Clinical Pathology - Theses
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ItemImproving the Differentiation of Inherited from Sporadic Causes of DNA Mismatch Repair Deficient Cancers( 2022)People with Lynch syndrome (LS), the most common cancer predisposition syndrome, have an increased risk of developing colorectal (CRC), endometrial (EC) and sebaceous skin (SST) tumours, among other cancer types. LS is caused by germline (likely) pathogenic variants in the DNA mismatch repair (MMR) genes, leading to a characteristic MMR-deficient (dMMR) / microsatellite unstable (MSI) tumour phenotype. However, dMMR / MSI is not only caused by LS and can also result from somatic causes of MMR gene inactivation. Identification of the dMMR / MSI tumour phenotype is of clinical significance for cancer prevention, prognosis, and response to immune checkpoint inhibitor treatment. However, diagnostic challenges still remain for accurate dMMR identification using current clinical tools. Therefore, the aim of my thesis is to address these two clinically relevant challenges: 1) can we improve detection of dMMR / MSI status in CRCs, ECs, and SSTs using next generation sequencing (NGS) derived tumour features and bioinformatic tools, and 2) can we improve differentiation of inherited (high risk) from sporadic (low risk) dMMR in CRCs, ECs, and SSTs using NGS? With the increased adoption of NGS in clinical practice for precision oncology and cancer genetics, the opportunity exists to develop a tumour-focused approach to improve the identification of LS. In Chapter 3, I investigated whether routinely collected clinicopathological tumour features could differentiate LS (inherited) from MLH1 methylated (sporadic) and suspected LS (unknown) subtypes in over 631 dMMR CRCs from the Colon Cancer Family Registry. Although age at diagnosis, sex and other variables were different between these subtypes, their power to differentiate was limited. Significantly, MLH1me tumours presented with a higher mortality rate than LS and suspected LS (SLS) tumours. These findings confirmed the need to examine new NGS-based approaches for differentiation purposes. In Chapter 4, I developed a novel model using NGS data to accurately determine dMMR from MMR-proficient (pMMR) tumour status in CRC and tested this model on EC and SST tumours. In total, 104 tumour features derived from whole exome sequencing of 300 CRCs were tested for their ability to identify dMMR with 10 features displaying >80% prediction accuracies. I established a novel model which combines the best predictive features for improved dMMR detection in CRC, EC, and SST sequenced tumours. In Chapter 5, using a custom-designed panel sequencing assay that I developed, tumour and blood-derived DNA were assessed from 134 SLS dMMR tumours (79 CRCs, 32 ECs, and 23 SSTs) in one of the largest investigations of SLS in these tumour types to date. Using the model determined in Chapter 4, I found 8.2% were not dMMR as clinically reported. The predominant cause of dMMR in SLS was biallelic somatic MMR mutations (61.9%) while only 1.5% were identified as LS that were missed by clinical testing. The findings from my thesis provide an evidence base to implement NGS-based diagnostic approaches for accurately detecting dMMR status and to resolve an SLS diagnosis in CRCs, ECs, and SSTs using a single test, which will ultimately improve utilisation of limited clinical resources for improved clinical management and cancer prevention.
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ItemOncogenes in KRAS Wild Type Pancreatic Cancer( 2019)Pancreatic ductal adenocarcinoma (PDAC) is an invasive cancer, ranked the fourth most prevalent cause of cancer related death. Somatic genetic alterations are primary drivers of PDAC. 93% of patients have activating mutations in the master oncogene, KRAS. Several studies have investigated the mutational landscapes of pancreatic cancer. However, comprehensive studies of KRAS wild type pancreatic tumours are limited. Hence the process of initiation and progression of this cancer remains to be discovered and may be associated with genes that have not been identified. The current project aims to identify oncogenes in KRAS wild type Pancreatic cancer. It also aims to identify whether these oncogenes are from the MAPK pathway or independent of it. The genomic and transcriptomic landscapes of KRAS wild type PDAC were verified. In the absence of KRAS mutation, alternative oncogenes were found. In the genomic data analysis, two cohorts were analysed including 70 samples in the KRAS wild type cohort and 571 in the KRAS mutant cohort. In the absence of KRAS mutation, tumours were found to be rare as were (i) Oncogenic BRAF in-frame deletions, hotspot alterations and oncogenic fusions (known and novel) (frequency of 17%), oncogenic GNAS hotspot mutation (frequency of 12%) and somatic alterations in RET (7% frequency). Recurrent copy number gains (CNV >4) were observed in MYC (23% frequency), CDK6 (16% frequency), AKT2 (16% frequency), KDM6A (14% frequency), EGFR (12% frequency), RICTOR (12% frequency), MET (11% frequency), FGFR1(10% frequency), FGF3 (9% frequency) and FGF4 (9% frequency) in the KRAS wild type cohort. Other low frequency fusion events in the MAPK pathway include: RET-CCDC6; ROS1-SLC4A4; BRAF-SND1; BRAF-SDK1; TRIM24-BRAF; STK4-SLC13A3; ARHGAP24-MAPk10; BRAF-BRAF; STMN1-CDK5RAP3, and; SLC4A4-RASGRF1. Two independent differential expression analyses were performed on the RNA-seq of KRAS wild type versus KRAS mutant Pancreatic Adenocarcinomas, generated by the Australian and Canadian ICGC- pancreatic cancer Consortium consisting of RNA-seq from 88 and 224 bulk tumour samples respectively. Pathway analysis showed that the Calcium signalling pathway was over-expressed in both the Australian and Canadian wild type.This up-regulation of the Calcium signalling pathway in the whole cohort of KRAS wild type is consistent with GNAS mutation in the genomic analysis of the KRAS wild type cohort. Additionally, the MAPK signalling pathway shows no difference throughout the whole cohort of KRAS wild type. Together, these findings at the genomic level reveal that the MAPK signalling pathway is the dominant pathway in the KRAS wild type cohort. The results of comparing RNA expression in two groups of KRAS wild type and KRAS mutant analysis suggest that one oncogene has been substituted for another oncogene in the MAPK pathway, creating an interruption in the MAPK pathway. The lack of differences between KRAS mutant and KRAS wildtype in the MAPK pathway could suggest that the MAPK pathway is up-regulated in both sets, resulting in a lack of difference in the expression.
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ItemThe genetics of gene expression: from simulations to the early-life origins of immune diseases( 2019)Human complex traits and diseases are often highly polygenic. Genome-wide association studies (GWAS) have been successful in identifying the underlying genetic components. However, challenges still remain and one of them is the biological interpretation of these findings. Genetic variants that are associated with diseases or traits are enriched in regulatory regions of the genome, suggesting that they may have a role in the regulation of intermediate molecular phenotypes, such as mRNA gene expression. Studies investigating the genetic architecture of gene expression variation, or expression quantitative trait loci (eQTLs), have aided the interpretation of GWAS findings by providing potential mechanisms through which the genetic variants contribute to higher-order phenotypes. In addition, eQTLs identified in disease-relevant tissues, or those that are specific to certain cell types or conditions are more informative in disease pathogenesis. This thesis first explored eQTL study design and analysis choices using extensive, empirically driven simulations with varying sample sizes, true effect sizes, and allele frequencies of true eQTLs. False discovery rate (FDR) control applied to the entire collection of tests had inflated FDR of genes with eQTLs (eGenes) in most scenarios; in contrast, hierarchical correction procedures had well-calibrated FDR. Significant eQTLs with low allele frequencies identified using small sample sizes were enriched for false positives. Overestimation of eQTL effect sizes was common in scenarios with low statistical power, and a bootstrap method (BootstrapQTL) which can lead to more accurate effect size estimation was developed. Based on the insights of the eQTL simulation study, optimal strategies were selected for the following eQTL analysis in two types of neonatal immune cells (monocytes and T cells) under resting and stimulated conditions. A great proportion of cis-eQTLs were specific to a certain cell type or condition, and the majority of them were observed only upon stimulation. Response eQTLs (reQTLs), with effects on gene expression modified by immune responses, were identified for 31% of the eGenes in monocytes and 52% of the eGenes in T cells. Trans-eQTL effects that were mediated through expression of cis-eGenes were observed. Lastly, integrative analyses were performed, using the early-life eQTLs, as well as GWAS variants associated with immune-related diseases obtained from external large cohorts. Significant overlaps between neonatal eQTLs and postnatal disease-associated variants were observed. Some cell type- or condition-specific cis-eQTLs colocalised with disease associations, suggesting that the potential risk genes involved in disease pathogenesis are linked to the stimulation of certain immune cells. Causal effects of genes were evaluated using Mendelian randomisation, and changes in expression levels (e.g. BTN3A2) were identified to have causal associations with multiple immune-related diseases. Taken together, it demonstrates that the early-life genetic variants and gene expression might contribute to later disease development. In conclusion, this thesis provides a strong evidence base for eQTL study design and guidance for analysis strategies in future studies. The characterisation of genetic regulation of neonatal immune responses and the interaction between regulatory variants and stimulatory conditions is a useful resource, and generates insights on the early-life origins of immune-related diseases that develop later in life.