Abstract A1: Impact of CYP2D6*10 and CYP3A5*3 Polymorphisms on the Pharmacokinetics of Tamoxifen in Asian Breast Cancer Patients

Tamoxifen (TAM) is a selective estrogen receptor modulator employed in the treatment of breast cancer. It is a prodrug with a complex metabolic pathway involving several phase I and II metabolic enzymes. TAM is metabolized by cytochrome P450 (CYP) enzymes to N-desmethyltamoxifen (NDM), 4-hydroxytamoxifen (4OHT) and endoxifen (END) with 4OHT and END being the active metabolites of TAM. CYP2D6 and CYP3A4/5 comprises the major CYP isoforms mediating the metabolism of TAM although other CYP isoforms also play a role. Polymorphisms present in genes encoding these CYP enzymes may influence the metabolism and pharmacokinetics of TAM and its metabolites

Cross-ancestry genome-wide association study defines the extended CYP2D6 locus as the principal genetic determinant of endoxifen plasma concentrations

The therapeutic efficacy of tamoxifen is predominantly mediated by its active metabolites 4-hydroxy-tamoxifen and endoxifen, whose formation is catalyzed by the polymorphic cytochrome P450 2D6 (CYP2D6). Yet, known CYP2D6 polymorphisms only partially determine metabolite concentrations in vivo. We performed the first cross-ancestry genome-wide association study with well-characterized patients of European, Middle-Eastern, and Asian descent (N = 497) to identify genetic factors impacting active and parent metabolite formation. Genome-wide significant variants were functionally evaluated in an independent liver cohort (N = 149) and in silico. Metabolite prediction models were validated in two independent European breast cancer cohorts (N = 287, N = 189). Within a single 1-megabase (Mb) region of chromosome 22q13 encompassing the CYP2D6 gene, 589 variants were significantly associated with tamoxifen metabolite concentrations, particularly endoxifen and metabolic ratio (MR) endoxifen/N-desmethyltamoxifen (minimal P = 5.4E-35 and 2.5E-65, respectively). Previously suggested other loci were not confirmed. Functional analyses revealed 66% of associated, mostly intergenic variants to be significantly correlated with hepatic CYP2D6 activity or expression (ρ = 0.35 to -0.52), and six hotspot regions in the extended 22q13 locus impacting gene regulatory function. Machine learning models based on hotspot variants (N = 12) plus CYP2D6 activity score (AS) increased the explained variability (~ 9%) compared with AS alone, explaining up to 49% (median R2 ) and 72% of the variability in endoxifen and MR endoxifen/N-desmethyltamoxifen, respectively. Our findings suggest that the extended CYP2D6 locus at 22q13 is the principal genetic determinant of endoxifen plasma concentration. Long-distance haplotypes connecting CYP2D6 with adjacent regulatory sites and nongenetic factors may account for the unexplained portion of variability.</p

Patterns of Oncogene Coexpression at Single-Cell Resolution Influence Survival in Lymphoma.

UNLABELLED: Cancers often overexpress multiple clinically relevant oncogenes, but it is not known if combinations of oncogenes in cellular subpopulations within a cancer influence clinical outcomes. Using quantitative multispectral imaging of the prognostically relevant oncogenes MYC, BCL2, and BCL6 in diffuse large B-cell lymphoma (DLBCL), we show that the percentage of cells with a unique combination MYC+BCL2+BCL6- (M+2+6-) consistently predicts survival across four independent cohorts (n = 449), an effect not observed with other combinations including M+2+6+. We show that the M+2+6- percentage can be mathematically derived from quantitative measurements of the individual oncogenes and correlates with survival in IHC (n = 316) and gene expression (n = 2,521) datasets. Comparative bulk/single-cell transcriptomic analyses of DLBCL samples and MYC/BCL2/BCL6-transformed primary B cells identify molecular features, including cyclin D2 and PI3K/AKT as candidate regulators of M+2+6- unfavorable biology. Similar analyses evaluating oncogenic combinations at single-cell resolution in other cancers may facilitate an understanding of cancer evolution and therapy resistance. SIGNIFICANCE: Using single-cell-resolved multiplexed imaging, we show that selected subpopulations of cells expressing specific combinations of oncogenes influence clinical outcomes in lymphoma. We describe a probabilistic metric for the estimation of cellular oncogenic coexpression from IHC or bulk transcriptomes, with possible implications for prognostication and therapeutic target discovery in cancer. This article is highlighted in the In This Issue feature, p. 1027

Patterns of Oncogene Coexpression at Single-Cell Resolution Influence Survival in Lymphoma

10.1158/2159-8290.CD-22-0998CANCER DISCOVERY1351144-116

Supplementary appendix from Patterns of Oncogene Coexpression at Single-Cell Resolution Influence Survival in Lymphoma

Supplementary methods. Supplementary Figure 1. Phenotyping of B-cells in non-malignant tissues. A, Quantitation of marker positivity across ten tonsil and two reactive lymph node samples (rLN). Analysis is spatially resolved between the GC and extra-GC zones. B, Spatial map of cellular coordinates based on cell segmentation of images in Figure 1B. Marker-positivity is indicated, and a total proportion of positive and negative cells is depicted as a pie chart. These maps were used to derive sub-population phenotypes depicted in Figure 1C. Scale bar is 100μm. C, Proliferation analysis (i.e., Ki67-positivity) among sub-populations in five tonsil samples. Median with interquartile range, whiskers denote 10th and 90th percentile. Supplementary figure 2. Example pseudo-colored mfIHC images for MYC, BCL2, BCL6 cases in DLBCL. Images of a range of mean fluorescent intensities are shown with equal scaling for reference. Supplementary figure 3. Global distribution of MYC, BCL2 and BCL6 sub-populations within DLBCL cohorts. Heat-maps displaying the percentage extent of individual markers and each sub-population within the DLBCL NUH, CMMC, SGH and MDA cohorts. Hierarchical k-means clustering of patients according to sub-population extent is applied. Positivity shading for single markers ranges between 0-100% positivity, whereas shading for sub-populations reflects 0-50% positivity and remains fully saturated until 100%. IPI Risk Group - International Prognostic Index Risk Group, FISH - fluorescence in situ hybridization. Supplementary figure 4. Intra-tumor heterogeneity of sub-populations. A, Correlation of sub-population extent quantification between two biopsies of the same patient for which at least two tissue microarray (TMA) biopsies are available. Correlation is shown separately for lymph node and extranodal biopsies. Spearman rho is indicated for each correlation. Axes are in exponential and equivalent in all panels. B, Sub-population percentage extent quantification across multiple TMA cores (columns) of the same patient (rows). Pie charts are ordered according to decreasing cell numbers evaluated per core. All patients from the NUH cohort with at least five cores are evaluated. A heterogenous cluster is highlighted by the red box. Supplementary figure 5. Spatial heterogeneity of sub-population interactions. A, Conceptual schematic of pair correlation function (PCF) plots depicting a clustered distribution (left, green) and a random distribution (right, grey). Representative counterpart spatial maps are above each plot. B, PCF analysis for sub-populations to investigate spatial clustering (top). Mean results for two independent cohorts (shading is cohort standard deviation). An example tissue microarray core is shown as physical distance reference for spatial analyses (bottom left). Absolute number of neighboring cells expected within a given radius (data from 3500 randomly selected cells across all images, mean with standard deviation) (bottom right). C, Actual spatial map of sub-populations of an example DLBCL case (top). Extent of all sub-populations within the sample is shown on the left. Simulated, hypothetical random distribution of cells for the same case (middle). PCF analysis for the shown sample and its matched simulated random distribution (bottom). Scale bars in B and C are 100µm. D, Mean deviations from expected neighbor abundance (Δ%) summarizing cell-cell interactions between sub-populations for the sample shown in (C). E, Sub-population interaction matrices from spatially distinct biopsies (cores in tissue microarray) for example DLBCL patients. Biopsies of stable, spatially homogenous, sub-population interaction profiles are grouped (top), whereas biopsies of a differing, heterogenous, interaction profile are grouped separately (bottom). Supplementary figure 6. Global deviations from expected spatial neighbor abundance (Δ%). Hierarchical clustering (minimum variance method) of measured Δ% for all cases in the SGH and MDA cohorts. Extents of sub-populations are indicated for reference (top). For the MDA cohort, multiple biopsies (n = 1-3) from the same patient were included in the analysis to determine spatial interaction similarity across spatially distinct regions (bottom). Supplementary figure 7. Correlation of predicted MYC, BCL2 and BCL6 sub-population percentage extent based on single oncogene positivity and observed percentage extent in DLBCL cohorts. Spearman rho, axes are equivalent in all panels. Supplementary figure 8. Variance of M+2+6- percentage extent in the context of positivity calling across a 15% cut-off. A, M+2+6- scoring variance across multiple pathological imaging fields. All whole-tissue DLBCL sections from University of Palermo (UP), and samples from the NUH TMA with at least four fields scored per patient and a mean M+2+6- score above 5% are shown. Mean with SD. Ordinates between 50-100% are compressed for clarity. Dashed line denotes M+2+6- 15% positivity. B, Stability of M+2+6- case positivity calling across scoring increasing number of imaging fields. All cases from panel A with at least five fields scored in this study are shown. Only one case is called M+2+6- Low (<15%) at the first image scored, and subsequently called M+2+6- High (≥15%) after two or more fields scored. Supplementary figure 9. Mapping of mRNA expression data into percentage extent data. A, Cumulative histogram of MYC, BCL2 and BCL6 protein percentage extent positivity in DLBCL cohorts (data transformed from Figure 4A) (top). B, Aggregated single oncogene cumulative distribution of MYC, BCL2 and BCL6 protein percentage extent positivity across all measured protein cohorts and its smoothed empirical cumulative distribution function (eCDF).C, Distribution of inferred single oncogene percentage extent in GEP cohorts. (see Supplementary table 6 for all values). Supplementary figure 10. Analysis of the GOYA clinical trial. A, Correlation of MYC mRNA with quantitative IHC score. Linear regression (left) and Wilcoxon rank sum test (right). B, Analysis as in (A) for BCL2. C, Kaplan-Meier curves for PFS and OS for patients stratified across the 15% M+2+6- metric (GEP-derived). Multivariate Cox proportional hazards model is available in Supplementary table 9. PFS - progression free survival, OS - overall survival. Supplementary figure 11. Proliferative advantage of cyclin D2 (CCND2) overexpressing B-cells. Representative FACS plots documenting to the expansion over time of the cyclin D2 positive GC B-cell population in cyclin D2 overexpressing GC B-cells (CCND2-Lyt2) and non-cyclin D2 overexpressing GC B-cells (Empty vector Lyt2). All GC B-cells co-overexpress BCL2, BCL6, MYC and GFP. Supplementary table 3. Non-parametric correlation of sub-population percentage extent with clinicopathological features. Supplementary table 4. Pooled univariate analysis for MYC, BCL2 and BCL6 single oncogene and sub-populations percentage extents as a continuous variable at 5% increments as predictors for overall survival (OS) in mfIHC cohorts of DLBCL (Cox proportional hazards model). Supplementary table 5. Univariate analysis of clinicopathological features as a predictor of overall survival (OS) after first-line R-CHOP treatment in the NUH, SGH and MDA cohorts of DLBCL (Cox proportional hazards model). Supplementary table 7. Pooled univariate analysis for sub-population metrics as a continuous variable at 5% increments as predictors for overall survival (OS) in GEP DLBCL cohorts (Cox proportional hazards model). Supplementary table 8. Multivariate analysis of continuous M+2+6- metric at 5% increments as a predictor of overall survival (OS) in cohorts with gene-expression data (Cox proportional hazards model). Supplementary table 9. Univariate and multivariate analysis of continuous M+2+6- metric as a continuous variable at 5% increments as predictor of progression-free survival (PFS) and overall survival (OS) in the GOYA trial cohort (Cox proportional hazards model). Supplementary table 10. Multivariate analysis of M+2+6- metric dichotomized at 15% as a predictor of overall survival (OS) in cohorts with gene-expression data (Cox proportional hazards model). Supplementary table 15. Clinicopathologic characteristics of DLBCL patients evaluated by multiplexed fluorescent immunohistochemistry (mfIHC) in this study. Supplementary table 16. Manual multiplexed fluorescent immunohistochemistry (mfIHC) staining protocol performed on the NUH and CMMC cohort TMA. Supplementary table 17. Automated multiplexed fluorescent immunohistochemistry (mfIHC) staining protocol performed on the SGH, MDA and BCA cohort TMA.</p

Supplementary tables from Patterns of Oncogene Coexpression at Single-Cell Resolution Influence Survival in Lymphoma

Supplementary table 1. Per-patient mfIHC MYC, BCL2 and BCL6 single oncogene and subpopulation scores for normal tonsil tissue and reactive lymph node tissue. Supplementary table 2. Per-patient mfIHC MYC, BCL2 and BCL6 single oncogene and subpopulation scores for DLBCL tissue (NUH, CMMC, SGH, MDA, BCA and UP). Supplementary table 6. Inferred percentage extents of MYC, BCL2, BCL6 and sub-population metrics in GEP cohorts. Supplementary table 11. Correlation of M+2+6- metric with gene expression in GEP cohorts. Supplementary table 12. Differential gene expression analysis of primary germinal center (GC) B-cells with M+2+ and M+2+6+ overexpression. Supplementary table 13. Differentially expressed genes between M+2+6- and all other malignant cells in scRNA-seq samples of DLBCL. Dichotomized non-parametric comparison, Wilcoxon rank sum test. Supplementary table 14. Analysis of positive enrichment of Wikipathways terms between M+2+6- and all other malignant cells in scRNA-seq samples of DLBCL by gprofiler2.</p