Urea Cycle Dysregulation Generates Clinically Relevant Genomic and Biochemical Signatures

The urea cycle (UC) is the main pathway by which mammals dispose of waste nitrogen. We find that specific alterations in the expression of most UC enzymes occur in many tumors, leading to a general metabolic hallmark termed “UC dysregulation” (UCD). UCD elicits nitrogen diversion toward carbamoyl-phosphate synthetase2, aspartate transcarbamylase, and dihydrooratase (CAD) activation and enhances pyrimidine synthesis, resulting in detectable changes in nitrogen metabolites in both patient tumors and their bio-fluids. The accompanying excess of pyrimidine versus purine nucleotides results in a genomic signature consisting of transversion mutations at the DNA, RNA, and protein levels. This mutational bias is associated with increased numbers of hydrophobic tumor antigens and a better response to immune checkpoint inhibitors independent of mutational load. Taken together, our findings demonstrate that UCD is a common feature of tumors that profoundly affects carcinogenesis, mutagenesis, and immunotherapy response. Urea cycle dysregulation (UCD) in cancer is a prevalent phenomenon in multiple cancers. UCD increases nitrogen utilization for pyrimidine synthesis, generating nucleotide imbalance that leads to detectable mutation patterns and biochemical signatures in cancer patients’ samples. UCD is associated with a worse prognosis but a better response to immunotherapy.