Discordance in Recommendation Between Next-Generation Sequencing Test Reports and Molecular Tumor Boards in India.

PURPOSE: Accurate understanding of the genomic and transcriptomic data provided by next-generation sequencing (NGS) is essential for the effective utilization of precision oncology. Molecular tumor boards (MTBs) aim to translate the complex data in NGS reports into effective clinical interventions. Often, MTB treatment recommendations differ from those in the NGS reports. In this study, we analyze the discordance between these recommendations and the rationales behind the discordances, in a non-high-income setting, with international input to evaluate the necessity of MTB in clinical practice. METHODS: We collated data from MTB that were virtually hosted in Chennai, India. We included patients with malignancies who had NGS reports on solid tissue or liquid biopsies, and excluded those with incomplete data. MTB forms and NGS reports of each clinical case were analyzed and evaluated for recommendation concordance. Concordance was defined as an agreement between the first recommendation in the MTB forms and the therapeutic recommendations suggested in the NGS report. Discordance was the absence of the said agreement. The rationales for discordance were identified and documented. RESULTS: Seventy MTB reports were analyzed with 49 cases meeting the inclusion criteria. The recommendation discordance was 49% (24 of 49). Discordant recommendations were mainly due to low level of evidence for the drug (75% of cases). CONCLUSION: The discordance between MTB and NGS vendor recommendations highlights the clinical utility of MTB. The educational experiences provided by this initiative are an example of how virtual academic collaborations can enhance patient care and provider education across geographic borders.

Treatment of recurrent or metastatic renal cell carcinoma.

The management of recurrent renal cell carcinoma is challenging as it requires close collaboration between surgeons, radiation oncologists and medical oncologists. To date, treatment options for metastatic disease have been of modest benefit. The disease has therefore been a good model for novel drug development programs. These endeavors are now bearing fruit with exciting preliminary data now emerging in relation to a number of novel agents.

FGFR4 overexpression in pancreatic cancer is mediated by an intronic enhancer activated by HNF1alpha.

Fibroblast growth factor receptor 4 (FGFR4) is expressed in 50-70% of pancreatic carcinomas (PC) and a similar proportion of derived cell lines. Here we determine the sites of FGFR4 transcriptional initiation which show a pattern characteristic of genes with GC-rich, TATA-less promoters. We have examined the chromatin structure around the FGFR4 gene in a panel of expressing and non-expressing PC lines using the DNase I hypersensitive site assay. One region of hypersensitivity, located largely within intron 1, was found to be greatly extended in expressing cells. Subsequent functional analyses using reporter assays demonstrated that this region was able to act as a cell-specific enhancer, only showing significant activity in PC lines expressing endogenous FGFR4. Transcription factors able to bind to the enhancer were investigated using footprinting and mobility shift assays and two binding sites for Sp1 proteins and two sites able to bind hepatic nuclear factor 1 (HNF1) proteins were identified. Further reporter assays using constructs mutated in each binding site demonstrated that HNF1 binding was essential for enhancer activity in expressing cells, an observation that correlated with the increased abundance of HNF1alpha in these same cells as measured by Western blotting. Finally we show that exogenous expression of HNF1 factors in an FGFR4 non-expressing line led to an induction of enhancer activity in reporter assays and also activated expression of the endogenous gene. We conclude that HNF1alpha is a major determinant of FGFR4 expression in PC.