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Kim SH, Weigelt B. Circulating cell-free (cf)DNA analysis: Current technologies and applications in gynecologic cancer. Gynecol Oncol Rep 2024; 54:101431. [PMID: 38947418 PMCID: PMC11211888 DOI: 10.1016/j.gore.2024.101431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/04/2024] [Accepted: 06/09/2024] [Indexed: 07/02/2024] Open
Abstract
Cell-free DNA (cfDNA) analysis has several promising clinical applications in the management of cancer patients, with clinical validity established in different types of solid tumors (e.g., lung, breast, and colon cancer). Cancers harbor unique genetic alterations that can be detected in the plasma and other bodily fluids of cancer patients, constituting an alternate source of tumor-derived DNA. Technologic advances and wide-spread availability of next-generation sequencing (NGS) have made sequencing analysis of circulating tumor DNA (ctDNA) possible, employing both off-the-shelf and personalized tumor-informed panels. Tumor size, disease burden and high-grade histologic types have been shown to correlate with ctDNA levels across multiple solid cancer types. Detection of tumor-derived genetic alterations in plasma-derived cfDNA can facilitate diagnosis, guide treatment selection, and serve as a biomarker for treatment response and prognostication. Molecular residual disease (MRD) is at the forefront of cfDNA analysis, with implications in treatment de-escalation/ escalation in the neoadjuvant and adjuvant settings. The development of cfDNA analysis in early detection of cancers is under active investigation. Proof-of-principles studies in gynecologic cancers have demonstrated feasibility and potential for innovation in cancers lacking specific biomarkers, including the tracking of human papillomavirus (HPV) cfDNA in patients with cervical cancer. In this review, we outline the assays currently available for cfDNA sequencing/ ctDNA detection, the role of cfDNA analysis in clinical decision-making and the current status and potential clinical uses of cfDNA research in gynecologic cancers.
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Affiliation(s)
- Sarah H Kim
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Britta Weigelt
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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2
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Scolding NJ. Worked up but not worked out: inconclusive cases. Pract Neurol 2024:pn-2024-004207. [PMID: 38960595 DOI: 10.1136/pn-2024-004207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 07/05/2024]
Affiliation(s)
- Neil J Scolding
- Neurology, Gloucestershire Royal Hospital Neurology Department, Gloucester, UK
- Clinical Neurosciences, University of Bristol, Bristol, UK
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3
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Zhang Y, Zhang W, Zhi Y, Sun H, Wu M, Huang Y. Glow in the dark fluid: Nanoparticles and DNA-binding antibodies as priming agents for liquid biopsies. Sci Bull (Beijing) 2024:S2095-9273(24)00406-7. [PMID: 38880683 DOI: 10.1016/j.scib.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Affiliation(s)
- Yi Zhang
- Key Laboratory of Bioresource Research and Development of Liaoning Province, College of Life and Health Sciences, Northeastern University, Shenyang 110169, China
| | - Wanlu Zhang
- Key Laboratory of Bioresource Research and Development of Liaoning Province, College of Life and Health Sciences, Northeastern University, Shenyang 110169, China
| | - Yinghao Zhi
- Wenzhou Traditional Chinese Medicine Hospital of Zhejiang Chinese Medical University, Wenzhou 325000, China.
| | - Hongwei Sun
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325035, China.
| | - Min Wu
- Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou 325000, China.
| | - Yongye Huang
- Key Laboratory of Bioresource Research and Development of Liaoning Province, College of Life and Health Sciences, Northeastern University, Shenyang 110169, China.
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4
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Bao Y, Zhang D, Guo H, Ma W. Beyond blood: Advancing the frontiers of liquid biopsy in oncology and personalized medicine. Cancer Sci 2024; 115:1060-1072. [PMID: 38308498 PMCID: PMC11007055 DOI: 10.1111/cas.16097] [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: 11/29/2023] [Revised: 01/08/2024] [Accepted: 01/16/2024] [Indexed: 02/04/2024] Open
Abstract
Liquid biopsy is emerging as a pivotal tool in precision oncology, offering a noninvasive and comprehensive approach to cancer diagnostics and management. By harnessing biofluids such as blood, urine, saliva, cerebrospinal fluid, and pleural effusions, this technique profiles key biomarkers including circulating tumor DNA, circulating tumor cells, microRNAs, and extracellular vesicles. This review discusses the extended scope of liquid biopsy, highlighting its indispensable role in enhancing patient outcomes through early detection, continuous monitoring, and tailored therapy. While the advantages are notable, we also address the challenges, emphasizing the necessity for precision, cost-effectiveness, and standardized methodologies in its broader application. The future trajectory of liquid biopsy is set to expand its reach in personalized medicine, fueled by technological advancements and collaborative research.
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Affiliation(s)
- Ying Bao
- Key Laboratory for Translational MedicineThe First Hospital Affiliated with Huzhou UniversityHuzhouChina
| | - Dejing Zhang
- Department of General SurgeryPuyang Oilfield General HospitalPuyangChina
| | - Huihui Guo
- Key Laboratory for Translational MedicineThe First Hospital Affiliated with Huzhou UniversityHuzhouChina
| | - Wenxue Ma
- Department of Medicine, Moores Cancer Center, and Sanford Stem Cell InstituteUniversity of California San DiegoLa JollaCaliforniaUSA
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5
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Giannini LAA, Boers RG, van der Ende EL, Poos JM, Jiskoot LC, Boers JB, van IJcken WFJ, Dopper EG, Pijnenburg YAL, Seelaar H, Meeter LH, van Rooij JGJ, Scheper W, Gribnau J, van Swieten JC. Distinctive cell-free DNA methylation characterizes presymptomatic genetic frontotemporal dementia. Ann Clin Transl Neurol 2024; 11:744-756. [PMID: 38481040 DOI: 10.1002/acn3.51997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/01/2023] [Accepted: 12/27/2023] [Indexed: 03/27/2024] Open
Abstract
OBJECTIVE Methylation of plasma cell-free DNA (cfDNA) has potential as a marker of brain damage in neurodegenerative diseases such as frontotemporal dementia (FTD). Here, we study methylation of cfDNA in presymptomatic and symptomatic carriers of genetic FTD pathogenic variants, next to healthy controls. METHODS cfDNA was isolated from cross-sectional plasma of 10 presymptomatic carriers (4 C9orf72, 4 GRN, and 2 MAPT), 10 symptomatic carriers (4 C9orf72, 4 GRN, and 2 MAPT), and 9 healthy controls. Genome-wide methylation of cfDNA was determined using a high-resolution sequencing technique (MeD-seq). Cumulative scores based on the identified differentially methylated regions (DMRs) were estimated for presymptomatic carriers (vs. controls and symptomatic carriers), and reevaluated in a validation cohort (8 presymptomatic: 3 C9orf72, 3 GRN, and 2 MAPT; 26 symptomatic: 7 C9orf72, 6 GRN, 12 MAPT, and 1 TARDBP; 13 noncarriers from genetic FTD families). RESULTS Presymptomatic carriers showed a distinctive methylation profile compared to healthy controls and symptomatic carriers. Cumulative DMR scores in presymptomatic carriers enabled to significantly differentiate presymptomatic carriers from healthy controls (p < 0.001) and symptomatic carriers (p < 0.001). In the validation cohort, these scores differentiated presymptomatic carriers from symptomatic carriers (p ≤ 0.007) only. Transcription-start-site methylation in presymptomatic carriers, generally associated with gene downregulation, was enriched for genes involved in ubiquitin-dependent processes, while gene body methylation, generally associated with gene upregulation, was enriched for genes involved in neuronal cell processes. INTERPRETATION A distinctive methylation profile of cfDNA characterizes the presymptomatic stage of genetic FTD, and could reflect neuronal death in this stage.
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Affiliation(s)
- Lucia A A Giannini
- Department of Neurology, Alzheimer Center Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ruben G Boers
- Department of Developmental Biology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Emma L van der Ende
- Department of Neurology, Alzheimer Center Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Clinical Chemistry, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Jackie M Poos
- Department of Neurology, Alzheimer Center Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lize C Jiskoot
- Department of Neurology, Alzheimer Center Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joachim B Boers
- Department of Developmental Biology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Wilfred F J van IJcken
- Erasmus Center for Biomics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Elise G Dopper
- Department of Neurology, Alzheimer Center Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Yolande A L Pijnenburg
- Alzheimer Center Amsterdam, Neurology, Vrije Universiteit, Amsterdam UMC location Vumc, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
| | - Harro Seelaar
- Department of Neurology, Alzheimer Center Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lieke H Meeter
- Department of Neurology, Alzheimer Center Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jeroen G J van Rooij
- Department of Neurology, Alzheimer Center Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Wiep Scheper
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
- Department of Functional Genomics, Center for Neurogenomics and Cognitive Research, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands
- Department of Human Genetics, Vrije Universiteit, Amsterdam UMC location Vumc, Amsterdam, The Netherlands
| | - Joost Gribnau
- Department of Developmental Biology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - John C van Swieten
- Department of Neurology, Alzheimer Center Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
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Wojtkowska M, Karczewska N, Pacewicz K, Pacak A, Kopeć P, Florczak-Wyspiańska J, Popławska-Domaszewicz K, Małkiewicz T, Sokół B. Quantification of Circulating Cell-Free DNA in Idiopathic Parkinson's Disease Patients. Int J Mol Sci 2024; 25:2818. [PMID: 38474065 DOI: 10.3390/ijms25052818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024] Open
Abstract
Parkinson's disease (PD) is one of the most common neurodegenerative disorders globally and leads to an excessive loss of dopaminergic neurons in the substantia nigra of the brain. Circulating cell-free DNA (ccf-DNA) are double-stranded DNA fragments of different sizes and origins that are released into the serum and cerebrospinal fluid (CSF) due to cell death (i.e., necrosis and apoptosis) or are actively released by viable cells via exocytosis and NETosis. Using droplet digital polymerase chain reaction (ddPCR), we comprehensively analyzed and distinguished circulating cell-free mitochondrial DNA (ccf mtDNA) and circulating cell-free nuclear DNA (ccfDNA) in the serum and CSF of PD and control patients. The quantitative analysis of serum ccf-DNA in PD patients demonstrated a significant increase in ccf mtDNA and ccfDNA compared to that in healthy control patients and a significantly higher copy of ccf mtDNA when compared to ccfDNA. Next, the serum ccf mtDNA levels significantly increased in male PD patients compared to those in healthy male controls. Furthermore, CSF ccf mtDNA in PD patients increased significantly compared to ccfDNA, and ccf mtDNA decreased in PD patients more than it did in healthy controls. These decreases were not statistically significant but were in agreement with previous data. Interestingly, ccf mtDNA increased in healthy control patients in both serum and CSF as compared to ccfDNA. The small sample size of serum and CSF were the main limitations of this study. To the best of our knowledge, this is the first comprehensive study on serum and CSF of PD patients using ddPCR to indicate the distribution of the copy number of ccf mtDNA as well as ccfDNA. If validated, we suggest that ccf mtDNA has greater potential than ccfDNA to lead the development of novel treatments for PD patients.
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Affiliation(s)
- Małgorzata Wojtkowska
- Department of Bioenergetics, Faculty of Biology, Adam Mickiewicz University, 61-614 Poznan, Poland
| | - Natalia Karczewska
- Centre for Chemical Biology, Institute of Bioorganic Chemistry, Polish Academy of Sciences, 61-704 Poznan, Poland
| | - Klaudia Pacewicz
- Department of Bioenergetics, Faculty of Biology, Adam Mickiewicz University, 61-614 Poznan, Poland
| | - Andrzej Pacak
- Department of Gene Expression, Faculty of Biology Poznan, Adam Mickiewicz University, 61-614 Poznan, Poland
| | - Piotr Kopeć
- Department of Computational Biology, Faculty of Biology, Adam Mickiewicz University, 61-614 Poznan, Poland
| | | | | | - Tomasz Małkiewicz
- Department of Teaching Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Bartosz Sokół
- Department of Neurosurgery, Poznan University of Medical Sciences, 60-355 Poznan, Poland
- Hospital of Joseph Strus in Poznan, 61-285 Poznan, Poland
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7
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Mansur A, Radovanovic I. The expansion of liquid biopsies to vascular care: an overview of existing principles, techniques and potential applications to vascular malformation diagnostics. Front Genet 2024; 15:1348096. [PMID: 38304336 PMCID: PMC10832994 DOI: 10.3389/fgene.2024.1348096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/08/2024] [Indexed: 02/03/2024] Open
Abstract
Vascular malformations are congenital lesions that occur due to mutations in major cellular signalling pathways which govern angiogenesis, cell proliferation, motility, and cell death. These pathways have been widely studied in oncology and are substrates for various small molecule inhibitors. Given their common molecular biology, there is now a potential to repurpose these cancer drugs for vascular malformation care; however, a molecular diagnosis is required in order to tailour specific drugs to the individual patient's mutational profile. Liquid biopsies (LBs), emerging as a transformative tool in the field of oncology, hold significant promise in this feat. This paper explores the principles and technologies underlying LBs and evaluates their potential to revolutionize the management of vascular malformations. The review begins by delineating the fundamental principles of LBs, focusing on the detection and analysis of circulating biomarkers such as cell-free DNA, circulating tumor cells, and extracellular vesicles. Subsequently, an in-depth analysis of the technological advancements driving LB platforms is presented. Lastly, the paper highlights the current state of research in applying LBs to various vascular malformations, and uses the aforementioned principles and techniques to conceptualize a liquid biopsy framework that is unique to vascular malformation research and clinical care.
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Affiliation(s)
- Ann Mansur
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, School of Graduate Studies, University of Toronto, Toronto, ON, Canada
| | - Ivan Radovanovic
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Krembil Brain Institute, University Health Network, Toronto, ON, Canada
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8
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Sacdalan DB, Ul Haq S, Lok BH. Plasma Cell-Free Tumor Methylome as a Biomarker in Solid Tumors: Biology and Applications. Curr Oncol 2024; 31:482-500. [PMID: 38248118 PMCID: PMC10814449 DOI: 10.3390/curroncol31010033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/30/2023] [Accepted: 01/10/2024] [Indexed: 01/23/2024] Open
Abstract
DNA methylation is a fundamental mechanism of epigenetic control in cells and its dysregulation is strongly implicated in cancer development. Cancers possess an extensively hypomethylated genome with focal regions of hypermethylation at CPG islands. Due to the highly conserved nature of cancer-specific methylation, its detection in cell-free DNA in plasma using liquid biopsies constitutes an area of interest in biomarker research. The advent of next-generation sequencing and newer computational technologies have allowed for the development of diagnostic and prognostic biomarkers that utilize methylation profiling to diagnose disease and stratify risk. Methylome-based predictive biomarkers can determine the response to anti-cancer therapy. An additional emerging application of these biomarkers is in minimal residual disease monitoring. Several key challenges need to be addressed before cfDNA-based methylation biomarkers become fully integrated into practice. The first relates to the biology and stability of cfDNA. The second concerns the clinical validity and generalizability of methylation-based assays, many of which are cancer type-specific. The third involves their practicability, which is a stumbling block for translating technologies from bench to clinic. Future work on developing pan-cancer assays with their respective validities confirmed using well-designed, prospective clinical trials is crucial in pushing for the greater use of these tools in oncology.
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Affiliation(s)
- Danielle Benedict Sacdalan
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, 1 King’s College Circle, Medical Sciences Building, Room 2374, Toronto, ON M5S 1A8, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, 610 University Ave, Toronto, ON M5G 2C4, Canada
| | - Sami Ul Haq
- Radiation Medicine Program, Princess Margaret Cancer Centre, 610 University Ave, Toronto, ON M5G 2C4, Canada
- Schulich School of Medicine & Dentistry, Western University, 1151 Richmond St, London, ON N6A 5C1, Canada
| | - Benjamin H. Lok
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, 1 King’s College Circle, Medical Sciences Building, Room 2374, Toronto, ON M5S 1A8, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, 610 University Ave, Toronto, ON M5G 2C4, Canada
- Department of Medical Biophysics, Temerty Faculty of Medicine, University of Toronto, 101 College Street, Room 15-701, Toronto, ON M5G 1L7, Canada
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9
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Lu Y, Zhang Y, Lou Z, He X, Zhang Q, Zhang Q, Zhao S, Chen H, Zhu H, Song Z, Zhang R, Ma C, Liu D. Metagenomic next-generation sequencing of cell-free DNA for the identification of viruses causing central nervous system infections. Microbiol Spectr 2024; 12:e0226423. [PMID: 38095471 PMCID: PMC10783088 DOI: 10.1128/spectrum.02264-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 11/22/2023] [Indexed: 01/13/2024] Open
Abstract
IMPORTANCE This study provides significant new data on the application of metagenomic next-generation sequencing (mNGS) to clinical diagnostics of central nervous system (CNS) viral infections, which can have high mortality rates and severe sequelae. Conventional diagnostic procedures for identifying viruses can be inefficient and rely on preconceived assumptions about the pathogen, making mNGS an appealing alternative. However, the effectiveness of mNGS is affected by the presence of human DNA contamination, which can be minimized by using cell-free DNA (cfDNA) instead of whole-cell DNA (wcDNA). This multi-center retrospective study of patients with suspected viral CNS infection found that mNGS using cfDNA had a significantly lower proportion of human DNA and higher sensitivity for detecting viruses than mNGS using wcDNA. Herpesviruses, particularly VZV, were found to be the most common DNA viruses in these patients. Overall, mNGS using cfDNA is a promising complementary diagnostic method for detecting CNS viral infections.
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Affiliation(s)
- Yuying Lu
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, China
- Key laboratory of Microbial Molecular Biology of Hunan Province, Hunan Provincial Center for Disease Control and Prevention, Changsha, China
| | - Ye Zhang
- Department of Scientific Affairs, Hugobiotech Co., Ltd., Beijing, China
| | - Zheng Lou
- Department of Scientific Affairs, Hugobiotech Co., Ltd., Beijing, China
| | - Xiaomin He
- Department of Scientific Affairs, Hugobiotech Co., Ltd., Beijing, China
| | - Qinghua Zhang
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Qingxia Zhang
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Shu Zhao
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Han Chen
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Haixia Zhu
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Zhi Song
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Ruxu Zhang
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Caiyu Ma
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, China
- Department of Neurology, The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Ding Liu
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, China
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10
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Appel HR, Rubens M, Roy M, Kotecha R, Hall MD, Mehta MP, Mohler A, Chen Z, Ahluwalia MS, Odia Y. Comparative evaluation of the diagnostic and prognostic performance of CNSide™ versus standard cytology for leptomeningeal disease. Neurooncol Adv 2024; 6:vdae071. [PMID: 38957163 PMCID: PMC11217905 DOI: 10.1093/noajnl/vdae071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024] Open
Abstract
Background This retrospective study compares the real-world performance of cerebrospinal fluid (CSF) CNSide™ versus cytology in leptomeningeal disease (LMD). Methods Consecutive patients with suspected LMD who underwent lumbar punctures for CSF cytology and CNSide™ from January 2020 to December 2022 were reviewed. LMD was classified by EANO criteria. Descriptive statistics, confusion matrix, Kaplan-Meier curves, and Cox proportional regression were used. Results Median age for 87 evaluable patients was 63 years (range: 23-93); 82 (94%) met EANO criteria for possible/probable/confirmed LMD (EANO/LMD). The commonest primary cancers were breast (36,44.0%) and lung (34,41.5%). Primary lung harbored actionable mutations in 18 (53.0%); primary breast expressed hormone receptors in 27 (75%), and HER2 amplification in 8 (22%). Uncontrolled systemic disease was detected in 35 (40%), while 25 (46%) received systemic therapy with medium/high CNS penetrance at LMD diagnosis. The median time from initial cancer to LMD diagnosis was 31 months (range: 13-73). LMD was confirmed by CSF cytology in 23/82 (28%), all identified by CNSide™. CNSide™ identified 13 additional cases (36/82, 43.9%), increasing diagnostic yield by 56.5%. Median overall survival (mOS) was 31 weeks (95%CI: 21-43), significantly worse for CNSide™ positive versus negative: 4.0 versus 16.0 weeks, respectively (HR = 0.50, P = .010). While survival since LMD diagnosis did not differ by histology, time to LMD diagnosis from initial cancer diagnosis was longer for breast (48.5 months, IQR: 30.0-87.5) versus lung (8 months, IQR:0.5-16.0) cohorts. mOS was longer for patients eligible for intrathecal chemotherapy (HR: 0.189, 95%CI: 0.053-0.672, P = .010). Conclusions This retrospective, real-world analysis of CNSide™ showed increased sensitivity versus cytology and provided clinically relevant molecular CSF analyses.
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Affiliation(s)
- Haley R Appel
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Muni Rubens
- Department of Clinical Informatics, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Mukesh Roy
- Department of Clinical Informatics, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
- Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Alexander Mohler
- Division of Neuro-Oncology, Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Zhijian Chen
- Division of Neuro-Oncology, Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Manmeet S Ahluwalia
- Division of Neuro-Oncology, Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Yazmin Odia
- Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
- Division of Neuro-Oncology, Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
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11
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Azad TD, Ran KR, Liu J, Vattipally VN, Khela H, Leite E, Materi JD, Davidar AD, Bettegowda C, Theodore N. A future blood test for acute traumatic spinal cord injury. Biomarkers 2023; 28:703-713. [PMID: 38126897 DOI: 10.1080/1354750x.2023.2298650] [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: 10/21/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023]
Abstract
Acute spinal cord injury (SCI) requires prompt diagnosis and intervention to minimize the risk of permanent neurologic deficit. Presently, SCI diagnosis and interventional planning rely on magnetic resonance imaging (MRI), which is not always available or feasible for severely injured patients. Detection of disease-specific biomarkers in biofluids via liquid biopsy may provide a more accessible and objective means of evaluating patients with suspected SCI. Cell-free DNA, which has been used for diagnosing and monitoring oncologic disease, may detect damage to spinal cord neurons via tissue-specific methylation patterns. Other types of biomarkers, including proteins and RNA species, have also been found to reflect neuronal injury and may be included as part of a multi-analyte assay to improve liquid biopsy performance. The feasibility of implementing liquid biopsy into current practices of SCI management is supported by the relative ease of blood sample collection as well as recent advancements in droplet digital polymerase chain reaction technology. In this review, we detail the current landscape of biofluid biomarkers for acute SCI and propose a framework for the incorporation of a putative blood test into the clinical management of SCI.
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Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Kathleen R Ran
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jiaqi Liu
- Georgetown University School of Medicine, Washington, DC, USA
| | | | - Harmon Khela
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Enzo Leite
- Faculdade Pernambucana de Saúde (FPS), Recife, PE, Brazil
| | - Joshua D Materi
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - A Daniel Davidar
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
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12
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Adhit KK, Wanjari A, Menon S, K S. Liquid Biopsy: An Evolving Paradigm for Non-invasive Disease Diagnosis and Monitoring in Medicine. Cureus 2023; 15:e50176. [PMID: 38192931 PMCID: PMC10772356 DOI: 10.7759/cureus.50176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/08/2023] [Indexed: 01/10/2024] Open
Abstract
Liquid biopsy stands as an innovative instrument in the realm of precision medicine, enabling non-invasive disease diagnosis and the early detection of cancer. Liquid biopsy helps in the extraction of circulating tumor DNA (ctDNA), circulating tumor cells (CTCs), and cell-free DNA (cfDNA) from blood samples and other body fluids, thereby facilitating disease diagnosis and prediction of high-risk patients. Various techniques such as advanced sequencing methods and biomarker-based cell capture have led to the isolation and study of the different biomarkers such as ctDNA, cfDNA, and CTCs. These biopsies also have immense potential in the early detection and diagnosis of various diseases across all medical specialties, prediction and screening of high-risk cases, and detection of different immune response patterns in response to infectious diseases, and also help in predicting treatment outcomes. Although liquid biopsy has the potential to disrupt the field of medical diagnosis, it is met by various challenges such as limited tumor-derived components, less specificity, and inadequate advancement in methods to isolate biomarkers. Despite all these challenges, liquid biopsies provide the potential to become a minimally invasive method of diagnosis that would facilitate real-time monitoring of patients, which differentiates them from traditional tissue biopsies. This article aims to provide a complete overview of the current technologies, different biomarkers, and body fluids that can be used in liquid biopsy and its clinical applications and the potential impact that liquid biopsy holds in the field of precision medicine, facilitating early diagnosis and prompt management of various diseases and cancers.
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Affiliation(s)
- Kanishk K Adhit
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Anil Wanjari
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sharanya Menon
- Pathology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Siddhaarth K
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Macías M, Acha B, Corroza J, Urdánoz-Casado A, Roldan M, Robles M, Sánchez-Ruiz de Gordoa J, Erro ME, Jericó I, Blanco-Luquin I, Mendioroz M. Liquid Biopsy in Alzheimer's Disease Patients Reveals Epigenetic Changes in the PRLHR Gene. Cells 2023; 12:2679. [PMID: 38067107 PMCID: PMC10705731 DOI: 10.3390/cells12232679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 12/18/2023] Open
Abstract
In recent years, new DNA methylation variants have been reported in genes biologically relevant to Alzheimer's disease (AD) in human brain tissue. However, this AD-specific epigenetic information remains brain-locked and unreachable during patients' lifetimes. In a previous methylome performed in the hippocampus of 26 AD patients and 12 controls, we found higher methylation levels in AD patients in the promoter region of PRLHR, a gene involved in energy balance regulation. Our aim was to further characterize PRLHR's role in AD and to evaluate if the liquid biopsy technique would provide life access to this brain information in a non-invasive way. First, we extended the methylation mapping of PRLHR and validated previous methylome results via bisulfite cloning sequencing. Next, we observed a positive correlation between PRLHR methylation levels and AD-related neuropathological changes and a decreased expression of PRLHR in AD hippocampus. Then, we managed to replicate the hippocampal methylation differences in plasma cfDNA from an additional cohort of 35 AD patients and 35 controls. The isolation of cfDNA from the plasma of AD patients may constitute a source of potential epigenetic biomarkers to aid AD clinical management.
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Affiliation(s)
- Mónica Macías
- Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, 31008 Pamplona, Spain; (M.M.); (B.A.); (A.U.-C.); (M.R.); (M.R.); (J.S.-R.d.G.); (M.E.E.); (I.B.-L.)
| | - Blanca Acha
- Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, 31008 Pamplona, Spain; (M.M.); (B.A.); (A.U.-C.); (M.R.); (M.R.); (J.S.-R.d.G.); (M.E.E.); (I.B.-L.)
| | - Jon Corroza
- Neurology Department, Hospital Universitario de Navarra, IdiSNA, 31008 Pamplona, Spain; (J.C.); (I.J.)
| | - Amaya Urdánoz-Casado
- Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, 31008 Pamplona, Spain; (M.M.); (B.A.); (A.U.-C.); (M.R.); (M.R.); (J.S.-R.d.G.); (M.E.E.); (I.B.-L.)
| | - Miren Roldan
- Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, 31008 Pamplona, Spain; (M.M.); (B.A.); (A.U.-C.); (M.R.); (M.R.); (J.S.-R.d.G.); (M.E.E.); (I.B.-L.)
| | - Maitane Robles
- Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, 31008 Pamplona, Spain; (M.M.); (B.A.); (A.U.-C.); (M.R.); (M.R.); (J.S.-R.d.G.); (M.E.E.); (I.B.-L.)
| | - Javier Sánchez-Ruiz de Gordoa
- Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, 31008 Pamplona, Spain; (M.M.); (B.A.); (A.U.-C.); (M.R.); (M.R.); (J.S.-R.d.G.); (M.E.E.); (I.B.-L.)
- Neurology Department, Hospital Universitario de Navarra, IdiSNA, 31008 Pamplona, Spain; (J.C.); (I.J.)
| | - María Elena Erro
- Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, 31008 Pamplona, Spain; (M.M.); (B.A.); (A.U.-C.); (M.R.); (M.R.); (J.S.-R.d.G.); (M.E.E.); (I.B.-L.)
- Neurology Department, Hospital Universitario de Navarra, IdiSNA, 31008 Pamplona, Spain; (J.C.); (I.J.)
| | - Ivonne Jericó
- Neurology Department, Hospital Universitario de Navarra, IdiSNA, 31008 Pamplona, Spain; (J.C.); (I.J.)
| | - Idoia Blanco-Luquin
- Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, 31008 Pamplona, Spain; (M.M.); (B.A.); (A.U.-C.); (M.R.); (M.R.); (J.S.-R.d.G.); (M.E.E.); (I.B.-L.)
| | - Maite Mendioroz
- Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, 31008 Pamplona, Spain; (M.M.); (B.A.); (A.U.-C.); (M.R.); (M.R.); (J.S.-R.d.G.); (M.E.E.); (I.B.-L.)
- Neurology Department, Hospital Universitario de Navarra, IdiSNA, 31008 Pamplona, Spain; (J.C.); (I.J.)
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Pollard C, Aston K, Emery BR, Hill J, Jenkins T. Detection of neuron-derived cfDNA in blood plasma: a new diagnostic approach for neurodegenerative conditions. Front Neurol 2023; 14:1272960. [PMID: 38020656 PMCID: PMC10643874 DOI: 10.3389/fneur.2023.1272960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Neurodegenerative diseases, such as Alzheimer's disease (AD), pose significant challenges in early diagnosis, leading to irreversible brain damage and cognitive decline. In this study, we present a novel diagnostic approach that utilizes whole molecule analysis of neuron-derived cell-free DNA (cfDNA) as a biomarker for early detection of neurodegenerative diseases. By analyzing Differential Methylation Regions (DMRs) between purified cortical neurons and blood plasma samples, we identified robust biomarkers that accurately distinguish between neuronal and non-neuronal cfDNA. The use of cfDNA offers the advantage of convenient and minimally invasive sample collection compared to traditional cerebrospinal fluid or tissue biopsies, making this approach more accessible and patient friendly. Targeted sequencing at the identified DMR locus demonstrated that a conservative cutoff of 5% of neuron-derived cfDNA in blood plasma accurately identifies 100% of patients diagnosed with AD, showing promising potential for early disease detection. Additionally, this method effectively differentiated between patients with mild cognitive impairment (MCI) who later progressed to AD and those who did not, highlighting its prognostic capabilities. Importantly, the differentiation between patients with neurodegenerative diseases and healthy controls demonstrated the specificity of our approach. Furthermore, this cfDNA-based diagnostic strategy outperforms recently developed protein-based assays, which often lack accuracy and convenience. While our current approach focused on a limited set of loci, future research should explore the development of a more comprehensive model incorporating multiple loci to increase diagnostic accuracy further. Although certain limitations, such as technical variance associated with PCR amplification and bisulfite conversion, need to be addressed, this study emphasizes the potential of cfDNA analysis as a valuable tool for pre-symptomatic detection and monitoring of neurodegenerative diseases. With further development and validation, this innovative diagnostic strategy has the potential to significantly impact the field of neurodegenerative disease research and patient care, offering a promising avenue for early intervention and personalized therapeutic approaches.
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Affiliation(s)
- Chad Pollard
- Department of Cell Biology and Physiology, Brigham Young University, Provo, UT, United States
| | - Kenneth Aston
- Department of Surgery, Division of Urology, University of Utah, Salt Lake City, UT, United States
| | - Benjamin R. Emery
- Department of Surgery, Division of Urology, University of Utah, Salt Lake City, UT, United States
| | - Jonathon Hill
- Department of Cell Biology and Physiology, Brigham Young University, Provo, UT, United States
| | - Timothy Jenkins
- Department of Surgery, Division of Urology, University of Utah, Salt Lake City, UT, United States
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15
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Clemente-Suárez VJ, Redondo-Flórez L, Beltrán-Velasco AI, Ramos-Campo DJ, Belinchón-deMiguel P, Martinez-Guardado I, Dalamitros AA, Yáñez-Sepúlveda R, Martín-Rodríguez A, Tornero-Aguilera JF. Mitochondria and Brain Disease: A Comprehensive Review of Pathological Mechanisms and Therapeutic Opportunities. Biomedicines 2023; 11:2488. [PMID: 37760929 PMCID: PMC10526226 DOI: 10.3390/biomedicines11092488] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/02/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
Mitochondria play a vital role in maintaining cellular energy homeostasis, regulating apoptosis, and controlling redox signaling. Dysfunction of mitochondria has been implicated in the pathogenesis of various brain diseases, including neurodegenerative disorders, stroke, and psychiatric illnesses. This review paper provides a comprehensive overview of the intricate relationship between mitochondria and brain disease, focusing on the underlying pathological mechanisms and exploring potential therapeutic opportunities. The review covers key topics such as mitochondrial DNA mutations, impaired oxidative phosphorylation, mitochondrial dynamics, calcium dysregulation, and reactive oxygen species generation in the context of brain disease. Additionally, it discusses emerging strategies targeting mitochondrial dysfunction, including mitochondrial protective agents, metabolic modulators, and gene therapy approaches. By critically analysing the existing literature and recent advancements, this review aims to enhance our understanding of the multifaceted role of mitochondria in brain disease and shed light on novel therapeutic interventions.
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Affiliation(s)
- Vicente Javier Clemente-Suárez
- Faculty of Sports Sciences, Universidad Europea de Madrid, Tajo Street, s/n, 28670 Madrid, Spain; (V.J.C.-S.); (J.F.T.-A.)
- Group de Investigación en Cultura, Educación y Sociedad, Universidad de la Costa, Barranquilla 080002, Colombia
| | - Laura Redondo-Flórez
- Department of Health Sciences, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, C/Tajo s/n, Villaviciosa de Odón, 28670 Madrid, Spain
| | - Ana Isabel Beltrán-Velasco
- Psychology Department, Facultad de Ciencias de la Vida y la Naturaleza, Universidad Antonio de Nebrija, 28240 Madrid, Spain
| | - Domingo Jesús Ramos-Campo
- LFE Research Group, Department of Health and Human Performance, Faculty of Physical Activity and Sport Science-INEF, Universidad Politécnica de Madrid, 28040 Madrid, Spain
| | - Pedro Belinchón-deMiguel
- Department of Nursing and Nutrition, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Spain;
| | | | - Athanasios A. Dalamitros
- Laboratory of Evaluation of Human Biological Performance, School of Physical Education and Sport Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Rodrigo Yáñez-Sepúlveda
- Faculty of Education and Social Sciences, Universidad Andres Bello, Viña del Mar 2520000, Chile;
| | - Alexandra Martín-Rodríguez
- Faculty of Sports Sciences, Universidad Europea de Madrid, Tajo Street, s/n, 28670 Madrid, Spain; (V.J.C.-S.); (J.F.T.-A.)
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16
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Tsoneva DK, Vinciguerra M. Epigenetics and companion diagnostics: opportunities and challenges. Epigenomics 2023; 15:835-838. [PMID: 37661843 DOI: 10.2217/epi-2023-0203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Affiliation(s)
- Desislava K Tsoneva
- Department of Medical Genetics, Medical University of Varna, 55 Marin Drinov str., Varna, Bulgaria
- Department of Translational Stem Cell Biology, Research Institute of the Medical University, 55 Marin Drinov str., Varna, Bulgaria
| | - Manlio Vinciguerra
- Department of Translational Stem Cell Biology, Research Institute of the Medical University, 55 Marin Drinov str., Varna, Bulgaria
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17
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Malhotra S, Miras MCM, Pappolla A, Montalban X, Comabella M. Liquid Biopsy in Neurological Diseases. Cells 2023; 12:1911. [PMID: 37508574 PMCID: PMC10378132 DOI: 10.3390/cells12141911] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/19/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
The most recent and non-invasive approach for studying early-stage biomarkers is liquid biopsy. This implies the extraction and analysis of non-solid biological tissues (serum, plasma, saliva, urine, and cerebrospinal fluid) without undergoing invasive procedures to determine disease prognosis. Liquid biopsy can be used for the screening of several components, such as extracellular vesicles, microRNAs, cell-free DNA, cell-free mitochondrial and nuclear DNA, circulating tumour cells, circulating tumour DNA, transfer RNA, and circular DNA or RNA derived from body fluids. Its application includes early disease diagnosis, the surveillance of disease activity, and treatment response monitoring, with growing evidence for validating this methodology in cancer, liver disease, and central nervous system (CNS) disorders. This review will provide an overview of mentioned liquid biopsy components, which could serve as valuable biomarkers for the evaluation of complex neurological conditions, including Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis, multiple sclerosis, epilepsy, stroke, traumatic brain injury, CNS tumours, and neuroinfectious diseases. Furthermore, this review highlights the future directions and potential limitations associated with liquid biopsy.
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Affiliation(s)
- Sunny Malhotra
- Multiple Sclerosis Center of Catalonia, Department of Neurology-Neuroimmunology, Vall d'Hebron University Hospital, 08035 Barcelona, Spain
| | - Mari Carmen Martín Miras
- Multiple Sclerosis Center of Catalonia, Department of Neurology-Neuroimmunology, Vall d'Hebron University Hospital, 08035 Barcelona, Spain
| | - Agustín Pappolla
- Multiple Sclerosis Center of Catalonia, Department of Neurology-Neuroimmunology, Vall d'Hebron University Hospital, 08035 Barcelona, Spain
| | - Xavier Montalban
- Multiple Sclerosis Center of Catalonia, Department of Neurology-Neuroimmunology, Vall d'Hebron University Hospital, 08035 Barcelona, Spain
| | - Manuel Comabella
- Multiple Sclerosis Center of Catalonia, Department of Neurology-Neuroimmunology, Vall d'Hebron University Hospital, 08035 Barcelona, Spain
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