Genomic and epigenomic evolution of metastatic prostate cancer: the first warm autopsy in China

Reviewer #1 (Public Review):

Summary:
Zhang et al. described a warm autopsy case of a metastatic prostate cancer patient and the follow-up genomic and epigenomic analysis. The authors provided a thorough description of the warm autopsy procedure including consent process, patient evaluation, layout of operation room, specialties required to conduct a warm autopsy, and many other details. Following autopsy, they conducted a series of genomics and epigenomics experiments on selected primary tumors and metastasized tumors from different body sites. Genomic data analysis revealed several interesting results. For example, they discovered a putative metastasis driver event, CDKN1B truncation, and they provided functional relevance of this gene using cell cultures. They were able to piece together the evolutionary history and subclonal structures of the tumors in this patient, which also revealed extensive heterogeneity. They showed a strong correlation between the genetic and epigenetic distances across the tumors.

Strengths:
Overall this is a very well-designed and nicely conducted study. According to the authors, warm autopsy procedures and systems are not yet well established in China. Therefore, this study represents the first warm autopsy in China, and will likely have a strong impact on similar future studies in China. The authors did a good job describing the rationale of a warm autopsy and provided a clear guideline. The genomics analyses were somewhat standard but provided interesting insights.

Weaknesses:
There are several limitations that can be improved upon.

First, while this reviewer does not require the authors to increase the sample size, the authors should provide some discussion, especially on the limitation of generalizing their findings to other patients/cases/cancer types.

Second, the DNA methylation data was used to estimate clonal evolution, but the authors did not investigate whether there is any driver epigenetic events in metastasis. It seems that the authors did not generate WGBS on the primary tumors, which is another limitation.

Third, the authors generated RNA-seq data across many samples but did not provide any analysis beyond the expression level of CDKN1B. This seems to be a missed opportunity.

Fourth, the clonal relationship between the three primary tumors (PB1, PB2, and PB3) and the metastasized tumors is not very well described. Do the authors believe that the metastasis came from a subclone ancestral to the three primary tumors?

Reviewer #2 (Public Review):

Summary:
The authors conducted the first warm autopsy of prostate cancer in China with clear and repeatable standard workflow, documented the transcriptional/genomic/epigenetic profiles across primary tumors and metastases, and highlighted CDKN1B mutation as a key driver mutation for prostate cancer metastases. They provided sufficient details and convincing evidence of multi-omics in their study to define a potential clonal evolution map for the metastatic progression of prostate cancer. The study will also stimulate the development of warm autopsy programs beneficial to patients in Asian populations.

Strengths:
Although the overall incidence of prostate cancer is lower in Asian men compared to men in Western countries, the incidence is increasing in China recently. Therefore the autopsy program will have an important significance in boosting the understanding of molecular mechanism and drug development in prostate cancer for Asian population.
1. Clear illustration on the warm autopsy workflow and detailed documentation of patient clinical course, sample sites, and downstream analyses. This established a great standard for future expansion of similar autopsy programs and may help boost the consent of more cases.
2. Systematic and in-depth multi-omic analyses based on limited samples resulted in an impressive atlas for the intratumoral heterogeneity and clonal evolution across primary tumors and metastases. Key driver mutations were thus highlighted.

Weaknesses:
1. Although the authors highlighted TP53, CDK12, and CDKN1B mutations in the results, not much new knowledge on mechanisms is added to the field since these are already documented in previous studies. Both the unique/private and representative patterns in the single patient, compared to the publicly documented Chinese populations and other ethnical populations will add more significance to this study.

2. The authors claimed that CDKN1B mutation may be the driver event for prostate cancer metastases, but the mutation was absent in the initial bone metastases according to the evolution map created. Although the authors acknowledged this gap and mentioned an FUS mutation in the bone metastases, this compromised the strength in demonstrating the driving significance of this gene mutation. The shRNA experiments on migration
and invasion were impressive but did not necessarily support the initiating potential of CDKN1B mutation in metastases to bone, which is the predominant site of metastases in prostate cancer. It might be a passenger mutation enriched in soft organ metastases or a driver mutation for the secondary metastases from bone metastases.

3. The epigenetic regulation highlighted in the study was not closely correlated to the genetic pattern highlighted (CDK12, CDKN1B, etc.).