rewrite it.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Describe potential applications of germline editing using CRISPR technology and arguments for/against.

A

i) Preventing devastating monogenic diseases, such as Huntington’s disease. Though avoiding the roughly 3600 rare monogenic disorders caused by known disease genes is a compelling goal, the rationale for embryo editing largely evaporates under careful scrutiny. Genome editing would require making IVF embryos, using preimplantation genetic diagnosis (PGD) to identify those that would have the disease, repairing the gene, and implanting the embryo. Yet it would be easier and safer simply to use PGD to identify and implant the embryos that aren’t at risk: the proportion is high in the typical cases of a parent heterozygous for a dominant disease (50%) or two parents who are carriers for a recessive disease (75%). To reduce the incidence of monogenic disease, what’s needed most is not embryo editing, but routine genetic testing so that the many couples who don’t know they are at risk can avail themselves of PGD. ii) Reducing the risk of common diseases, such as heart disease, cancer, diabetes, and multiple sclerosis. The heritable influence on disease risk is polygenic, shaped by variants in dozens to hundreds of genes. Common variants tend to make only modest contributions (for example, reducing risk from 10% to 9.5%); rare variants sometimes have larger effects, including a few for which heterozygosity provides significant protection against disease. iii) Reshaping the human gene pool by endowing all children with many naturally occurring “protective” variants. However, genetic variants that decrease risk for some diseases can increase risk for others. (For example, the CCR5 mutations that protect against HIV also elevate the risk for West Nile virus, and multiple genes have variants with opposing effects on risk for type 1 diabetes and Crohn’s disease.) The full medical effect of most variants is poorly characterized, let alone the combined effects of many variants. Safety studies would be needed to assess effects across various genetic backgrounds and environmental exposures. The situation is particularly dicey for rare protective heterozygous variants: most have never been seen in the homozygous state in humans and might have deleterious effects. Yet heterozygous parents would routinely produce homozygous children (one quarter of the total) — unless humans forswore natural reproduction in favor of IVF. iv) Currently, the best arguments might be for eliminating the ε4 variant at the APOE gene (which increases risk for Alzheimer’s disease and cardiovascular disease) and bestowing null alleles at the PCSK9 gene (which reduces the risk of myocardial infarction). Still, our knowledge is incomplete. For example, APOE ε4 has also been reported to be associated with better episodic and working memory in young adults. v) Why limit ourselves to naturally occurring genetic variants? Why not use synthetic biology to write new cellular circuits that, for example, cause cells to commit suicide if they start down the road toward cancer? But such efforts would be reckless, at least for now. We remain terrible at predicting the consequences of even simple genetic modifications in mice. One cautionary tale among many is a genetic modification of the tp53 gene that protected mice against cancer while unexpectedly causing premature aging.5 We would also need to anticipate the potential interactions among the diverse genetic circuits that creative scientists will cast into the gene pool. Mistakes would be inevitable, and there would be no way to recall novel genes from the human population. vi) Reshape non-medical traits. Height may prove challenging (the hundreds of natural variants have tiny effects), but hair and eye color may be pliable. Disruption of the MC1R gene is associated with bright red hair, although it also heightens the risk of melanoma. Sports-minded parents might want to introduce the overactive erythropoietin gene that conferred high oxygen-carrying ability on a seven-time Olympic medalist in cross-country skiing. Nonnatural genetic modifications hold even bolder prospects — and risks.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is X-chromosome skewing? By what mechanisms can it occur? How common is it? Why is it medically significant?

A
  • Skewed X chromosome inactivation occurs when the inactivation of one X chromosome is favored over the other, leading to an uneven number of cells with each chromosome inactivated. It is usually defined as one allele being found on the active X chromosome in over 75% of cells, and extreme skewing is when over 90% of cells are have inactivated the same X chromosome. - It can be caused by a) primary nonrandom inactivation, either by chance due to a small cell pool or directed by genes, or b) caused by secondary nonrandom inactivation, which occurs by selection. - Most females will have some levels of skewing. It is relatively common in adult females; around 35% of women have skewed ratio over 70:30, and 7% of women have an extreme skewed ratio of over 90:10. - This is of medical significance due to the potential for the expression of disease genes present on the X chromosome that are normally not expressed due to random X inactivation. - X chromosome inactivation occurs in females to provide dosage compensation between the sexes. If females kept both X chromosomes active they would have twice the number of active X genes than males, who only have one copy of the X chromosome. At approximately the time of implantation, one of the two X chromosomes is randomly selected for inactivation. The cell undergoes transcriptional and epigenetic changes to ensure this inactivation is permanent. All progeny from these initial cells will maintain the inactivation of the same chromosome, resulting in a mosaic pattern of cells in females.
20
Q

What is a ‘double minute’

A

Double minutes are small fragments of extrachromosomal DNA, which have been observed in a large number of human tumors including breast, lung, ovary, colon, and most notably, neuroblastoma. They are a manifestation of gene amplification during the development of tumors, which give the cells selective advantages for growth and survival. They frequently harbor amplified oncogenes and genes involved in drug resistance. Double minutes, like actual chromosomes, are composed of chromatin and replicate in the nucleus of the cell during cell division. Unlike typical chromosomes, they are composed of circular fragments of DNA, up to only a few million base pairs in size and contain no centromere or telomere.

21
Q

What is an ‘amplicon’?

A

An amplicon is a piece of DNA or RNA that is the source and/or product of natural or artificial amplification or replication events. It can be formed using various methods including PCR, ligase chain reactions (LCR), or natural gene duplication. In this context, “amplification” refers to the production of one or more copies of a genetic fragment or target sequence, specifically the amplicon. As the product of an amplification reaction, amplicon is used interchangeably with common laboratory terms, such as PCR product. Artificial amplification is used in research, forensics, and medicine for purposes that include detection and quantification of infectious agents, identification of human remains, and extracting genotypes from human hair. Natural gene duplication is implicated in several forms of human cancer including primary mediastinal B cell lymphoma and Hodgkin’s lymphoma. Amplicons in this context can refer both to sections of chromosomal DNA that have been excised, amplified, and reinserted elsewhere in the genome, and to extrachromasomal DNA known as double minutes, each of which can be composed of one or more genes. Amplification of the genes encoded by these amplicons generally increases transcription of those genes and ultimately the volume of associated proteins.

22
Q

Oncogene. 2013 Jan 10;32(2):135-40. doi: 10.1038/onc.2012.48. Epub 2012 Feb 20. Clonal evolution of acute leukemia genomes. Jan M1, Majeti R.

A

In large part, cancer results from the accumulation of multiple mutations in a single cell lineage that are sequentially acquired and subject to an evolutionary process where selection drives the expansion of more fit subclones. Owing to the technical challenge of distinguishing and isolating distinct cancer subclones, many aspects of this clonal evolution are poorly understood, including the diversity of different subclones in an individual cancer, the nature of the subclones contributing to relapse, and the identity of pre-cancerous mutations. These issues are not just important to our understanding of cancer biology, but are also clinically important given the need to understand the nature of subclones responsible for the refractory and relapsed disease that cause significant morbidity and mortality in patients. Recently, advanced genomic techniques have been used to investigate clonal diversity and evolution in acute leukemia. Studies of pediatric acute lymphoblastic leukemia (ALL) demonstrated that in individual patients there are multiple genetic subclones of leukemia-initiating cells, with a complex clonal architecture. Separate studies also investigating pediatric ALL determined that the clonal basis of relapse was variable and complex, with relapse often evolving from a clone ancestral to the predominant de novo leukemia clone. Additional studies in both ALL and acute myeloid leukemia have identified pre-leukemic mutations in some individual cases. This review will highlight these recent reports investigating the clonal evolution of acute leukemia genomes and discuss the implications for clinical therapy.

23
Q

Nature. 2011 Jan 20;469(7330):356-61. doi: 10.1038/nature09650. Epub 2010 Dec 15. Genetic variegation of clonal architecture and propagating cells in leukaemia. Anderson K1, Lutz C, van Delft FW, Bateman CM, Guo Y, Colman SM, Kempski H, Moorman AV, Titley I, Swansbury J, Kearney L, Enver T, Greaves M.

A

Abstract Little is known of the genetic architecture of cancer at the subclonal and single-cell level or in the cells responsible for cancer clone maintenance and propagation. Here we have examined this issue in childhood acute lymphoblastic leukaemia in which the ETV6-RUNX1 gene fusion is an early or initiating genetic lesion followed by a modest number of recurrent or ‘driver’ copy number alterations. By multiplexing fluorescence in situ hybridization probes for these mutations, up to eight genetic abnormalities can be detected in single cells, a genetic signature of subclones identified and a composite picture of subclonal architecture and putative ancestral trees assembled. Subclones in acute lymphoblastic leukaemia have variegated genetics and complex, nonlinear or branching evolutionary histories. Copy number alterations are independently and reiteratively acquired in subclones of individual patients, and in no preferential order. Clonal architecture is dynamic and is subject to change in the lead-up to a diagnosis and in relapse. Leukaemia propagating cells, assayed by serial transplantation in NOD/SCID IL2Rγ(null) mice, are also genetically variegated, mirroring subclonal patterns, and vary in competitive regenerative capacity in vivo. These data have implications for cancer genomics and for the targeted therapy of cancer.

24
Q

A nucleotide comprises…

A

sugar, phosphate and one of four nitrogenous bases (A,T,G,C)

25
Q

How many base pairs of DNA are there in the human genome?

A
  • 3.2 billion bp of DNA in the human genome
  • 2 copies (one from each parent) = 6.4 billion bp
26
Q

What percentage of the genome comprises repetitive elements? Putative functions?

What percentage of the genome is highly conserved across organisms?

What percentage is thought to be protein coding?

A
  • About 30% of the genome is comprised of repetitive DNA (SINEs 13%, LINEs 20%), thought to have roles in packaging, segregation and replication of chromosomes.
  • About 5% of genome is conserved aross diverse species, implying essential function
  • About 1.5% of the genome is protein coding genes.
27
Q

What is the generic structure of a gene?

What is the average size in kb and exons of an average gene?

Estimated number of genes in the human genome?

A
  • Structure: introns, exons (coding), regulatory regions (5’ promoter, 3’ regulatory sequence)
  • Average size: 20kb, 8 exons, but highly variable
  • Estimated 22,000 genes concentrated in random areas along the genome
28
Q

What proportion of genes are thought to undergo alternative splicing?

A

>90%

29
Q

3 broad mechanisms for DNA expression regulation?

A
  • Protein-DNA interaction (transcription factors binding to promotor…)
  • RNA-DNA interaction (miRNA, sncRNA)
  • Epigenetic
30
Q

How would you classify structural genetic variants?

A
  • Numerical variants (aneuploidies)
  • Translocations (balanced, unbalanced)
  • Copy number variants (CNVs) - deletions, duplications
31
Q

How do aneuploidies arise?

Which three autosomal aneuploidies are viable?

Which sex chromosome anueploidies are viable?

A
  • Aneuploidies arise due to non-disjunction of chromosomes during meiosis. Can have entire chromosome missing (monosomy) or extra (trisomy)
  • Viable autosomal trisomies: Trisomy 21 (Down syndrome); trisomy 13 (Patau syndrome); trisomy 18 (Edwards syndrome)
  • Viable sex chromosome aneuploidies: XO (Turner), XXX (Triple X), XXY (Klinefelter), XYY
32
Q

Translocations - how common are they? What determines pathogenicity?

A
  • Visible by karyotype
  • No gain or loss of DNA, just rearranged
  • Rare: e.g. translocations ~ 1/600 newborns
  • Usually harmless unless breakpoint is in a gene
33
Q

What are Copy Number Variants? Are they visible on karyotypes? What is the typical size of a CNV? What distinuishes larger CNVs from smaller CNVs? How do larger CNVs cause disease?

A
  • Deletions or duplications
  • Usually too small to visualize under microscope
  • Typically 1-10 Kb but can be several Mb in size
  • Single or multiple copies in tandem

Larger CNVs….

  • Less polymorphic (monosomy/trisomy instead of tandem)
  • Less common in population
  • More likely to be pathogenic (affect more genes)
  • More likely to be de novo
  • How they cause disease:
    • Too little or too much gene product
    • Unmasking of recessive trait
34
Q

How many small (<100kb) CNVs does a typical person carry?

What proportion of people carry a CNV of roughly 100-500kb?

What proportion carry a CNV of 500-1000kb? of >1000kb?

A
  • Typical person carries about 1000 CNVs down to 500bp
  • 65-80% of the population carries CNV of up to 500kb
  • Only 5-10% of people have a CNV 500-1000kb and <1% carries a CNV larger than this
35
Q

What is the estimated human mutation rate per bp per generation?

Roughly how many de novo germline mutations are currently thought to be present in the average newborn?

MODULE 3: Human genetic variation — single nucleotide variants

A
  • Human mutation rate: 10-8 per bp per generation
  • 50 to 100 de novo (new) mutations in average newborn
  • Single nucleotide changes can be thought of as mutation, variant, polymorphism
  • The index individual is the founder. All alleles are shared among individuals in the population by descent, not by recurrent mutations at the same location.
36
Q

Allele frequencies of single nucleotide variants (SNVs/SNPs) in the population. What determines minor allele frequencies in a population?

MODULE 3: Human genetic variation — single nucleotide variants

A
  • Allele frequency is determined by
    • Natural selection
    • Genetic drift (change in the frequency of a gene variant (allele) in a population due to random sampling of organisms - eg founder in a small population)
    • Gene flow (migrations, emigrations). Allele frequencies in an ethnic population can reflect when the founder arose (for example, a common SNP in a native american population that isn’t found in any africans probably occured after departure from Africa)…
37
Q

How are SNVs/SNPs classified according to allele frequency? How is a polymorphism conventionally defined?

UCSF MOOC module 3

A
  • A rare variant occurs with an allele frequency of <0.5%
  • Low frequency variant: 0.5-5%
  • Common variant: >5%
  • Polymorphism: mutations with allele frequencies >1% in the population
38
Q

How many SNVs are there in the population at large?

UCSF genomics MOOD module 3

A
  • Common variants (>5% allele frequency): about 10 million positions in the human genome where there is a common SNV. There is approx 1 common SNV per 1000bp of the human genome.
  • Low frequency alleles (0.5-5% allele frequency): there are around 15-20 million of these
  • Rare SNVs (each occurs in <0.5% of human population): collectively the most abundant type of SNV, with about 60 million found so far. A known rare SNV happens about once per 50bp of human genome.
39
Q

How many SNVs, InDels and CNVs does the average individual have?

UCSF genomics MOOC

A
  • The average person has about 4 million DNA sequence variants
    • 3.7 SNVs
    • 357,000 InDels
    • 1000 CNVs
40
Q
A
41
Q

Telomerase Inhibitor Imetelstat for Myelofibrosis

A Pilot Study of the Telomerase Inhibitor Imetelstat for Myelofibrosis

Ayalew Tefferi, M.D., … and Animesh Pardanani, M.D., Ph.D.

N Engl J Med 2015;373:908-19.

A

BACKGROUND Current drugs for myeloproliferative neoplasm–associated myelofibrosis, including Janus kinase (JAK) inhibitors, do not induce complete or partial remissions. Imetelstat is a 13-mer lipid-conjugated oligonucleotide that targets the RNA template of human telomerase reverse transcriptase. METHODS We sought to obtain preliminary information on the therapeutic activity and safety of imetelstat in patients with high-risk or intermediate-2–risk myelofibrosis. Imetelstat was administered as a 2-hour intravenous infusion (starting dose, 9.4 mg per kilogram of body weight) every 1 to 3 weeks. The primary end point was the overall response rate, and the secondary end points were adverse events, spleen response, and independence from red-cell transfusions.

RESULTS A total of 33 patients (median age, 67 years) met the eligibility criteria; 48% had received prior JAK inhibitor therapy. A complete or partial remission occurred in 7 patients (21%), with a median duration of response of 18 months (range, 13 to 20+) for complete responses and 10 months (range, 7 to 10+) for partial responses. Bone marrow fibrosis was reversed in all 4 patients who had a complete response, and a molecular response occurred in 3 of the 4 patients. Response rates were 27% among patients with a JAK2 mutation versus 0% among those without a JAK2 mutation (P=0.30) and 32% among patients without an ASXL1 mutation versus 0% among those with an ASXL1 mutation (P=0.07). The rate of complete response was 38% among patients with a mutation in SF3B1 or U2AF1 versus 4% among patients without a mutation in these genes (P=0.04). Responses did not correlate with baseline telomere length. Treatment-related adverse events included grade 4 thrombocytopenia (in 18% of patients), grade 4 neutropenia (in 12%), grade 3 anemia (in 30%), and grade 1 or 2 elevation in levels of total bilirubin (in 12%), alkaline phosphatase (in 21%), and aspartate aminotransferase (in 27%).

CONCLUSIONS Imetelstat was found to be active in patients with myelofibrosis but also had the potential to cause clinically significant myelosuppression.

FULL BACKGROUND:

Allogeneic stem-cell transplantation is currently the only method of treatment for patients with myeloproliferative neoplasm–associated myelofibrosis that has been shown to induce long-term disease-free remission.1 Unfortunately, allogeneic stem-cell transplantation is associated with a relatively high rate of treatment-related death and complications, including chronic graft-versus-host disease. Furthermore, many older patients are not eligible for this intervention. Other treatment strategies, including the use of Janus kinase (JAK) inhibitors, are palliative and lack selective anticlonal activity.2 Ruxolitinib and other JAK inhibitors can alleviate constitutional symptoms and reduce spleen size, but they often cannot induce complete or partial remissions, reversal of bone marrow fibrosis, or molecular responses.3-6

Telomeres are protein-bound repetitive DNA sequences (TTAGGG in humans)7 that constitute the natural end of linear chromosomes and that protect coding DNA from genetic damage and cells from replicative senescence.8 Telomere length is genetically determined and shortens after each round of cell division, with age, and during neoplastic transformation.9,10 Telomerase, a holoenzyme made up of human telomerase reverse transcriptase (hTERT), an RNA template, and specialized proteins (e.g., dyskerin), participates in the synthesis of telomeres and maintenance of telomere length in rapidly dividing cells.11-13 Telomerase has been shown to be active in most cancer cells but not in normal somatic tissue.14 In addition, studies suggest telomere-independent mechanisms by which hTERT might contribute to cancer development and progression, including modulation of Wnt–β-catenin15 and nuclear factor κB16 signaling and mitochondrial RNA processing.17

Imetelstat (GRN163L) is a 13-mer lipid-conjugated oligonucleotide that targets the RNA template of hTERT and has been shown to inhibit telomerase activity and cell proliferation in various cancer cell lines and tumor xenografts in mice.18 Phase 1 studies involving patients with breast cancer, non–small-cell lung cancer, multiple myeloma, or chronic lymphocytic leukemia have provided information on drug pharmacokinetics and pharmacodynamics and helped establish 9.4 mg per kilogram of body weight (given as a 2-hour intravenous infusion) as the maximum dose associated with an acceptable side-effect profile, with reversible myelosuppression constituting the dose-limiting toxic effect.19 A subsequent phase 2 study, reported in this issue of the Journal, involving patients with essential thrombocythemia showed platelet-lowering activity accompanied by a significant reduction in JAK2 V617F and CALR mutant allele burdens.20 Previously published data on short telomeres and up-regulated telomerase activity in myeloproliferative neoplasms provided additional rationale for conducting the current study.21,22

Methods extract: Laboratory Correlative Studies

Laboratory correlative studies were performed to gain insight into the mechanism of drug action and to identify biomarkers of response. Mutation screening for prognostically relevant genes (JAK2, CALR, MPL, ASXL1, EZH2, IDH1, IDH2, and SRSF2) and phenotypically relevant genes (spliceosomal mutations including SF3B1 and U2AF1) was performed in peripheral-blood granulocytes or bone marrow cells, according to methods described previously.28,29 In addition, exome sequencing was performed to compare paired baseline and posttreatment samples in one of the patients who had an imetelstat-induced complete remission; matched genomic libraries were prepared from DNA extracted from granulocytes, and data were analyzed with the use of GeneSifter software (PerkinElmer). For analysis of telomere length, a Geron-developed assay was used (see the Methods section in the Supplementary Appendix).

FULL RESULTS

Clinical and Laboratory Features at Study Entry

A total of 33 consecutive patients with myelofibrosis were enrolled and met eligibility criteria. The median age of the patients was 67 years; 67% were men. Of the 33 patients, 18 (55%) had primary myelofibrosis, 10 (30%) had post–polycythemia vera myelofibrosis, and 5 (15%) had post–essential thrombocythemia myelofibrosis.

A total of 26 patients (79%) had a JAK2 mutation (JAK2 V617F in all cases), 6 (18%) had a CALRmutation (type 1 [L367fs*46] in all cases), and 1 (3%) had an MPL mutation (W515S). In addition, 11 patients (33%) had an ASXL1 mutation, 3 (9%) had an IDH1 mutation, and 11 (33%) had a mutation in a spliceosome component gene (5 had a U2AF1 mutation, 3 had an SRSF2 mutation, and 3 had an SF3B1 mutation; these mutations were mutually exclusive). The specific ASXL1, IDH1, U2AF1, and SF3B1 mutation variants are provided in the Results section in theSupplementary Appendix.

Approximately 52% of the patients had high-risk disease and 48% had intermediate-2–risk disease, according to the DIPSS Plus. A total of 13 patients (39%) were dependent on red-cell transfusions, 21 (64%) had constitutional symptoms, 23 (70%) had palpable splenomegaly (median, 15 cm below the left costal margin; range, 5 to 33), and 18 (55%) had an abnormal karyotype, including 6 (18%) with an unfavorable karyotype. Approximately 79% of the patients had received prior therapy, including 48% who had received JAK inhibitors.

Toxic Effects

At the data-cutoff date of December 5, 2014, treatment had been discontinued in 25 patients (76%); the median duration of treatment for all study patients was 8.6 months (range, 1.4 to 21.7). Causes of treatment discontinuation included insufficient response (16 patients); disease progression or relapse after an initial response (3 patients); death during the treatment period (2 patients), including 1 death due to intracranial hemorrhage that was attributed by the treating physician to drug-induced grade 4 thrombocytopenia after weekly dosing and 1 due to an upper gastrointestinal hemorrhage that was not considered to be drug-related; adverse events (2 patients) in the form of persistent thrombocytopenia; and other reasons (2 patients), including financial constraints in 1 patient and a preexisting condition (atrial fibrillation) in 1 patient.

Hematologic adverse events, liver-function abnormalities, and other adverse events that occurred during the treatment period, regardless of attribution, are shown in Tables S1, S2, and S3, respectively, in the Supplementary Appendix. The most clinically significant side effect of imetelstat was myelosuppression, which was the primary reason for the protocol-mandated dose reduction that occurred in 22 patients (67%). Grade 4 thrombocytopenia, regardless of attribution to the study drug, occurred in 21% of the patients, grade 4 neutropenia in 18%, and grade 3 anemia in 52%. Febrile episodes from any cause occurred in 21% of the patients, epistaxis in 18%, bruising in 15%, hematoma in 6%, lung infection in 6%, skin infection in 3%, and upper gastrointestinal hemorrhage in 3%. Grade 3 or higher myelosuppression occurred in 22 patients (88%), of whom 18 (82%) had a return to grade 2 or lower myelosuppression or to baseline values; plots of drug reintroduction after resolution of grade 3 or 4 thrombocytopenia or neutropenia in individual patients are shown in Figures S1A, S1B, and S1C in the Supplementary Appendix.

Another notable side effect of imetelstat therapy in patients with myelofibrosis was low-grade elevation of liver-enzyme levels (Tables S2A and S2B in the Supplementary Appendix). A grade 3 or higher elevation of total bilirubin level, regardless of attribution, occurred in 3% of the patients, and a grade 3 or higher elevation of alkaline phosphatase level occurred in 6%. The rates of grade 1 or 2 increases in levels of total bilirubin, alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase that occurred during the treatment period, regardless of attribution, were 45%, 52%, 58% and 27%, respectively. None of the abnormalities in liver-enzyme levels were linked to clinically overt liver damage, and reversal of the changes to baseline values was documented in the majority of patients. Table S4 in the Supplementary Appendix lists all grade 3 or higher nonhematologic and nonhepatic adverse events.

Table 1 lists adverse events (of any grade) that occurred in at least three patients during the treatment period and were attributed as being at least possibly related to the study drug. None of the four infusion-related reactions (one instance each of flushing, itching, thrombophlebitis, and pain at the infusion site) were anaphylactic.

Efficacy Data

Seven patients (21%) had a complete response (four patients) or partial response (three patients); Table 2 lists their baseline characteristics, including their mutational status. The median time to the onset of response in these seven patients was 3.5 months (range, 1.4 to 7.2), and the median duration of response was 18 months (range, 13 to 20+) for complete responses and 10 months (range, 7 to 10+) for partial responses. The four patients with a complete response had documented reversal of bone marrow fibrosis (two illustrative cases are shown in Fig. 1 and 2), and three of them also had molecular remissions (two illustrative cases are shown in Fig. 3); additional details on each of these four patients are provided in the Results section in the Supplementary Appendix. At the data-cutoff date, a relapse had occurred in one patient who had had a complete response (Patient 4 in Table 2) and another patient who had had a partial response (Patient 7 in Table 2); an additional patient who had had a partial response (Patient 6 in Table 2) discontinued imetelstat therapy while still having a response, because of financial constraints. Three of the seven patients with a response who had been heavily dependent on red-cell transfusions at study entry became transfusion-independent and sustained a hemoglobin level of more than 10 g per deciliter for a minimum of 3 months during imetelstat therapy, with peak posttreatment hemoglobin levels of 17.4 g per deciliter (Patient 1), 13.9 g per deciliter (Patient 3), and 12.6 g per deciliter (Patient 5) (Table 2). At the data-cutoff date, these three patients were still transfusion-independent. In addition to response, we measured other biologically relevant treatment effects and found that a high proportion of patients had such effects. Eight of the 10 patients (80%) with marked leukocytosis (defined as >25×109 white cells per liter) had either complete resolution (3 patients) or more than a 50% reduction in the white-cell count (5 patients). All 11 patients (100%) with thrombocytosis had complete resolution (10 patients) or more than a 50% reduction in the platelet count (1 patient). A total of 22 of the 27 patients (81%) with leukoerythroblastosis had either complete resolution (13 patients) or more than a 50% reduction in the percentage of immature myeloid cells and nucleated red cells (9 patients). A total of 17 of the 21 patients (81%) with at least 1% circulating blasts had either complete disappearance of the circulating blasts (14 patients) or at least a 50% reduction in the blast count (3 patients). The proportion of patients who had a spleen response was 35% (8 of 23 patients in whom the spleen could be evaluated for response). Four of the 13 patients (31%) who had been dependent on red-cell transfusions became transfusion-independent for at least 3 months.

Laboratory Correlates of Response see paper - good sequencing data interpretation figure

DISCUSSION

The current study suggests the potential value of telomerase-targeting treatment strategies in patients with myelofibrosis and identifies imetelstat as an active drug for this disease. The observed morphologic and molecular remissions confirm selective anticlonal activity, which has not previously been documented in drug treatment for myelofibrosis.1 Moreover, the prospect of imetelstat-induced abrogation of dependency on red-cell transfusions is particularly noteworthy, because JAK inhibitor therapy, with some exceptions,6 is more likely to cause rather than alleviate anemia in patients with myelofibrosis.2 If the significant association between a complete response and spliceosome pathway mutations is validated in a larger group of informative cases, it would suggest a broader application of the drug in other hematologic cancers.30 Equally important was the negative influence on treatment response of mutations that have previously been shown to be prognostically detrimental in myelofibrosis,28 such as mutations in ASXL1. However, our observations regarding telomere length were inconclusive in terms of either prognostic relevance or mechanism of action.

Our preliminary correlative studies did not elucidate the precise mechanism by which imetelstat induces clinical responses in some patients but not others. However, it is reasonable to hypothesize that certain spliceosome mutations contribute to suboptimal telomerase up-regulation through altered splicing, which in turn might have made affected patients vulnerable to further telomerase deprivation by imetelstat. This hypothesis is consistent with previous observations on the role of spliceosomal cleavage in the processing of telomerase RNA and the generation of functional telomerase.31-33 A much larger clinical and laboratory study is needed to establish the most effective dosing schedules, clarify the mechanism of action, and address concerns about toxic effects of the drug, including the induction of genomic instability to telomerase-competent normal and clonal hematopoietic stem cells and progenitor cells.34

42
Q

Telomerase Inhibitor Imetelstat in Patients with Essential Thrombocythemia

Gabriela M. Baerlocher, M.D., …..and David S. Snyder, M.D.

N Engl J Med 2015;373:920-8.

A

BACKGROUND Imetelstat, a 13-mer oligonucleotide that is covalently modified with lipid extensions, competitively inhibits telomerase enzymatic activity. It has been shown to inhibit megakaryocytic proliferation in vitro in cells obtained from patients with essential thrombocythemia. In this phase 2 study, we investigated whether imetelstat could elicit hematologic and molecular responses in patients with essential thrombocythemia who had not had a response to or who had had unacceptable side effects from prior therapies. METHODS A total of 18 patients in two sequential cohorts received an initial dose of 7.5 or 9.4 mg of imetelstat per kilogram of body weight intravenously once a week until attainment of a platelet count of approximately 250,000 to 300,000 per cubic millimeter. The primary end point was the best hematologic response. RESULTS Imetelstat induced hematologic responses in all 18 patients, and 16 patients (89%) had a complete hematologic response. At the time of the primary analysis, 10 patients were still receiving treatment, with a median follow-up of 17 months (range, 7 to 32 [ongoing]). Molecular responses were seen in 7 of 8 patients who were positive for the JAK2 V617F mutation (88%; 95% confidence interval, 47 to 100). CALR and MPL mutant allele burdens were also reduced by 15 to 66%. The most common adverse events during treatment were mild to moderate in severity; neutropenia of grade 3 or higher occurred in 4 of the 18 patients (22%) and anemia, headache, and syncope of grade 3 or higher each occurred in 2 patients (11%). All the patients had at least one abnormal liver-function value; all persistent elevations were grade 1 or 2 in severity. CONCLUSIONS Rapid and durable hematologic and molecular responses were observed in patients with essential thrombocythemia who received imetelstat. (Funded by Geron; ClinicalTrials.gov number, NCT01243073.)

43
Q

Treating Myeloproliferation — On Target or Off? Mary Armanios, M.D., and Carol W. Greider, Ph.D.

n engl j med 373;10 September 3, 2015

A

The classic myeloproliferative neoplasms — essential thrombocythemia, polycythemia vera, and primary myelofibrosis — are clonal disorders marked by overproduction of mature blood cells.1 Disease often evolves over many decades, and affected patients have symptoms related to extramedullary hematopoiesis, a thrombotic tendency, and, rarely, leukemic transformation.1 Hematopoietic stem-cell transplantation is the only curative therapy, and treatments usually focus on controlling symptoms. In this issue of the Journal, two groups of investigators present the results of studies of imetelstat, an antisense oligonucleotide, in phase 2 trials involving patients with essential thrombocythemia and primary myelofibrosis. Baerlocher et al.,2 who conducted a multi-institutional trial of imetelstat involving 18 patients with essential thrombocythemia in whom first-line therapies had failed, report a complete hematologic response rate of 89%. Ten of the 18 patients received therapy for a median of 17 months. Tefferi et al.3 describe the results of a single-institution trial involving 33 patients with myelofibrosis, and they report a partial or complete response rate of 21%. The duration of response ranged from 10 to 18 months. The studies used slightly different dosing schedules, but both documented side effects that included hepatotoxicity, myelosuppression, and bleeding tendencies. Given the limited treatment options in myeloproliferative neoplasms, these results are compelling and warrant further study, especially as to whether imetelstat can change the natural history of these disorders. Imetelstat was designed as a telomerase enzyme inhibitor; it is an antisense phosphorothioate oligonucleotide that targets the telomerase RNA template. Cell-culture and xenograft studies have shown that imetelstat can block telomerase and shorten telomeres4 ; however, telomere shortening in animal tissues or in humans has not been demonstrated. Imetelstat has been previously studied in two telomerase-positive cancers — non–small-cell lung cancer5 and breast cancer (ClinicalTrials.gov number, NCT01256762)6 — and there was no clinical benefit. Short telomeres trigger a DNA-damage response that induces cell death or senescence, which is the primary effect that limits tumor growth; telomerase inhibition itself is not sufficient.7 Thus, an effective telomerase inhibitor would be expected to shorten telomeres in malignant cells to exert its therapeutic effect. In the studies reported here, the initial telomere length did not predict the clinical responses, and there was no change in telomere length over the course of treatment in the myelofibrosis cohort. Both groups of investigators examined telomere length with the use of a quantitative polymerase-chain-reaction method that has high variability, rather than with the use of the flow cytometry–based assay that has emerged as the clinical standard for diagnosing telomere syndromes.8 Precise measurement of telomere length will be critical for testing the biologic efficacy of a drug that targets telomerase.

If telomere shortening is not the primary mechanism underlying the clinical effects of imetelstat, what might be the mechanism? Myelosuppression, especially thrombocytopenia, is a common side effect of phosphorothioate antisense oligonucleotides.9 In fact, in previous trials of imetelstat, these toxic effects were dose-limiting.5,6 These side effects are independent of the antisense sequence and are thought to be mediated through mechanisms that include binding to cell-surface receptors such as TLR9.9 If such an off-target effect is the primary mechanism of imetelstat action in myeloproliferative neoplasms, this knowledge will be critical for patient selection, for understanding mechanisms of resistance, and for future drug development in myeloproliferative neoplasms.

Telomerase is up-regulated in most cancers, and the concept of inhibiting telomerase to treat cancer was proposed more than 25 years ago.10 The recent evidence of frequent somatic mutations that up-regulate telomerase levels in many cancers7 lends further support to the idea that telomerase inhibition is an important target in cancer. However, if the mechanism of action of imetelstat in myeloproliferative neoplasms is through off-target effects, the generalizability of imetelstat for treatment of other cancers is drawn into question.

Whether the mechanism is on target or off, the results of the clinical studies published here spark new possibilities for the treatment of myeloproliferative neoplasms. Further analysis of both the mechanism and, more importantly, the longterm side-effect profile of imetelstat may provide a new approach to treat these debilitating disorders.

44
Q

Erosion of the chronic myeloid leukaemia stem cell pool by PPARγ agonists.
Nature. 2015 Sep 2. doi: 10.1038/nature15248.

Prost S… Leboulch P1,11,12.

A

Abstract

Whether cancer is maintained by a small number of stem cells or is composed of proliferating cells with approximate phenotypic equivalency is a central question in cancer biology. In the stem cell hypothesis, relapse after treatment may occur by failure to eradicate cancer stem cells. Chronic myeloid leukaemia (CML) is quintessential to this hypothesis. CML is a myeloproliferative disorder that results from dysregulated tyrosine kinase activity of the fusion oncoprotein BCR-ABL. During the chronic phase, this sole genetic abnormality (chromosomal translocation Ph+: t(9;22)(q34;q11)) at the stem cell level causes increased proliferation of myeloid cells without loss of their capacity to differentiate. Without treatment, most patients progress to the blast phase when additional oncogenic mutations result in a fatal acute leukaemia made of proliferating immature cells. Imatinib mesylate and other tyrosine kinase inhibitors (TKIs) that target the kinase activity of BCR-ABL have improved patient survival markedly. However, fewer than 10% of patients reach the stage of complete molecular response (CMR), defined as the point when BCR-ABL transcripts become undetectable in blood cells. Failure to reach CMR results from the inability of TKIs to eradicate quiescent CML leukaemia stem cells (LSCs). Here we show that the residual CML LSC pool can be gradually purged by the glitazones, antidiabetic drugs that are agonists of peroxisome proliferator-activated receptor-γ (PPARγ). We found that activation of PPARγ by the glitazones decreases expression of STAT5 and its downstream targets HIF2α and CITED2, which are key guardians of the quiescence and stemness of CML LSCs. When pioglitazone was given temporarily to three CML patients in chronic residual disease in spite of continuous treatment with imatinib, all of them achieved sustained CMR, up to 4.7 years after withdrawal of pioglitazone. This suggests that clinically relevant cancer eradication may become a generally attainable goal by combination therapy that erodes the cancer stem cell pool.

45
Q

Clonality inference in multiple tumor samples using phylogeny.

Bioinformatics. 2015 May 1;31(9):1349-56. doi: 10.1093/bioinformatics/btv003. Epub 2015 Jan 6.

Malikic S1, McPherson AW1, Donmez N1, Sahinalp CS2.

A

Abstract

MOTIVATION:

Intra-tumor heterogeneity presents itself through the evolution of subclones during cancer progression. Although recent research suggests that this heterogeneity has clinical implications, in silico determination of the clonal subpopulations remains a challenge.

RESULTS:

We address this problem through a novel combinatorial method, named clonality inference in tumors using phylogeny (CITUP), that infers clonal populations and their frequencies while satisfying phylogenetic constraints and is able to exploit data from multiple samples. Using simulated datasets and deep sequencing data from two cancer studies, we show that CITUP predicts clonal frequencies and the underlying phylogeny with high accuracy.

AVAILABILITY AND IMPLEMENTATION:

CITUP is freely available at: http://sourceforge.net/projects/citup/.