Genetic Risk Categories Research Articles

Genetic Risk, Incident Depression, and the Benefits of Adhering to a Healthy Lifestyle: A Prospective Analysis of the UK Biobank Cohort

Background: Genetic factors increase the risk of depression, but the extent to which this can be offset by lifestyle factors is unknown. In the present study, we investigated whether a healthy lifestyle is associated with lower risk of depression regardless of genetic risk. Methods: Data for this prospective analysis were obtained from the UK Biobank and consisted of 339,944 participants (37-73 years old) without depression between 2006 and 2010. Genetic risk was categorized as low (quintile 1), intermediate (quintiles 2-4), or high (quintile 5) according to polygenic risk scores for depression. Healthy lifestyle scores — including no current smoking, regular physical activity, a healthy diet, and a body mass index < 30 kg/m2 — was categorized into favorable, intermediate, and unfavorable lifestyles. Cox proportional hazards models were used to calculate hazard ratios (HRs) and confidence intervals (CIs) of the associations of genetic risk and lifestyle factors with depression. Finding: During a median follow-up of 8.1 years (2,723,692 person-years), 5,749 incidences of depression were ascertained. The risk of depression was 25% higher among those at high genetic risk compared with those at low genetic risk (HR = 1.25, 95% CI: 1.15-1.36). Unfavorable lifestyle was associated with a 70% increased risk of depression compared with that of a favorable lifestyle (HR = 1.70, 95% CI: 1.57-1.84). Of the participants with a high genetic risk and unfavorable lifestyle, 2.75% (95% CI, 2.36%-3.19%) developed depression compared with 1.25% (95% CI: 1.15%-1.36%) of participants with low genetic risk and a favorable lifestyle (HR = 2.06, 95% CI: 1.74-2.45). There was no significant interaction between genetic risk and healthy lifestyle (P for interaction = 0.75). Among participants at high genetic risk, a favorable lifestyle was associated with a 40% lower relative risk of depression than an unfavorable lifestyle (HR = 0.60, 95% CI: 0.51-0.72). Interpretation: Genetic and combined lifestyle factors were independently associated with the incidence of depression. Hence, our findings suggest that a healthy lifestyle may lower the risk of depression across different genetic risk categories, emphasizing the benefit of adherence to a healthy lifestyle independent of genetic risk. Funding Statement: National Natural Science Foundation of China (91746205, 71910107004, 71673199). Declaration of Interests: The authors declare that they have no conflicts of interests. Ethics Approval Statement: Not required.

Genetic Risk, a Healthy Lifestyle, and Type 2 Diabetes: the Dongfeng-Tongji Cohort Study.

The objective of this study is to examine whether healthy lifestyle could reduce diabetes risk among individuals with different genetic profiles. A prospective cohort study with a median follow-up of 4.6 years from the Dongfeng-Tongji cohort was performed. A total of 19 005 individuals without diabetes at baseline participated in the study. A healthy lifestyle was determined based on 6 factors: nonsmoker, nondrinker, healthy diet, body mass index of 18.5 to 23.9 kg/m2, waist circumference less than 85 cm for men and less than 80 cm for women, and higher level of physical activity. Associations of combined lifestyle factors and incident diabetes were estimated using Cox proportional hazard regression. A polygenic risk score of 88 single-nucleotide polymorphisms previously associated with diabetes was constructed to test for association with diabetes risk among 7344 individuals, using logistic regression. A total of 1555 incident diabetes were ascertained. Per SD increment of simple and weighted genetic risk score was associated with a 1.39- and 1.34-fold higher diabetes risk, respectively. Compared with poor lifestyle, intermediate and ideal lifestyle were reduced to a 23% and 46% risk of incident diabetes, respectively. Association of lifestyle with diabetes risk was independent of genetic risk. Even among individuals with high genetic risk, intermediate and ideal lifestyle were separately associated with a 29% and 49% lower risk of diabetes. Genetic and combined lifestyle factors were independently associated with diabetes risk. A healthy lifestyle could lower diabetes risk across different genetic risk categories, emphasizing the benefit of entire populations adhering to a healthy lifestyle.

Homogeneity in the association of body mass index with type 2 diabetes across the UK Biobank: A Mendelian randomization study.

Lifestyle interventions to reduce body mass index (BMI) are critical public health strategies for type 2 diabetes prevention. While weight loss interventions have shown demonstrable benefit for high-risk and prediabetic individuals, we aimed to determine whether the same benefits apply to those at lower risk. We performed a multi-stratum Mendelian randomization study of the effect size of BMI on diabetes odds in 287,394 unrelated individuals of self-reported white British ancestry in the UK Biobank, who were recruited from across the United Kingdom from 2006 to 2010 when they were between the ages of 40 and 69 years. Individuals were stratified on the following diabetes risk factors: BMI, diabetes family history, and genome-wide diabetes polygenic risk score. The main outcome measure was the odds ratio of diabetes per 1-kg/m2 BMI reduction, in the full cohort and in each stratum. Diabetes prevalence increased sharply with BMI, family history of diabetes, and genetic risk. Conversely, predicted risk reduction from weight loss was strikingly similar across BMI and genetic risk categories. Weight loss was predicted to substantially reduce diabetes odds even among lower-risk individuals: for instance, a 1-kg/m2 BMI reduction was associated with a 1.37-fold reduction (95% CI 1.12-1.68) in diabetes odds among non-overweight individuals (BMI < 25 kg/m2) without a family history of diabetes, similar to that in obese individuals (BMI ≥ 30 kg/m2) with a family history (1.21-fold reduction, 95% CI 1.13-1.29). A key limitation of this analysis is that the BMI-altering DNA sequence polymorphisms it studies represent cumulative predisposition over an individual's entire lifetime, and may consequently incorrectly estimate the risk modification potential of weight loss interventions later in life. In a population-scale cohort, lower BMI was consistently associated with reduced diabetes risk across BMI, family history, and genetic risk categories, suggesting all individuals can substantially reduce their diabetes risk through weight loss. Our results support the broad deployment of weight loss interventions to individuals at all levels of diabetes risk.

Integrating Geriatric Assessment and Genetic Profiling to Personalize Therapy Selection in Older Adults with Acute Myeloid Leukemia (AML)

Introduction: Geriatric assessment can predict the risk of toxicities of chemotherapy in older adults. Genetic risk categories correlate with survival following intensive chemotherapy in AML. Integrating geriatric assessment for patient profiling and genetic profiling of leukemic cells represents an innovative precision medicine approach to personalize therapy selection in older adults with AML. We report results of a pre-planned interim analysis of a pragmatic phase II trial using such strategy that has an overarching goal to reduce early mortality (NCT03226418). Methods: Patients ≥60 years with a new diagnosis of AML underwent geriatric assessment prior to initiation of treatment. Geriatric assessment of physical function, cognitive function and comorbidity burden were used to determine fitness for intensive chemotherapy (Table 1). Additional assessment included Karnofsky Performance Scale (KPS), Patient Health Questionnaire-9 (PHQ-9), and Mini Nutritional Assessment-Short Form (MNA). Genetic profiling for therapy selection relied on karyotyping and followed the 2017 European LeukemiaNet criteria. While available mutation test results were incorporated to risk stratify, the study did not require to wait for the results prior to therapy initiation given an anticipated turnaround time of 1-2 weeks for mutation test results. Therapy selection followed the algorithm demonstrated in Figure 1. Patients with good or intermediate-risk AML received intensive chemotherapy such as 7+3 +/- gemtuzumab or midostaurin if determined to be fit. Patients with high-risk AML received low-intensity chemotherapy such as a hypomethylating agent with or without novel drugs, or CPX 351 if they were fit and met the FDA-approved indications. Patients with organ dysfunction (e.g. creatinine ≥2 mg/dl) and those requiring chemotherapy for other malignancy received low-intensity chemotherapy. Chemotherapy at diagnosis or follow up could be administered in community oncology settings. Patients were followed for assessment of quality of life, functional and oncologic outcomes. Results: Between July 2017-June 2019, a total of 31 patients (including 1 MDS patient considered screen failure) were enrolled. The pre-planned interim analysis results are based on the first 27 AML patients. Baseline characteristics included a median age of 70 years (range 60-84 years), 56% female, 96% white, and a median KPS of 80% (range 60-100%). As presented in Table 1, over half of the patients had ≥3 comorbidities, impairment in objective physical function (short physical performance battery) and Montreal Cognitive Assessment. Additionally, 67% had poor nutritional status (MNA score of ≤11) and 26% had abnormal depression screen (PHQ-9 score of ≥10). Risk categories included adverse (64%), intermediate (16%), and good-risk AML (20%). Patients had one or more of the following mutations: FLT3 ITD (11%), NPM1 (22%), biallelic CEBPA (4%), IDH1 (15%), IDH2 (8%), RUNX1 (15%), ASXL1 (22%), and TP53 (19%). Three patients received intensive chemotherapy; CPX 351 (n=2) or 7+3+ gemtuzumab (n=1). Other patients received decitabine or azacitidine alone (n=16), azacitidine and venetoclax (n=5) or decitabine and midostaurin (n=3). The median time from diagnosis to therapy initiation was 7 days (0-20 days) whereas the median time from enrollment to therapy initiation was 2 days (range 0-9). Mortality at 30 days from diagnosis was 3.7% (95% confidence interval, CI 0.7-18.3%) and at 90 days was 29.6% (95% CI 15.9-48.5%). Mortality compared favorably to an unmatched historical cohort of patients ≥60 years treated at our center between 2011-2016, where 30-day mortality was 30% (95% CI 22-40%) and 90-day was 41% (95% CI 32-52%) (Future Oncol. 2019;15:1989-95). Conclusions: Our model to personalize AML therapy selection represents an innovative approach to precision medicine that incorporates both geriatric assessment for patient profiling and genetic profiling of leukemia cells. Geriatric assessment demonstrated high frequency of impairment in objective physical and cognitive function. Patients were able to start therapy within a median of 2 days following enrollment. Pragmatic aspects of the trial included broad eligibility criteria and co-management of patients with community oncologists. Our pre-planned interim analysis data appear promising with lower rates of early mortality compared to unmatched historical controls. Disclosures Bhatt: Pfizer: Consultancy; CSL Behring: Consultancy; Agios: Consultancy; Abbvie: Consultancy; Partner therapeutics: Consultancy; Incyte: Consultancy, Research Funding; Tolero Pharmaceuticals: Research Funding; National Marrow Donor Program: Consultancy. Al-Kadhimi:Celldex Biotech: Other: Stocks; Seattle Genetics: Other: Stocks. Armitage:Oncology Analytics: Consultancy; Partner Therapeutics: Consultancy; Samus Therapeutics: Consultancy; Ascentage: Consultancy; Tesaro bio: Membership on an entity's Board of Directors or advisory committees; Union Pacific: Consultancy. Holstein:GSK: Consultancy; Genentech: Membership on an entity's Board of Directors or advisory committees; Sorrento: Consultancy; Celgene: Consultancy; Takeda: Membership on an entity's Board of Directors or advisory committees; Adaptive Biotechnologies: Membership on an entity's Board of Directors or advisory committees. Gundabolu:Samus Therapeutics: Research Funding; Jazz pharmaceuticals: Consultancy; Pfizer: Consultancy; Novartis: Consultancy. OffLabel Disclosure: Single agent azacitidine and decitabine as well as decitabine in combination with midostaurin are not approved by the US FDA for acute myeloid leukemia.

A Phase 1b Study of Glasdegib in Combination with Azacitidine in Patients with Untreated Higher-Risk Myelodysplastic Syndromes, Acute Myeloid Leukemia, and Chronic Myelomonocytic Leukemia

A Phase 1b Study of Glasdegib in Combination with Azacitidine in Patients with Untreated Higher-Risk Myelodysplastic Syndromes, Acute Myeloid Leukemia, and Chronic Myelomonocytic Leukemia

Impact of genetic counseling on the uptake of contralateral prophylactic mastectomy among younger women with breast cancer

Background: Preoperative genetic testing affects the surgical decision-making among women with breast cancer. To avoid breast-conserving surgery and to offer the possibility of mastectomy with immediate reconstruction in high-risk patients, genetic testing for pathogenic variants in BRCA1 or BRCA2 and a pedigree-based familial breast cancer risk assessment was offered to younger women with breast cancer in Denmark. We evaluated the impact of the risk stratification through genetic counseling on the uptake of contralateral prophylactic mastectomy (CPM).Material and methods: The prospective cohort study included all women with unilateral breast cancer before the age of 45 who participated in a genetic counseling program during their primary diagnostics in the Central Denmark Region (2013–2018). Each patient was followed from the time of the genetic test result to the end of follow-up to estimate the long-term uptake of CPM as a competing risk-adjusted cumulative incidence. We compared the uptake of CPM between the various genetic risk categories, ages of onset, and family histories in a multivariable Cox proportional hazards regression model, reporting hazard ratios (HR) with two-sided 95% confidence intervals (CIs).Results: 156 females, aged 21–44, learned their genetic test result within a median of 92 days [interquartile range (IQR): 75–114]. The maximal follow-up was 3.8 years (median 1.8; IQR: 0.49–2.5), after which 33% (95% CI: 24–42%) of the patients had undergone CPM. The uptake of CPM was inversely associated with the age of onset (HR 0.92; 95% CI: 0.86–0.98) and significantly higher among BRCA carriers (HR 2.9; 95% CI: 1.3–6.8) and patients from the high risk of breast cancer families (HR 5.6; 95% CI: 1.9–16) compared to the lower genetic risk categories.Conclusion: The risk stratification obtained through genetic counseling had a considerable impact on the surgical decision-making among younger women with breast cancer at long-term follow-up.

Abstract 963: The interplay between lifestyle-related factors and genetics with risk of invasive breast cancer among postmenopausal women from the UK Biobank

Abstract Background: Many genetic variants have been associated with increased risk of breast cancer. In contrast, an overall healthy lifestyle has been associated with a reduced risk. However, the degree to which an overall healthy lifestyle may attenuate the impact of genetic variants on risk of breast cancer remains equivocal. In this study, we examined the association of a healthy lifestyle index (HLI) with risk of breast cancer by genetic risk groups. Methods: The study included 106,814 postmenopausal women of white descent aged 40 to 70 years who were enrolled in the UK Biobank cohort between 2006 and 2010. The HLI was based on a combination of diet, physical activity, smoking, alcohol consumption and anthropometry (ranging from 0 to 20, with the higher scores representing more favorable lifestyle). A polygenic risk score (categorized as low, intermediate and high) was generated as the sum of risk alleles weighted by the logOR of 117 breast cancer associated single nucleotide polymorphisms. A total of 1,949 incident invasive breast cancer cases were ascertained after a median follow-up of 5.7 years. Cox proportional hazards regression models were used to estimate the hazard ratios (HR) and 95% confidence intervals (CI) for the association of a healthy lifestyle risk score with risk of breast cancer by genetic risk groups. Results: Compared to women with an unfavorable lifestyle (lowest quartile), women with a favorable lifestyle (highest quartile) had a 32% reduced risk of invasive breast cancer (HR: 0.68: 0.59, 0.79). Women with high genetic risk (highest tertile) had an 86% increased risk of invasive breast cancer (1.86: 1.66, 2.08) compared to those with low genetic risk (lowest tertile). Compared with women who had an unfavorable lifestyle, a favorable lifestyle did not significantly reduce risk of invasive breast cancer among women with low genetic risk (0.80: 0.63-1.02), while women with a favorable lifestyle had 32% and 43% reduced risk of invasive breast cancer in the intermediate and high genetic risk categories, respectively (0.68: 0.53, 0.86 and 0.57; 0.44, 0.74, respectively). However, interaction between the genetic score and the lifestyle score did not achieve statistical significance (pinteraction=0.162). Conclusion: This study suggests that an overall healthy lifestyle may attenuate the impact of genetics on risk of breast cancer, particularly among women with intermediate and high genetic risk. Citation Format: Rhonda S. Arthur, Tao Wang, Thomas Rohan. The interplay between lifestyle-related factors and genetics with risk of invasive breast cancer among postmenopausal women from the UK Biobank [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 963.

PF232 PROGNOSTIC IMPACT OF THE 2017 EUROPEAN LEUKEMIANET (ELN) CLASSIFICATION OF YOUNGER ADULT PATIENTS WITH ACUTE MYELOID LEUKEMIA (AML) TREATED ON CANCER AND LEUKEMIA GROUP B (CALGB)/ALLIANCE PROTOCOLS

Background:AML is a clinically, biologically and molecularly heterogeneous disease with diverse patient (pt) outcomes. In 2010, the ELN proposed guidelines for reporting cytogenetic and selected molecular abnormalities in AML to enable meaningful comparisons among studies. The prognostic value of the 2010 ELN risk groups [Favorable (Fav), Intermediate (Int)‐I, Int‐II and Adverse (Adv)] has been confirmed in several studies (Röllig et al. JCO 2011;29:2758; Mrózek et al. JCO 2012;30:4515; Alpermann et al. Leuk Res 2013;37:197; Bill et al. Bone Marrow Transplant 2017;52:932). The 2017 revision of the ELN classification (Döhner et al. Blood 2017;129:424) replaced the 4 with 3 risk categories (Fav, Int, Adv) and increased the number of molecular markers used to classify pts.Aims:To our knowledge, a validation of the prognostic value of the 2017 ELN classification in a large cohort of younger adult pts [aged &lt;60 years (y)] is lacking.Methods:We analyzed 863 pts (median 45 y, 17–59 y) with de novo AML treated on CALGB/Alliance protocols. All pts received similar cytarabine/anthracycline‐based treatments; none received allogeneic stem cell transplantation in first complete remission (CR). The pts’ pretreatment karyotypes were centrally reviewed. The mutational status of NPM1, RUNX1, ASXL1 and TP53 were determined by targeted next‐generation sequencing, of the CEBPA gene by Sanger sequencing, and of FLT3‐ITD by fragment analysis in pretreatment bone marrow or blood samples. Pts were classified into the Fav, Int or Adv groups according to the 2017 ELN criteria. Fisher's exact and Wilcoxon rank‐sum tests were used to test categorical and continuous variables, respectively. Estimated probabilities of disease‐free survival (DFS) and overall survival (OS) were calculated using the Kaplan‐Meier method.Results:Most pts were classified as Fav (49%), followed by Adv (29%) and Int (22%). At diagnosis, Fav pts had the lowest percentage of blood (P = .05; 52% Fav v 56% Adv v 62% Int) and bone marrow blasts (P &lt; .001; 63% Fav v 67% Adv v 74% Int) and highest percentage of extramedullary disease (P = .01; 31% Fav v 26% Int v 20% Adv). Adv pts had the lowest white blood cell counts (P = .01; 20.7 x109/l Adv v 24.2 x109/l Fav v 28.6 x109/l Int) at diagnosis. Concerning outcome, there were significant differences among the 2017 ELN genetic risk categories in rates of CR (P &lt; .001; 92% Fav v 77% Int v 48% Adv). There were also differences in DFS (P &lt; .001; Fig. 1A) with 5‐y DFS rates of 49% Fav, 20% Int and 7% Adv. For OS, we found also significant differences (P &lt; .001; Fig. 1B) among the ELN groups with 5‐y OS rates of 58% Fav, 26% Int and 15% Adv. Pairwise comparisons between the ELN risk categories for DFS and OS were also significant for all combinations, except for DFS between the Int and Adv groups (P = .12). Next, we analyzed whether the prognostic markers that were newly included in the 2017 ELN revision (i.e. biallelic CEBPA, RUNX1, ASXL1, TP53 and FLT3‐ITD allelic ratio) refined its prognostic impact. In our cohort, we found that indeed all markers had a significant impact on outcome except ASXL1 (DFS: P = .31; OS: P = .26).Summary/Conclusion:The 2010 ELN reporting system for AML is one of the most commonly used classifications and its prognostic impact is well established. Our validation study of the revised 2017 ELN risk classification, performed on a large cohort of younger adult de novo AML pts receiving intensive chemotherapy, showed that the Fav group has a significantly better outcome followed by the Int and Adv risk groups.imageSupport: U10CA180821, U10CA180882, U10CA180861, U24CA196171

Diabetic ketoacidosis in children newly diagnosed with type 1 diabetes mellitus: Role of demographic, clinical, and biochemical features along with genetic and immunological markers as risk factors. A 20-year experience in a tertiary Belgian center.

Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes (T1D). Little is known about the association between genetic and immunological markers and the risk for DKA at onset of T1D. The aim of this study was to create a model foreseeing the onset of DKA in newly diagnosed patients. This retrospective study included 532 T1D children (aged <18 years at diagnosis) recruited in our hospital, from 1995 to 2014. DKA and its severity were defined according to the criteria of ISPAD. Genetic risk categories for developing T1D were defined according to the Belgian Diabetes Registry. Multivariate statistical analyses were applied to investigate risk factors related to DKA at diagnosis. Overall 42% of patients presented DKA at diagnosis. This study outlined the major risk of DKA at diagnosis for younger children (<3 years) and for those belonging to ethnic minorities. Children carrying neutral genotypes had a 1.5-fold increased risk of DKA at diagnosis than those with susceptible or protective genotypes, a paradoxical observation not previously reported. Only solitary positive IA-2A increased the risk of DKA at diagnosis. The proposed model could help to predict the probability of DKA in 70% of newly diagnosed cases. This was the first reported implication of IA-2A positivity and neutral genotypes predisposing to DKA at diagnosis regardless of its severity. Earlier diagnosis through genetic and immunological screening of high-risk children could decrease DKA incidence at diabetes onset.

Genetic Risk, Adherence to Healthy Lifestyle, and Type 2 Diabetes: The Dongfeng-Tongji Cohort Study

Background: Genetic and lifestyle factors both contribute to diabetes development, but whether healthy lifestyle could reduce diabetes risk among individuals with different genetic profile is unknown. Methods: A prospective cohort study with 19,005 participants from the Dongfeng-Tongji Cohort were performed. Adherence to a healthy lifestyle was determined on the basis of six factors: non-smoker, non-drinker, healthy diet, body mass index of 18.5 to 23.9 kg/m2, waist circumference <85 cm for men and <80 cm for women, and higher level of physical exercise. Hazard ratios (HRs) of combined healthy lifestyle factors on incident diabetes were estimated using Cox proportional hazard regression. A polygenic risk score of 88 single nucleotide polymorphisms previously associated with diabetes was constructed to test for an association with diabetes risk among 7,344 individuals, estimated using Logistic regression. Findings: Of 19,005 individuals, 10,438 (54.9%) were female, and the mean (SD) age was 63.2 (7.7) years. During a median follow-up of 4.6 years 1,555 incident diabetes (8.2%) were ascertained. The risk of diabetes escalated with the increment of genetic risk score. Per SD of simple and weighted GRS increase was respectively significantly associated with 1.42 and 1.45 fold higher diabetes risk. Compared with poor lifestyle (0 to 2 healthy lifestyle factors), individuals with intermediate (3 or 4 healthy lifestyle factors) or ideal lifestyle (5 or 6 healthy lifestyle factors) had 23% (HR, 0.77; 95% CI, 0.69-0.87) and 46% (HR, 0.54; 95% CI, 0.45-0.65) decreased risk of incident diabetes, respectively. The association of lifestyle factors with diabetes risk was independent of genetic risk stratums. Among individuals at the high genetic risk group, intermediate and ideal lifestyle was associated with 29% lower (OR, 0.71; 95% CI: 0.58-0.86) and 49% lower (OR, 0.51; 95% CI: 0.38-0.69) risk of diabetes. Interpretation: Genetic and lifestyle factors were independently associated with diabetes risk. A healthy lifestyle could lower diabetes risk across different genetic risk categories, emphasizing the benefit of entire populations adhering to a healthy lifestyle, independent of genetic risk. Funding Statement: This work was supported by the grant from the National Natural Science Foundation (grant NSFC-81522040, 81473051, and 81230069); the Program for HUST Academic Frontier Youth Team; National Key RD the 111 Project (No. B12004); the Program for Changjiang Scholars; Innovative Research Team in University of Ministry of Education of China (No. IRT1246); China Postdoctoral Science Funding (2018M630869); and China Medical Board (No. 12-113). Declaration of Interests: No potential conflicts of interest relevant to this article were reported. Ethics Approval Statement: The present study has been approved by the Ethics and Human Subject Committee of the School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, and Dongfeng General Hospital, the Dongfeng Motor Corporation (DMC). All study participants provided written informed consents.

Staining Pattern of Leukemic Lymphoblasts for Coagulation Factor XIII Subunit a Correlates with Clinical Outcome and B-Other Genotype in Childhood Acute Lymphoblastic Leukemia

Introduction: Subunit A of blood coagulation factor XIII (FXIIIA) may be expressed in leukemic B-cell precursor (BCP) lymphoblasts in addition to platelets, megakaryocytes, monocytes and macrophages (Kiss F. et al Thromb Haemost 2006;96:172-82.). In a retrospective single-center cohort of children with acute lymphoblastic leukemia (ALL) treated with the BFM ALL-IC 2002 protocol, expression of FXIIIA was correlated with statistically significant survival advantage (Kárai B et al. Pathol Oncol Res 2018; 24:345-52.). Our aim was to investigate the impact of FXIIIA expression pattern on EFS and its correlation with known clinical and genetic prognostic factors in a multi-center pilot study within the frames of the BFM ALL-IC 2009 clinical trial (EuDract: 2010-019722-13).Patients and Methods: We examined 317 children with BCP-ALL between 2011 and 2018 at institutions in Poland (n=188), Hungary (n=116), and Slovakia (n=13). Patients with Down-syndrome, t(9;22), and infants (<1 year) were excluded. Immunophenotype and minimal residual disease (MRD) were determined by flow cytometry (FC). Cytogenetic analysis and fluorescence in situ hybridization were performed according to standard methods. DNA extracted from bone marrow samples was processed for SALSA multiplex ligation-dependent probe amplification P335-B2 ALL-IKZF1 probe mix (MRC-Holland, Amsterdam, The Netherlands) analysis according to manufacturer's instructions. Statistical analysis: Survival analysis was carried out by the Kaplan-Meier estimator. More than 2 groups were analyzed by the Kruskal-Wallis test. Dunn's multiple comparison was applied as post host test. Dichotomous categorical variables were compared by Chi square test and logistic regression to analyze multiple variables. P<0.05 was considered significant.Results: We observed 3 different patterns of FXIIIA expression in leukemic lymphoblasts: negative pattern (<20%), moderate positive expression (20-79%), and strong positive pattern (>80%). Evaluation of FC histograms of the moderate positive pattern showed that FXIIIA expression increased continuously which excluded the existence of distinct FXIIIA negative and FXIIIA positive subpopulations within the moderate positive expression group (Fig.1). In contrast to the previous single-center retrospective cohort, EFS of patients with FXIIIA positive BCP-ALL was not significantly different from that of patients of FXIIIA negative BCP-ALL (Fig.2A). However, a significant EFS advantage of patients with moderate FXIIIA positivity was demonstrated when compared with patients with FXIIIA negative BCP-ALL (p=0.019), and with patients with FXIIIA strong positive BCP-ALL (p=0.001) (Fig.2B). The 3 different FXIIIA expression patterns did not correlate significantly with either risk stratification according to BFM ALL-IC 2009 or FC MRD categories. Intermediate genetic risk categories (low hyperdiploidy, t(1;19), and “B-other”) were significantly more prevalent (p=0.042) among patients with FXIIIA negative BCP-ALL than among patients with strong FXIIIA positive BCP-ALL. The “B-other” subgroup was also significantly more prevalent (p=0.022) among patients of the above 2 groups (Table 1). Distribution of the “B-other” genetic group and the prednisone response differed significantly between the FXIIIA positive and negative groups. Intermediate genetic risk group is mostly made up of patients assigned to the “B-other” group explaining the significant difference between the FXIIIA positive and negative groups, in terms that FXIIIA negative patients had 50% lower chance of facing low instead of intermediate genetic risk compared to FXIIIA positive patients. The multivariate logistic regression analysis confirmed the association between the FXIIIA characteristics and the intermediate genetic risk group. This association persisted after adjusting for categorical variables, i.e. gender, age, WBC, and BFM ALL-IC 2009 stratification (Table 2). High risk copy number alterations were detected in 4/7 samples of the FXIIIA negative group and in 1/17 of the FXIIIA positive group.Conclusions: FXIIIA expression status of leukemic lymphoblasts can easily be determined by FC. Patients with FXIIIA negative lymphoblasts should be further investigated with sophisticated and more expensive genetic and molecular methods.Grant sponsor: OTKA K108885. DisclosuresNo relevant conflicts of interest to declare.

Additional Gene Mutations Refine the 2017 European Leukemianet (ELN) Classification of Adult Patients (Pts) with De Novo Acute Myeloid Leukemia (AML) Aged

The ELN recommendations for diagnosis and management of AML in adults, authored by a panel of international experts, have become an important tool to assess pts' prognosis and guide treatment decisions. Following advances in our understanding of the molecular landscape of AML, several gene mutations were added as criteria for assigning pts to genetic risk categories in the 2017 ELN classification.The aim of our study was to apply the 2017 ELN risk groups to a large cohort of 864 AML pts aged <60 years who were similarly treated with intensive cytarabine/daunorubicin based chemotherapy on Cancer and Leukemia Group B/Alliance protocols. In addition, we sought to identify novel gene markers that could refine the ELN classification.Using the 2017 ELN genetic risk-stratification criteria, we assigned 49% of pts to the Favorable-risk group, whereas 22% and 29% of pts belonged to the Intermediate- and Adverse-risk groups, respectively. The complete remission (CR) rate of Favorable-risk pts was 92%, compared with 77% and 48% CR rates of Intermediate-risk and Adverse-risk pts. Fifty-two percent of Favorable-risk pts were disease-free and 63% were alive 3 years after diagnosis, compared with the respective 3-year rates of 22% and 32% for pts belonging to the Intermediate-risk group, and only 10% and 19%, respectively, for pts classified in the Adverse-risk group. Using a targeted 80-gene sequencing panel, we detected 2,354 mutations, with a median of 3 per pt. The frequencies of specific mutations differed between the ELN risk groups. We performed multivariable outcome analyses for the achievement of CR, disease-free (DFS) and overall (OS) survival within each of the ELN groups. Within the Favorable-risk group MVA analyses, the presence of WT1 mutations associated with lower CR rates (P=0.02). Mutations in BCOR (P=0.02), IDH1 (P=0.04), KIT (P<0.001), PTPN11 (P=0.01) and SETBP1 (P=0.02) associated with a shorter DFS; mutated BCOR (P=0.02), IDH1 (P=0.006), SETBP1 (P=0.004), WT1 (P<0.001) and ZRSR2 (P=0.002) associated with a shorter OS. In the Intermediate-risk group MVA analyses, mutations in WT1 associated with lower CR rates (P=0.02). Mutations in DNMT3A and WT1 associated with shorter DFS (DNMT3A, P<0.001; WT1, P=0.01) and OS (DNMT3A, P<0.001; WT1, P=0.005). In the Adverse-risk group MVA analyses, IDH2 mutations associated with lower CR rates (P=0.05). NRAS mutations associated with shorter DFS (P<0.001) and OS (P=0.008). In addition, IDH2- (P=0.03) and TET2-mutated pts (P=0.009) had shorter OS than pts without these mutations. Among FLT3-ITDlow pts, those harboring NPM1 mutation had higher CR rates (P<0.001) and longer OS (P=0.001), but not DFS (P=0.16), than pts with wild-type (wt) NPM1. Within the FLT3-ITDhigh cohort, pts with an NPM1 mutation had higher CR rates than those without (P<0.001). However, there was no difference in either DFS or OS between NPM1 mutated and NPM1 wt pts, indicating that the negative prognostic impact of FLT3-ITDhigh may outweigh the positive prognostic impact of NPM1 mutations with respect to those survival endpoints. We also noted that the negative prognostic impact of WT1 mutations was worsened by co-occurring NPM1 mutations. Similarly, the impact of IDH1 mutations within the Favorable group was influenced by NPM1 mutations, with IDH1/NPM1 co-mutated patients having inferior survival. Based on the results of our multivariable analyses, as well as co-occurring mutations, we provide a possible refinement of the ELN genetic risk stratification in Table 1. DFS and OS of the re-classified pts were comparable to DFS and OS of the original ELN groups (Figure 1). Importantly, the re-classification also changed the percentages of AML patients assigned to specific risk groups, reducing the Favorable-risk group from 49% to 39% and increasing the Adverse-risk group from 29% to 38%, with the Intermediate-risk group remaining almost the same (23% vs 22%). In summary, our study provides a comprehensive analysis of genetic prognostic markers in younger AML pts treated with standard chemotherapy within the framework of the ELN risk classification. Furthermore, we identified several combinations of co-occurring mutations with prognostic significance. Our results provide a refinement of the 2017 ELN risk classification, and identify additional pts that may need more intensive treatment early on.Support: U10CA180821, U10CA180882, U10CA180861, U24CA196171; ClinicalTrials.gov [Display omitted] DisclosuresMims:Abbvie Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Agios Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy. Kolitz:Magellan Health: Consultancy, Honoraria. Powell:Rafael Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees.

Favorable Outcome in Patients with Acute Myeloblastic Leukemia (AML) with NPM1 Mutation Who Present an Inadequate Clearance or Relapse of Minimal/Measurable Residual Disease (MRD): Results of a Preemptive Intervention Policy (CETLAM-2012 Protocol)

IntroductionPatients diagnosed with AML with NPM1mutation (NPM1mut AML) included in the European LeukemiaNet favorable genetic risk category (ELNfav, i.e., without FLT3-ITD or with a low allelic burden FLT3-ITD comutation [FLT3-ITD/FLT3wt <0.5; FLT3-ITDLOW]) do not benefit from an allogeneic stem cell transplantation (alloSCT) in first complete remission (CR1). However, a significant proportion of these patients fail to frontline chemotherapy and require salvage therapy. Persistence or detection of MRD after post-CR treatment is associated with a high relapse risk and worse prognosis. With this background, the cooperative group CETLAM proposed an early therapeutic intervention in CETLAM-2012 protocol for patients with ELNfavNPM1mut AML patients not achieving a sustained MRD clearance after consolidation therapy, defined as molecular failure (MF). Herein we analyzed the outcome and predictive risk factors of MF.MethodsAll patients diagnosed with ELNfav NPM1mut AML treated according to CETLAM-12 protocol who achieved CR after 1 or 2 courses of induction chemotherapy were included in the study. Intended post-CR therapy consisted of 3 courses of high-dose cytarabine chemotherapy (HDAC). MRD was assessed in bone marrow samples after each chemotherapy course and thereafter, at regular 3-month interval during 3 years, in reference labs from CETLAM group following standard NPM1-mutation specific RQ-PCR. MF was defined as failure to achieve a molecular response (molCR) after consolidation therapy (i.e., NPM1mut/ABL·100 ratio > 0.05) or MRD reappearance after molCR. All MFs were confirmed in a second sample collected at least 4 weeks apart from previous sample. For patients who present a MF, alloSCT was recommended, without a predefined indication of debulking previous salvage chemotherapy.ResultsOut of 145 patients with ELNfav NPM1mut AML (75 M/70 F; median age, 56, 18-74), 132 (91%) achieved CR after 1 (n=124) or 2 courses (n=8). After a median follow-up of 25 months, 2-year overall survival (OS), event-free survival (EFS), leukemia-free survival (LFS) of the entire cohort were 79.9% (±3.6), 71.8% (±4) and 79.4% (±3.8), respectively. Among patients with available complete MRD information (n=89), 33 patients developed an hematological and/or molecular failure (Mol/Hem failure), resulting into a Mol/Hem failure-free survival at 2 years of 62% (±5.6%); median time from CR to Mol/Hem failures was 8.2 months (2-43). Fourteen patients presented with an overt hematological relapse (hREL), preceded by a detectable MF in 8. Overall, 14 received salvage therapy in morphological CR, MRD(+) status (MF), and 14 For hREL. Among MF, 5 patients received HDAC-type salvage treatment (followed by alloSCT in 3) and 9 proceeded directly to alloSCT. In 5 additional MF patients with MRD persistence after consolidation, subsequent MRD monitoring showed decreasing MRD levels until complete clearance (n=4) or intermitent detection (n=1) and have not received further therapy. After salvage therapy, 12/14 (86%) patients with MF achieved molCR, and 10/14 (71%) treated for hREL achieved CR2 (MRD negative in 7, 50%), followed by alloSCT in 9. OS after Mol/Hem failure was 64.8% (± 8.4) at 2 years, 88.8 (±7.5%) in patients treated for MRD(+)-status (MF) and 32.1% (±13.6%) in patients treated with overt hREL (p<0.001; figure 1).Potential predictive factors of Mol/Hem failure were investigated. Interestingly, a ratio of NPM1mut/ABL*100 ≥1 after induction allowed distinction of two patient subpopulation with strikingly different Mol/Hem failure risk: Mol/Hem failure-free survival at 2 years of 84±6% vs. 33±10% in patients with a lower (<1) and higher (³1) tumor burden (p<0.001; figure 2). Remarkably, concurrence of FLT3-ITDLOWdid not correlate with outcome or Mol/Hem failure risk.ConclusionDespite a significant proportion of Mol/Hem failures, NPM1mut AML patients allocated in the ELN favorable risk group presented a favorable overall outcome. NPM1mut-based MRD surveillance is able to anticipate most hematological relapses, and a MRD-driven early intervention policy, at time of MF, allowed a successful rescue of a significant proportion of patients. Moreover, an early measure of residual tumor burden, after induction therapy, might identify those patients with a high risk of molecular or hematological subsequent failure, allowing the potential implementation of preemptive intensification strategies. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

HLA-DQ distribution and risk assessment of celiac disease in a Spanish center.

celiac disease is a multisystem immune-mediated disease triggered by gluten in genetically susceptible individuals. The HLA-DQ2 and/or HLA-DQ8 heterodimers are encoded by the main genetic predisposing factors and their presence is required for the development of the immunological response that leads to the disease. However, the HLA-conferred risk can differ within different countries. The aim of the study was to analyze the risk of Spanish children to develop celiac disease according to their HLA-DQ genotype. a retrospective observational case-control study was performed using a sample of 475 celiac patients and 628 controls. children carrying the HLA-DQ2.5 had the highest disease risk, especially those with two HLA-DQB1*02 alleles. A similar high risk was observed in HLA-DQ8 homozygous individuals. A risk conferred by HLA-DQ8 in heterozygosity and HLA-DQ2.2 was also found and two patients with celiac disease carried the HLA-DQ7.5 haplotype as the only HLA risk factor. there are four genetic risk categories according to the HLA-DQ genotype. The HLA-DQ7.5 genotype does not confer risk but should not be used to rule out celiac disease when a high suspicion of the disease exists. These findings could be relevant to determine when to perform serological screening in asymptomatic subjects at risk of celiac disease.

Genetic Risk, Adherence to a Healthy Lifestyle, and Coronary Disease

BackgroundBoth genetic and lifestyle factors contribute to individual-level risk of coronary artery disease. The extent to which increased genetic risk can be offset by a healthy lifestyle is unknown.MethodsUsing a polygenic score of DNA sequence polymorphisms, we quantified genetic risk for coronary artery disease in three prospective cohorts — 7814 participants in the Atherosclerosis Risk in Communities (ARIC) study, 21,222 in the Women’s Genome Health Study (WGHS), and 22,389 in the Malmö Diet and Cancer Study (MDCS) — and in 4260 participants in the cross-sectional BioImage Study for whom genotype and covariate data were available. We also determined adherence to a healthy lifestyle among the participants using a scoring system consisting of four factors: no current smoking, no obesity, regular physical activity, and a healthy diet.ResultsThe relative risk of incident coronary events was 91% higher among participants at high genetic risk (top quintile of polygenic scores) than among those at low genetic risk (bottom quintile of polygenic scores) (hazard ratio, 1.91; 95% confidence interval [CI], 1.75 to 2.09). A favorable lifestyle (defined as at least three of the four healthy lifestyle factors) was associated with a substantially lower risk of coronary events than an unfavorable lifestyle (defined as no or only one healthy lifestyle factor), regardless of the genetic risk category. Among participants at high genetic risk, a favorable lifestyle was associated with a 46% lower relative risk of coronary events than an unfavorable lifestyle (hazard ratio, 0.54; 95% CI, 0.47 to 0.63). This finding corresponded to a reduction in the standardized 10-year incidence of coronary events from 10.7% for an unfavorable lifestyle to 5.1% for a favorable lifestyle in ARIC, from 4.6% to 2.0% in WGHS, and from 8.2% to 5.3% in MDCS. In the BioImage Study, a favorable lifestyle was associated with significantly less coronary-artery calcification within each genetic risk category.ConclusionsAcross four studies involving 55,685 participants, genetic and lifestyle factors were independently associated with susceptibility to coronary artery disease. Among participants at high genetic risk, a favorable lifestyle was associated with a nearly 50% lower relative risk of coronary artery disease than was an unfavorable lifestyle. (Funded by the National Institutes of Health and others.)

Will Diet and Exercise Save Us All?

Will Diet and Exercise Save Us All?

Is there a role for genetic risk assessment in the treatment of dyslipidemia in primary and secondary prevention of coronary heart disease?

Genetic variants have been associated with the risk of coronary heart disease (CHD). Mega et al studied the association of a genetic risk score based on 27 genetic variants with incidents of recurrent CHD, adjusting for traditional risk factors using data from a community based study and 4 randomized controlled trials of both primary and secondary prevention with statin therapy. When individuals were divided into low, intermediate and high genetic risk categories, a significant gradient in risk of incident and recurrent CHD was shown.

Genetic risk, coronary heart disease events, and the clinical benefit of statin therapy: an analysis of primary and secondary prevention trials

Genetic variants have been associated with the risk of coronary heart disease. In this study, we tested whether or not a composite of these variants could ascertain the risk of both incident and recurrent coronary heart disease events and identify those individuals who derive greater clinical benefit from statin therapy. A community-based cohort study (the Malmo Diet and Cancer Study) and four randomised controlled trials of both primary prevention (JUPITER and ASCOT) and secondary prevention (CARE and PROVE IT-TIMI 22) with statin therapy, comprising a total of 48,421 individuals and 3477 events, were included in these analyses. We studied the association of a genetic risk score based on 27 genetic variants with incident or recurrent coronary heart disease, adjusting for traditional clinical risk factors. We then investigated the relative and absolute risk reductions in coronary heart disease events with statin therapy stratified by genetic risk. We combined data from the different studies using a meta-analysis. When individuals were divided into low (quintile 1), intermediate (quintiles 2-4), and high (quintile 5) genetic risk categories, a significant gradient in risk for incident or recurrent coronary heart disease was shown. Compared with the low genetic risk category, the multivariable-adjusted hazard ratio for coronary heart disease for the intermediate genetic risk category was 1·34 (95% CI 1·22-1·47, p<0·0001) and that for the high genetic risk category was 1·72 (1·55-1·92, p<0·0001). In terms of the benefit of statin therapy in the four randomised trials, we noted a significant gradient (p=0·0277) of increasing relative risk reductions across the low (13%), intermediate (29%), and high (48%) genetic risk categories. Similarly, we noted greater absolute risk reductions in those individuals in higher genetic risk categories (p=0·0101), resulting in a roughly threefold decrease in the number needed to treat to prevent one coronary heart disease event in the primary prevention trials. Specifically, in the primary prevention trials, the number needed to treat to prevent one such event in 10 years was 66 in people at low genetic risk, 42 in those at intermediate genetic risk, and 25 in those at high genetic risk in JUPITER, and 57, 47, and 20, respectively, in ASCOT. A genetic risk score identified individuals at increased risk for both incident and recurrent coronary heart disease events. People with the highest burden of genetic risk derived the largest relative and absolute clinical benefit from statin therapy. National Institutes of Health.

Somatic Mutations of ASXL1, RUNX1 and SETBP1 Improve Prognostic Stratification of Patients with Chronic Myelomonocytic Leukemia

Chronic myelomonocytic leukemia (CMML) is a myelodysplastic/myeloproliferative neoplasm characterized by a highly variable clinical course. Based on clinical, hematologic and cytogenetic parameters, we previously developed a CMML-specific Prognostic Scoring System (CPSS) that stratifies patients into 4 different risk groups [Blood 2013;121:3005-15]. Recently, recurrent somatic mutations have been identified in CMML, and preliminary evidence suggests that selected mutated genes may provide useful prognostic information.In this study, we performed a comprehensive mutation analysis of genes implicated in myeloid malignancies in a large and well characterized cohort of CMML patients with the aim to dissect relationships between genotype and disease phenotype and to integrate somatic mutations into a clinical/molecular prognostic model.Thirty-eight genes were analyzed by high throughput sequencing (Illumina MiSeq, San Diego, CA) in a cohort of 199 CMML patients (pts) diagnosed according to WHO classification, and in 12 pts with monocytosis not fulfilling WHO diagnostic criteria. Myelodysplastic and myeloproliferative subtypes (CMML-MD and CMML-MP, respectively) were defined according to FAB criteria. Least absolute shrinkage and selection operator (Lasso) and Cox proportional hazards methods were adopted to select and weight variables for prognostic scoring.Ninety-three percent of pts showed at least one somatic mutation (median number per patient: 2, range 0-6). The most frequently mutated genes were TET2 (44%), SRSF2 (43%), ASXL1 (34%), KRAS (11%), NRAS (10%), CUX1 (10%), CBL (9%), RUNX1 (7%), SETBP1 (7%), JAK2 (6%), SF3B1 (6%), and U2AF1 (5%). A significant association was found between mutations in TET2 and RNA splicing factors (P=.037), 42 of 199 CMML pts (21%) showing co-occurrence of TET2 and SRSF2 mutations. Mutations in genes involved in signaling were significantly associated with CMML-MP (P=.002), whereas SF3B1 mutations were associated with CMML-MD (P=.024).The number of mutations per patient inversely correlated with overall survival (OS) (HR=1.32, P=.021). In univariate analysis, mutations in ASXL1 (HR=2.31, P=.026) , RUNX1 (HR=3.53, P=.02) and SETBP1 (HR=3.85, P=.005) significantly affected OS. Focusing the analysis on disease subtype, ASXL1 mutations significantly affected survival in CMML-MD (HR=3.45, P=.025), whereas CUX1 and SETBP1 had a significant prognostic value in CMML-MP (HR=4.33, P=.013 and HR=4.4, P=.025, respectively).In order to investigate the additive value of somatic mutations to current prognostic assessment, we first fitted a Lasso Cox regression model for genetic variable selection. The selected variables were then included in an unpenalized Cox regression in order to obtain unbiased coefficients. The statistically significant variables were CPSS-specific cytogenetic risk groups (HR=2.49, P=.001), mutations in ASXL1 (HR=2.77, P=.018), RUNX1 (HR=5.39, P=.009) and SETBP1 (HR=3.96, P=.013). Based on regression coefficients, we defined a CMML-specific genetic risk score that was able to identify three different groups (Low risk: normal karyotype and –Y; Intermediate: other abnormalities, mutations in ASXL1; High: trisomy 8, complex karyotype, mutations in RUNX1 or SETBP1), with significantly different OS (HR=2.24, P<.001). The Akaike information criterion showed that this genetic risk score performed better than the original CPSS cytogenetic risk classification (AIC 274 vs. 282, respectively). According to the CMML-specific genetic risk score, 36% of patients had a shift toward a higher risk category compared with cytogenetic risk classification. Then, the new genetic risk categories were integrated in the CPSS (CPSS-Mol), which was able to identify 4 risk groups with different OS (HR=2.29, P<.001) and risk of disease progression (HR=2.62, P<.001). As a robustness analysis, we also fitted a Lasso Cox regression model including clinical and genetic variables, and all variables included in the clinical/molecular score were confirmed. The Akaike information criterion showed that the CPSS-Mol performed better than the original CPSS (AIC 251 vs. 253, respectively).In conclusion, this study showed that mutation pattern in CMML significantly correlates with disease phenotype. The integration of somatic mutations in current scoring systems significantly improves prognostic stratification of patients. DisclosuresNo relevant conflicts of interest to declare.

Gene dosage as a relevant mechanism contributing to the determination of ovarian function in Turner syndrome

STUDY QUESTIONWhat is the burden of X chromosome mosaicism in the occurrence of spontaneous menarche (SM) in Turner syndrome (TS)?SUMMARY ANSWERSM was significantly associated with X chromosome mosaicism in the TS patients; a mosaicism with around 10% euploid cell line may predict spontaneous pubertal development when determined by molecular-cytogenetic techniques on uncultivated tissues.WHAT IS KNOWN ALREADYSpontaneous puberty can be observed in a minority of patients with TS, more frequently, but not exclusively, in those with a high level of 46,XX/45,X mosaicism at standard karyotype. The genetic mechanisms contributing to ovarian function in TS patients are still not determined. However, submicroscopic X-linked and autosomal copy number variations (CNVs) have recently emerged as an important genetic risk category for premature ovarian insufficiency and may be involved in modulating the TS ovarian phenotype.STUDY DESIGN, SIZE, DURATIONA group of 40 patients with a diagnosis of TS at conventional karyotyping participated in the study; 6 patients had SM and 34 patients had primary amenorrhoea (PA). All clinical data and the patients’ DNA samples were collected over the years at a single paediatric clinic.PARTICIPANTS/MATERIALS, SETTING, METHODSThe patients' samples were used to perform both genetic (Copy Number Assay) and molecular-cytogenetic (array-CGH and iFISH, interphase-FISH) analyses in order to evaluate the X chromosome mosaicism rate and to detect possible rare CNVs of genes with a known or predicted role in female fertility.MAIN RESULTS AND THE ROLE OF CHANCEAll TS patients showed variable percentages of the 46,XX lineage, but these percentages were higher in the SM group (P < 0.01). A mosaicism around 10% for the euploid cell line may predict spontaneous pubertal development when determined by molecular-cytogenetic techniques performed in uncultivated tissues. A few CNVs involving autosomal and X-linked ovary-related loci were identified by array-CGH analysis and confirmed by real-time quantitative PCR, including a BMP15 gene duplication at Xp11.22, a deletion interrupting the PAPPA gene at 9q33.1, and an intragenic duplication involving the PDE8A gene at 15q25.3.LIMITATIONS, REASONS FOR CAUTIONThis is a pilot study on a relatively small sample size and confirmation in larger TS cohorts may be required. The ovarian tissue could not be studied in any patients and in a subgroup of patients, the mosaicism was estimated in tissues of different embryonic origin.WIDER IMPLICATIONS OF THE FINDINGSThe combined determination of X chromosome mosaicism by molecular and molecular-cytogenetic techniques may become useful for the prediction of SM in TS. The detection of CNVs in both X-linked and autosomal ovary-related genes further suggests gene dosage as a relevant mechanism contributing to the ovarian phenotype of TS patients. These CNVs may pinpoint novel candidates relevant to female fertility and generate further insights into the mechanisms contributing to ovarian function.STUDY FUNDING/COMPETING INTEREST(S)This study was funded by Telethon Foundation (grant no: GGP09126 to L.P.), the Italian Ministry of the University and Research (grant number: 2006065999 to P.F.) and a Ministry of Health grant ‘Ricerca Corrente’ to IRCCS Istituto Auxologico Italiano (grant number: 08C704-2006). The authors have no conflict of interest to declare.