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CONTENTS: 717 I. 717 II. 718 III. 718 IV. 720 V. 722 VI. 722 VII. 728 730 References 730 SUMMARY: It is estimated that around half of all species of flowering plants show self‐incompatibility (SI). However, the great majority of species alleged to have SI simply comply with ‘the inability of a fully fertile hermaphrodite plant to produce zygotes when self‐pollinated’ – a definition that is neutral as to cause. Surprisingly few species have been investigated experimentally to determine whether their SI has the type of genetic control found in one of the three established mechanisms, that is, homomorphic gametophytic, homomorphic sporophytic or heteromorphic SI. Furthermore, our knowledge of the molecular basis of homomorphic SI derives from a few species in just five families – a small sample that has nevertheless revealed the existence of three different molecular mechanisms. Importantly, a sizeable cohort of species are self‐sterile despite the fact that self‐pollen tubes reach the ovary and in most cases penetrate ovules, a phenomenon called late‐acting self‐incompatibility (LSI). This review draws attention to the confusion between species that show ‘self‐incompatibility’ and those that possess one of the ‘conventional SI mechanisms’ and to argue the case for recognition of LSI as having a widespread occurrence and as a mechanism that inhibits selfing and promotes outbreeding in many plant species.

In patients with resectable colorectal liver metastases (CRLM), the role of pre- and postoperative systemic therapy continues to be debated. Previous studies have shown that circulating tumor DNA (ctDNA) analysis, as a marker of minimal residual disease, is a powerful prognostic factor in patients with nonmetastatic colorectal cancer (CRC). Serial analysis of ctDNA in patients with resectable CRLM could inform the optimal use of perioperative chemotherapy. Here, we performed a validation study to confirm the prognostic impact of postoperative ctDNA in resectable CRLM observed in a previous discovery study. We prospectively collected plasma samples from patients with resectable CRLM, including presurgical and postsurgical samples, serial samples during any pre- or postoperative chemotherapy, and serial samples in follow-up. Via targeted sequencing of 15 genes commonly mutated in CRC, we identified at least 1 somatic mutation in each patient's tumor. We then designed a personalized assay to assess 1 mutation in plasma samples using the Safe-SeqS assay. A total of 380 plasma samples from 54 patients recruited from July 2011 to Dec 2014 were included in our analysis. Twenty-three (43%) patients received neoadjuvant chemotherapy, and 42 patients (78%) received adjuvant chemotherapy after surgery. Median follow-up was 51 months (interquartile range, 31 to 60 months). At least 1 somatic mutation was identified in all patients' tumor tissue. ctDNA was detectable in 46/54 (85%) patients prior to any treatment and 12/49 (24%) patients after surgery. There was a median 40.93-fold (19.10 to 87.73, P < 0.001) decrease in ctDNA mutant allele fraction with neoadjuvant chemotherapy, but ctDNA clearance during neoadjuvant chemotherapy was not associated with a better recurrence-free survival (RFS). Patients with detectable postoperative ctDNA experienced a significantly lower RFS (HR 6.3; 95% CI 2.58 to 15.2; P < 0.001) and overall survival (HR 4.2; 95% CI 1.5 to 11.8; P < 0.001) compared to patients with undetectable ctDNA. For the 11 patients with detectable postoperative ctDNA who had serial ctDNA sampling during adjuvant chemotherapy, ctDNA clearance was observed in 3 patients, 2 of whom remained disease-free. All 8 patients with persistently detectable ctDNA after adjuvant chemotherapy have recurred. End-of-treatment (surgery +/- adjuvant chemotherapy) ctDNA detection was associated with a 5-year RFS of 0% compared to 75.6% for patients with an undetectable end-of-treatment ctDNA (HR 14.9; 95% CI 4.94 to 44.7; P < 0.001). Key limitations of the study include the small sample size and the potential for false-positive findings with multiple hypothesis testing. We confirmed the prognostic impact of postsurgery and posttreatment ctDNA in patients with resected CRLM. The potential utility of serial ctDNA analysis during adjuvant chemotherapy as an early marker of treatment efficacy was also demonstrated. Further studies are required to define how to optimally integrate ctDNA analyses into decision-making regarding the use and timing of adjuvant therapy for resectable CRLM. ACTRN12612000345886.

Colorectal cancer is genetically heterogeneous. Tumors in some patients have defects in mismatch DNA repair. These tumors have a high level of mutations that can lead to immune recognition. In a group of patients with microsatellite-unstable tumors, pembrolizumab led to longer progression-free survival and was less toxic than standard chemotherapy.

The role of adjuvant chemotherapy in stage II colon cancer continues to be debated. The presence of circulating tumor DNA (ctDNA) after surgery predicts very poor recurrence-free survival, whereas its absence predicts a low risk of recurrence. The benefit of adjuvant chemotherapy for ctDNA-positive patients is not well understood. We conducted a trial to assess whether a ctDNA-guided approach could reduce the use of adjuvant chemotherapy without compromising recurrence risk. Patients with stage II colon cancer were randomly assigned in a 2:1 ratio to have treatment decisions guided by either ctDNA results or standard clinicopathological features. For ctDNA-guided management, a ctDNA-positive result at 4 or 7 weeks after surgery prompted oxaliplatin-based or fluoropyrimidine chemotherapy. Patients who were ctDNA-negative were not treated. The primary efficacy end point was recurrence-free survival at 2 years. A key secondary end point was adjuvant chemotherapy use. Of the 455 patients who underwent randomization, 302 were assigned to ctDNA-guided management and 153 to standard management. The median follow-up was 37 months. A lower percentage of patients in the ctDNA-guided group than in the standard-management group received adjuvant chemotherapy (15% vs. 28%; relative risk, 1.82; 95% confidence interval [CI], 1.25 to 2.65). In the evaluation of 2-year recurrence-free survival, ctDNA-guided management was noninferior to standard management (93.5% and 92.4%, respectively; absolute difference, 1.1 percentage points; 95% CI, -4.1 to 6.2 [noninferiority margin, -8.5 percentage points]). Three-year recurrence-free survival was 86.4% among ctDNA-positive patients who received adjuvant chemotherapy and 92.5% among ctDNA-negative patients who did not. A ctDNA-guided approach to the treatment of stage II colon cancer reduced adjuvant chemotherapy use without compromising recurrence-free survival. (Supported by the Australian National Health and Medical Research Council and others; DYNAMIC Australian New Zealand Clinical Trials Registry number, ACTRN12615000381583.).

Activation of the MEK/ERK/Elk-signaling cascade is a mechanism for relaying mitogenic and stress stimuli for gene activation. MEK1 is the proximate kinase for activation of ERK1/2, and nuclear targeting of ERK1/2 is obligatory for Elk1 transcriptional activity. Human biliverdin reductase (hBVR) is a recently described Ser/Thr/Tyr kinase in the MAPK insulin/insulin-like growth factor 1 (IGF1)-signaling cascade. Using 293A cells and in vitro experiments, we detail the formation of a ternary complex of MEK/ERK/hBVR, activation of MEK1 and ERK1/2 kinase activities by hBVR, and phosphorylation of hBVR by ERK1/2. hBVR is nearly as effective as IGF1 in activating ERK; intact hBVR ATP-binding domain is necessary for Elk1 activation, whereas protein-protein interaction is the basis for hBVR activation of MEK1 and ERK. The two MAPK docking consensus sequences present in hBVR, F¹⁶²GFP and K²⁷⁵KRILHCLGL (C- and D-box, respectively), are ERK interactive sites; interaction at each site is critical for ERK/Elk1 activation. Transfection with mutant hBVR-P¹⁶⁵ or peptides corresponding to the C- or D-box blocked activation of ERK by IGF1. Transfection with D-box mutant hBVR prevented the activation of ERK by wild-type protein and dramatically decreased Elk1 transcriptional activity. hBVR is a nuclear transporter of ERK; experiments with hBVR nuclear export signal (NES) and nuclear localization signal (NLS) mutants demonstrated its critical role in the nuclear localization of IGF-stimulated ERK for Elk1 activation. These findings, together with observations that si-hBVR blocked activation of ERK and Elk1 by IGF1 and prevented formation of ternary complex between MEK/ERK/hBVR, define the critical role of hBVR in ERK signaling and nuclear functions of the kinase.

To the Editor: Tie and colleagues (June 16 issue) 1 reported that basing decisions regarding adjuvant chemotherapy in stage II colon cancer on the presence of circulating tumor DNA (ctDNA) after surgery was noninferior to basing such decisions on standard clinicopathological features and that it reduced chemotherapy use (15% vs. 28% of patients). Recurrence-free survival at 2 years was 93.5% in the ctDNA-guided group and 92.4% in the standard-management group (absolute difference, 1.1 percentage points; 95% confidence interval, −4.1 to 6.2 [noninferiority margin, −8.5]). However, it should be possible to use ctDNA information without disregarding clinicopathological features. Of the 44 patients . . .

Traditional randomised controlled trials (RCTs) have long been considered the gold standard for evaluating clinical interventions. However, registry-based trials (RBTs) are emerging as a promising methodology, offering the potential for generating high-quality clinical evidence with greater external validity, reduced complexity, and lower costs. Despite being hailed as the “next disruptive technology in clinical research”, the adoption of RBTs has been slower than anticipated. This lag could be attributed, in part, to the lack of consistent definitions for RBTs, which are often conflated with registry-based RCTs (RRCTs). Our analysis of seven RRCT reviews revealed significant variability in how RRCTs are defined and reported across clinical trial registries, reflecting the absence of standardised descriptors and nomenclature when registering these trials on clinical trial registries. This ambiguity complicates accurate estimation of their implementation and impact, reflected in reviews reporting widely varying numbers of trials registered as RRCTs. While RRCTs represent a valuable approach for addressing critical research questions, for their full potential to be realised, clear and consistent definitions, along with consensus on standardised registration terms, are essential. Given this, we would propose a taxonomy for RRCTs based on how the registry is used to support a RCT. We also welcome the CONSORT extension for the reporting of RRCTs and advocate for a standardised approach on how they are registered on clinical trial registries. Achieving this would not only enhance the recognition of RRCTs but also their impact on clinical practice. We propose a two-tier RRCT classification based on the number of outcomes captured in the registry and its use for identification or recruitment of participants, and encourage ongoing discussion around RRCT taxonomy to help guide future research.

Identification and quantification of low-frequency mutations remain challenging despite improvements in the baseline error rate of next-generation sequencing technologies. Here, we describe a method, termed SaferSeqS, that addresses these challenges by (1) efficiently introducing identical molecular barcodes in the Watson and Crick strands of template molecules and (2) enriching target sequences with strand-specific PCR. The method achieves high sensitivity and specificity and detects variants at frequencies below 1 in 100,000 DNA template molecules with a background mutation rate of <5 × 10 –7 mutants per base pair (bp). We demonstrate that it can evaluate mutations in a single amplicon or simultaneously in multiple amplicons, assess limited quantities of cell-free DNA with high recovery of both strands and reduce the error rate of existing PCR-based molecular barcoding approaches by >100-fold. Mutations present at a low frequency in a sample are detected with high sensitivity and a low error rate.