The development and continuous optimization of newborn screening (NBS) programs remains an important and challenging task due to the low prevalence of screened diseases and high sensitivity requirements for screening methods. Recently, different machine learning (ML) methods have been applied to support NBS. However, most studies only focus on single diseases or specific ML techniques making it difficult to draw conclusions on which methods are best to implement. Therefore, we performed a systematic literature review of peer-reviewed publications on ML-based NBS methods. Overall, 125 related papers, published in the past two decades, were collected for the study, and 17 met the inclusion criteria. We analyzed the opportunities and challenges of ML methods for NBS including data preprocessing, classification models and pattern recognition methods based on their underlying approaches, data requirements, interpretability on a modular level, and performance. In general, ML methods have the potential to reduce the false positive rate and identify so far unknown metabolic patterns within NBS data. Our analysis revealed, that, among the presented, logistic regression analysis and support vector machines seem to be valuable candidates for NBS. However, due to the variety of diseases and methods, a general recommendation for a single method in NBS is not possible. Instead, these methods should be further investigated and compared to other approaches in comprehensive studies as they show promising results in NBS applications.
Illustration of machine learning pipeline in NBS
The classification model is the essential part of the ML pipeline in NBS including the interpretable and non-interpretable classification methods and their performance optimization. Data preprocessing is an optional module applied before the classification model. It can include data sampling, feature selection and feature construction methods. Pattern recognition is applied after the classification method evaluating feature importance for biomarker discovery.
@article{Zaunseder2022Opportunities,
author = {Zaunseder, Elaine and Haupt, Saskia and M{\" u}tze, Ulrike and Garbade, Sven F. and K{\" o}lker, Stefan and Heuveline, Vincent},
journal = {JIMD Reports},
year = {2022},
month = {mar 23},
publisher = {Wiley},
title = {Opportunities and challenges in machine learningbased newborn screening---{A} systematic literature review},
}
@article{Zaunseder2022Opportunities,
abstract = {The development and continuous optimization of newborn screening (NBS) programs remains an important and challenging task due to the low prevalence of screened diseases and high sensitivity requirements for screening methods. Recently, different machine learning (ML) methods have been applied to support NBS. However, most studies only focus on single diseases or specific ML techniques making it difficult to draw conclusions on which methods are best to implement. Therefore, we performed a systematic literature review of peer-reviewed publications on ML-based NBS methods. Overall, 125 related papers, published in the past two decades, were collected for the study, and 17 met the inclusion criteria. We analyzed the opportunities and challenges of ML methods for NBS including data preprocessing, classification models and pattern recognition methods based on their underlying approaches, data requirements, interpretability on a modular level, and performance. In general, ML methods have the potential to reduce the false positive rate and identify so far unknown metabolic patterns within NBS data. Our analysis revealed, that, among the presented, logistic regression analysis and support vector machines seem to be valuable candidates for NBS. However, due to the variety of diseases and methods, a general recommendation for a single method in NBS is not possible. Instead, these methods should be further investigated and compared to other approaches in comprehensive studies as they show promising results in NBS applications.},
author = {Zaunseder, Elaine and Haupt, Saskia and M{\" u}tze, Ulrike and Garbade, Sven F. and K{\" o}lker, Stefan and Heuveline, Vincent},
journaltitle = {JIMD Reports},
shortjournal = {JIMD Reports},
doi = {10.1002/jmd2.12285},
issn = {2192-8312},
date = {2022-03-23},
language = {en},
publisher = {Wiley},
title = {Opportunities and challenges in machine learningbased newborn screening---{A} systematic literature review},
url = {http://dx.doi.org/10.1002/jmd2.12285},
}
Lynch syndrome (LS), the most common inherited colorectal cancer (CRC) syndrome, increases the cancer risk in affected individuals. LS is caused by pathogenic germline variants in one of the DNA mismatch repair (MMR) genes, complete inactivation of which causes numerous mutations in affected cells. As CRC is believed to originate in colonic crypts, understanding the intra- crypt dynamics caused by mutational processes is essential for a complete picture of LS CRC and may have significant implications for cancer prevention. We propose a computational model describing the evolution of colonic crypts during LS carcinogenesis. Extending existing modeling approaches for the non-Lynch scenario, we incorporated MMR deficiency and implemented recent experimental data demonstrating that somatic CTNNB1 mutations are common drivers of LS-associated CRCs, if affecting both alleles of the gene.Further, we simulated the effect of different mutations on the entire crypt, distinguishing non-transforming and transforming mutations. As an example, we analyzed the spread of mutations in the genes APC and CTNNB1, which are frequently mutated in LS tumors, as well as of MMR deficiency itself. We quantified each mutation's potential for monoclonal conversion and investigated the influence of the cell location and of stem cell dynamics on mutation spread. The in silico experiments underline the importance of stem cell dynamics for the overall crypt evolution. Further, simulating different mutational processes is essential in LS since mutations without survival advantages (the MMR deficiency-inducing second hit) play a key role. The effect of other mutations can be simulated with the proposed model. Our results provide first mathematical clues towards more effective surveillance protocols for LS carriers.
Overview of the computational model of colonic crypts
Top: The colonic crypt is represented by a cylinder consisting of stem cells (red) at the bottom, transit- amplifying cells (orange) in the middle and fully-differentiated (FD) cells (green) at the top of the crypt. An active stem cell populates the crypt at any point in time. As we model LS, all cells are initialized with a germline variant in exactly one of the MMR genes. The cylinder is transformed into a rectangle with periodic boundary conditions, where the cells are represented by a Voronoi tessellation. Bottom: For each cell type, we model the cell cycle including cell division, possible mutations in one of the MMR genes, in APC and CTNNB1, and multiple death mechanisms.
@article{Haupt2021computational,
author = {Haupt, Saskia and Gleim, Nils and Ahadova, Aysel and Bl{\" a}ker, Hendrik and Knebel Doeberitz, Magnus and Kloor, Matthias and Heuveline, Vincent},
journal = {Computational and Systems Oncology},
number = {2},
year = {2021},
month = {jun 21},
publisher = {Wiley},
title = {A computational model for investigating the evolution of colonic crypts during {Lynch} syndrome carcinogenesis},
volume = {1},
}
@article{Haupt2021computational,
abstract = {Lynch syndrome (LS), the most common inherited colorectal cancer (CRC) syndrome, increases the cancer risk in affected individuals. LS is caused by pathogenic germline variants in one of the DNA mismatch repair (MMR) genes, complete inactivation of which causes numerous mutations in affected cells. As CRC is believed to originate in colonic crypts, understanding the intra- crypt dynamics caused by mutational processes is essential for a complete picture of LS CRC and may have significant implications for cancer prevention. We propose a computational model describing the evolution of colonic crypts during LS carcinogenesis. Extending existing modeling approaches for the non-Lynch scenario, we incorporated MMR deficiency and implemented recent experimental data demonstrating that somatic \textit{CTNNB1} mutations are common drivers of LS-associated CRCs, if affecting both alleles of the gene.Further, we simulated the effect of different mutations on the entire crypt, distinguishing non-transforming and transforming mutations. As an example, we analyzed the spread of mutations in the genes \textit{APC} and \textit{CTNNB1}, which are frequently mutated in LS tumors, as well as of MMR deficiency itself. We quantified each mutation's potential for monoclonal conversion and investigated the influence of the cell location and of stem cell dynamics on mutation spread. The \textit{in silico} experiments underline the importance of stem cell dynamics for the overall crypt evolution. Further, simulating different mutational processes is essential in LS since mutations without survival advantages (the MMR deficiency-inducing second hit) play a key role. The effect of other mutations can be simulated with the proposed model. Our results provide first mathematical clues towards more effective surveillance protocols for LS carriers.},
author = {Haupt, Saskia and Gleim, Nils and Ahadova, Aysel and Bl{\" a}ker, Hendrik and Knebel Doeberitz, Magnus and Kloor, Matthias and Heuveline, Vincent},
journaltitle = {Computational and Systems Oncology},
shortjournal = {Comp Sys Onco},
doi = {10.1002/cso2.1020},
issn = {2689-9655},
number = {2},
date = {2021-06-21},
language = {en},
publisher = {Wiley},
title = {A computational model for investigating the evolution of colonic crypts during {Lynch} syndrome carcinogenesis},
url = {http://dx.doi.org/10.1002/cso2.1020},
volume = {1},
}
Like many other types of cancer, colorectal cancer (CRC) develops through multiple pathways of carcinogenesis. This is also true for colorectal carcinogenesis in Lynch syndrome (LS), the most common inherited CRC syndrome. However, a comprehensive understanding of the distribution of these pathways of carcinogenesis, which allows for tailored clinical treatment and even prevention, is still lacking. We suggest a linear dynamical system modeling the evolution of different pathways of colorectal carcinogenesis based on the involved driver mutations. The model consists of different components accounting for independent and dependent mutational processes. We define the driver gene mutation graphs and combine them using the Cartesian graph product. This leads to matrix components built by the Kronecker sum and product of the adjacency matrices of the gene mutation graphs enabling a thorough mathematical analysis and medical interpretation. Using the Kronecker structure, we developed a mathematical model which we applied exemplarily to the three pathways of colorectal carcinogenesis in LS. Beside a pathogenic germline variant in one of the DNA mismatch repair (MMR) genes, driver mutations in APC, CTNNB1, KRAS and TP53 are considered. We exemplarily incorporate mutational dependencies, such as increased point mutation rates after MMR deficiency, and based on recent experimental data, biallelic somatic CTNNB1 mutations as common drivers of LS-associated CRCs. With the model and parameter choice, we obtained simulation results that are in concordance with clinical observations. These include the evolution of MMR-deficient crypts as early precursors in LS carcinogenesis and the influence of variants in MMR genes thereon. The proportions of MMR-deficient and MMR-proficient APC-inactivated crypts as first measure for the distribution among the pathways in LS-associated colorectal carcinogenesis are compatible with clinical observations. The approach provides a modular framework for modeling multiple pathways of carcinogenesis yielding promising results in concordance with clinical observations in LS CRCs.
From the Medical Hypothesis Over the Modeling Approach To the Mathematical Structure.
The medical hypothesis of multiple pathways of carcinogenesis is widely known for various types of cancer. (A) We present a model for this phenomenon at the example of Lynch syndrome, the most common inherited CRC syndrome, with specific key driver events in the MMR genes, CTNNB1, APC, KRAS and TP53. (B) This current medical understanding of carcinogenesis is translated into a mathematical model using a specific dynamical system, which can be represented by a graph structure, where each vertex in the graph represents a genotypic state and the edges correspond to the transition probabilities between those states. Starting with all colonic crypts in the state of all genes being wild-type and a single MMR germline variant due to Lynch syndrome, we are interested in the distribution of the crypts among the graph at different ages of the patient in order to obtain estimates for the number of crypts in specific states, e.g., adenomatous or cancerous states. (C) The underlying matrix of the dynamical system makes use of the Kronecker sum and product. It is a sparse upper triangular matrix accounting for the assumption that mutations cannot be reverted. This allows fast numerical solving by using the matrix exponential. Each nonzero entry of the matrix represents a connection between genotypic states in the graph.
@article{Haupt2021Mathematical,
author = {Haupt, Saskia and Zeilmann, Alexander and Ahadova, Aysel and Bl{\" a}ker, Hendrik and von Knebel Doeberitz, Magnus and Kloor, Matthias and Heuveline, Vincent},
journal = {PLOS Computational Biology},
editor = {Chen, Jing},
number = {5},
year = {2021},
month = {may 18},
pages = {e1008970},
publisher = {Public Library of Science (PLoS)},
title = {Mathematical modeling of multiple pathways in colorectal carcinogenesis using dynamical systems with {Kronecker} structure},
volume = {17},
}
@article{Haupt2021Mathematical,
abstract = {Like many other types of cancer, colorectal cancer (CRC) develops through multiple pathways of carcinogenesis. This is also true for colorectal carcinogenesis in Lynch syndrome (LS), the most common inherited CRC syndrome. However, a comprehensive understanding of the distribution of these pathways of carcinogenesis, which allows for tailored clinical treatment and even prevention, is still lacking. We suggest a linear dynamical system modeling the evolution of different pathways of colorectal carcinogenesis based on the involved driver mutations. The model consists of different components accounting for independent and dependent mutational processes. We define the driver gene mutation graphs and combine them using the Cartesian graph product. This leads to matrix components built by the Kronecker sum and product of the adjacency matrices of the gene mutation graphs enabling a thorough mathematical analysis and medical interpretation. Using the Kronecker structure, we developed a mathematical model which we applied exemplarily to the three pathways of colorectal carcinogenesis in LS. Beside a pathogenic germline variant in one of the DNA mismatch repair (MMR) genes, driver mutations in \textit{APC}, \textit{CTNNB1}, \textit{KRAS} and \textit{TP53} are considered. We exemplarily incorporate mutational dependencies, such as increased point mutation rates after MMR deficiency, and based on recent experimental data, biallelic somatic \textit{CTNNB1} mutations as common drivers of LS-associated CRCs. With the model and parameter choice, we obtained simulation results that are in concordance with clinical observations. These include the evolution of MMR-deficient crypts as early precursors in LS carcinogenesis and the influence of variants in MMR genes thereon. The proportions of MMR-deficient and MMR-proficient \textit{APC}-inactivated crypts as first measure for the distribution among the pathways in LS-associated colorectal carcinogenesis are compatible with clinical observations. The approach provides a modular framework for modeling multiple pathways of carcinogenesis yielding promising results in concordance with clinical observations in LS CRCs.},
author = {Haupt, Saskia and Zeilmann, Alexander and Ahadova, Aysel and Bl{\" a}ker, Hendrik and von Knebel Doeberitz, Magnus and Kloor, Matthias and Heuveline, Vincent},
journaltitle = {PLOS Computational Biology},
shortjournal = {PLoS Comput Biol},
doi = {10.1371/journal.pcbi.1008970},
editor = {Chen, Jing},
issn = {1553-7358},
number = {5},
date = {2021-05-18},
language = {en},
pages = {e1008970},
eid = {e1008970},
eprint = {34003820},
eprinttype = {pubmed},
publisher = {Public Library of Science (PLoS)},
title = {Mathematical modeling of multiple pathways in colorectal carcinogenesis using dynamical systems with {Kronecker} structure},
url = {http://dx.doi.org/10.1371/journal.pcbi.1008970},
volume = {17},
}
Lynch syndrome (LS), the most common inherited colorectal cancer (CRC) syndrome, increases the cancer risk in affected individuals. LS is caused by pathogenic germline variants in one of the DNA mismatch repair (MMR) genes, complete inactivation of which causes numerous mutations in affected cells. As CRC is believed to originate in colonic crypts, understanding the intra-crypt dynamics caused by mutational processes is essential for a complete picture of LS CRC and may have significant implications for cancer prevention. We propose a computational model describing the evolution of colonic crypts during LS carcinogenesis. Extending existing modeling approaches for the non-Lynch scenario, we incorporated MMR deficiency and implemented recent experimental data demonstrating that somatic CTNNB1 mutations are common drivers of LS-associated CRCs, if affecting both alleles of the gene. Further, we simulated the effect of different mutations on the entire crypt, distinguishing non-transforming and transforming mutations. As an example, we analyzed the spread of mutations in the genes APC and CTNNB1, which are frequently mutated in LS tumors, as well as of MMR deficiency itself. We quantified each mutation's potential for monoclonal conversion and investigated the influence of the cell location and of stem cell dynamics on mutation spread. The in silico experiments underline the importance of stem cell dynamics for the overall crypt evolution. Further, simulating different mutational processes is essential in LS since mutations without survival advantages (the MMR deficiency-inducing second hit) play a key role. The effect of other mutations can be simulated with the proposed model. Our results provide first mathematical clues towards more effective surveillance protocols for LS carriers.
Overview of the computational model of colonic crypts
Top: The colonic crypt is represented by a cylinder consisting of stem cells (red) at the bottom, transit- amplifying cells (orange) in the middle and fully-differentiated (FD) cells (green) at the top of the crypt. An active stem cell populates the crypt at any point in time. As we model LS, all cells are initialized with a germline variant in exactly one of the MMR genes. The cylinder is transformed into a rectangle with periodic boundary conditions, where the cells are represented by a Voronoi tessellation. Bottom: For each cell type, we model the cell cycle including cell division, possible mutations in one of the MMR genes, in APC and CTNNB1, and multiple death mechanisms.
@article{Haupt2020computational,
author = {Haupt, Saskia and Gleim, Nils and Ahadova, Aysel and Bl{\" a}ker, Hendrik and von Knebel Doeberitz, Magnus and Kloor, Matthias and Heuveline, Vincent},
journal = {bioRxiv},
year = {2020},
month = {dec 29},
publisher = {Cold Spring Harbor Laboratory},
title = {A computational model for investigating the evolution of colonic crypts during {Lynch} syndrome carcinogenesis},
}
@article{Haupt2020computational,
abstract = {Lynch syndrome (LS), the most common inherited colorectal cancer (CRC) syndrome, increases the cancer risk in affected individuals. LS is caused by pathogenic germline variants in one of the DNA mismatch repair (MMR) genes, complete inactivation of which causes numerous mutations in affected cells. As CRC is believed to originate in colonic crypts, understanding the intra-crypt dynamics caused by mutational processes is essential for a complete picture of LS CRC and may have significant implications for cancer prevention. We propose a computational model describing the evolution of colonic crypts during LS carcinogenesis. Extending existing modeling approaches for the non-Lynch scenario, we incorporated MMR deficiency and implemented recent experimental data demonstrating that somatic \textit{CTNNB1} mutations are common drivers of LS-associated CRCs, if affecting both alleles of the gene. Further, we simulated the effect of different mutations on the entire crypt, distinguishing non-transforming and transforming mutations. As an example, we analyzed the spread of mutations in the genes \textit{APC} and \textit{CTNNB1}, which are frequently mutated in LS tumors, as well as of MMR deficiency itself. We quantified each mutation's potential for monoclonal conversion and investigated the influence of the cell location and of stem cell dynamics on mutation spread. The \textit{in silico} experiments underline the importance of stem cell dynamics for the overall crypt evolution. Further, simulating different mutational processes is essential in LS since mutations without survival advantages (the MMR deficiency-inducing second hit) play a key role. The effect of other mutations can be simulated with the proposed model. Our results provide first mathematical clues towards more effective surveillance protocols for LS carriers.},
author = {Haupt, Saskia and Gleim, Nils and Ahadova, Aysel and Bl{\" a}ker, Hendrik and von Knebel Doeberitz, Magnus and Kloor, Matthias and Heuveline, Vincent},
journaltitle = {bioRxiv},
doi = {10.1101/2020.12.29.424555},
date = {2020-12-29},
publisher = {Cold Spring Harbor Laboratory},
title = {A computational model for investigating the evolution of colonic crypts during {Lynch} syndrome carcinogenesis},
url = {http://dx.doi.org/10.1101/2020.12.29.424555},
}
The immune system can recognize and attack cancer cells, especially those with a high load of mutation-induced neoantigens. Such neoantigens are abundant in DNA mismatch repair (MMR)-deficient, microsatellite-unstable (MSI) cancers. MMR deficiency leads to insertion/deletion (indel) mutations at coding microsatellites (cMS) and to neoantigen-inducing translational frameshifts. Here, we develop a tool to quantify frameshift mutations in MSI colorectal and endometrial cancer. Our results show that frameshift mutation frequency is negatively correlated to the predicted immunogenicity of the resulting peptides, suggesting counterselection of cell clones with highly immunogenic frameshift peptides. This correlation is absent in tumors with Beta-2-microglobulin mutations, and HLA-A*02:01 status is related to cMS mutation patterns. Importantly, certain outlier mutations are common in MSI cancers despite being related to frameshift peptides with functionally confirmed immunogenicity, suggesting a possible driver role during MSI tumor evolution. Neoantigens resulting from shared mutations represent promising vaccine candidates for prevention of MSI cancers.
@article{Ballhausen2020shared,
author = {Ballhausen, Alexej and Przybilla, Moritz Jakob and Jendrusch, Michael and Haupt, Saskia and Pfaffendorf, Elisabeth and Seidler, Florian and Witt, Johannes and Hernandez Sanchez, Alejandro and Urban, Katharina and Draxlbauer, Markus and Krausert, Sonja and Ahadova, Aysel and Kalteis, Martin Simon and Pfuderer, Pauline L. and Heid, Daniel and Stichel, Damian and Gebert, Johannes and Bonsack, Maria and Schott, Sarah and Bl{\" a}ker, Hendrik and Sepp{\" a}l{\" a}, Toni and Mecklin, Jukka-Pekka and Ten Broeke, Sanne and Nielsen, Maartje and Heuveline, Vincent and Krzykalla, Julia and Benner, Axel and Riemer, Angelika Beate and von Knebel Doeberitz, Magnus and Kloor, Matthias},
journal = {Nature Communications},
number = {1},
year = {2020},
month = {sep 21},
publisher = {{Springer Science and Business Media LLC}},
title = {The shared frameshift mutation landscape of microsatellite-unstable cancers suggests immunoediting during tumor evolution},
volume = {11},
}
@article{Ballhausen2020shared,
abstract = {The immune system can recognize and attack cancer cells, especially those with a high load of mutation-induced neoantigens. Such neoantigens are abundant in DNA mismatch repair (MMR)-deficient, microsatellite-unstable (MSI) cancers. MMR deficiency leads to insertion/deletion (indel) mutations at coding microsatellites (cMS) and to neoantigen-inducing translational frameshifts. Here, we develop a tool to quantify frameshift mutations in MSI colorectal and endometrial cancer. Our results show that frameshift mutation frequency is negatively correlated to the predicted immunogenicity of the resulting peptides, suggesting counterselection of cell clones with highly immunogenic frameshift peptides. This correlation is absent in tumors with \textit{Beta-2-microglobulin} mutations, and HLA-A*02:01 status is related to cMS mutation patterns. Importantly, certain outlier mutations are common in MSI cancers despite being related to frameshift peptides with functionally confirmed immunogenicity, suggesting a possible driver role during MSI tumor evolution. Neoantigens resulting from shared mutations represent promising vaccine candidates for prevention of MSI cancers.},
author = {Ballhausen, Alexej and Przybilla, Moritz Jakob and Jendrusch, Michael and Haupt, Saskia and Pfaffendorf, Elisabeth and Seidler, Florian and Witt, Johannes and Hernandez Sanchez, Alejandro and Urban, Katharina and Draxlbauer, Markus and Krausert, Sonja and Ahadova, Aysel and Kalteis, Martin Simon and Pfuderer, Pauline L. and Heid, Daniel and Stichel, Damian and Gebert, Johannes and Bonsack, Maria and Schott, Sarah and Bl{\" a}ker, Hendrik and Sepp{\" a}l{\" a}, Toni and Mecklin, Jukka-Pekka and Ten Broeke, Sanne and Nielsen, Maartje and Heuveline, Vincent and Krzykalla, Julia and Benner, Axel and Riemer, Angelika Beate and von Knebel Doeberitz, Magnus and Kloor, Matthias},
journaltitle = {Nature Communications},
shortjournal = {Nat Commun},
doi = {10.1038/s41467-020-18514-5},
issn = {2041-1723},
number = {1},
date = {2020-09-21},
language = {en},
eprint = {32958755},
eprinttype = {pubmed},
publisher = {{Springer Science and Business Media LLC}},
title = {The shared frameshift mutation landscape of microsatellite-unstable cancers suggests immunoediting during tumor evolution},
url = {http://dx.doi.org/10.1038/s41467-020-18514-5},
volume = {11},
}
H. BlĂ€ker, S. Haupt, M. Morak, E. HolinskiâFeder, A. Arnold, D. Horst, J. SieberâFrank, F. Seidler, M. Winterfeld, E. Alwers, J. ChangâClaude, H. Brenner, W. Roth, C. Engel, M. Löffler, G. Möslein, H. Schackert, J. Weitz, C. Perne, S. Aretz, R. HĂŒneburg, W. Schmiegel, D. Vangala, N. Rahner, V. SteinkeâLange, V. Heuveline, M. von Knebel Doeberitz, A. Ahadova, M. Hoffmeister, M. Kloor, The German Consortium for Familial Intestinal Cancer: Age-dependent performance of BRAF mutation testing in Lynch syndrome diagnostics. International Journal of Cancer, September 2020 DOI: 10.1002/ijc.33273
BRAF V600E mutations have been reported as a marker of sporadic microsatellite instability (MSI) colorectal cancer (CRC).Current international diagnostic guidelines recommend BRAF mutation testing in MSI CRC patients to predict low risk of Lynch syndrome (LS). We evaluated the age-specific performance of BRAF testing in LS diagnostics. We systematically compared the prevalence of BRAF mutations in LS-associated CRCs and unselected MSI CRCs in different age groups as available from published studies, databases and population-based patient cohorts. Sensitivity/specificity analysis of BRAF testing for exclusion of LS and cost calculations were performed. Among 969 MSI CRCs from LS carriers in the literature and German HNPCC Consortium, 15 (1.6 %) harbored BRAF mutations. Six of seven LS patients with BRAF-mutant CRC and reported age were < 50âyears. Among 339 of 756 (44.8 %) of BRAF mutations detected in unselected MSI CRC, only 2 of 339 (0.6 %) BRAF mutations were detected in patients < 50âyears. The inclusion of BRAF testing led to high risk of missing LS patients and increased costs at age < 50âyears. BRAF testing in patients < 50âyears carries a high risk of missing a hereditary cancer predisposition and is cost-inefficient. We suggest direct referral of MSI CRC patients < 50âyears to genetic counseling without BRAF testing.
â
BRAF mutation testing correctly identifies sporadic MSI CRC patients and saves germline analysis costs in patients aged â„60, whereas in patients aged < 50âyears, BRAF mutation testing leads to misclassification of true LS carriers as sporadic MSI CRC patients and to increased costs of analyses
@article{Blaker2020Age,
author = {Bl{\" a}ker, Hendrik and Haupt, Saskia and Morak, Monika and HolinskiFeder, Elke and Arnold, Alexander and Horst, David and SieberFrank, Julia and Seidler, Florian and Winterfeld, Moritz and Alwers, Elizabeth and ChangClaude, Jenny and Brenner, Hermann and Roth, Wilfried and Engel, Christoph and L{\" o}ffler, Markus and M{\" o}slein, Gabriela and Schackert, HansKonrad and Weitz, J{\" u}rgen and Perne, Claudia and Aretz, Stefan and H{\" u}neburg, Robert and Schmiegel, Wolff and Vangala, Deepak and Rahner, Nils and SteinkeLange, Verena and Heuveline, Vincent and von Knebel Doeberitz, Magnus and Ahadova, Aysel and Hoffmeister, Michael and Kloor, Matthias},
journal = {International Journal of Cancer},
number = {10},
year = {2020},
month = {sep 14},
pages = {2801--2810},
publisher = {Wiley},
title = {Age-dependent performance of \textit{{BRAF}} mutation testing in {Lynch} syndrome diagnostics},
volume = {147},
}
@article{Blaker2020Age,
abstract = {BRAF V600E mutations have been reported as a marker of sporadic microsatellite instability (MSI) colorectal cancer (CRC).Current international diagnostic guidelines recommend \textit{BRAF} mutation testing in MSI CRC patients to predict low risk of Lynch syndrome (LS). We evaluated the age-specific performance of \textit{BRAF} testing in LS diagnostics. We systematically compared the prevalence of \textit{BRAF} mutations in LS-associated CRCs and unselected MSI CRCs in different age groups as available from published studies, databases and population-based patient cohorts. Sensitivity/specificity analysis of \textit{BRAF} testing for exclusion of LS and cost calculations were performed. Among 969 MSI CRCs from LS carriers in the literature and German HNPCC Consortium, 15 (1.6 %) harbored \textit{BRAF} mutations. Six of seven LS patients with \textit{BRAF}-mutant CRC and reported age were \textless{} 50 years. Among 339 of 756 (44.8 %) of \textit{BRAF} mutations detected in unselected MSI CRC, only 2 of 339 (0.6 %) \textit{BRAF} mutations were detected in patients \textless{} 50 years. The inclusion of \textit{BRAF} testing led to high risk of missing LS patients and increased costs at age \textless{} 50 years. \textit{BRAF} testing in patients \textless{} 50 years carries a high risk of missing a hereditary cancer predisposition and is cost-inefficient. We suggest direct referral of MSI CRC patients \textless{} 50 years to genetic counseling without \textit{BRAF} testing.},
author = {Bl{\" a}ker, Hendrik and Haupt, Saskia and Morak, Monika and HolinskiFeder, Elke and Arnold, Alexander and Horst, David and SieberFrank, Julia and Seidler, Florian and Winterfeld, Moritz and Alwers, Elizabeth and ChangClaude, Jenny and Brenner, Hermann and Roth, Wilfried and Engel, Christoph and L{\" o}ffler, Markus and M{\" o}slein, Gabriela and Schackert, HansKonrad and Weitz, J{\" u}rgen and Perne, Claudia and Aretz, Stefan and H{\" u}neburg, Robert and Schmiegel, Wolff and Vangala, Deepak and Rahner, Nils and SteinkeLange, Verena and Heuveline, Vincent and von Knebel Doeberitz, Magnus and Ahadova, Aysel and Hoffmeister, Michael and Kloor, Matthias},
journaltitle = {International Journal of Cancer},
shortjournal = {Int. J. Cancer},
doi = {10.1002/ijc.33273},
issn = {0020-7136},
number = {10},
date = {2020-09-14},
language = {en},
pages = {2801--2810},
eprint = {32875553},
eprinttype = {pubmed},
publisher = {Wiley},
title = {Age-dependent performance of \textit{{BRAF}} mutation testing in {Lynch} syndrome diagnostics},
url = {http://dx.doi.org/10.1002/ijc.33273},
volume = {147},
}
Like many other tumors, colorectal cancers develop through multiple pathways containing different driver mutations. This is also true for colorectal carcinogenesis in Lynch syndrome, the most common inherited colorectal cancer syndrome. However, a comprehensive understanding of Lynch syndrome tumor evolution which allows for tailored clinical treatment and even prevention is still lacking. We suggest a linear autonomous dynamical system modeling the evolution of the different pathways. Starting with the gene mutation graphs of the driver genes, we formulate three key assumptions about how these different mutations might be combined. This approach leads to a dynamical system that is built by the Kronecker sum of the adjacency matrices of the gene mutation graphs. This Kronecker structure makes the dynamical system amenable to a thorough mathematical analysis and medical interpretation, even if the number of incorporated genes or possible mutation states is increased. For the case that some of the mathematical key assumptions are not satisfied, we explain possible extensions to our model. Additionally, improved bio-medical measurements or novel medical insights can be integrated into the model in a straightforward manner, as all parameters in the model have a biological interpretation. Modifications of the model are able to account for other forms of colorectal carcinogenesis, such as Lynch-like and familial adenomatous polyposis cases.
From the Medical Hypothesis Over the Modeling Approach To the Mathematical Structure.
The medical hypothesis of multiple pathways in carcinogenesis is widely known for various types of cancer. Left: We present a model for this phenomenon at the example of Lynch syndrome, the most common inherited colorectal cancer syndrome, with specific key driver events in the MMR genes, CTNNB1, APC, KRAS and TP53. Middle: This current medical understanding of carcinogenesis is translated into a mathematical model using a specific dynamical system, which can be represented by a graph structure, where each vertex in the graph represents a genotypic state and the edges correspond to the transition probabilities between those states. Starting with all colonic crypts in the state of all genes being wild-type and a single MMR germline mutation due to Lynch syndrome, we are interested in the distribution of the crypts among the graph at different ages of the patient in order to obtain estimates for the number of crypts in specific states, e.g. adenomatous or cancerous states. Right: The underlying matrix of the dynamical system makes use of the Kronecker sum and product. It is a sparse upper triangular matrix accounting for the assumption that mutations cannot be reverted. This allows fast numerical solving by using the matrix exponential. Each nonzero entry of the matrix represents a connection between genotypic states in the graph.
@article{Haupt2020Mathematical,
author = {Haupt, Saskia and Zeilmann, Alexander and Ahadova, Aysel and von Knebel Doeberitz, Magnus and Kloor, Matthias and Heuveline, Vincent},
journal = {bioRxiv},
year = {2020},
month = {aug 14},
publisher = {Cold Spring Harbor Laboratory},
title = {Mathematical {Modeling} of {Multiple} {Pathways} in {Colorectal} {Carcinogenesis} using {Dynamical} {Systems} with {Kronecker} {Structure}},
}
@article{Haupt2020Mathematical,
abstract = {Like many other tumors, colorectal cancers develop through multiple pathways containing different driver mutations. This is also true for colorectal carcinogenesis in Lynch syndrome, the most common inherited colorectal cancer syndrome. However, a comprehensive understanding of Lynch syndrome tumor evolution which allows for tailored clinical treatment and even prevention is still lacking. We suggest a linear autonomous dynamical system modeling the evolution of the different pathways. Starting with the gene mutation graphs of the driver genes, we formulate three key assumptions about how these different mutations might be combined. This approach leads to a dynamical system that is built by the Kronecker sum of the adjacency matrices of the gene mutation graphs. This Kronecker structure makes the dynamical system amenable to a thorough mathematical analysis and medical interpretation, even if the number of incorporated genes or possible mutation states is increased. For the case that some of the mathematical key assumptions are not satisfied, we explain possible extensions to our model. Additionally, improved bio-medical measurements or novel medical insights can be integrated into the model in a straightforward manner, as all parameters in the model have a biological interpretation. Modifications of the model are able to account for other forms of colorectal carcinogenesis, such as Lynch-like and familial adenomatous polyposis cases.},
author = {Haupt, Saskia and Zeilmann, Alexander and Ahadova, Aysel and von Knebel Doeberitz, Magnus and Kloor, Matthias and Heuveline, Vincent},
journaltitle = {bioRxiv},
doi = {10.1101/2020.08.14.250175},
date = {2020-08-14},
publisher = {Cold Spring Harbor Laboratory},
title = {Mathematical {Modeling} of {Multiple} {Pathways} in {Colorectal} {Carcinogenesis} using {Dynamical} {Systems} with {Kronecker} {Structure}},
url = {http://dx.doi.org/10.1101/2020.08.14.250175},
}
2019
H. BlĂ€ker, S. Haupt, M. Morak, E. Holinski-Feder, A. Arnold, D. Horst, J. Sieber-Frank, F. Seidler, M. von Winterfeld, E. Alwers, J. Chang-Claude, H. Brenner, W. Roth, C. Engel, M. Löffler, G. Möslein, H. Schackert, J. Weitz, C. Perne, S. Aretz, R. HĂŒneburg, W. Schmiegel, D. Vangala, N. Rahner, V. Steinke-Lange, V. Heuveline, M. von Knebel Doeberitz, A. Ahadova, M. Hoffmeister, M. Kloor, the German Consortium for Familial Intestinal Cancer: BRAF mutation testing of MSI CRCs in Lynch syndrome diagnostics: performance and efficiency according to patient's age. medRxiv, October 2019. Preprint DOI: 10.1101/19009274
Background and aimsBRAF V600E mutations have been reported to be associated with sporadic microsatellite-unstable (MSI) colorectal cancer (CRC), while rarely detected in CRCs of Lynch syndrome (LS) patients. Therefore, current international diagnostic guidelines recommend somatic BRAF mutation testing in MLH1-deficient MSI CRC patients to exclude LS. As sporadic BRAF-mutant MSI CRC is a disease of the elderly, while LS-associated CRC usually occurs at younger age, we hypothesized that the efficacy of BRAF testing in LS diagnostics may be age-dependent. Methods We systematically compared the prevalence of BRAF V600E mutations in LS-associated CRCs and MSI CRCs from population-based cohorts in different age groups as available from published studies, databases, and population-based patient cohorts. Cost calculations and sensitivity analysis of the BRAF testing for exclusion of LS was performed. Results Among 969 MSI CRCs from LS mutation carriers from the literature and German HNPCC Consortium, 15 (1.6%, 95% CI: 0.9-2.6%) harbored BRAF mutations. 6/7 LS patients with BRAF-mutant CRC and reported age were <50 years. Among unselected MSI CRCs, 44.8% (339/756) harbored BRAF mutations, 92.3% (313/339) of which were detected in patients >60 years. In MSI CRC patients <50, BRAF mutations were detected only in 0.6% (2/339), and the inclusion of BRAF testing led to increased costs and higher risk of missing LS patients (1.2%) compared to other age groups. ConclusionBRAF testing in patients <50 years is cost-inefficient and carries the highest risk of missing LS patients among different age groups. We suggest direct referral of MSI CRC patients <50 years to genetic counseling without prior BRAF testing.
@article{Blaker2019BRAF,
author = {Bl{\" a}ker, Hendrik and Haupt, Saskia and Morak, Monika and Holinski-Feder, Elke and Arnold, Alexander and Horst, David and Sieber-Frank, Julia and Seidler, Florian and von Winterfeld, Moritz and Alwers, Elizabeth and Chang-Claude, Jenny and Brenner, Hermann and Roth, Wilfried and Engel, Christoph and L{\" o}ffler, Markus and M{\" o}slein, Gabriela and Schackert, Hans-Konrad and Weitz, J{\" u}rgen and Perne, Claudia and Aretz, Stefan and H{\" u}neburg, Robert and Schmiegel, Wolff and Vangala, Deepak and Rahner, Nils and Steinke-Lange, Verena and Heuveline, Vincent and von Knebel Doeberitz, Magnus and Ahadova, Aysel and Hoffmeister, Michael and Kloor, Matthias},
journal = {medRxiv},
year = {2019},
month = {oct 16},
publisher = {Cold Spring Harbor Laboratory},
title = {\textit{{BRAF}} mutation testing of {MSI} {CRCs} in {Lynch} syndrome diagnostics: performance and efficiency according to patient's age},
}
@article{Blaker2019BRAF,
abstract = {\textbf{Background and aims} \textit{BRAF} V600E mutations have been reported to be associated with sporadic microsatellite-unstable (MSI) colorectal cancer (CRC), while rarely detected in CRCs of Lynch syndrome (LS) patients. Therefore, current international diagnostic guidelines recommend somatic \textit{BRAF} mutation testing in MLH1-deficient MSI CRC patients to exclude LS. As sporadic \textit{BRAF}-mutant MSI CRC is a disease of the elderly, while LS-associated CRC usually occurs at younger age, we hypothesized that the efficacy of \textit{BRAF} testing in LS diagnostics may be age-dependent. \textbf{Methods} We systematically compared the prevalence of \textit{BRAF} V600E mutations in LS-associated CRCs and MSI CRCs from population-based cohorts in different age groups as available from published studies, databases, and population-based patient cohorts. Cost calculations and sensitivity analysis of the \textit{BRAF} testing for exclusion of LS was performed. \textbf{Results} Among 969 MSI CRCs from LS mutation carriers from the literature and German HNPCC Consortium, 15 (1.6%, 95% CI: 0.9-2.6%) harbored \textit{BRAF} mutations. 6/7 LS patients with \textit{BRAF}-mutant CRC and reported age were <50 years. Among unselected MSI CRCs, 44.8% (339/756) harbored \textit{BRAF} mutations, 92.3% (313/339) of which were detected in patients >60 years. In MSI CRC patients <50, \textit{BRAF} mutations were detected only in 0.6% (2/339), and the inclusion of \textit{BRAF} testing led to increased costs and higher risk of missing LS patients (1.2%) compared to other age groups. \textbf{Conclusion} \textit{BRAF} testing in patients <50 years is cost-inefficient and carries the highest risk of missing LS patients among different age groups. We suggest direct referral of MSI CRC patients <50 years to genetic counseling without prior \textit{BRAF} testing.},
author = {Bl{\" a}ker, Hendrik and Haupt, Saskia and Morak, Monika and Holinski-Feder, Elke and Arnold, Alexander and Horst, David and Sieber-Frank, Julia and Seidler, Florian and von Winterfeld, Moritz and Alwers, Elizabeth and Chang-Claude, Jenny and Brenner, Hermann and Roth, Wilfried and Engel, Christoph and L{\" o}ffler, Markus and M{\" o}slein, Gabriela and Schackert, Hans-Konrad and Weitz, J{\" u}rgen and Perne, Claudia and Aretz, Stefan and H{\" u}neburg, Robert and Schmiegel, Wolff and Vangala, Deepak and Rahner, Nils and Steinke-Lange, Verena and Heuveline, Vincent and von Knebel Doeberitz, Magnus and Ahadova, Aysel and Hoffmeister, Michael and Kloor, Matthias},
journaltitle = {medRxiv},
doi = {10.1101/19009274},
date = {2019-10-16},
publisher = {Cold Spring Harbor Laboratory},
title = {\textit{{BRAF}} mutation testing of {MSI} {CRCs} in {Lynch} syndrome diagnostics: performance and efficiency according to patient's age},
url = {http://dx.doi.org/10.1101/19009274},
}
A. Ballhausen, M. Przybilla, M. Jendrusch, S. Haupt, E. Pfaffendorf, M. Draxlbauer, F. Seidler, S. Krausert, A. Ahadova, M. Kalteis, D. Heid, J. Gebert, M. Bonsack, S. Schott, H. BlÀker, T. SeppÀlÀ, J. Mecklin, S. Broeke, M. Nielsen, V. Heuveline, J. Krzykalla, A. Benner, A. Riemer, M. von Knebel Doeberitz, M. Kloor: The shared neoantigen landscape of MSI cancers reflects immunoediting during tumor evolution. bioRxiv, July 2019. Preprint DOI: 10.1101/691469
The immune system can recognize and attack cancer cells, especially those with a high load of mutation-induced neoantigens. Such neoantigens are particularly abundant in DNA mismatch repair (MMR)-deficient, microsatellite-unstable (MSI) cancers. MMR deficiency leads to insertion/deletion (indel) mutations at coding microsatellites (cMS) and to neoantigen-inducing translational frameshifts. The abundance of mutational neoantigens renders MSI cancers sensitive to immune checkpoint blockade. However, the neoantigen landscape of MMR-deficient cancers has not yet been systematically mapped. In the present study, we used a novel tool to monitor neoantigen-inducing indel mutations in MSI colorectal and endometrial cancer. Our results show that MSI cancers share several highly immunogenic neoantigens that result from specific, recurrent indel mutation events. Notably, the frequency of such indel mutations was negatively correlated to the predicted immunogenicity of the resulting neoantigens. These observations suggest continuous immunoediting of emerging MMR-deficient cells during tumor evolution.
@article{Ballhausen2019shared,
author = {Ballhausen, Alexej and Przybilla, Moritz Jakob and Jendrusch, Michael and Haupt, Saskia and Pfaffendorf, Elisabeth and Draxlbauer, Markus and Seidler, Florian and Krausert, Sonja and Ahadova, Aysel and Kalteis, Martin Simon and Heid, Daniel and Gebert, Johannes and Bonsack, Maria and Schott, Sarah and Bl{\" a}ker, Hendrik and Sepp{\" a}l{\" a}, Toni and Mecklin, Jukka-Pekka and Broeke, Sanne Ten and Nielsen, Maartje and Heuveline, Vincent and Krzykalla, Julia and Benner, Axel and Riemer, Angelika Beate and von Knebel Doeberitz, Magnus and Kloor, Matthias},
journal = {bioRxiv},
year = {2019},
month = {jul 16},
publisher = {Cold Spring Harbor Laboratory},
title = {The shared neoantigen landscape of {MSI} cancers reflects immunoediting during tumor evolution},
}
@article{Ballhausen2019shared,
abstract = {The immune system can recognize and attack cancer cells, especially those with a high load of mutation-induced \textit{neo}antigens. Such \textit{neo}antigens are particularly abundant in DNA mismatch repair (MMR)-deficient, microsatellite-unstable (MSI) cancers. MMR deficiency leads to insertion/deletion (indel) mutations at coding microsatellites (cMS) and to \textit{neo}antigen-inducing translational frameshifts. The abundance of mutational \textit{neo}antigens renders MSI cancers sensitive to immune checkpoint blockade. However, the neoantigen landscape of MMR-deficient cancers has not yet been systematically mapped. In the present study, we used a novel tool to monitor \textit{neo}antigen-inducing indel mutations in MSI colorectal and endometrial cancer. Our results show that MSI cancers share several highly immunogenic \textit{neo}antigens that result from specific, recurrent indel mutation events. Notably, the frequency of such indel mutations was negatively correlated to the predicted immunogenicity of the resulting \textit{neo}antigens. These observations suggest continuous immunoediting of emerging MMR-deficient cells during tumor evolution.},
author = {Ballhausen, Alexej and Przybilla, Moritz Jakob and Jendrusch, Michael and Haupt, Saskia and Pfaffendorf, Elisabeth and Draxlbauer, Markus and Seidler, Florian and Krausert, Sonja and Ahadova, Aysel and Kalteis, Martin Simon and Heid, Daniel and Gebert, Johannes and Bonsack, Maria and Schott, Sarah and Bl{\" a}ker, Hendrik and Sepp{\" a}l{\" a}, Toni and Mecklin, Jukka-Pekka and Broeke, Sanne Ten and Nielsen, Maartje and Heuveline, Vincent and Krzykalla, Julia and Benner, Axel and Riemer, Angelika Beate and von Knebel Doeberitz, Magnus and Kloor, Matthias},
journaltitle = {bioRxiv},
doi = {10.1101/691469},
date = {2019-07-16},
publisher = {Cold Spring Harbor Laboratory},
title = {The shared neoantigen landscape of {MSI} cancers reflects immunoediting during tumor evolution},
url = {http://dx.doi.org/10.1101/691469},
}
2017
S. Gawlok, P. Gerstner, S. Haupt, V. Heuveline, J. Kratzke, P. Lösel, K. Mang, M. Schmidtobreick, N. Schoch, N. Schween, J. Schwegler, C. Song, M. Wlotzka: HiFlow3 â Technical Report on Release 2.0. Preprint Series of the Engineering Mathematics and Computing Lab, November 2017 DOI: 10.11588/EMCLPP.2017.06.42879
HiFlow3 Version 2.0 continues the path as a multi-purpose finite element software, which provides powerful tools for efficient and accurate solution of a wide range of problems modeled by partial differen- tial equations (PDEs). New features and functionalities, which allow to run numerical simulations with more advanced solution algorithms and discretizations in comparison to previous releases of HiFlow3, have been implemented. These comprise Uncertainty Quantification (UQ), energy-efficient multigrid techniques, Schur complement solvers for saddle-point problems, extended third-party library support, and adaptive local mesh refinement in a parallel computing environment. Furthermore, HiFlow3 has been successfully integrated into advanced and state-of-the-art simulation environments by means of the Medical Simulation Markup Language (MSML), for example.
The presented new algorithms and features as well as general under-the-hood improvements have enabled excellent and relevant research activities in the fields of both medical engineering and meteorol- ogy and environmental sciences. The described show cases demonstrate the potential and advantages, which HiFlow3 can offer in performing a numerical simulation by means of finite element methods. Especially, the high performance computing capabilities of HiFlow3 â not only in the mentioned fields of applications, but also in general â have been significantly improved in Version 2.0.
@article{Gawlok2017HiFlow3,
author = {Gawlok, Simon and Gerstner, Philipp and Haupt, Saskia and Heuveline, Vincent and Kratzke, Jonas and L{\" o}sel, Philipp and Mang, Katrin and Schmidtobreick, Mareike and Schoch, Nicolai and Schween, Nils and Schwegler, Jonathan and Song, Chen and Wlotzka, Martin},
journal = {Preprint Series of the Engineering Mathematics and Computing Lab},
year = {2017},
month = {nov 22},
pages = {No 06 (2017): HiFlow3 -- Technical Report on Release 2.0},
publisher = {Heidelberg University, Interdisciplinary Center for Scientific Computing (IWR)},
title = {HiFlow3 -- {Technical} {Report} on {Release} 2.0},
}
@article{Gawlok2017HiFlow3,
abstract = {HiFlow3 Version 2.0 continues the path as a multi-purpose finite element software, which provides powerful tools for efficient and accurate solution of a wide range of problems modeled by partial differen- tial equations (PDEs). New features and functionalities, which allow to run numerical simulations with more advanced solution algorithms and discretizations in comparison to previous releases of HiFlow3, have been implemented. These comprise Uncertainty Quantification (UQ), energy-efficient multigrid techniques, Schur complement solvers for saddle-point problems, extended third-party library support, and adaptive local mesh refinement in a parallel computing environment. Furthermore, HiFlow3 has been successfully integrated into advanced and state-of-the-art simulation environments by means of the Medical Simulation Markup Language (MSML), for example.
The presented new algorithms and features as well as general under-the-hood improvements have enabled excellent and relevant research activities in the fields of both medical engineering and meteorol- ogy and environmental sciences. The described show cases demonstrate the potential and advantages, which HiFlow3 can offer in performing a numerical simulation by means of finite element methods. Especially, the high performance computing capabilities of HiFlow3 -- not only in the mentioned fields of applications, but also in general -- have been significantly improved in Version 2.0.},
author = {Gawlok, Simon and Gerstner, Philipp and Haupt, Saskia and Heuveline, Vincent and Kratzke, Jonas and L{\" o}sel, Philipp and Mang, Katrin and Schmidtobreick, Mareike and Schoch, Nicolai and Schween, Nils and Schwegler, Jonathan and Song, Chen and Wlotzka, Martin},
journaltitle = {Preprint Series of the Engineering Mathematics and Computing Lab},
doi = {10.11588/EMCLPP.2017.06.42879},
date = {2017-11-22},
language = {en},
pages = {No 06 (2017): HiFlow3 -- Technical Report on Release 2.0},
publisher = {Heidelberg University, Interdisciplinary Center for Scientific Computing (IWR)},
title = {HiFlow3 -- {Technical} {Report} on {Release} 2.0},
url = {https://journals.ub.uni-heidelberg.de/index.php/emcl-pp/article/view/42879},
}
