ARTICLE
Recei ed 7 Sep 2015 |Accep ed 13 Jul 2016 |Published 12 Sep 2016
Mu a ional signa u es o ionizing adia ion
in second malignancies
Sam Behja i1,2,*, Gunes Gundem1,*, Da id C. Wedge1,3, Nicola D. Robe s1, Pa ick S. Ta pey1,
Susanna L. Cooke1, Pe e Van Loo4,5, Ludmil B. Alexand o 1, Manasa Ramak ishna1, Helen Da ies1,
Se ena Nik-Zainal1, Clai e Ha dy1, Calli La ime 1, Kei an M. Raine1, Lucy S ebbings1, Andy Menzies1, Da id Jones1,
Rebecca Shephe d1, Adam P. Bu le 1, Jon W. Teague1, Me e Jo gensen6, Bha isha Kha i7, Nischalan Pillay6,7,
Adam Shlien1,8, P. And ew Fu eal1,9, Ch is ophe Badie10, ICGC P os a e G oupz, Ul an McDe mo 1,
G. S e en Bo a11, And ea L. Richa dson12,13,w, Ad ienne M. Flanagan6,7, Michael R. S a on1
& Pe e J. Campbell1,14
Ionizing adia ion is a po en ca cinogen, inducing cance h ough DNA damage. The signa u es
o mu a ions a ising in human issues ollowing in i o exposu e o ionizing adia ion ha e no
been documen ed. He e, we sea ched o signa u es o ionizing adia ion in 12 adia ion-asso-
cia ed second malignancies o di e en umou ypes. Two signa u es o soma ic mu a ion
cha ac e ize ionizing adia ion exposu e i espec i e o umou ype. Compa ed wi h 319
adia ion-nai e umou s, adia ion-associa ed umou s ca y a median ex a 201 dele ions
genome-wide, sized 1–100 base pai s o en wi h mic ohomology a he junc ion. Unlike dele ions
o adia ion-nai e umou s, hese show no a ia ion in densi y ac oss he genome o co ela ion
wi h sequence con ex , eplica ion iming o ch oma in s uc u e. Fu he mo e, we obse e a
significan inc ease in balanced in e sions in adia ion-associa ed umou s. Bo h small dele ions
and in e sions gene a e d i e mu a ions. Thus, ionizing adia ion gene a es dis inc i e mu a-
ional signa u es ha explain i s ca cinogenic po en ial.
DOI: 10.1038/ncomms12605 OPEN
1Cance Genome P ojec , Wellcome T us Sange Ins i u e, Wellcome T us Genome Campus, Hinx on, Camb idgeshi e CB10 1SA UK. 2Depa men o Paedia ics, Uni e si y o
Camb idge, Camb idge CB2 0QQ, UK. 3Ox o d Big Da a Ins i u e and Ox o d Cen e o Cance Gene Resea ch, Wellcome T us Cen e o Human Gene ics, Roose el D i e,
Ox o d OX3 7BN, UK. 4The F ancis C ick Ins i u e, London WC2A 3LY, UK. 5Depa men o Human Gene ics, Uni e si y o Leu en, Leu en B-3000, Belgium. 6Uni e si y College
London Cance Ins i u e, Hun ley S ee , London WC1E 6BT, UK. 7His opa hology, Royal Na ional O hopaedic Hospi al NHS T us , S anmo e, Middlesex HA7 4LP, UK.
8Depa men o Paedia ic Labo a o y Medicine, The Hospi al o Sick Child en, To on o, On a io, Canada M5G 1X8. 9Depa men o Genomic Medicine, MD Ande son Cance
Cen e , Uni e si y o Texas, Hous on, Texas 77030, USA. 10 Cance Mechanisms and Bioma ke s G oup, Radia ion E ec s Depa men , Cen e o Radia ion Chemical and
En i onmen al Haza ds, Public Heal h England, Chil on, Didco OX11 0RQ, UK. 11 Ins i u e o Biosciences and Medical Technology, BioMediTech, Uni e si y o Tampe e and Fimlab
Labo a o ies, Tampe e Uni e si y Hospi al, Tampe e FI-33520, Finland. 12 Dana-Fa be Cance Ins i u e, Bos on, Massachuse s 02215-5450, USA. 13 B igham and Women’s
Hospi al, Ha a d Medical School, Bos on, Massachuse s 02115 USA. 14 Depa men o Haema ology, Uni e si y o Camb idge, Hills Road, Camb idge CB2 2XY, UK. * These
au ho s con ibu ed equally o his wo k. wP esen add ess: Sibley Memo ial Hospi al, Johns Hopkins Medicine, Washing on, Dis ic O Columbia 20016, USA. Co espondence
and eques s o ma e ials should be add essed o P.J.C. (email: pc8@sange .ac.uk).
zA ull lis o conso ium membe s appea s a he end o he pape .
NATURE COMMUNICATIONS | 7:12605 | DOI: 10.1038/ncomms12605 | www.na u e.com/na u ecommunica ions 1
Exposu e o ionizing adia ion inc eases he isk o
subsequen cance . This isk exhibi s a s ong dose–
esponse ela ionship, and he e appea o be no sa e limi s
o adia ion exposu e1. This associa ion was fi s no ed by Ma ch
who obse ed an inc eased incidence o leukaemia amongs
adiologis s2. A leading cause o adia ion-induced cance s
appea s o be exposu e o medical adia ion, ei he in he o m
o adio he apy o an un ela ed malignancy3o diagnos ic
adiog aphy4,5. These ia ogenic umou s a ise as de no o
neoplasms in a field o he apeu ic adia ion a e a la ency
pe iod ha can span decades6, and a e no ecu ences o he
o iginal cance 7.
Many, bu no all, en i onmen al ca cinogens induce cance by
inc easing he a e o mu a ion in soma ic cells. The physico-
chemical p ope ies o a gi en ca cinogen go e n i s in e ac ion
wi h DNA, leading o ecu en ‘signa u es’ o pa e ns o
mu a ions in he genome. These can be econs uc ed ei he om
expe imen al model sys ems8,9 o om s a is ical analyses o
cance genomes in exposed pa ien s10–12. Ionizing adia ion
di ec ly damages DNA, and can gene a e lesions on single bases,
single-s anded nicks in he DNA backbone, clus e ed lesions a
se e al nea by si es and double-s anded DNA b eaks13.In
expe imen al sys ems exposed o adia ion, including he mu ine
ge mline and A abidopsis haliana cells, ionizing adia ion can
cause all classes o mu a ions, wi h possible en ichmen o
indels14–22. Ta ge ed gene sc eens in adia ion-induced sa coma
ha e indica ed an inc eased bu den o dele ions and subs i u ions
wi h equen inac i a ion o TP53 and RB1 ( e s 23–25). In
addi ion, a ansc ip ome p ofile ha ep esen s a s a e o ch onic
oxida i e s ess has been p oposed o be specific o adia ion-
associa ed sa coma26.
We s udied he genomes o 12 adia ion-associa ed second
malignancies o ou di e en umou ypes: os eosa coma;
spindle cell sa coma; angiosa coma; b eas cance . These we e
seconda y umou s ha a ose wi hin a field o he apeu ic
ionizing adia ion and we e no hough o be ecu ences o he
o iginal malignancy ea ed wi h adia ion. We chose his
expe imen al design o se e al easons: he umou s a e classic
adio he apy-induced cance s wi h high a ibu able isks o he
adia ion exposu e; he adia ion exposu e occu s o e a sho
ime pe iod ela i e o he e olu ion o he cance ; and he
mu a ional signa u es o spo adic b eas cance s and sa comas
ha e been well documen ed10,27–29. I should be no ed ha in he
absence o bioma ke s, a diagnosis o a umou being adia ion-
induced canno be defini i ely made (see Supplemen a y No e 1
o clinical de ails and u he discussion).
We subjec ed hese 12 umou s, along wi h no mal issues om
he same pa ien s, o whole-genome sequencing and ob ained
ca alogues o soma ic mu a ions. We compa ed ou findings o
319 adia ion-nai e b eas cance s and sa comas p ocessed by he
same sequencing and bioin o ma ics pipeline: 251 b eas
umou s; 33 b eas umou s wi h pa hogenic BRCA1 o BRCA2
ge mline mu a ions; 35 os eosa comas (see Me hods o coho
de ails). In addi ion, we alida ed ou findings in a published
se ies o adia ion-naı
¨ e and adia ion-exposed p os a e umou s
om en pa ien s30.
The main aim o ou analyses was o sea ch o umou - ype
independen , o e a ching signa u es o ionizing adia ion. O e all
we iden ified wo such signa u es in adia ion-associa ed second
malignancies, an excess o balanced in e sions and o small
dele ions.
Resul s
Tumou - ype specific ea u es. The 12 adia ion-associa ed
umou s ha bou ed 1,506–9,245 subs i u ions pe genome
(median 4113), 135–943 indels pe genome, (median 429) and
6–321 ea angemen b eak poin s pe genome (median 74;
Supplemen a y Da a 1–3). The obse ed d i e mu a ions
ollowed he pa e ns expec ed o he umou ype consis en ly
(Supplemen a y Table 1). Angiosa comas ha bou ed PTPRB and
PLCG1 mu a ions. In spindle cell sa coma and os eosa coma
d i e al e a ion o TP53 and CDKN2A we e ound. Canonical
PIK3CA mu a ions we e seen in he adia ion-associa ed b eas
umou s. Simila ly, many o he mu a ional signa u es seen in
spo adic cance s we e also p esen in adia ion-associa ed
umou s, such as ch omo h ipsis in sa comas (Supplemen a y
Fig. 1). Agains his backd op o genomic di e si y, we ound
e idence o wo mu a ional signa u es in he adia ion-associa ed
cance s ha anscended umou ype: small dele ions and
balanced in e sions.
En ichmen o dele ions in adia ion-associa ed umou s.
Al hough he absolu e bu den o indels a ied ac oss he 12
adia ion-associa ed umou s, in each umou he indel bu den
was high compa ed wi h ha umou ’s subs i u ion bu den
(Fig. 1a). Compa ed wi h 319 adia ion-nai e umou s, he indel/
subs i u ion a io was significan ly inc eased in adia ion-
associa ed umou s (P¼0.0003, linea mixed e ec s model, see
Me hods).
Dele ions and inse ions we e no equally en iched. The e was
a significan excess o dele ions ela i e o inse ions in adia ion-
associa ed second malignancies (Fig. 1b; Po2.2 1016, linea
mixed e ec s model). This excess o dele ions was also seen in
BRCA1 o BRCA2 ge mline-deficien b eas umou s, as p e-
iously desc ibed27, bu was no seen in adia ion-nai e spo adic
b eas umou s o sa comas. In each adia ion-associa ed umou ,
he adio he apy had been gi en o e a ela i ely sho ime
pe iod many yea s ea lie . I he excess dele ions we obse ed
we e di ec ly a ibu able o ionizing adia ion, hen he
en ichmen should only be e iden amongs he ea ly, clonal
mu a ions and no in he la e, subclonal mu a ions. We we e able
o define subclones in h ee o he adia ion-associa ed umou
genomes. S ikingly, compa ed wi h subclonal mu a ions,
dele ions we e significan ly inc eased compa ed wi h inse ions
amongs clonal mu a ions in all h ee cases (Fig. 1c, Po0.00005;
Fishe ’s exac es ).
Dis ibu ion o dele ions ac oss he genome. Many mu a ional
signa u es show une en dis ibu ion ac oss he genome, especially
hose associa ed wi h ca cinogens such as obacco smoke and
ul a iole ligh 31, hough o a ise due o highe o de ch oma in
o ganiza ion and accessibili y o he ca cinogen and epai
p o eins o DNA ( e . 32). Dele ions ound in adia ion-nai e
umou s showed conside able long- ange a ia ion in densi y
ac oss he genome, as did inse ions in bo h adia ion-associa ed
and adia ion-nai e umou s, co ela ing wi h se e al genomic
ea u es (Fig. 1d,e; Supplemen a y Da a 4). In s a k con as ,
dele ions in adia ion-induced cance s showed almos no
a iabili y ac oss he genome and minimal co ela ion wi h
genomic p ope ies such as eplica ion iming, sequence
complexi y o GC con en . We hypo hesize ha his is because
o he pe asi e pene a ion o ionizing adia ion h ough issue,
meaning ha i s in e ac ion wi h DNA is s ochas ic and
una ec ed by highe o de ch oma in s uc u e. Since small
dele ions a e he p edominan ead-ou o his damage, hey show
no associa ion wi h he genomic ea u es ha influence o he
mu a ional p ocesses.
E idence o non-homologous end-joining causing dele ions.In
wo aspec s, he dele ions o adia ion-associa ed cance s
ARTICLE NATURE COMMUNICATIONS | DOI: 10.1038/ncomms12605
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esembled hose o BRCA1 o BRCA2 ge mline-deficien b eas
umou s (Supplemen a y Fig. 2): en ichmen o dele ions 4
2–3 bp in leng h and significan ly highe a es o mic ohomology
a he b eakpoin junc ion (P¼21016, Kolmogo o –Smi no
es )27. This simila i y sugges s ha mic ohomology media ed o
non-homologous end-joining a e he pa hways o epai ing
adia ion-induced DNA damage, a he han homologous
ecombina ion. Possible explana ions o his include ha
damage occu s a phases o he cell cycle when homologous
ecombina ion pa hways a e less ac i e33 o because he damaged
PD7189a PD7191a PD7192a
0
500
P = 9.3 x 10–10
Clonal
Subclonal
P = 1.1 x 10–5
0
500
P = 4.1 x 10–5
0
500
Numbe o mu a ions
Os eosa coma
B eas
Spindle cell sa coma
Angiosa coma
c
251 35 33 12
P ima y
b eas
P ima y
os eo-
sa coma
B eas
BRCA1/
BRCA2
Radia ion
umou s
n
0
0.1
0.2
0.3
0.4
Ra io genome wide indel / subs i u ion bu den
a
*
P ima y
b eas
P ima y
os eo-
sa coma
B eas
BRCA1/
BRCA2
Radia ion
umou s
PD7530a
251 35 33 12n
0
2
4
6
8
10
Ra io genome wide dele ions / inse ions
b
Dele ions
Inse ions
Complex
20 40 60 80 100
Mu a ion likelihood
20 40 60 80 100
Genomic posi ion (MB)
Ch 14 Ch 14
Dele ions Inse ions
Radia ion-associa ed mu a ionsNon- adia ion associa ed mu a ions
d
–1 0 1 0 1
*
*
*
*
*
*
*
*
*
*
*
–1
e
Z DNA
T iplex
Telome e
Simple epea
Sho andem epea
Sequence complexici y
Replica ion iming
MIR
LTR
LAD
L2
L2
Gene
GC con en
G quad uplex
DNA epea
Di ec epea
C uci o m
CpG islands
Ch oma in
Cen ome e
ALU
Non- adia ion associa ed indels
Radia ion-associa ed indels
Backg ound
dis ibu ion
Backg ound
dis ibu ion
Inse ions Dele ions
Radia ion umou s
**
Clonal
Subclonal
Clonal
Subclonal
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DNA ends con ain s uc u es ha in e e e wi h homologous
ecombina ion34.
En ichmen o balanced in e sions. Fo s uc u al a ian s, we
ound en ichmen o a a e ype o ea angemen , balanced
in e sions, among adia ion-associa ed second malignancies,
i espec i e o umou ype (Table 1; Fig. 2). While ea ange-
men s wi h an in e ed o ien a ion a e common in cance
genomes, hey a e ypically unbalanced, associa ed wi h copy-
numbe changes and caused by p ocesses such as b eakage-
usion-b idge cycles35, ch omo h ipsis29 and ch omoplexy36.We
ound a significan en ichmen o balanced in e sions in
adia ion-associa ed cance s: 52 in 11/12 umou s compa ed
wi h 66 balanced in e sions in 43 o he 286 adia ion-nai e
umou s s udied (P¼21016, gene alized linea model). O
no e, comple e in e sions we e also significan ly en iched
amongs BRCA1 and BRCA2 ge mline-deficien b eas umou s
(Table 1, P¼21016). Balanced in e sions anged in size om
a ew hund ed base pai s o nea ly 100 megabases, and a
b eakpoin junc ions showed a iabili y in mic ohomology and in
non- empla ed sequence inse ed (Supplemen a y Da a 5).
Valida ion o findings in p os a e umou s. To alida e ou
obse a ion ha dele ions and balanced in e sions a e genomic
imp in s o ionizing adia ion, we examined he genomes o
p ima y and/o me as a ic p os a e umou s om en pa ien s,
p e iously published30. Fi e pa ien s had de eloped me as ases
a e i adia ion o he p ima y lesion; ou pa ien s had ne e
ecei ed adia ion ea men ; and one pa ien , PD11331, ecei ed
adio he apy o he p ima y lesion a e me as ases had al eady
o med. Consis en wi h he obse a ions made in he 12
adia ion-associa ed second malignancies, we ound a significan
en ichmen o dele ions in p os a e cance lesions exposed
o adio he apy compa ed wi h adia ion-nai e umou s’
(P¼0.0002, gene alized linea model, Fig. 3a). S ikingly, in
pa ien PD11331, he adia ion-exposed p ima y umou (sample
PD11331c), bu no adia ion-nai e me as ases, exhibi ed a
p eponde ance o dele ions (Fig. 3b, P¼1015, Fishe ’s exac
es ). Simila ly, balanced in e sions we e en iched amongs
adia ion-exposed lesions (P¼0.04, gene alized linea model;
Supplemen a y Table 2). In pa ien PD11331, again i was he
adia ion-exposed p ima y umou , bu no any o he me as ases,
ha ha bou ed a balanced in e sion.
D i e e en s gene a ed by dele ions and in e sions. The
oncogenic po en ial o a mu a ional p ocess de i es om i s
capaci y o gene a e d i e mu a ions. Wi h hei absence o
copy-numbe e ec s, unc ional consequences o balanced
in e sions mos commonly a ise om genes b oken a ei he end
o he in e sion, no wi hs anding he possibili y o long- ange
gene-enhance dis up ion. In ou da a, 48/104 in e sion b eak
poin s dis up ed o used genes (Supplemen a y Da a 5), wi h one
o ming a d i e mu a ion h ough dis up ion o TP53. Fo he
mu a ional signa u e o small dele ions ha we obse e, we es i-
ma e ha he median excess o indels in he adia ion-induced
cance s sequenced he e is 201 indels pe genome (linea mixed
e ec s model, s.d. 348 indels). Among hese a e a 14 base pai
dele ion in CASP8 and a 4 base pai dele ion in TP53, bo h
dis up ing essen ial splice si es and hus gene a ing d i e e en s.
Discussion
O e all we iden ified wo genomic imp in s o ionizing adia ion,
an excess o dele ions and o an exceedingly a e ype o
ea angemen , balanced in e sions. The alidi y o ou s udy
may be limi ed by he o e all numbe o umou s we examined
and he small numbe o each umou ype. Ye i would seem
unlikely ha he en ichmen in adia ion-associa ed umou s o
dele ions and o balanced in e sions occu ed by chance. This
iew is suppo ed by ou s a is ical analyses as well as he ac ha
he signa u es we e umou - ype independen . Bo h signa u es
we e p esen ac oss ou di e en umou ypes and could be
alida ed in a coho o adia ion-exposed p os a e cance lesions,
despi e di e ences in he biological con ex o adia ion-exposed
p os a e umou s and adia ion-associa ed second malignancies
(Supplemen a y No e 2). Pa icula ly s iking is pa ien PD11331
whose p ima y p os a e lesion was i adia ed a e me as ases had
o med. The p ima y lesion, bu no he me as ases, exhibi ed he
genomic ea u es o ionizing adia ion.
The ela i ely low numbe o mu a ions ha we di ec ly linked
o ionizing adia ion may seem su p ising o such a well-known
ca cinogen. I is ce ainly conside ably less han seen o cance s
associa ed wi h obacco, sunligh o a is olochic acid exposu e10.
This p obably eflec s he ac ha al hough he a ibu able isk
o such cance s is high, he absolu e isk is ela i ely low. Fo
example, 490% o angiosa comas occu ing a e adio he apy
o p ima y b eas cance a e a ibu able o adia ion, bu only
one in a housand women ecei ing such adio he apy will
de elop angiosa comas37, wi h a la ency o many yea s. This
sugges s ha al hough ionizing adia ion clea ly pushes bys ande
cells in he adio he apy field owa ds cance , he absolu e bu den
o adia ion-induced mu a ions pe cell would no be high and
addi ional d i e mu a ions would be equi ed.
Figu e 1 | Indels in adia ion-associa ed umou s. (a) Indel/subs i u ion a io. Shown is he indel/subs i u ion a io o each umou . The a io was
significan ly inc eased in adia ion-associa ed second malignancies (0.0003, linea mixed e ec s model). Each do ep esen s a umou . Di e en colou s
ep esen di e en umou ypes (see legend, op igh ). Boxplo s: e ical line – median; whiske s – minimum and maximum wi hou ou lie s. (b) Dele ion/
inse ion a io. Shown is he dele ion/inse ion a io o e e y umou . Dele ions we e significan ly (*) en iched in adia ion-associa ed second malignancies
(Po2.2 1016, linea mixed e ec s model) and in b eas umou s wi h ge mline BRCA1 o BRCA2 deficiency. Symbols, boxplo s as pe a.(c) Clonal e sus
subclonal indels in adia ion-associa ed second malignancies. Shown a e he absolu e clonal (ea ly) and subclonal (la e) indel bu dens o each umou , by
indel ype. Amongs clonal indels, dele ions we e significan ly en iched. P- alues e e o he compa ison o p opo ion o dele ions/o he indels in clonal
e sus subclonal indels (Fishe ’s exac es ). (d) Indel likelihood ac oss he genome. Shown is he p obabili y o dele ion o inse ion o occu ( e ical axis)
ac oss di e en egions o he genome (ho izon al axis). The p obabili y was modelled on he basis o associa ions be ween indels and genomic p ope ies
(see Me hods). Ch omosome 14 is shown as a ep esen a i e ch omosome. Radia ion-associa ed indels we e compa ed o indels o 35 non- adia ion-
associa ed os eosa comas. Radia ion-associa ed dele ions, bu no inse ions, ollowed a mo e uni o m dis ibu ion ac oss he genome han in adia ion-
nai e samples. (e) Dis ibu ion o indels in ela ion o genomic ea u es. Compa ison o he mu a ion densi y o adia ion e sus non- adia ion indels in
ela ion o genomic ea u es. Xaxis: a io o mu a ion densi y o non- adia ion-associa ed indels o adia ion-associa ed indels o e backg ound densi y. Y
axis: genomic ea u e. The dis ibu ion o inse ions in bo h adia ion-associa ed and adia ion-naı¨ e umou s co ela ed wi h se e al genomic ea u es, wi h
ew significan di e ences (as e isk) be ween he wo. In con as , he dis ibu ion o dele ions in adia ion-induced cance s, bu no in adia ion-nai e
umou s, showed li le a iabili y and esembled he backg ound dis ibu ion mo e closely. Thus, significan di e ences (as e isk) we e seen in he dele ion
densi y in ela ion o genomic ea u es compa ing adia ion-associa ed and adia ion-naı¨ e umou s. P- alues a e de ailed in Supplemen a y Da a 4.
ARTICLE NATURE COMMUNICATIONS | DOI: 10.1038/ncomms12605
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Table 1 | Su ey o balanced in e sions in di e en umou ypes.
Tumou s wi h a leas one balanced
in e sion
Numbe o umou s
sc eened
O e all numbe o balanced
in e sions
P ima y b eas umou s 39 251 59
P ima y os eosa coma 4 35 7
BRCA1/2-deficien b eas umou s 19 33 46
Radia ion-associa ed second
malignancies
11 12 52
Rea angemen ca alogues o umou s we e sea ched in o ma ically o he p esence o balanced in e sions. The basic p inciple o he sea ch was o find pai s o head- o-head and ail- o- ail in e sions in
which he b eakpoin coo dina es o e lap a bo h ends. Compa ed wi h all 286 p ima y umou s, balanced in e sions we e significan ly en iched in adia ion-associa ed second malignancies
(P¼21016, gene alized linea model) and also in BRCA1 o BRCA1 deficien b eas umou s (P¼21016, gene alized linea model). Fu he , compa ed o BRCA1 o BRCA1 deficien b eas umou s
balanced in e sions we e significan ly en iched in adia ion-associa ed second malignancies (P¼0.0006, gene alized linea model).
108
PD7188a
0.0
0.2
0.4
0.6
0.8
1.0
71
PD7192a
0.0
0.2
0.4
0.6
0.8
1.0
49
PD7530a
0.0
0.2
0.4
0.6
0.8
1.0
51
PD7189a
0.0
0.2
0.4
0.6
0.8
1.0
177
PD7191a
0.0
0.2
0.4
0.6
0.8
1.0
321
PD7190a
0.0
0.2
0.4
0.6
0.8
1.0
180
PD9056a
0.0
0.2
0.4
0.6
0.8
1.0
76
PD9972a
0.0
0.2
0.4
0.6
0.8
1.0
156
PD13489a
0.0
0.2
0.4
0.6
0.8
1.0
6
PD8618a
0.0
0.2
0.4
0.6
0.8
1.0
59
PD8622a
0.0
0.2
0.4
0.6
0.8
1.0
31
PD8623a
0.0
0.2
0.4
0.6
0.8
1.0
Os eosa coma B eas umou s
Spindle cell sa comaAngiosa coma
Dele ions
Tandem duplica ion
Unbalanced in e sion
Balanced in e sion T ansloca ion
To al numbe
o ea agemen s
F ac ion o
ea angemen s
a
b
++
Head o head
in e sion
Tail o ail
in e sion
PD7188a (angiosa coma)
Ch 9p 28,098,34128,098,34027,829,511
Head Tail
Tumou
No mal
Tumou
No mal
Ge mline DNA
sequence:
Wild ype eads
a b eakpoin
coo dina es
Allele A
Tumou DNA
sequence:
Mu an eads
(spli eads)
27,829,512 28,098,34528,098,34027,829,511
3
′
5
′
SNP
Allele B
Mu an
allele B
Spli eads
B eakpoin s
27,829,512
4 base pai dele ion
––
Figu e 2 | Balanced in e sions in adia ion-associa ed umou s. (a) O e iew o ea angemen s. Tumou s exhibi ed umou - ype specific ea u es.
Balanced in e sions (black ba s) we e ound in e e y umou , excep PD7530a. (b) Example o a balanced in e sion in PD7188a. A 0.9 Mb in e sion. The
in e sion was alida ed by PCR ac oss he b eakpoin (gel image) and by spli eads. No e ha he spli eads ca ied a he e ozygous SNP a he head end.
NATURE COMMUNICATIONS | DOI: 10.1038/ncomms12605 ARTICLE
NATURE COMMUNICATIONS | 7:12605 | DOI: 10.1038/ncomms12605 | www.na u e.com/na u ecommunica ions 5

Me hods
Pa ien samples.In o med consen was ob ained om all subjec s and e hical
app o al ob ained om Camb idgeshi e 2 Resea ch E hics Se ice ( e e ence
09/H0308/165). Collec ion and use o pa ien samples we e app o ed by he
app op ia e ins i u ional e iew boa d o each Ins i u ion.
Whole-genome sequencing.DNA was ex ac ed om 12 adia ion-associa ed
umou s and subjec ed o whole-genome sequencing, along wi h no mal issue
de i ed om he same indi iduals. All umou samples had been eshly ozen and
we e e iewed by e e ence pa hologis s. DNA ex ac ion and p epa a ion ollowed
s anda d me hods as p e iously desc ibed38. Reads we e aligned o he e e ence
human genome (NCBI37) by using BWA on de aul se ings39. Reads which we e
unmapped o PCR-de i ed duplica es we e excluded om he analysis. The a e age
co e age o umou s was a leas 40 and o no mal DNA 30 , as pe s anda d
se by he In e na ional Cance Genome Conso ium.
Va ian de ec ion.The CaVEMan (cance a ian s h ough expec a ion max-
imiza ion) algo i hm was used o call single-nucleo ide subs i u ions (gi hub.com/
cance i /CaVEMan). To call inse ions and dele ions, we used spli - ead mapping
implemen ed as a modifica ion o he Pindel algo i hm38. To call ea angemen s
we applied he BRASS (b eakpoin ia assembly) algo i hm, which iden ifies
ea angemen s by g ouping disco dan ead pai s ha poin o he same
b eakpoin e en (gi hub.com/cance i /BRASS). Pos -p ocessing fil e s we e
applied o he ou pu o imp o e specifici y. Copy-numbe da a we e de i ed om
whole-genome eads using he ASCAT ( e sion 2.2) algo i hm40. Mu a ions we e
anno a ed o Ensembl e sion 58.
Va ian alida ion.The p ecision o indels and subs i u ions p esen ed he e was
assessed by manual inspec ion o 100 andomly selec ed subs i u ions and was
ound o be a leas o 90% ac oss he 12 adia ion-associa ed umou s. This
p ecision o coding indels and subs i u ions was confi med by e-sequencing
h ough whole-exome sequencing. S uc u al ea angemen s we e alida ed by
defining exac b eak poin s h ough local eassembly, as implemen ed in BRASS.
Only ea angemen s ha could be alida ed ha e been included in his epo
(lis ed indi idually in Supplemen a y Da a 3).
Sc een/ alida ion o balanced in e sions.Rea angemen ca alogues we e
sc eened o he p esence o balanced in e sions by means o a bespoke PERL
sc ip . Pai s o ea angemen calls we e sough ha we e in e sions in opposi e
di ec ions wi h o e lapping anges o uppe and lowe b eak poin s. The sea ch was
di ec ly pe o med on ou pu om he B ass algo i hm wi h he ollowing pos -
p ocessing fil e s: ead coun suppo ing he b eak poin o g ea e han fi e eads
and size o in e sion g ea e han 2,500 base pai s unless he ead coun suppo ing
he b eak poin was g ea e han en eads in which case no size h eshold was
applied. This pos -p ocessing s a egy emo es in e sion a e ac s, which a e small
and gene ally ha e a ead coun suppo ing he b eak poin o less han fi e eads,
wi hou excluding small, high confidence in e sions (defined as b eak poin s
suppo ed by a leas en eads). The p ecision o balanced in e sion calls yielded
by his sea ch we e assessed in he 12 adia ion-associa ed umou s. In all bu one
balanced in e sion, bo h ea angemen s defining he in e sion could be alida ed
by algo i hmic local eassembly o manual spli - ead mapping. In addi ion, a
p opo ion o balanced in e sions in 20/52 was subjec ed o PCR ac oss he
b eakpoin in s ock DNA om umou and no mal issue. These in e sions we e
all confi med o be genuine and soma ic (Supplemen a y Fig. 3).
Ge mline a ian s.Ge mline poin mu a ions in TP53, BRCA1 and BRCA2 we e
sea ched o in ca alogues o ge mline indels and subs i u ions, as de e mined by
he poin mu a ion a ian calling algo i hms employed he e. Pu a i e mu a ions
we e compa ed agains publicly a ailable ca alogues o pa hogenic ge mline
mu a ions in hese genes (www.ia c. ).
Ex ac ion o subs i u ion signa u es.Subs i u ion signa u es we e ex ac ed by
using non-nega i e ma ix ac o iza ion, as p e iously desc ibed10.
a
Radia ion-nai e p os a e umou s Radia ion-exposed p os a e umou s
Numbe o mu a ions
b
Indels exclusi e
o i adia ed
p ima y lesion
All o he
indels
0
500
PD11331
Numbe o
mu a ions
P = 10–15
P = 0.0002
Dele ions Inse ionsComplex
PD11328
PD11329
PD11333
PD12337
PD11330
PD11332
PD11334
PD13412
PD11335
0
1,000
2,000
Figu e 3 | Indels in p os a e umou s. (a) Indels in adia ion-nai e e sus adia ion-exposed p os a e umou s. Shown is he indel bu den, by indel
sub ype, ound in adia ion-nai e and in adia ion-exposed p os a e umou s. In adia ion-exposed umou s adio he apy had been adminis e ed o he
p ima y umou be o e o ma ion o me as ases. Dele ions we e significan ly en iched in adia ion-exposed umou s (P¼0.0002, gene alized linea
model). No e ha adia ion-associa ed umou s wi h con ounding BRCA1 o BRCA2 deficiency we e excluded om he s a is ical analysis (cases PD13412
and PD11335). (b) Indels in umou s om a pa ien whose p ima y lesion was ea ed wi h ionizing adia ion a e o ma ion o me as ases. Shown a e
indels ha we e ound exclusi ely in he p ima y lesion and indels ound in all o he lesions. Dele ions we e significan ly en iched amongs indels exclusi e
o he p ima y lesion. Compa ison by Fishe ’s exac es , o he a io o dele ions o e o he indels.
ARTICLE NATURE COMMUNICATIONS | DOI: 10.1038/ncomms12605
6NATURE COMMUNICATIONS | 7:12605 | DOI: 10.1038/ncomms12605 | www.na u e.com/na u ecommunica ions
Subclonali y analyses.Subclonal umou cell popula ions ha exis wi hin
umou s can be sc eened o by sea ching o non-he e ozygous mu a ions in
mu a ion ca alogues, as p e iously desc ibed, using a Di ichle p ocess41. This was
applied o subs i u ion and indel ca alogues o he 12 adia ion-associa ed whole
genomes. Howe e , wi h indels he e is a conce n ha mu an ead equencies
may be unde es ima ed o la ge indels, as eads con aining la ge indels may be
less amenable o mapping. To o e come his bias, he indel mu an ead
equencies we e co ec ed by ex ac ing unmapped eads (spli eads) om
sequencing eads. The Di ichle p ocess was hen applied o indel ca alogues wi h,
and wi hou , co ec ion. The esul s in e ms o numbe o subclonal peaks we e
indis inguishable whe he co ec ed o unco ec ed indel ca alogues we e analysed.
Th ee o he wel e genomes sc eened o subclones con ained subclones which
co esponded o subclones defined by subs i u ions in hese umou s. Thus, he
indel-defined subclones we e conside ed genuine. Indels we e subdi ided in o
clonal (peak o mu a ion copy numbe B1) o subclonal (peak o mu a ion copy
numbe o1).
Non- adia ion umou s.A o al o 319 umou s, 284 b eas cance s and 35
os eosa comas we e included o compa ison in analyses. These we e spon aneous
(p ima y), non- adia ion-associa ed umou s. These umou s we e sequenced o
B40 o mo e, along wi h no mal issue DNA om he same pa ien s.
These umou s we e p epa ed, sequenced, analysed by he same pipeline as
he 12 adia ion-associa ed umou s, including use o he same algo i hms.
The os eosa coma cases we e a se ies o paedia ic and adul umou s (sequencing
da a published in he Eu opean Genome-phenome A chi e, accession
EGAD00001000147). The b eas umou s we e comp ised o oes ogen ecep o
posi i e and nega i e umou s42. Fo he pu poses o his analysis hey we e
subdi ided in o spon aneous cases (n¼251) and hose associa ed wi h pa hogenic
ge mline BRCA1 o BRCA2 mu a ion (n¼33). No con ol p ima y angiosa coma
and spindle cell sa comas we e a ailable o inclusion in ou analyses.
Associa ion o mu a ion densi y wi h genomic ea u es.The genomic
p ope ies lis ed in Supplemen a y Table 3 we e calcula ed a e e y a ian
posi ion, and, o compa ison, a 100,000 andom posi ions sampled uni o mly
om he callable egions o hg19. Only ch omosomes 1–22 and X we e conside ed.
To es o di e ences in he genomic p ope ies o a ian s in adia ion-induced
e sus non- adia ion-induced umou s, we used a wo-p opo ion z- es o he
bina y a iables, a - es o he o he quan i a i e a iables (la ge sample size
jus ifies cen al limi heo em), and a w2- es o he ca ego ical ch oma in a iable.
A Benjamini-Yeku ieli co ec ion was applied o he aw P- alues o accoun o
mul iple es ing in he p esence o likely co ela ion be ween hese p ope ies.
Genomic p ope ies a e conside ed significan ly di e en be ween adia ion and
non- adia ion samples i he adjus ed q- alue is o0.01 and he e is a leas a 5%
di e ence in magni ude be ween he wo g oup means.
O he s a is ical analyses.To assess whe he adia ion-associa ed umou s
ha bou significan ly mo e indels ela i e o subs i u ions and mo e dele ions
ela i e o inse ions, a mixed linea e ec s model was implemen ed using he
R package lme4. A e inco po a ing as fixed e ec s ype o mu a ion (subs i u ion,
dele ion and inse ion) and g oup o umou , in e ac ions be ween umou g oup
and ype o mu a ion we e assessed. Fo compa ison o indel size dis ibu ion
unde lying he clus e ing in Supplemen a y Fig. 2a, he s a is ic o he
Kolmogo o –Smi no es was used (command in R: ks. es (x,y)$s a is ic). Unless
indica ed, R was used o calcula ions.
Da a a ailabili y.Sequencing da a ha e been deposi ed a he Eu opean Genome-
Phenome A chi e (EGA, h p://www.ebi.ac.uk/ega/), which is hos ed by he
Eu opean Bioin o ma ics Ins i u e; accession numbe s EGAS00001000138;
EGAS00001000147; EGAS00001000195.
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Acknowledgemen s
This wo k was suppo ed by unding om he Wellcome T us (g an e e ence 077012/
Z/05/Z), Skele al Cance Ac ion T us , Rose ees T us UK, Bone Cance Resea ch T us ,
he RNOH NHS T us , he Na ional Ins i u e o Heal h Resea ch Heal h P o ec ion
Resea ch Uni in Chemical and Radia ion Haza ds and Th ea s a Newcas le Uni e si y
in pa ne ship wi h Public Heal h England. The iews exp essed a e hose o he
au ho (s) and no necessa ily hose o he NHS, he NIHR, he Depa men o Heal h o
Public Heal h England. Tissue was ob ained om he RNOH Musculoskele al Resea ch
P og amme and Biobank, co-o dina ed by M s Deid e B ooking and M s Ru G innell,
Biobank s a , RNOH. Suppo was p o ided o AMF by he Na ional Ins i u e o Heal h
Resea ch, UCLH Biomedical Resea ch Cen e, and he CRUK UCL Expe imen al Cance
Cen e. S.N.Z. and S.B. a e pe sonally unded h ough Wellcome T us In e media e
Clinical Resea ch Fellowships, P.J.C. h ough a Wellcome T us Senio Clinical Resea ch
Fellowship. We a e g a e ul o he pa ien s o pa icipa ing in his esea ch and o he
clinicians and suppo s a in ol ed in hei ca e.
Au ho con ibu ions
S.B. and G.G. pe o med analyses o sequence da a. D.C.W. and N.D.R. pe o med
s a is ical analyses. P.S.T., M.R., H.D., S.N-Z con ibu ed da a and o da a analysis. S.L.C.
con ibu ed o ea angemen s analyses. P.V.L pe o med copy-numbe analysis. L.B.A.
analysed subs i u ion signa u es. C.H. and C.L. pe o med echnical in es iga ions.
K.M.R., L.S., A.M., D.J., and R.S. con ibu ed in o ma ics ools. A.B. and J.W.T.
co-o dina ed in o ma ics analyses. B.K. co-o dina ed sample cu a ion. P.A.F., A.S.,
C.B. and U.M. con ibu ed o discussion. M.J., N.P., R.T., M.F.A., G.S.B., A.R. and A.M.F.
cu a ed samples, clinical da a, and/o p o ided clinical expe ise. A.M.F., M.R.S. and
P.J.C. di ec ed he esea ch. S.B. and P.J.C. w o e he manusc ip , wi h con ibu ions
om A.M.F., D.C.W., G.G. and G.S.B.
Addi ional in o ma ion
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How o ci e his a icle: Behja i, S. e al. Mu a ional signa u es o ionizing adia ion in
second malignancies. Na . Commun. 7:12605 doi: 10.1038/ncomms12605 (2016).
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The Au ho (s) 2016
ICGC P os a e G oup
Colin S. Coope 15,16, Rosalind A. Eeles16, Douglas Eas on17, Ch is ophe Fos e 18, Da id E. Neal19,20,
Daniel S. B ewe 15,16,21, F eddie Hamdy22, Yong-Jie Lu23, And ew G. Lynch24, Cha lie E. Massi19, An hony Ng25,
Hayley C. Whi ake 19, Yongwei Yu26, Hongwei Zhang26, Elizabe h Banc o 16, Dan Be ney23,
Niedzica Camacho16, Ca hy Co bishley27, Tokhi Dadae 16, Nening Dennis16, Tim Dudde idge28,
Sand a Edwa ds16, Cy il Fishe 28, Jilu Gho i15, Vincen J. Gnanap agasam30, Ch is ophe G eenman29,
S e e Hawkins19, S e en Hazell28, Will Howa 19, Ka alin Ka aszi22, Jona han Kay19, Zsofia Ko e-Ja ai16,
Ba ba a K emeye 1, Pa deep Kuma 28, Adam Lambe 22, Daniel Leongamo nle 16, Naomi Li ni28,
Hayley Lux on19, Lucy Ma hews16, E ik Maye 16, Susan Me son16, Da id Nicol28, Ch is ophe Ogden28,
Sa ah O’Mea a1, Gill Pel ende 31, Nimish C. Shah30, Simon Ta a e32, Sa ah Thomas16, Alan Thompson28,
Clai e Ve ill31, Anne Wa en19 & Jo ge Zamo a1
15No wich Medical School and Depa men o Biological Sciences, Uni e si y o Eas Anglia, No wich NR4 7TJ, UK; 16Di ision o Gene ics and Epidemiology,
The Ins i u e O Cance Resea ch, London SW7 3RP, UK; 17Cen e o Cance Gene ic Epidemiology, Depa men o Oncology, Uni e si y o Camb idge,
Camb idge CB1 8RN, UK; 18Uni e si y o Li e pool and HCA Pa hology Labo a o ies, London WC1E 6JA, UK; 19U ological Resea ch Labo a o y, Cance
Resea ch UK Camb idge Ins i u e, Camb idge CB2 0RE, UK; 20Depa men o Su gical Oncology, Uni e si y o Camb idge, Addenb ooke’s Hospi al,
Camb idge CB2 0QQ, UK; 21The Genome Analysis Cen e, No wich NR4 7UH, UK; 22The Uni e si y o Ox o d, Ox o d OX1 2JD, UK; 23Depa men o
Molecula Oncology, Ba s Cance Ins i u e, Queen Ma y Uni e si y o London, John Vane Science Cen e, London EC1M 6BQ, UK.; 24S a is ics and
Compu a ional Biology Labo a o y, Cance Resea ch UK Camb idge Ins i u e, Camb idge CB2 0RE, UK; 25The Chinese Uni e si y o Hong Kong, Hong Kong,
China; 26Second Mili a y Medical Uni e si y, Shanghai 200433, China; 27S Geo ge’s Hospi al, London SW17 0QT, UK; 28Royal Ma sden NHS Founda ion
T us , London SW3 6JJ, UK; 29School o Compu ing Sciences, Uni e si y o Eas Anglia, No wich NR4 7TJ, UK; 30Camb idge Uni e si y Hospi als NHS
Founda ion T us , Camb idge CB2 0QQ, UK; 31Ox o d Uni e si y Hospi als NHS T us , John Radcli e Hospi al, Ox o d OX3 9DU, UK; 32S a is ics and
Compu a ional Biology Labo a o y, Cance Resea ch UK Camb idge Ins i u e, Camb idge CB2 0RE, UK.
ARTICLE NATURE COMMUNICATIONS | DOI: 10.1038/ncomms12605
8NATURE COMMUNICATIONS | 7:12605 | DOI: 10.1038/ncomms12605 | www.na u e.com/na u ecommunica ions