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Heesterbeek CJ, Lenaerts L, Tjan-Heijnen VCG, Amant F, van Rij MC, Theunis M, de Die-Smulders CEM, Vermeesch JR, Macville MVE. Comprehensive Recommendations for the Clinical Management of Pregnant Women With Noninvasive Prenatal Test Results Suspicious of a Maternal Malignancy. JCO Oncol Pract 2024; 20:1027-1034. [PMID: 38608208 DOI: 10.1200/op.23.00594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 02/12/2024] [Accepted: 02/29/2024] [Indexed: 04/14/2024] Open
Abstract
In this article, we defined comprehensive recommendations for the clinical follow-up of pregnant women with a malignancy-suspicious NIPT result, on the basis of the vast experience with population-based NIPT screening programs in two European countries complemented with published large data sets. These recommendations provide a tool for classifying NIPT results as malignancy-suspicious, and guide health care professionals in structured clinical decision making for the diagnostic process of pregnant women who receive such a malignancy-suspicious NIPT result.
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Affiliation(s)
- Catharina J Heesterbeek
- Department of Medical Oncology, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Vivianne C G Tjan-Heijnen
- Department of Medical Oncology, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Frédéric Amant
- Department of Medical Oncology, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Gynecologic Oncology, Catholic University Leuven, Leuven, Belgium
- Department of Gynecologic Oncology, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Maartje C van Rij
- Department of Medical Oncology, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Miel Theunis
- Centre of Human Genetics, Catholic University Leuven, Leuven, Belgium
| | - Christine E M de Die-Smulders
- Department of Medical Oncology, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Clinical Genetics, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Joris R Vermeesch
- Centre of Human Genetics, Catholic University Leuven, Leuven, Belgium
| | - Merryn V E Macville
- Department of Clinical Genetics, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
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2
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Shree R, MacKinnon HJ, Hannan J, Kolarova TR, Reichel J, Lockwood CM. Anticoagulation use is associated with lower fetal fraction and more indeterminate results. Am J Obstet Gynecol 2024; 230:95.e1-95.e10. [PMID: 37429430 PMCID: PMC10772208 DOI: 10.1016/j.ajog.2023.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Maternal anticoagulation use may increase indeterminate result rates on cell-free DNA-based screening, but existing studies are confounded by inclusion of individuals with autoimmune disease, which alone is associated with indeterminate results. Changes in chromosome level Z-scores are proposed by others as a reason for indeterminate results, but the etiology of this is uncertain. OBJECTIVE This study aimed to evaluate differences in fetal fraction, indeterminate result rate, and total cell-free DNA concentration in individuals on anticoagulation without autoimmune disease compared with controls undergoing noninvasive prenatal screening. Secondly, using a nested case-control design, we evaluated differences in fragment size, GC-content, and Z-scores to evaluate laboratory-level test characteristics. STUDY DESIGN This was a retrospective single-institution study of pregnant individuals undergoing cell-free DNA-based noninvasive prenatal screening using low-pass whole-genome sequencing between 2017 and 2021. Individuals with autoimmune disease, suspected aneuploidy, and cases where fetal fraction was not reported were excluded. Anticoagulation included heparin-derived products (unfractionated heparin, low-molecular-weight heparin), clopidogrel, and fondaparinux, with a separate group for those on aspirin alone. An indeterminate result was defined as fetal fraction <4%. We evaluated the association between maternal anticoagulation or aspirin use, and fetal fraction, indeterminate results, and total cell-free DNA concentration using univariate and multivariate analyses, controlling for body mass index, gestational age at sample collection, and fetal sex. For the anticoagulation cohort, we compared laboratory-level test characteristics among cases (on anticoagulation) and a subset of controls. Lastly, we evaluated for differences in chromosome level Z-scores among those on anticoagulation with and without indeterminate results. RESULTS A total of 1707 pregnant individuals met the inclusion criteria. Of those, 29 were on anticoagulation and 81 were on aspirin alone. For those on anticoagulation, the fetal fraction was significantly lower (9.3% vs 11.7%; P<.01), the indeterminate result rate was significantly higher (17.2% vs 2.7%; P<.001), and the total cell-free DNA concentration was significantly higher (218 pg/μL vs 83.7 pg/μL; P<.001). Among those on aspirin alone, the fetal fraction was lower (10.6% vs 11.8%; P=.04); however, there were no differences in the rate of indeterminate results (3.7% vs 2.7%; P=.57) or total cell-free DNA concentration (90.1 pg/μL vs 83.8 pg/μL; P=.31). After controlling for maternal body mass index, gestational age at sample collection, and fetal sex, anticoagulation was associated with an >8-fold increase in the likelihood of an indeterminate result (adjusted odds ratio, 8.7; 95% confidence interval, 3.1-24.9; P<.001), but not aspirin (adjusted odds ratio, 1.2; 95% confidence interval, 0.3-4.1; P=.8). Anticoagulation was not associated with appreciable differences in cell-free DNA fragment size or GC-content. Although differences in chromosome 13 Z-scores were observed, none were observed for chromosomes 18 or 21, and this difference did not contribute to the indeterminate result call. CONCLUSION In the absence of autoimmune disease, anticoagulation use, but not aspirin, is associated with lower fetal fraction, higher total cell-free DNA concentration, and higher rates of indeterminate results. Anticoagulation use was not accompanied by differences in cell-free DNA fragment size or GC-content. Statistical differences in chromosome level Z-scores did not clinically affect aneuploidy detection. This suggests a likely dilutional effect by anticoagulation on cell-free DNA-based noninvasive prenatal screening assays contributing to low fetal fraction and indeterminate results, and not laboratory or sequencing-level changes.
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Affiliation(s)
- Raj Shree
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.
| | - Hayley J MacKinnon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Joely Hannan
- University of Washington School of Medicine, University of Washington, Seattle, WA
| | - Teodora R Kolarova
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Jonathan Reichel
- Department of Laboratory Medicine & Pathology, University of Washington, Seattle, WA
| | - Christina M Lockwood
- Department of Laboratory Medicine & Pathology, University of Washington, Seattle, WA
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3
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Nitsche JF, Lovell D, Stephens N, Conrad S, Bebeau K, Brost BC. The effects of heparin, aspirin, and maternal clinical factors on the rate of nonreportable cell-free DNA results: a retrospective cohort study. Am J Obstet Gynecol MFM 2023; 5:100846. [PMID: 36572105 DOI: 10.1016/j.ajogmf.2022.100846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/02/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Technological advances in the analysis of cell-free DNA in maternal serum have allowed expanded prenatal screening possibilities for fetal aneuploidies. The sensitivity and positive predictive value of the assay are partly dependent on the amount of cell-free DNA present in maternal circulation. Thus, it is important to know what fetal and maternal factors influence the level of cell-free DNA in maternal circulation. Maternal heparin use has been associated with an increase in nonreportable cell-free DNA results because of a low fetal fraction in some, but not all, previous studies. In addition, there are likely additional factors that affect cell-free DNA that remain uncharacterized. OBJECTIVE This study aimed to determine whether heparins, low-dose aspirin, and maternal clinical factors affect the rate of nonreportable cell-free DNA testing results. STUDY DESIGN A retrospective cohort study was conducted using pregnant people receiving cell-free fetal DNA testing from January 1, 2014, to June 30, 2018. Data were collected on patient demographics, medical comorbidities, medication use, and cell-free DNA test results. Univariate and multivariate analyses were performed to determine which factors were independently associated with the rate of nonreportable results. RESULTS From an original sample of 1117 pregnant people, 743 met the inclusion criteria. Maternal weight (odds ratio, 1.02), heparin use (odds ratio, 12.06), aspirin use (odds ratio, 4.70), chronic hypertension (odds ratio, 5.26), pregestational diabetes mellitus (odds ratio, 2.46), and autoimmune disease (odds ratio, 3.59) were significantly associated with an increased rate of nonreportable results in the univariate analysis. Moreover, the association was present for maternal weight (odds ratio, 1.02), heparin use (odds ratio, 21.87),and aspirin use (odds ratio, 2.85) in the multivariate analysis. CONCLUSION The previously seen association between maternal heparin use and an increase in nonreportable cell-free DNA results was confirmed. Furthermore, there seems to be an increase in nonreportable results in pregnant people taking low-dose aspirin. Providers should consider the effect of these medications when counseling patients on prenatal genetic screening options.
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Affiliation(s)
- Joshua F Nitsche
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, NC (Dr Nitsche).
| | - Daniel Lovell
- Department of Obstetrics and Gynecology, Atrium Health Carolinas Medical Center, Charlotte, NC (Dr Lovell)
| | - Nicole Stephens
- Department of Obstetrics and Gynecology, Sinai Chicago, Chicago, IL (Dr Stephens)
| | - Sarah Conrad
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Conrad)
| | - Katherine Bebeau
- Department of Obstetrics and Gynecology, St. Joseph's/Candler Hospital, Savannah, GA (Dr Bebeau)
| | - Brian C Brost
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, KS (Dr Brost)
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Mousavi S, Shokri Z, Bastani P, Ghojazadeh M, Riahifar S, Nateghian H. Factors affecting low fetal fraction in fetal screening with cell-free DNA in pregnant women: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2022; 22:918. [PMID: 36482322 PMCID: PMC9733315 DOI: 10.1186/s12884-022-05224-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 11/16/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Cell-Free DNA (cfDNA) is a non-invasive perinatal test (NIPT) used to assess fetal anomalies. The ability to detect fetal chromosomal aneuploidies is directly related to a sample's fetal to total DNA fraction, known as the fetal fraction (FF). The minimum FF is considered 4%, and the test result below 4% is uncertain due to low fetal fraction (LFF). This study aimed to conduct a systematic review and a meta-analysis to determine the possible factors affecting LFF in cfDNA testing for fetal screening. METHODS PubMed, Web of Science, Google Scholar, Since Direct, Scopus, CINHAL, Cochrane Library, and Persian databases, including Scientific Information Database, Irandoc, and Magiran were searched for studies investigating factors affecting LFF in cfDNA testing from 2000 until the end of 2021. Gathered data were analyzed using Comprehensive Meta-Analysis (CMA) software version 3.3.070. The quality of the included studies was assessed using the Joanna Briggs Institute Critical Appraisal of Cohort Studies tool. RESULTS Thirteen articles related to the topic were included, and seven related articles were reviewed for meta-analysis. The other six were reviewed qualitatively. Four factors were identified that might have a potential effect on the LFF, of which only gestational age had a significant association with LFF (Pooled mean difference= -1.111, SE = 0.515, 95% CI= -2.121, -0.101, (P-value < 0.05)). Maternal age (P-value = 0.573), maternal weight (P-value = 0.113), and Body Mass Index (P-value = 0.104) had no statically significant effect. The effect size was pooled by mean difference and 95% confidence interval. CONCLUSION Lower gestational age is significantly associated with LFF. Thus, this factor can be considered when interpreting prenatal cfDNA screening tests.
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Affiliation(s)
- Sanaz Mousavi
- grid.412888.f0000 0001 2174 8913Department of Gynecology and Obstetrics, Al-Zahra Hospital, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ziba Shokri
- grid.412888.f0000 0001 2174 8913Department of Gynecology and Obstetrics, Al-Zahra Hospital, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Parvin Bastani
- grid.412888.f0000 0001 2174 8913Department of Gynecology and Obstetrics, Al-Zahra Hospital, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Ghojazadeh
- grid.412888.f0000 0001 2174 8913Research Center for Evidence‑Based Medicine, Iranian EBM Centre: A Joanna Briggs Institute Affiliated Group, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sevda Riahifar
- grid.411746.10000 0004 4911 7066Department of Biostatistics, Faculty of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Hooman Nateghian
- grid.412888.f0000 0001 2174 8913Research Center for Evidence‑Based Medicine, Iranian EBM Centre: A Joanna Briggs Institute Affiliated Group, Tabriz University of Medical Sciences, Tabriz, Iran
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Hallermayr A, Wohlfrom T, Steinke-Lange V, Benet-Pagès A, Scharf F, Heitzer E, Mansmann U, Haberl C, de Wit M, Vogelsang H, Rentsch M, Holinski-Feder E, Pickl JMA. Somatic copy number alteration and fragmentation analysis in circulating tumor DNA for cancer screening and treatment monitoring in colorectal cancer patients. J Hematol Oncol 2022; 15:125. [PMID: 36056434 PMCID: PMC9438339 DOI: 10.1186/s13045-022-01342-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background Analysis of circulating free DNA (cfDNA) is a promising tool for personalized management of colorectal cancer (CRC) patients. Untargeted cfDNA analysis using whole-genome sequencing (WGS) does not need a priori knowledge of the patient´s mutation profile. Methods Here we established LIquid biopsy Fragmentation, Epigenetic signature and Copy Number Alteration analysis (LIFE-CNA) using WGS with ~ 6× coverage for detection of circulating tumor DNA (ctDNA) in CRC patients as a marker for CRC detection and monitoring.
Results We describe the analytical validity and a clinical proof-of-concept of LIFE-CNA using a total of 259 plasma samples collected from 50 patients with stage I-IV CRC and 61 healthy controls. To reliably distinguish CRC patients from healthy controls, we determined cutoffs for the detection of ctDNA based on global and regional cfDNA fragmentation patterns, transcriptionally active chromatin sites, and somatic copy number alterations. We further combined global and regional fragmentation pattern into a machine learning (ML) classifier to accurately predict ctDNA for cancer detection. By following individual patients throughout their course of disease, we show that LIFE-CNA enables the reliable prediction of response or resistance to treatment up to 3.5 months before commonly used CEA. Conclusion In summary, we developed and validated a sensitive and cost-effective method for untargeted ctDNA detection at diagnosis as well as for treatment monitoring of all CRC patients based on genetic as well as non-genetic tumor-specific cfDNA features. Thus, once sensitivity and specificity have been externally validated, LIFE-CNA has the potential to be implemented into clinical practice. To the best of our knowledge, this is the first study to consider multiple genetic and non-genetic cfDNA features in combination with ML classifiers and to evaluate their potential in both cancer detection and treatment monitoring. Trial registration DRKS00012890. Supplementary Information The online version contains supplementary material available at 10.1186/s13045-022-01342-z.
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Affiliation(s)
- Ariane Hallermayr
- MGZ - Medizinisch Genetisches Zentrum, Munich, Germany.,Pettenkofer School of Public Health, Munich, Germany.,Institute for Medical Information Processing, Biometry, and Epidemiology -IBE, LMU Munich, Munich, Germany
| | | | - Verena Steinke-Lange
- MGZ - Medizinisch Genetisches Zentrum, Munich, Germany.,Medizinische Klinik Und Poliklinik IV, Campus Innenstadt, Klinikum Der Universität München, Munich, Germany
| | - Anna Benet-Pagès
- MGZ - Medizinisch Genetisches Zentrum, Munich, Germany.,Institute of Neurogenomics, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
| | | | - Ellen Heitzer
- Institute of Human Genetics, Diagnostic and Research Center for Molecular Biomedicine (Austria), Medical University of Graz, Graz, Austria.,BioTechMed-Graz, Graz, Austria.,Christian Doppler Laboratory for Liquid Biopsies for Early Detection of Cancer, Graz, Austria
| | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry, and Epidemiology -IBE, LMU Munich, Munich, Germany
| | - Christopher Haberl
- Department of Oncology and Hematology, Barmherzige Brüder, Klinikum St. Elisabeth, Straubing, Germany
| | - Maike de Wit
- Department of Hematology, Oncology and Palliative Medicine, Vivantes Klinikum Neukoelln, Berlin, Germany.,Department of Oncology, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - Holger Vogelsang
- Department of General, Visceral, Thoracic and Endocrine Surgery, Klinikum Garmisch-Partenkirchen, Teaching Hospital, Ludwig Maximilian University Munich, Garmisch-Partenkirchen, Germany
| | - Markus Rentsch
- Department of General, Visceral and Thorax Surgery, Klinikum Ingolstadt, Ingolstadt, Germany.,Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Munich, Ludwig-Maximilians University of Munich, Campus Großhadern, Munich, Germany
| | - Elke Holinski-Feder
- MGZ - Medizinisch Genetisches Zentrum, Munich, Germany.,Medizinische Klinik Und Poliklinik IV, Campus Innenstadt, Klinikum Der Universität München, Munich, Germany
| | - Julia M A Pickl
- MGZ - Medizinisch Genetisches Zentrum, Munich, Germany. .,Medizinische Klinik Und Poliklinik IV, Campus Innenstadt, Klinikum Der Universität München, Munich, Germany.
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Shree R, Kolarova TR, MacKinnon HJ, Lockwood CM, Chandrasekaran S. Association of fetal fraction with hypertensive disorders of pregnancy incidence and disease severity. Am J Obstet Gynecol MFM 2022; 4:100671. [PMID: 35644526 PMCID: PMC9452472 DOI: 10.1016/j.ajogmf.2022.100671] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/06/2022] [Accepted: 05/24/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hypertensive disorders of pregnancy contribute to maternal and offspring morbidity and mortality. Studies suggest that a lower early pregnancy fetal fraction is associated with an increased risk of hypertensive disorders of pregnancy. However, maternal obesity significantly affects fetal fraction and is a risk factor for hypertensive disorders of pregnancy. OBJECTIVE We determined the association between fetal fraction (using a standardized single-institution platform, including male and female fetuses) and hypertensive disorders of pregnancy, stratified by obesity status. Second, we evaluated differences in total cell-free DNA concentration and correlation of fetal fraction with clinical markers of hypertensive disorders of pregnancy severity. STUDY DESIGN This was a retrospective, single-institution study of a previously validated cell-free DNA-based noninvasive prenatal screening assay of 1058 samples. Maternal body mass index at the time of noninvasive prenatal screening was assessed, and hypertensive disorders of pregnancy were confirmed by a detailed medical record review. Differences in fetal fraction and total cell-free DNA concentration between the groups were assessed with univariate analyses. Multivariable regression was used to evaluate the association between fetal fraction and hypertensive disorders of pregnancy, adjusted for body mass index, maternal age, gestational age at noninvasive prenatal screening, and fetal sex. The association between fetal fraction and hypertensive disorders of pregnancy among individuals with obesity (body mass index, ≥30 kg/m2) and individuals without obesity (body mass index, <30 kg/m2) was investigated while controlling for the aforementioned covariates. Lastly, multivariable linear regression was used to evaluate the association between fetal fraction and clinical markers of hypertensive disorders of pregnancy severity. RESULTS We identified individuals with (n=117) and without (n=941) hypertensive disorders of pregnancy with noninvasive prenatal screening drawn before 20 weeks of gestation and with fetal fraction and body mass index data available. Those with hypertensive disorders of pregnancy had a lower fetal fraction (10.2%±4.2% vs 11.6%±4.7%; P<.01), without differences in total cell-free DNA concentration (P=.14). When groups were stratified by obesity status, this relationship was only valid for individuals without obesity (P=.02). Only when logistic regression analysis was restricted to individuals without obesity did the likelihood of hypertensive disorders of pregnancy rise with decreasing fetal fraction (odds ratio, 0.93; 95% confidence interval, 0.88-0.99; P=.02). In addition, fetal fraction was inversely associated with maximum systolic blood pressure at the time of hypertensive disorders of pregnancy only in the population without obesity (β, -0.08; 95% confidence interval, -0.147 to -0.01; P=.02). CONCLUSION Although a lower fetal fraction is associated with the development of hypertensive disorders of pregnancy, the use of this parameter for the prediction may be problematic in individuals with obesity, as obesity has such a profound effect on fetal fraction. However, we uniquely noted that among individuals without obesity, fetal fraction is lower for those that develop hypertensive disorders of pregnancy and lower fetal fraction increases the odds of hypertensive disorders of pregnancy development. Lastly, low fetal fraction in the population without obesity that developed hypertensive disorders of pregnancy was associated with higher systolic blood pressure at the time of hypertensive disorders of pregnancy, an important clinical marker of hypertensive disorders of pregnancy severity. As analytical approaches of cell-free DNA interrogation advance, the prediction of placental-mediated disorders with first-trimester sampling is likely to improve, although this may remain challenging in gravidas with obesity, a cohort at high risk of developing hypertensive disorders of pregnancy.
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Affiliation(s)
- Raj Shree
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA (Drs Shree, Kolarova, Mackinnon, and Chandrasekaran).
| | - Teodora R Kolarova
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA (Drs Shree, Kolarova, Mackinnon, and Chandrasekaran)
| | - Hayley J MacKinnon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA (Drs Shree, Kolarova, Mackinnon, and Chandrasekaran)
| | - Christina M Lockwood
- Department of Laboratory Medicine, University of Washington, Seattle, WA (Dr Lockwood)
| | - Suchitra Chandrasekaran
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA (Drs Shree, Kolarova, Mackinnon, and Chandrasekaran); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Emory University, Atlanta, GA (Dr Chandrasekaran)
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7
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Heesterbeek CJ, Aukema SM, Galjaard RJH, Boon EMJ, Srebniak MI, Bouman K, Faas BHW, Govaerts LCP, Hoffer MJV, den Hollander NS, Lichtenbelt KD, van Maarle MC, van Prooyen Schuurman L, van Rij MC, Schuring-Blom GH, Stevens SJC, Tan-Sindhunata G, Zamani Esteki M, de Die-Smulders CEM, Tjan-Heijnen VCG, Henneman L, Sistermans EA, Macville MVE. Noninvasive Prenatal Test Results Indicative of Maternal Malignancies: A Nationwide Genetic and Clinical Follow-Up Study. J Clin Oncol 2022; 40:2426-2435. [PMID: 35394817 DOI: 10.1200/jco.21.02260] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Noninvasive prenatal testing (NIPT) for fetal aneuploidy screening using cell-free DNA derived from maternal plasma can incidentally raise suspicion for cancer. Diagnostic routing after malignancy suspicious-NIPT faces many challenges. Here, we detail malignancy suspicious-NIPT cases, and describe the clinical characteristics, chromosomal aberrations, and diagnostic routing of the patients with a confirmed malignancy. Clinical lessons can be learned from our experience. METHODS Patients with NIPT results indicative of a malignancy referred for tumor screening between April 2017 and April 2020 were retrospectively included from a Dutch nationwide NIPT implementation study, TRIDENT-2. NIPT profiles from patients with confirmed malignancies were reviewed, and the pattern of chromosomal aberrations related to tumor type was analyzed. We evaluated the diagnostic contribution of clinical and genetic examinations. RESULTS Malignancy suspicious-NIPT results were reported in 0.03% after genome-wide NIPT, and malignancies confirmed in 16 patients (16/48, 33.3%). Multiple chromosomal aberrations were seen in 23 of 48 patients with genome-wide NIPT, and a malignancy was confirmed in 16 patients (16/23, 69.6%). After targeted NIPT, 0.005% malignancy suspicious-NIPT results were reported, in 2/3 patients a malignancy was confirmed. Different tumor types and stages were diagnosed, predominantly hematologic malignancies (12/18). NIPT data showed recurrent gains and losses in primary mediastinal B-cell lymphomas and classic Hodgkin lymphomas. Magnetic resonance imaging and computed tomography were most informative in diagnosing the malignancy. CONCLUSION In 231,896 pregnant women, a low percentage (0.02%) of NIPT results were assessed as indicative of a maternal malignancy. However, when multiple chromosomal aberrations were found, the risk of a confirmed malignancy was considerably high. Referral for extensive oncologic examination is recommended, and may be guided by tumor-specific hallmarks in the NIPT profile.
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Affiliation(s)
- Catharina J Heesterbeek
- Department of Medical Oncology, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Sietse M Aukema
- Department of Clinical Genetics, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Elles M J Boon
- Department of Human Genetics, and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - Katelijne Bouman
- Department of Human Genetics, and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Brigitte H W Faas
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Mariëtte J V Hoffer
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Klaske D Lichtenbelt
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Merel C van Maarle
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Lisanne van Prooyen Schuurman
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Human Genetics, and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Maartje C van Rij
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Servi J C Stevens
- Department of Clinical Genetics, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Gita Tan-Sindhunata
- Department of Human Genetics, and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Masoud Zamani Esteki
- Department of Clinical Genetics, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands.,Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Christine E M de Die-Smulders
- Department of Clinical Genetics, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Vivianne C G Tjan-Heijnen
- Department of Medical Oncology, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Lidewij Henneman
- Department of Human Genetics, and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Erik A Sistermans
- Department of Human Genetics, and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Merryn V E Macville
- Department of Clinical Genetics, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
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The impact of maternal autoimmune disease on cell-free DNA test characteristics. Am J Obstet Gynecol MFM 2021; 3:100466. [PMID: 34418590 DOI: 10.1016/j.ajogmf.2021.100466] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/11/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Maternal biologic factors can affect the fetal fraction in cell-free DNA-based prenatal screening assays, thereby limiting the effectiveness. Higher rates of indeterminate results because of a low fetal fraction have been described in cases of maternal autoimmune disease in pregnancy. Existing studies are confounded by the concomitant maternal use of anticoagulants, which may independently influence the test characteristics. OBJECTIVE This study aimed to evaluate the differences in fetal fraction, indeterminate results, and total cell-free DNA concentration among women with an autoimmune disease in comparison with controls, using our in-house developed, noninvasive prenatal screening platform in the absence of maternal anticoagulation use. STUDY DESIGN This was a retrospective, single institution cohort study of a previously validated, cell-free DNA-based, noninvasive prenatal screening assay using a low-pass whole-genome sequencing platform between 2017 and 2019. A diagnosis of an autoimmune disease included systemic lupus erythematosus, rheumatoid arthritis, multiple sclerosis, inflammatory bowel disease, and others. Immunomodulator therapies included biologics, corticosteroids, hydroxychloroquine, azathioprine, and intravenous immunoglobulin. Women who were using anticoagulants were excluded. We evaluated the association between autoimmune disease and fetal cell-free DNA fraction, indeterminate results, and total cell-free DNA concentration using univariate and multivariate analyses, stratified according to immunomodulator therapy and adjusted for body mass index, fetal sex, and gestational age at sample collection. RESULTS A total of 1445 patients met inclusion criteria. Of those, 43 women had a confirmed autoimmune disease, with 25 of those not on immunomodulator therapy and 18 on immunomodulator therapy. The mean fetal fraction for women with an autoimmune disease was significantly lower than for controls (9.7% vs 11.9%; P=.004). The rate of indeterminate results was significantly higher among women with an autoimmune disease than among controls (16.3% vs 3.5%; P<.001). The total cell-free DNA concentration was not statistically different between the groups (94.8 pg/µL for women with an autoimmune disease vs 83.9 pg/µL for controls; P=.06). In a logistic regression, women with an autoimmune disease had significantly higher odds of receiving an indeterminate result than controls, (adjusted odds ratio, 5.3; 95% confidence interval, 2.0-14.2). Linear regression analysis showed a significant negative association between having an autoimmune disease and the fetal cell-free DNA fraction (aβ, -2.1; 95% confidence interval, -3.4 to -0.6). When stratifying by treatment status, the mean fetal fraction was 9.8%, 9.6%, and 11.9% for women with an autoimmune disease not on immunomodulator therapy, women with an autoimmune disease on immunomodulator therapy, and the controls, respectively (P=.02). The rate of indeterminate results increased in a stepwise fashion from 3.5% to 11.1% to 20.0% for controls, women with an autoimmune disease on immunomodulator therapy, and women with an autoimmune disease not on immunomodulator therapy, respectively (P<.001). Logistic regression analysis demonstrated higher odds of an indeterminate result for women with an autoimmune disease not on immunomodulator therapy than for controls, (adjusted odds ratio, 7.3; 95% confidence interval, 2.3-22.5). There was a negative association between women with an autoimmune disease not on immunomodulator therapy and the fetal fraction when compared with controls (aβ, -2.2; 95% confidence interval, -4.2 to -0.3). CONCLUSION Women with an autoimmune disease have lower fetal cell-free DNA fractions and higher rates of indeterminate results than women without an autoimmune disease. There was no difference in total cell-free DNA concentration. Treatment of maternal autoimmune diseases with immunomodulator therapy may decrease the indeterminate result rate.
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Shree R, Kolarova TR, MacKinnon HJ, Hedge JM, Vinopal E, Ma KK, Lockwood CM, Chandrasekaran S. Low fetal fraction in obese women at first trimester cell-free DNA based prenatal screening is not accompanied by differences in total cell-free DNA. Prenat Diagn 2021; 41:1277-1286. [PMID: 34297415 DOI: 10.1002/pd.6023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/26/2021] [Accepted: 07/10/2021] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Reasons for first trimester noninvasive prenatal screening (NIPS) test failure in obese women remain elusive. As dilution from maternal sources may be explanatory, we determined the relationship between obesity, fetal fraction (FF), and total cell-free DNA (cfDNA) using our NIPS platform. METHODS We assessed differences in first trimester (≤14 weeks) FF, indeterminate rate, and total cfDNA between obese (n = 518) and normal-weight women (n = 237) after exclusion of confounders (anticoagulation, autoimmunity, aneuploidy) and controlling for covariates. RESULTS Fetal fraction was lower, and the indeterminate rate higher, in obese compared to controls (9.2% ± 4.4 vs. 12.5% ± 4.5, p < 0.001 and 8.4 vs. 1.7%, p < 0.001, respectively), but total cfDNA was not different (92.0 vs. 82.1 pg/µl, p = 0.10). For each week, the FF remained lower in obese women (all p < 0.01) but did not increase across the first trimester for either group. Obesity increased the likelihood of indeterminate result (OR 6.1, 95% CI 2.5, 14.8; p < 0.001) and maternal body mass index correlated with FF (β -0.27, 95% CI -0.3, -0.22; p < 0.001), but not with total cfDNA (β 0.49, 95% CI -0.55, 1.53; p = 0.3). CONCLUSIONS First trimester obese women have persistently low FF and higher indeterminate rates, without differences in total cfDNA, suggesting placental-specific mechanisms versus dilution from maternal sources as a potential etiology.
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Affiliation(s)
- Raj Shree
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Washington, Seattle, Washington, USA
| | - Teodora R Kolarova
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Washington, Seattle, Washington, USA
| | - Hayley J MacKinnon
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Washington, Seattle, Washington, USA
| | - Jaclynne M Hedge
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Elena Vinopal
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Kimberly K Ma
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Washington, Seattle, Washington, USA
| | - Christina M Lockwood
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA
| | - Suchitra Chandrasekaran
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Washington, Seattle, Washington, USA
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Lu YL, Bianchi DW. Trends in prenatal diagnosis: An analysis of 40 years of Medical Subject Heading (MeSH) terms in publications. Prenat Diagn 2020; 40:1636-1640. [PMID: 33225453 PMCID: PMC10040213 DOI: 10.1002/pd.5871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/19/2020] [Accepted: 11/21/2020] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To understand the evolution of the field of prenatal diagnosis over the past four decades. METHOD We analyzed the publications in the journal Prenatal Diagnosis from its inception in 1980 to 2019 using Medical Subject Headings (MeSH) to examine the major research topics and trends. The results were analyzed by 10-year intervals. RESULTS Publications on prenatal cytogenetics, congenital anomalies and fetal imaging predominated during the first three decades, with a steady increase in molecular genetics over time. Publications on NIPT did not appear until the most recent decade and are likely under-counted because there was no MeSH term for NIPT until 2020. CONCLUSION The topics covered in Prenatal Diagnosis articles have evolved considerably over the past four decades and reflect a response to advances in technology and widespread incorporation of prenatal screening and diagnosis into standard obstetric care. The strengths of this analysis are its objective nature, its use of the standard MeSH terms used for coding, and application of a novel cluster analysis to visualize trends. The analysis also pointed out the fact that MeSH terms in this sub-specialty area are often inconsistent due to manually coding based on individual subject matter expertise.
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Affiliation(s)
- Ya-Ling Lu
- NIH Library, Office of Research Services, National Institutes of Health, Bethesda, Maryland, USA
| | - Diana W Bianchi
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA.,Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
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