Microhomology-Driven Genomic Alterations in Cancer Genomes: Patterns, Prevalence, and Clinical Implications.

Homologous recombination deficiency (HRD) can force cancer cells to rely on alternative DNA repair pathways, including microhomology-mediated end joining (MMEJ), an error-prone mechanism that can generate deletions with microhomology at repair junctions. Because such patterns may reflect DNA repair defects with clinical relevance, this study aimed to assess the biological and prognostic significance of microhomology-associated deletions and optimize their detection parameters to improve patient stratification and inform targeted therapeutic strategies, including PARP inhibition. We optimized the microhomology length threshold (Mlt parameter) using signal-to-noise ratios and survival models. We evaluated the utility of whole-exome (WES) versus whole-genome sequencing (WGS). We then investigated how Loss of Function (LoF) alterations affect microhomology-associated deletion burden and assessed their prognostic significance across an ovarian cancer (OV) cohort and a TCGA Pan-Cancer dataset. Applying an Mlt = 2 threshold maximized the precision and statistical reliability of microhomology-associated deletion identification. WGS yielded higher reproducibility, whereas WES proved insufficient for accurate estimation. Inactivation of tumor suppressor genes, including RB1 and CCDC122, was associated with increased microhomology-associated deletion burden. Importantly, higher burden correlated with extended overall survival in ovarian cancer. Furthermore, while baseline microhomology-associated deletion burden varies by tumor type, Pan-Cancer analysis identified candidate gene-level alterations, including FDX1 and PDE8B, whose LoF increased microhomology-associated deletion burden across tumors. Precise parameterization combined with WGS resolution highlights the extent to which specific gene losses affect deletion burden consistent with MMEJ-mediated repair. Identifying these genetic vulnerabilities and the resulting deletion burden may provide a candidate prognostic biomarker and foundation for personalized therapies.