A review on drug repurposing applicable to COVID-19.

Drug repurposing involves the identification of new applications for existing drugs at a lower cost and in a shorter time. There are different computational drug-repurposing strategies and some of these approaches have been applied to the coronavirus disease 2019 (COVID-19) pandemic. Computational drug-repositioning approaches applied to COVID-19 can be broadly categorized into (i) network-based models, (ii) structure-based approaches and (iii) artificial intelligence (AI) approaches. Network-based approaches are divided into two categories: network-based clustering approaches and network-based propagation approaches. Both of them allowed to annotate some important patterns, to identify proteins that are functionally associated with COVID-19 and to discover novel drug-disease or drug-target relationships useful for new therapies. Structure-based approaches allowed to identify small chemical compounds able to bind macromolecular targets to evaluate how a chemical compound can interact with the biological counterpart, trying to find new applications for existing drugs. AI-based networks appear, at the moment, less relevant since they need more data for their application.

A multiple network-based bioinformatics pipeline for the study of molecular mechanisms in oncological diseases for personalized medicine.

MOTIVATION: Assessment of genetic mutations is an essential element in the modern era of personalized cancer treatment. Our strategy is focused on 'multiple network analysis' in which we try to improve cancer diagnostics by using biological networks. Genetic alterations in some important hubs or in driver genes such as BRAF and TP53 play a critical role in regulating many important molecular processes. Most of the studies are focused on the analysis of the effects of single mutations, while tumors often carry mutations of multiple driver genes. The aim of this work is to define an innovative bioinformatics pipeline focused on the design and analysis of networks (such as biomedical and molecular networks), in order to: (1) improve the disease diagnosis; (2) identify the patients that could better respond to a given drug treatment; and (3) predict what are the primary and secondary effects of gene mutations involved in human diseases. RESULTS: By using our pipeline based on a multiple network approach, it has been possible to demonstrate and validate what are the joint effects and changes of the molecular profile that occur in patients with metastatic colorectal carcinoma (mCRC) carrying mutations in multiple genes. In this way, we can identify the most suitable drugs for the therapy for the individual patient. This information is useful to improve precision medicine in cancer patients. As an application of our pipeline, the clinically significant case studies of a cohort of mCRC patients with the BRAF V600E-TP53 I195N missense combined mutation were considered. AVAILABILITY: The procedures used in this paper are part of the Cytoscape Core, available at (www.cytoscape.org). Data used here on mCRC patients have been published in [55]. SUPPLEMENTARY INFORMATION: A supplementary file containing a more detailed discussion of this case study and other cases is available at the journal site as Supplementary Data.

Machine Learning as a Support for the Diagnosis of Type 2 Diabetes.

Diabetes is a chronic, metabolic disease characterized by high blood sugar levels. Among the main types of diabetes, type 2 is the most common. Early diagnosis and treatment can prevent or delay the onset of complications. Previous studies examined the application of machine learning techniques for prediction of the pathology, and here an artificial neural network shows very promising results as a possible valuable aid in the management and prevention of diabetes. Additionally, its superior ability for long-term predictions makes it an ideal choice for this field of study. We utilized machine learning methods to uncover previously undiscovered associations between an individual's health status and the development of type 2 diabetes, with the goal of accurately predicting its onset or determining the individual's risk level. Our study employed a binary classifier, trained on scratch, to identify potential nonlinear relationships between the onset of type 2 diabetes and a set of parameters obtained from patient measurements. Three datasets were utilized, i.e., the National Center for Health Statistics' (NHANES) biennial survey, MIMIC-III and MIMIC-IV. These datasets were then combined to create a single dataset with the same number of individuals with and without type 2 diabetes. Since the dataset was balanced, the primary evaluation metric for the model was accuracy. The outcomes of this study were encouraging, with the model achieving accuracy levels of up to 86% and a ROC AUC value of 0.934. Further investigation is needed to improve the reliability of the model by considering multiple measurements from the same patient over time.

Signal metrics analysis of oscillatory patterns in bacterial multi-omic networks.

MOTIVATION: One of the branches of Systems Biology is focused on a deep understanding of underlying regulatory networks through the analysis of the biomolecules oscillations and their interplay. Synthetic Biology exploits gene or/and protein regulatory networks towards the design of oscillatory networks for producing useful compounds. Therefore, at different levels of application and for different purposes, the study of biomolecular oscillations can lead to different clues about the mechanisms underlying living cells. It is known that network-level interactions involve more than one type of biomolecule as well as biological processes operating at multiple omic levels. Combining network/pathway-level information with genetic information it is possible to describe well-understood or unknown bacterial mechanisms and organism-specific dynamics. RESULTS: Following the methodologies used in signal processing and communication engineering, a methodology is introduced to identify and quantify the extent of multi-omic oscillations. These are due to the process of multi-omic integration and depend on the gene positions on the chromosome. Ad hoc signal metrics are designed to allow further biotechnological explanations and provide important clues about the oscillatory nature of the pathways and their regulatory circuits. Our algorithms designed for the analysis of multi-omic signals are tested and validated on 11 different bacteria for thousands of multi-omic signals perturbed at the network level by different experimental conditions. Information on the order of genes, codon usage, gene expression and protein molecular weight is integrated at three different functional levels. Oscillations show interesting evidence that network-level multi-omic signals present a synchronized response to perturbations and evolutionary relations along taxa. AVAILABILITY AND IMPLEMENTATION: The algorithms, the code (in language R), the tool, the pipeline and the whole dataset of multi-omic signal metrics are available at: https://github.com/lodeguns/Multi-omicSignals. SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.

Investigating the Effects of Amino Acid Variations in Human Menin.

Human menin is a nuclear protein that participates in many cellular processes, as transcriptional regulation, DNA damage repair, cell signaling, cell division, proliferation, and migration, by interacting with many other proteins. Mutations of the gene encoding menin cause multiple endocrine neoplasia type 1 (MEN1), a rare autosomal dominant disorder associated with tumors of the endocrine glands. In order to characterize the structural and functional effects at protein level of the hundreds of missense variations, we investigated by computational methods the wild-type menin and more than 200 variants, predicting the amino acid variations that change secondary structure, solvent accessibility, salt-bridge and H-bond interactions, protein thermostability, and altering the capability to bind known protein interactors. The structural analyses are freely accessible online by means of a web interface that integrates also a 3D visualization of the structure of the wild-type and variant proteins. The results of the study offer insight into the effects of the amino acid variations in view of a more complete understanding of their pathological role.

Robust clustering of noisy high-dimensional gene expression data for patients subtyping.

Motivation: One of the most important research areas in personalized medicine is the discovery of disease sub-types with relevance in clinical applications. This is usually accomplished by exploring gene expression data with unsupervised clustering methodologies. Then, with the advent of multiple omics technologies, data integration methodologies have been further developed to obtain better performances in patient separability. However, these methods do not guarantee the survival separability of the patients in different clusters. Results: We propose a new methodology that first computes a robust and sparse correlation matrix of the genes, then decomposes it and projects the patient data onto the first m spectral components of the correlation matrix. After that, a robust and adaptive to noise clustering algorithm is applied. The clustering is set up to optimize the separation between survival curves estimated cluster-wise. The method is able to identify clusters that have different omics signatures and also statistically significant differences in survival time. The proposed methodology is tested on five cancer datasets downloaded from The Cancer Genome Atlas repository. The proposed method is compared with the Similarity Network Fusion (SNF) approach, and model based clustering based on Student's t-distribution (TMIX). Our method obtains a better performance in terms of survival separability, even if it uses a single gene expression view compared to the multi-view approach of the SNF method. Finally, a pathway based analysis is accomplished to highlight the biological processes that differentiate the obtained patient groups. Availability and implementation: Our R source code is available online at https://github.com/angy89/RobustClusteringPatientSubtyping. Supplementary information: Supplementary data are available at Bioinformatics online.

Robust and sparse correlation matrix estimation for the analysis of high-dimensional genomics data.

Motivation: Microarray technology can be used to study the expression of thousands of genes across a number of different experimental conditions, usually hundreds. The underlying principle is that genes sharing similar expression patterns, across different samples, can be part of the same co-expression system, or they may share the same biological functions. Groups of genes are usually identified based on cluster analysis. Clustering methods rely on the similarity matrix between genes. A common choice to measure similarity is to compute the sample correlation matrix. Dimensionality reduction is another popular data analysis task which is also based on covariance/correlation matrix estimates. Unfortunately, covariance/correlation matrix estimation suffers from the intrinsic noise present in high-dimensional data. Sources of noise are: sampling variations, presents of outlying sample units, and the fact that in most cases the number of units is much larger than the number of genes. Results: In this paper, we propose a robust correlation matrix estimator that is regularized based on adaptive thresholding. The resulting method jointly tames the effects of the high-dimensionality, and data contamination. Computations are easy to implement and do not require hand tunings. Both simulated and real data are analyzed. A Monte Carlo experiment shows that the proposed method is capable of remarkable performances. Our correlation metric is more robust to outliers compared with the existing alternatives in two gene expression datasets. It is also shown how the regularization allows to automatically detect and filter spurious correlations. The same regularization is also extended to other less robust correlation measures. Finally, we apply the ARACNE algorithm on the SyNTreN gene expression data. Sensitivity and specificity of the reconstructed network is compared with the gold standard. We show that ARACNE performs better when it takes the proposed correlation matrix estimator as input. Availability and implementation: The R software is available at https://github.com/angy89/RobustSparseCorrelation. Contact: aserra@unisa.it or robtag@unisa.it. Supplementary information: Supplementary data are available at Bioinformatics online.

A study on multi-omic oscillations in Escherichia coli metabolic networks.

BACKGROUND: Two important challenges in the analysis of molecular biology information are data (multi-omic information) integration and the detection of patterns across large scale molecular networks and sequences. They are are actually coupled beause the integration of omic information may provide better means to detect multi-omic patterns that could reveal multi-scale or emerging properties at the phenotype levels. RESULTS: Here we address the problem of integrating various types of molecular information (a large collection of gene expression and sequence data, codon usage and protein abundances) to analyse the E.coli metabolic response to treatments at the whole network level. Our algorithm, MORA (Multi-omic relations adjacency) is able to detect patterns which may represent metabolic network motifs at pathway and supra pathway levels which could hint at some functional role. We provide a description and insights on the algorithm by testing it on a large database of responses to antibiotics. Along with the algorithm MORA, a novel model for the analysis of oscillating multi-omics has been proposed. Interestingly, the resulting analysis suggests that some motifs reveal recurring oscillating or position variation patterns on multi-omics metabolic networks. Our framework, implemented in R, provides effective and friendly means to design intervention scenarios on real data. By analysing how multi-omics data build up multi-scale phenotypes, the software allows to compare and test metabolic models, design new pathways or redesign existing metabolic pathways and validate in silico metabolic models using nearby species. CONCLUSIONS: The integration of multi-omic data reveals that E.coli multi-omic metabolic networks contain position dependent and recurring patterns which could provide clues of long range correlations in the bacterial genome.

E2FM: an encrypted and compressed full-text index for collections of genomic sequences.

MOTIVATION: Next Generation Sequencing (NGS) platforms and, more generally, high-throughput technologies are giving rise to an exponential growth in the size of nucleotide sequence databases. Moreover, many emerging applications of nucleotide datasets-as those related to personalized medicine-require the compliance with regulations about the storage and processing of sensitive data. RESULTS: We have designed and carefully engineered E 2 FM -index, a new full-text index in minute space which was optimized for compressing and encrypting nucleotide sequence collections in FASTA format and for performing fast pattern-search queries. E 2 FM -index allows to build self-indexes which occupy till to 1/20 of the storage required by the input FASTA file, thus permitting to save about 95% of storage when indexing collections of highly similar sequences; moreover, it can exactly search the built indexes for patterns in times ranging from few milliseconds to a few hundreds milliseconds, depending on pattern length. AVAILABILITY AND IMPLEMENTATION: Source code is available at https://github.com/montecuollo/E2FM . CONTACT: ferdinando.montecuollo@unicampania.it. SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.

CONDOP: an R package for CONdition-Dependent Operon Predictions.

The use of high-throughput RNA sequencing to predict dynamic operon structures in prokaryotic genomes has recently gained popularity in bioinformatics. We provide the R implementation of a novel method that uses transcriptomic features extracted from RNA-seq transcriptome profiles to develop ensemble classifiers for condition-dependent operon predictions. The CONDOP package provides a deeper insight into RNA-seq data analysis and allows scientists to highlight the operon organization in the context of transcriptional regulation with a few lines of code. AVAILABILITY AND IMPLEMENTATION: CONDOP is implemented in R and is freely available at CRAN. CONTACT: vittorio.fortino@helsinki.fiSupplementary information: Supplementary data are available at Bioinformatics online.

MVDA: a multi-view genomic data integration methodology.

BACKGROUND: Multiple high-throughput molecular profiling by omics technologies can be collected for the same individuals. Combining these data, rather than exploiting them separately, can significantly increase the power of clinically relevant patients subclassifications. RESULTS: We propose a multi-view approach in which the information from different data layers (views) is integrated at the levels of the results of each single view clustering iterations. It works by factorizing the membership matrices in a late integration manner. We evaluated the effectiveness and the performance of our method on six multi-view cancer datasets. In all the cases, we found patient sub-classes with statistical significance, identifying novel sub-groups previously not emphasized in literature. Our method performed better as compared to other multi-view clustering algorithms and, unlike other existing methods, it is able to quantify the contribution of single views on the final results. CONCLUSION: Our observations suggest that integration of prior information with genomic features in the subtyping analysis is an effective strategy in identifying disease subgroups. The methodology is implemented in R and the source code is available online at http://neuronelab.unisa.it/a-multi-view-genomic-data-integration-methodology/ .

A multi-view genomic data simulator.

BACKGROUND: OMICs technologies allow to assay the state of a large number of different features (e.g., mRNA expression, miRNA expression, copy number variation, DNA methylation, etc.) from the same samples. The objective of these experiments is usually to find a reduced set of significant features, which can be used to differentiate the conditions assayed. In terms of development of novel feature selection computational methods, this task is challenging for the lack of fully annotated biological datasets to be used for benchmarking. A possible way to tackle this problem is generating appropriate synthetic datasets, whose composition and behaviour are fully controlled and known a priori. RESULTS: Here we propose a novel method centred on the generation of networks of interactions among different biological molecules, especially involved in regulating gene expression. Synthetic datasets are obtained from ordinary differential equations based models with known parameters. Our results show that the generated datasets are well mimicking the behaviour of real data, for popular data analysis methods are able to selectively identify existing interactions. CONCLUSIONS: The proposed method can be used in conjunction to real biological datasets in the assessment of data mining techniques. The main strength of this method consists in the full control on the simulated data while retaining coherence with the real biological processes. The R package MVBioDataSim is freely available to the scientific community at http://neuronelab.unisa.it/?p=1722.

Transcriptome dynamics-based operon prediction in prokaryotes.

BACKGROUND: Inferring operon maps is crucial to understanding the regulatory networks of prokaryotic genomes. Recently, RNA-seq based transcriptome studies revealed that in many bacterial species the operon structure vary with the change of environmental conditions. Therefore, new computational solutions that use both static and dynamic data are necessary to create condition specific operon predictions. RESULTS: In this work, we propose a novel classification method that integrates RNA-seq based transcriptome profiles with genomic sequence features to accurately identify the operons that are expressed under a measured condition. The classifiers are trained on a small set of confirmed operons and then used to classify the remaining gene pairs of the organism studied. Finally, by linking consecutive gene pairs classified as operons, our computational approach produces condition-dependent operon maps. We evaluated our approach on various RNA-seq expression profiles of the bacteria Haemophilus somni, Porphyromonas gingivalis, Escherichia coli and Salmonella enterica. Our results demonstrate that, using features depending on both transcriptome dynamics and genome sequence characteristics, we can identify operon pairs with high accuracy. Moreover, the combination of DNA sequence and expression data results in more accurate predictions than each one alone. CONCLUSION: We present a computational strategy for the comprehensive analysis of condition-dependent operon maps in prokaryotes. Our method can be used to generate condition specific operon maps of many bacterial organisms for which high-resolution transcriptome data is available.

Label-free cell classification in holographic flow cytometry through an unbiased learning strategy.

Nowadays, label-free imaging flow cytometry at the single-cell level is considered the stepforward lab-on-a-chip technology to address challenges in clinical diagnostics, biology, life sciences and healthcare. In this framework, digital holography in microscopy promises to be a powerful imaging modality thanks to its multi-refocusing and label-free quantitative phase imaging capabilities, along with the encoding of the highest information content within the imaged samples. Moreover, the recent achievements of new data analysis tools for cell classification based on deep/machine learning, combined with holographic imaging, are urging these systems toward the effective implementation of point of care devices. However, the generalization capabilities of learning-based models may be limited from biases caused by data obtained from other holographic imaging settings and/or different processing approaches. In this paper, we propose a combination of a Mask R-CNN to detect the cells, a convolutional auto-encoder, used to the image feature extraction and operating on unlabelled data, thus overcoming the bias due to data coming from different experimental settings, and a feedforward neural network for single cell classification, that operates on the above extracted features. We demonstrate the proposed approach in the challenging classification task related to the identification of drug-resistant endometrial cancer cells.

Bioinformatic pipelines in Python with Leaf.

BACKGROUND: An incremental, loosely planned development approach is often used in bioinformatic studies when dealing with custom data analysis in a rapidly changing environment. Unfortunately, the lack of a rigorous software structuring can undermine the maintainability, communicability and replicability of the process. To ameliorate this problem we propose the Leaf system, the aim of which is to seamlessly introduce the pipeline formality on top of a dynamical development process with minimum overhead for the programmer, thus providing a simple layer of software structuring. RESULTS: Leaf includes a formal language for the definition of pipelines with code that can be transparently inserted into the user's Python code. Its syntax is designed to visually highlight dependencies in the pipeline structure it defines. While encouraging the developer to think in terms of bioinformatic pipelines, Leaf supports a number of automated features including data and session persistence, consistency checks between steps of the analysis, processing optimization and publication of the analytic protocol in the form of a hypertext. CONCLUSIONS: Leaf offers a powerful balance between plan-driven and change-driven development environments in the design, management and communication of bioinformatic pipelines. Its unique features make it a valuable alternative to other related tools.

Integrative genetic, epigenetic and pathological analysis of paraganglioma reveals complex dysregulation of NOTCH signaling.

Head and neck paragangliomas, rare neoplasms of the paraganglia composed of nests of neurosecretory and glial cells embedded in vascular stroma, provide a remarkable example of organoid tumor architecture. To identify genes and pathways commonly deregulated in head and neck paraganglioma, we integrated high-density genome-wide copy number variation (CNV) analysis with microRNA and immunomorphological studies. Gene-centric CNV analysis of 24 cases identified a list of 104 genes most significantly targeted by tumor-associated alterations. The "NOTCH signaling pathway" was the most significantly enriched term in the list (P = 0.002 after Bonferroni or Benjamini correction). Expression of the relevant NOTCH pathway proteins in sustentacular (glial), chief (neuroendocrine) and endothelial cells was confirmed by immunohistochemistry in 47 head and neck paraganglioma cases. There were no relationships between level and pattern of NOTCH1/JAG2 protein expression and germline mutation status in the SDH genes, implicated in paraganglioma predisposition, or the presence/absence of immunostaining for SDHB, a surrogate marker of SDH mutations. Interestingly, NOTCH upregulation was observed also in cases with no evidence of CNVs at NOTCH signaling genes, suggesting altered epigenetic modulation of this pathway. To address this issue we performed microarray-based microRNA expression analyses. Notably 5 microRNAs (miR-200a,b,c and miR-34b,c), including those most downregulated in the tumors, correlated to NOTCH signaling and directly targeted NOTCH1 in in vitro experiments using SH-SY5Y neuroblastoma cells. Furthermore, lentiviral transduction of miR-200s and miR-34s in patient-derived primary tympano-jugular paraganglioma cell cultures was associated with NOTCH1 downregulation and increased levels of markers of cell toxicity and cell death. Taken together, our results provide an integrated view of common molecular alterations associated with head and neck paraganglioma and reveal an essential role of NOTCH pathway deregulation in this tumor type.

Discovery of drug mode of action and drug repositioning from transcriptional responses.

A bottleneck in drug discovery is the identification of the molecular targets of a compound (mode of action, MoA) and of its off-target effects. Previous approaches to elucidate drug MoA include analysis of chemical structures, transcriptional responses following treatment, and text mining. Methods based on transcriptional responses require the least amount of information and can be quickly applied to new compounds. Available methods are inefficient and are not able to support network pharmacology. We developed an automatic and robust approach that exploits similarity in gene expression profiles following drug treatment, across multiple cell lines and dosages, to predict similarities in drug effect and MoA. We constructed a "drug network" of 1,302 nodes (drugs) and 41,047 edges (indicating similarities between pair of drugs). We applied network theory, partitioning drugs into groups of densely interconnected nodes (i.e., communities). These communities are significantly enriched for compounds with similar MoA, or acting on the same pathway, and can be used to identify the compound-targeted biological pathways. New compounds can be integrated into the network to predict their therapeutic and off-target effects. Using this network, we correctly predicted the MoA for nine anticancer compounds, and we were able to discover an unreported effect for a well-known drug. We verified an unexpected similarity between cyclin-dependent kinase 2 inhibitors and Topoisomerase inhibitors. We discovered that Fasudil (a Rho-kinase inhibitor) might be "repositioned" as an enhancer of cellular autophagy, potentially applicable to several neurodegenerative disorders. Our approach was implemented in a tool (Mode of Action by NeTwoRk Analysis, MANTRA, http://mantra.tigem.it).

An automated pipeline integrating AlphaFold 2 and MODELLER for protein structure prediction.

The ability to predict a protein's three-dimensional conformation represents a crucial starting point for investigating evolutionary connections with other members of the corresponding protein family, examining interactions with other proteins, and potentially utilizing this knowledge for the purpose of rational drug design. In this work, we evaluated the feasibility of improving AlphaFold2's three-dimensional protein predictions by developing a novel pipeline (AlphaMod) that incorporates AlphaFold2 with MODELLER, a template-based modeling program. Additionally, our tool can drive a comprehensive quality assessment of the tertiary protein structure by incorporating and comparing a set of different quality assessment tools. The outcomes of selected tools are combined into a composite score (BORDASCORE) that exhibits a meaningful correlation with GDT_TS and facilitates the selection of optimal models in the absence of a reference structure. To validate AlphaMod's results, we conducted evaluations using two distinct datasets summing up to 72 targets, previously used to independently assess AlphaFold2's performance. The generated models underwent evaluation through two methods: i) averaging the GDT_TS scores across all produced structures for a single target sequence, and ii) a pairwise comparison of the best structures generated by AlphaFold2 and AlphaMod. The latter, within the unsupervised setups, shows a rising accuracy of approximately 34% over AlphaFold2. While, when considering the supervised setup, AlphaMod surpasses AlphaFold2 in 18% of the instances. Finally, there is an 11% correspondence in outcomes between the diverse methodologies. Consequently, AlphaMod's best-predicted tertiary structures in several cases exhibited a significant improvement in the accuracy of the predictions with respect to the best models obtained by AlphaFold2. This pipeline paves the way for the integration of additional data and AI-based algorithms to further improve the reliability of the predictions.

StaSiS-Net: A stacked and siamese disparity estimation network for depth reconstruction in modern 3D laparoscopy.

Developing accurate and real-time algorithms for a non-invasive three-dimensional representation and reconstruction of internal patient structures is one of the main research fields in computer-assisted surgery and endoscopy. Mono and stereo endoscopic images of soft tissues are converted into a three-dimensional representation by the estimation of depth maps. However, automatic, detailed, accurate and robust depth map estimation is a challenging problem that, in the stereo setting, is strictly dependent on a robust estimate of the disparity map. Many traditional algorithms are often inefficient or not accurate. In this work, novel self-supervised stacked and Siamese encoder/decoder neural networks are proposed to compute accurate disparity maps for 3D laparoscopy depth estimation. These networks run in real-time on standard GPU-equipped desktop computers and the outputs may be used for depth map estimation using the a known camera calibration. We compare performance on three different public datasets and on a new challenging simulated dataset and our solutions outperform state-of-the-art mono and stereo depth estimation methods. Extensive robustness and sensitivity analyses on more than 30000 frames has been performed. This work leads to important improvements in mono and stereo real-time depth map estimation of soft tissues and organs with a very low average mean absolute disparity reconstruction error with respect to ground truth.

Artificial neural network analysis of circulating tumor cells in metastatic breast cancer patients.

A cut-off of 5 circulating tumor cells (CTCs) per 7.5 ml of blood in metastatic breast cancer (MBC) patients is highly predictive of outcome. We analyzed the relationship between CTCs as a continuous variable and overall survival in immunohistochemically defined primary tumor molecular subtypes using an artificial neural network (ANN) prognostic tool to determine the shape of the relationship between risk of death and CTC count and to predict individual survival. We analyzed a training dataset of 311 of 517 (60%) consecutive MBC patients who had been treated at MD Anderson Cancer Center from September 2004 to 2009 and who had undergone pre-therapy CTC counts (CellSearch(®)). Age; estrogen, progesterone receptor, and HER2 status; visceral metastasis; metastatic disease sites; therapy type and line; and CTCs as a continuous value were evaluated using ANN. A model with parameter estimates obtained from the training data was tested in a validation set of the remaining 206 (40%) patients. The model estimates were accurate, with good discrimination and calibration. Risk of death, as estimated by ANN, linearly increased with increasing CTC count in all molecular tumor subtypes but was higher in ER+ and triple-negative MBC than in HER2+. The probabilities of survival for the four subtypes with 0 CTC were as follows: ER+/HER2- 0.947, ER+/HER2+ 0.959, ER-/HER2+ 0.902, and ER-/HER2- 0.875. For patients with 200 CTCs, they were ER+/HER2- 0.439, ER+/HER2+ 0.621, ER-/HER2+ 0.307, ER-/HER2- 0.130. In this large study, ANN revealed a linear increase of risk of death in MBC patients with increasing CTC counts in all tumor subtypes. CTCs' prognostic effect was less evident in HER2+ MBC patients treated with targeted therapy. This study may support the concept that the number of CTCs, along with the biologic characteristics, needs to be carefully taken into account in future analysis.