A new device to seal large coronary aneurysms: a case report

<p>Abstract</p> <p>Introduction</p> <p>Coronary artery aneurysm is an uncommon disease. It is defined as a coronary artery dilatation, exceeding the diameter of the normal adjacent segment or the diameter of the patient's largest coronary vessel by 1.5 to 2 times. Coronary artery aneurysms are typically diagnosed by coronary angiography. The prognosis of coronary artery aneurysm is not well known and the management is challenging.</p> <p>Case presentation</p> <p>A 68-year-old Italian-Caucasian man presented to our hospital with angina. Coronary angiography revealed a large coronary aneurysm of the right coronary artery, which was successfully treated by the percutaneous implantation of an MGuard™stent.</p> <p>Conclusion</p> <p>This case report provides evidence that coronary artery aneurysms, even if very large, can be safely treated by MGuard™stent implantation. We strongly emphasize the high flexibility and good deliverability of this device, which leads to the complete exclusion of the aneurysm mediated by the process of endothelization of its thin mesh sleeves.</p

Molecular genetics of familial hypercholesterolemia in Israel-revisited

BACKGROUND AND AIMS: Familial hypercholesterolemia (FH) is an autosomal dominant disease caused by mutations in the genes for LDL receptor (LDLR), apolipoprotein B (APOB) and proprotein convertase subtilisin/kexin type9 (PCSK9). The purpose of the current investigation was to define the current spectrum of mutations causing FH in Israel. METHODS: New families were collected through the MEDPED (Make Early Diagnosis Prevent Early Death) FH program. Molecular analysis of the LDLR, PCSK9 and APOB genes was done using High Resolution Melt and direct sequencing in 67 index cases. A 6-SNP LDL-C gene score calculation for polygenic hypercholesterolaemia was done using TaqMan genotyping. RESULTS: Mean serum cholesterol was 7.48 ± 1.89 mmol/L and the mean serum LDL-C was 5.99 ± 1.89 mmol/L. Mutations in the LDLR and APOB gene were found in 24 cases (35.8%), with 16 in LDLR, none in PCSK9 and one, p.(R3527Q), in the APOB gene, which is the first APOB mutation carrier identified in the Israeli population. Of the LDLR mutations, two were novel; p.(E140A) and a promoter variant, c.-191C > A. The c.2479G > A p.(V827I) in exon 17 of the LDLR gene was found in 8 patients (33.3% of the mutations) with modestly elevated LDL-C, but also in a compound heterozygous patient with a clinical homozygous FH phenotype, consistent with this being a "mild" FH-causing variant. A significantly higher 6-SNP LDL-C score was found in mutation-negative cases compared with a normal Caucasian cohort (p = 0.03), confirming that polygenic inheritance of common LDL-C raising SNPs can produce an FH phenocopy. CONCLUSIONS: The results indicate a different spectrum of genetic causes of FH from that found previously, in concordance with the heterogeneous and changing origins of the Israeli population, and confirm that a polygenic cause is also contributing to the FH phenotype in Israel

A targeted sequencing approach in multiple myeloma reveals a complex landscape of genomic lesions that has implications for prognosis

Background: Next-generation sequencing (NGS) studies have shown that mul- tiple myeloma is a heterogeneous disease with a complex subclonal architecture and few recurrently mutated genes. The analysis of smaller regions of interest in the genome (\u201ctargeted studies\u201d) allows interrogation of recurrent genomic events with reduces complexity of downstream analysis at a lower price. Aims: Here, we performed the largest targeted study to date in multiple myelo- ma to analyze gene mutations, deletions and amplifications, chromosomal copy number changes and immunoglobulin heavy chain locus (IGH) translo- cations and correlate results with biological and clinical features. Methods: We used Agilent SureSelect cRNA pull down baits to target: 246 genes implicated in myeloma or cancer in general in a mixed gene discovery/confirmation effort; 2538 single nucleotide polymorphisms to detect amplifications and deletions at the single-gene and chromosome level; the IGH locus to detect translocations. We sequenced unmatched DNA from CD138- purified plasma cells from 418 patients with multiple myeloma at diagnosis, with a median follow-up of 5.3 years. We sequenced at an average depth of 337x using Hiseq2000 machines (Illumina Inc.). We applied algorithms developed in- house to call genomic events, filtering out potential artifacts and germline vari- ants. We then ranker each event on its likelihood of being \u201concogenic\u201d based on clustering, recurrence and cross-reference with the COSMIC database. Results: We identified 2270 gene mutations in 412/418 patients, and of those 688 were oncogenic. 342 patients harbored at least one oncogenic mutation. 215/246 genes showed at lease one likely somatic mutation, but only 106 showed at least one oncogenic mutation. 63% of oncogenic mutations were accounted for by the top 9 driver genes previously identified (KRAS, NRAS, TP53, FAM46C, BRAF, DIS3, TRAF3, SP140, IRF4), implying our gene discov- ery effort did not identify novel mutated genes. We included deletion of tumor suppressors, amplification of oncogenes, chromosomal copy number changes and IGH translocations for a total of 76 variables, so that 413/418 patients showed at least one informative driver genomic event, (median 4/patient). We investigated pairwise associations between events and found significant corre- lations, such as TP53 mutations and del(17p), CYLD mutations and del(16), FAM46C mutations and del(1p), SF3B1 mutations and t(11;14). Hotspots muta- tions of IRF4 lysine p.123 showed an inverse correlation with a hyperdiploid karyotype and del(16) as opposed to other missense mutations scattered along the gene, which has pathogenic implications. Survival was negatively affected by the cumulative burden of lesions in an almost linear fashion, with median survival of 10.97 and 4.07 years in patients with =7 lesions respectively, and this was independent of the nature of the genomic events. Given the het- erogeneity and complex interplay of the variables we fitted a cox-proportional hazard model to predict survival. We found that mutations in TP53, amplifications of MYC, deletions of CYLD, amp(1q), del12p13.31 and del17p13 where the only significant events, all promoting shorter survival. In particular, TP53 muta- tions and deletions, often co-occurring, had an additive effect so that carriers of both showed a dismal survival of 17 months (Figure 1).Summary/Conclusions: Due to the complex genomic landscape in MM, a discovery effort still requires large studies to derive significant associations. We conclude that a targeted sequencing approach may provide prognostic models and give insights into myeloma biology

A high-risk, Double-Hit, group of newly diagnosed myeloma identified by genomic analysis

Patients with newly diagnosed multiple myeloma (NDMM) with high-risk disease are in need of new treatment strategies to improve the outcomes. Multiple clinical, cytogenetic, or gene expression features have been used to identify high-risk patients, each of which has significant weaknesses. Inclusion of molecular features into risk stratification could resolve the current challenges. In a genome-wide analysis of the largest set of molecular and clinical data established to date from NDMM, as part of the Myeloma Genome Project, we have defined DNA drivers of aggressive clinical behavior. Whole-genome and exome data from 1273 NDMM patients identified genetic factors that contribute significantly to progression free survival (PFS) and overall survival (OS) (cumulative R2 = 18.4% and 25.2%, respectively). Integrating DNA drivers and clinical data into a Cox model using 784 patients with ISS, age, PFS, OS, and genomic data, the model has a cumlative R2 of 34.3% for PFS and 46.5% for OS. A high-risk subgroup was defined by recursive partitioning using either a) bi-allelic TP53 inactivation or b) amplification (≥4 copies) of CKS1B (1q21) on the background of International Staging System III, comprising 6.1% of the population (median PFS = 15.4 months; OS = 20.7 months) that was validated in an independent dataset. Double-Hit patients have a dire prognosis despite modern therapies and should be considered for novel therapeutic approaches

Nucleotide excision repair is a potential therapeutic target in multiple myeloma

Despite the development of novel drugs, alkylating agents remain an important component of therapy in multiple myeloma (MM). DNA repair processes contribute towards sensitivity to alkylating agents and therefore we here evaluate the role of nucleotide excision repair (NER), which is involved in the removal of bulky adducts and DNA crosslinks in MM. We first evaluated NER activity using a novel functional assay and observed a heterogeneous NER efficiency in MM cell lines and patient samples. Using next-generation sequencing data, we identified that expression of the canonical NER gene, excision repair cross-complementation group 3 (ERCC3), significantly impacted the outcome in newly diagnosed MM patients treated with alkylating agents. Next, using small RNA interference, stable knockdown and overexpression, and small-molecule inhibitors targeting xeroderma pigmentosum complementation group B (XPB), the DNA helicase encoded by ERCC3, we demonstrate that NER inhibition significantly increases sensitivity and overcomes resistance to alkylating agents in MM. Moreover, inhibiting XPB leads to the dual inhibition of NER and transcription and is particularly efficient in myeloma cells. Altogether, we show that NER impacts alkylating agents sensitivity in myeloma cells and identify ERCC3 as a potential therapeutic target in MM

The apobec mutational activity in multiple myeloma: from diagnosis to cell lines

Next generation sequencing (NGS) studies have highlighted the role of aberrant activity of APOBEC DNA deaminases in generating the mu- tational repertoire of multiple myeloma (MM). However, the contribu- tion of this mutational process across the landscape of plasma cell dyscrasias, or its prognostic role, has never been investigated in detail. To answer these unexplored aspects of MM biology, we used published NGS data from our own work as well as others, including the large CoMMpass trial for a total of 1153 whole-exomes of MM. Furthermore, we investigated 5 MGUS, 6 primary plasma cell leukemias (pPCL) and 18 MM cell lines (MMCL). Overall, we identified signatures of two mu- tational processes, one related to spontaneous deamination of methy- lated cytosines (30% of variants, range 0-100%) and one attributed to aberrant APOBEC activity (70% of variants, range 0-100%). APOBEC contribution was extremely heterogeneous among MM patients, but was correlated with a higher mutational burden (r=0.71, p=<0.0001) and with MAF gene translocations t(14;16) and t(14;20). The activity of APOBEC increased from MGUS to MM to pPCL, both in terms of ab- solute number of mutations and as percentage contribution. In MMCL we instead observed a bi-modal distribution whereby 8 cell lines showed the highest numbers of mutations caused by APOBEC (5/8 car- ried MAF translocations), while 10 where virtually devoid of APOBEC mutations (0/10 carried MAF translocations). The contribution of APOBEC to the total mutational repertoire in MM had a clear prognos- tic impact. MM patients with APOBEC mutations in the lowest quartile had a survival advantage over patients with APOBEC mutations in the highest quartile both in terms of progression-free survival (3-y PFS 46% vs 67% months, p=<0.0001) and overall survival (3-y OS 52% vs 83%, p=0.0084). This association was retained in a multivariate model that included age, gender, cytogenetic class, ISS, and quartiles of mutational load both in PFS [p=0.02, HR 2.06 (95IC 1.11-3.81] and OS [p=0.02, HR 2.88 (95IC 1.17-7.09)]. Interestingly we found that APOBEC mutations in the 4th quartile retained its independent prognostic respect to high mutational load and presence of MAF translocations. Overall, our data suggest that APOBEC-mediated mutagenesis is strongly involved in MM pathogenesis and its activity persists during different phases of evolution, playing a critical role in MM genomic complexity, and im- pacting prognosis of the patients

A high-risk, Double-Hit, group of newly diagnosed myeloma identified by genomic analysis

Patients with newly diagnosed multiple myeloma (NDMM) with high-risk disease are in need of new treatment strategies to improve the outcomes. Multiple clinical, cytogenetic, or gene expression features have been used to identify high-risk patients, each of which has significant weaknesses. Inclusion of molecular features into risk stratification could resolve the current challenges. In a genome-wide analysis of the largest set of molecular and clinical data established to date from NDMM, as part of the Myeloma Genome Project, we have defined DNA drivers of aggressive clinical behavior. Whole-genome and exome data from 1273 NDMM patients identified genetic factors that contribute significantly to progression free survival (PFS) and overall survival (OS) (cumulative R2 = 18.4% and 25.2%, respectively). Integrating DNA drivers and clinical data into a Cox model using 784 patients with ISS, age, PFS, OS, and genomic data, the model has a cumlative R2 of 34.3% for PFS and 46.5% for OS. A high-risk subgroup was defined by recursive partitioning using either a) bi-allelic TP53 inactivation or b) amplification ( 654 copies) of CKS1B (1q21) on the background of International Staging System III, comprising 6.1% of the population (median PFS = 15.4 months; OS = 20.7 months) that was validated in an independent dataset. Double-Hit patients have a dire prognosis despite modern therapies and should be considered for novel therapeutic approaches

DNA repair processes target transcribed region in multiple myeloma

Background: Multiple myeloma (MM) is a plasma cells malignancy charac- terized by a complex and heterogeneous genomic landscape. Using whole- exome and targeted sequencing, two main active mutational processes have been identified in MM provide initial insight into both initial pathogenic mechanisms and the processes affecting disease progression. However, lim- ited numbers of mutations identified using WES does not allow interrogation of question whether different parts of the genome are targeted by different mutational processes. Aims: Here we interrogate various genomic regions and mutation types such as non-coding regions and protein coding regions with missense mutations, to understand activated processes that cause DNA alteration in MM. Methods: We have processed 39 purified CD138+ MM cells samples with Whole Genome Sequencing; ten samples also have RNA and ATAC sequenc- ing. Public WES data from 999 samples were collected from dbGaP and CoMMpass study. Mutational processes were analyzed using non-negative matrix factorization and multiple linear regression model. Results: We identified an average >5000 SNVs per patient sample with a total of over 200K SNVs from WGS and additional >170K SNVs from pub- lic WES data. Overall C>T mutations constituted 30% of all detected muta- tions across the genome, including a small fraction of C>T mutations within CpG islands. Majority of the mutations were observed in the intergenic (IGR), introns and non-coding RNAs regions (lincRNAs and ncRNA). Tran- scribed strand of the genome showed enrichment in C>A and C>T muta- tions. With non-negative matrix factorization we were able to identify 8 mutational processes in MM genome six of which were not described before. Although APOBEC/AID processes were the majority for the non coding genome, DNA repair related processes were highly active in the coding genome. We have integrated WGS, ATACseq and RNAseq data from same patients and identified that DNA damage activity increased in the expressed genes and sub clonal populations. We have confirmed our results using pub- licly available WES data from 999 samples. Summary and Conclusions: C>A and C>T enrichment on the transcribed strand has been connected to high transcriptional activities and different mechanisms such as single versus double-strand DNA repair functions. Tar- geting of non-coding regions by APOBEC/AID could be part of ongoing somatic hypermutation in MM. However, missense mutations may be driven by DNA double-strand break-repair by homologous recombination and DNA mismatch repair processes. Increased intensity for DNA repair signa- tures in subclonal missense mutations may indicate that these processes may occur late during the MM progression. Future studies that can compare paired samples from early stage to relapsed and refractory myeloma can help us understand if DNA repair processes become dominant during the MM development