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Although coexistence of somatic mutations on EGFR pathway networks have been observed in some individual cases (Toyooka et al, 2005), the low frequency of this occurrence has presented limitations to determining the clinical implications for these multiple mutation cases.
Interestingly, we found high frequencies of S768I in multiple mutation cases: in two triple-mutation cases (2 out of 7) and in 15 double-mutation cases (15 out of 153), in four cases of L858R/S768I and in 11 cases of G719X/S768I.
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In the remaining cases, multiple mutation clusters corresponding to different subclones were detected in the primary sample.
Given the fast pace of current development of targeted drugs aiming at common cancer mutated genes, the identification of multiple mutations in this case may justify her enrollment in future clinical trials of targeted therapy.
In these cases, multiple mutations are required to turn a fully susceptible strain into a clinically resistant one.
Among our 160 cases of multiple mutations, an EGFR-activating mutation plus a T790M point mutation was accounted for in 32 cases (20%), and 24 cases (15%) also included E545K.
Cases where multiple mutations work collectively to give resistance, while of clear importance, are not well understood, in part because the range of mutations that can increase a particular bacterium's antibiotic tolerance is rarely known.
Other cases of multiple mutations in a given gene, or even mutations located in different genes, underlying similar adaptive phenotypes in humans include resistance to malaria, adaptation to high altitude, or skin pigmentation.
Among the eight cases without TP53 or PIK3CA mutations, three demonstrated multiple mutations (two to six mutations per case).
In case 7, multiple mutations were identified in the primary tumour, and these differed from the mutations identified in the secondary tumour.
This is particularly important in cases in which multiple mutations are present and a cooperative effect needs to be evaluated.
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