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Ducos C, Aba N, Rosselli F, Fresneau B, Al Ahmad Nachar B, Zidane M, de Vathaire F, Benhamou S, Haddy N. Genetic Risk of Second Malignant Neoplasm after Childhood Cancer Treatment: A Systematic Review. Cancer Epidemiol Biomarkers Prev 2024; 33:999-1011. [PMID: 38801411 DOI: 10.1158/1055-9965.epi-24-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 03/07/2024] [Accepted: 05/22/2024] [Indexed: 05/29/2024] Open
Abstract
Second malignant neoplasm (SMN) is one of the most severe long-term risks for childhood cancer survivors (CCS), significantly impacting long-term patient survival. While radiotherapy and chemotherapy are known risk factors, the observed inter-individual variability suggests a genetic component contributing to the risk of SMN. This article aims to conduct a systematic review of genetic factors implicated in the SMN risk among CCS. Searches were performed in PubMed, Scopus, and Web of Sciences. Eighteen studies were included (eleven candidate gene studies, three genome-wide association studies, and four whole exome/genome sequencing studies). The included studies were based on different types of first cancers, investigated any or specific types of SMN, and focused mainly on genes involved in drug metabolism and DNA repair pathways. These differences in study design and methods used to characterize genetic variants limit the scope of the results and highlight the need for further extensive and standardized investigations. However, this review provides a valuable compilation of SMN risk-associated variants and genes, facilitating efficient replication and advancing our understanding of the genetic basis for this major risk for CCS.
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Affiliation(s)
- Claire Ducos
- Radiation Epidemiology Team, Center for Research in Epidemiology and Population Health, INSERM Unit 1018, University Paris Saclay, Villejuif, France
| | - Naïla Aba
- Radiation Epidemiology Team, Center for Research in Epidemiology and Population Health, INSERM Unit 1018, University Paris Saclay, Villejuif, France
| | - Filippo Rosselli
- CNRS UMR9019, Gustave Roussy Cancer Campus, Université Paris-Saclay, Equipe Labellisée Ligue Nationale Contre le Cancer Villejuif, France
| | - Brice Fresneau
- Radiation Epidemiology Team, Center for Research in Epidemiology and Population Health, INSERM Unit 1018, University Paris Saclay, Villejuif, France
- Department of Children and Adolescents Oncology, Gustave Roussy Cancer Campus, Université Paris-Saclay, Villejuif, France
| | - Baraah Al Ahmad Nachar
- CNRS UMR9019, Gustave Roussy Cancer Campus, Université Paris-Saclay, Equipe Labellisée Ligue Nationale Contre le Cancer Villejuif, France
| | - Monia Zidane
- Radiation Epidemiology Team, Center for Research in Epidemiology and Population Health, INSERM Unit 1018, University Paris Saclay, Villejuif, France
| | - Florent de Vathaire
- Radiation Epidemiology Team, Center for Research in Epidemiology and Population Health, INSERM Unit 1018, University Paris Saclay, Villejuif, France
| | - Simone Benhamou
- Oncostat Team, Center for Research in Epidemiology and Population Health, INSERM Unit 1018, University Paris Saclay, Villejuif, France
| | - Nadia Haddy
- Radiation Epidemiology Team, Center for Research in Epidemiology and Population Health, INSERM Unit 1018, University Paris Saclay, Villejuif, France
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2
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Maintenance therapy for acute lymphoblastic leukemia: basic science and clinical translations. Leukemia 2022; 36:1749-1758. [PMID: 35654820 PMCID: PMC9252897 DOI: 10.1038/s41375-022-01591-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 01/21/2023]
Abstract
Maintenance therapy (MT) with oral methotrexate (MTX) and 6-mercaptopurine (6-MP) is essential for the cure of acute lymphoblastic leukemia (ALL). MTX and 6-MP interfere with nucleotide synthesis and salvage pathways. The primary cytotoxic mechanism involves the incorporation of thioguanine nucleotides (TGNs) into DNA (as DNA-TG), which may be enhanced by the inhibition of de novo purine synthesis by other MTX/6-MP metabolites. Co-medication during MT is common. Although Pneumocystis jirovecii prophylaxis appears safe, the benefit of glucocorticosteroid/vincristine pulses in improving survival and of allopurinol to moderate 6-MP pharmacokinetics remains uncertain. Numerous genetic polymorphisms influence the pharmacology, efficacy, and toxicity (mainly myelosuppression and hepatotoxicity) of MTX and thiopurines. Thiopurine S-methyltransferase (encoded by TPMT) decreases TGNs but increases methylated 6-MP metabolites (MeMPs); similarly, nudix hydrolase 15 (encoded by NUDT15) also decreases TGNs available for DNA incorporation. Loss-of-function variants in both genes are currently used to guide MT, but do not fully explain the inter-patient variability in thiopurine toxicity. Because of the large inter-individual variations in MTX/6-MP bioavailability and metabolism, dose adjustments are traditionally guided by the degree of myelosuppression, but this does not accurately reflect treatment intensity. DNA-TG is a common downstream metabolite of MTX/6-MP combination chemotherapy, and a higher level of DNA-TG has been associated with a lower relapse hazard, leading to the development of the Thiopurine Enhanced ALL Maintenance (TEAM) strategy-the addition of low-dose (2.5-12.5 mg/m2/day) 6-thioguanine to the 6-MP/MTX backbone-that is currently being tested in a randomized ALLTogether1 trial (EudraCT: 2018-001795-38). Mutations in the thiopurine and MTX metabolism pathways, and in the mismatch repair genes have been identified in early ALL relapses, providing valuable insights to assist the development of strategies to detect imminent relapse, to facilitate relapse salvage therapy, and even to bring about changes in frontline ALL therapy to mitigate this relapse risk.
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3
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Junk SV, Klein N, Schreek S, Zimmermann M, Möricke A, Bleckmann K, Alten J, Dagdan E, Cario G, Kratz CP, Schrappe M, Stanulla M. TP53, ETV6 and RUNX1 germline variants in a case series of patients developing secondary neoplasms after treatment for childhood acute lymphoblastic leukemia. Haematologica 2019; 104:e402-e405. [PMID: 31289210 PMCID: PMC6717588 DOI: 10.3324/haematol.2018.205849] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Stefanie V Junk
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover
| | - Norman Klein
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover
| | - Sabine Schreek
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover
| | - Martin Zimmermann
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover
| | - Anja Möricke
- Department of Pediatrics, University Hospital Schleswig-Holstein, Kiel
| | - Kirsten Bleckmann
- Department of Pediatrics, University Hospital Schleswig-Holstein, Kiel
| | - Julia Alten
- Department of Pediatrics, University Hospital Schleswig-Holstein, Kiel
| | - Elif Dagdan
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover
- Department of Pathology, Ruhr-University Bochum, Bochum, Germany
| | - Gunnar Cario
- Department of Pediatrics, University Hospital Schleswig-Holstein, Kiel
| | - Christian P Kratz
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover
| | - Martin Schrappe
- Department of Pediatrics, University Hospital Schleswig-Holstein, Kiel
| | - Martin Stanulla
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover
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4
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Nielsen SN, Eriksson F, Rosthoej S, Andersen MK, Forestier E, Hasle H, Hjalgrim LL, Aasberg A, Abrahamsson J, Heyman M, Jónsson ÓG, Pruunsild K, Vaitkeviciené GE, Vettenranta K, Schmiegelow K. Children with low-risk acute lymphoblastic leukemia are at highest risk of second cancers. Pediatr Blood Cancer 2017; 64. [PMID: 28500740 DOI: 10.1002/pbc.26518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 02/02/2017] [Accepted: 02/09/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND The improved survival rates for childhood acute lymphoblastic leukemia (ALL) may be jeopardized by the development of a second cancer, which has been associated with thiopurine therapy. PROCEDURE We retrospectively analyzed three sequential Nordic Society of Paediatric Haematology and Oncology's protocols characterized by increasing intensity of thiopurine-based maintenance therapy. We explored the risk of second cancer in relation to protocols, risk group, thiopurine methyltransferase (TPMT) activity, ALL high hyperdiploidy (HeH), and t(12;21)[ETV6/RUNX1]. RESULTS After median 9.5 years (interquartile range, 5.4-15.3 yrs) of follow-up, 40 of 3,591 patients had developed a second cancer, of whom 38 had non-high-risk B-cell precursor ALL. Patients with standard-risk ALL, who received the longest maintenance therapy, had the highest adjusted hazard of second cancer (hazard ratio [HR], intermediate vs. standard risk: 0.16, 95% CI: 0.06-0.43, P < 0.001; HR, high vs. standard risk: 0.09, 95% CI: 0.02-0.49, P = 0.006); no significant effects of protocol, age, or white blood cell count at diagnosis, ALL HeH, or t(12;21)[ETV6/RUNX1] were observed. A subset analysis on the patients with standard-risk ALL did not show an increased hazard of second cancer from either HeH or t(12;21) (adjusted HR 2.02, 95% CI: 0.69-5.96, P = 0.20). The effect of low TPMT low activity was explored in patients reaching maintenance therapy in clinical remission (n = 3,368); no association with second cancer was observed (adjusted HR 1.43, 95% CI: 0.54-3.76, P = 0.47). CONCLUSIONS The rate of second cancer was generally highest in patients with low-risk ALL, but we could not identify a subset at higher risk than others.
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Affiliation(s)
- Stine N Nielsen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Frank Eriksson
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Susanne Rosthoej
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Mette K Andersen
- Department of Clinical Genetics, Copenhagen University Hospital, Copenhagen, Denmark
| | - Erik Forestier
- Department of Medical Biosciences, Clinical Genetics, Umeå University, Umeå, Sweden
| | - Henrik Hasle
- Department of Paediatrics, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Lisa L Hjalgrim
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ann Aasberg
- Department of Paediatrics, University Hospital of Trondheim, Trondheim, Norway
| | - Jonas Abrahamsson
- Department of Pediatrics, Institution for Clinical Sciences Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Heyman
- Department of Paediatric Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Ólafur G Jónsson
- Pediatric Hematology-Oncology, Children's Hospital, Barnaspitali Hringsins, Landspitali University Hospital, Reykjavik, Iceland
| | - Kaie Pruunsild
- Department of Oncology and Hematology, Tallinn Children's Hospital, Tallinn, Estonia
| | - Goda E Vaitkeviciené
- Centre for Paediatric Oncology and Haematology, University Children's Hospital, Vilnius, Lithuania
| | - Kim Vettenranta
- Department of Paediatrics, University of Tampere, Tampere, Finland
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
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5
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Jiménez-Morales S, Ramírez-Florencio M, Mejía-Aranguré JM, Núñez-Enríquez JC, Bekker-Mendez C, Torres-Escalante JL, Flores-Lujano J, Jiménez-Hernández E, Del Carmen Rodríguez-Zepeda M, Leal YA, González-Montalvo PM, Pantoja-Guillen F, Peñaloza-Gonzalez JG, Gutiérrez-Juárez EI, Núñez-Villegas NN, Pérez-Saldivar ML, Guerra-Castillo FX, Flores-Villegas LV, Ramos-Cervantes MT, Fragoso JM, García-Escalante MG, Del Carmen Pinto-Escalante D, Ramírez-Bello J, Hidalgo-Miranda A. Analysis of Thiopurine S-Methyltransferase Deficient Alleles in Acute Lymphoblastic Leukemia Patients in Mexican Patients. Arch Med Res 2017; 47:615-622. [PMID: 28476189 DOI: 10.1016/j.arcmed.2016.11.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/23/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS It has been demonstrated that heterozygote and homozygote thiopurine S-methyltransferase (TPMT) mutant allele carriers are at high risk to develop severe and potentially fatal hematopoietic toxicity after treatment with standard doses of 6-mercaptopurine (6-MP) and methotrexate (MX). Those drugs are the backbone of acute lymphoblastic leukemia (ALL) and several autoimmune disease treatments. We undertook this study to determine the frequency of the TPMT deficient alleles in children with ALL and non-ALL subjects from Mexico City and Yucatan, Mexico. METHODS We included 849 unrelated subjects, of which 368 ALL children and 342 non-ALL subjects were from Mexico City, and 60 ALL cases and 79 non-ALL individuals were from Yucatan. Genotyping of the rs1800462, rs1800460 and rs1142345 SNPs was performed by 5'exonuclease technique using TaqMan probes (Life Technologies Foster City, CA). RESULTS The mutant TPMT alleles were present in 4.8% (81/1698 chromosomes) and only 0.2% were homozygote TPMT*3A/TPMT*3A. We did not find statistically significant differences in the distribution of the mutant alleles between patients from Mexico City and Yucatan in either ALL cases or non-ALL. Nonetheless, the TPMT*3C frequency in ALL patients was higher than non-ALL subjects (p = 0.03). To note, the null homozygous TPMT*3A/TPMT*3A genotype was found in 2.5% of the non-ALL subjects. CONCLUSIONS TPMT mutant alleles did not exhibit differential distribution between both evaluated populations; however, TPMT*3C is overrepresented in ALL cases in comparison with non-ALL group. Assessing the TPMT mutant alleles could benefit the ALL children and those undergoing 6-MP and MX treatment.
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Affiliation(s)
- Silvia Jiménez-Morales
- Laboratorio de Genómica del Cáncer, Instituto Nacional de Medicina Genómica, Mexico City, México.
| | - Mireya Ramírez-Florencio
- Facultad de Estudios Superiores Zaragoza, Universidad Nacional Autónoma de México, Mexico City, México
| | - Juan Manuel Mejía-Aranguré
- Unidad de Investigación Médica en Epidemiología Clínica, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, México; Coordinación de Investigación en Salud, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, México
| | - Juan Carlos Núñez-Enríquez
- Unidad de Investigación Médica en Epidemiología Clínica, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, México
| | - Carolina Bekker-Mendez
- Unidad de Investigación en Inmunología e Infectología Hospital de Infectologia, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, México
| | - José Luis Torres-Escalante
- Servicio de Pediatría de la UMAE, IMSS, Yucatán, Mexico; Facultad de Medicina, Universidad Autónoma de Yucatán, Yucatán, Mexico
| | - Janet Flores-Lujano
- Unidad de Investigación Médica en Epidemiología Clínica, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, México
| | - Elva Jiménez-Hernández
- Servicio de Hematología Pediátrica, Hospital General "Gaudencio González Garza", CMN "La Raza", IMSS, Ciudad de México, México
| | | | - Yelda A Leal
- Unidad de Investigación Médica Yucatán (UIMY), Registro de Cáncer Unidad Médica de Alta Especialidad UMAE-IMSS, Yucatán, México
| | - Pablo Miguel González-Montalvo
- Facultad de Medicina, Universidad Autónoma de Yucatán, Yucatán, Mexico; Servicio de Oncología Pediátrica del Hospital ÓHorán, SS, Yucatán, Mexico
| | - Francisco Pantoja-Guillen
- Facultad de Medicina, Universidad Autónoma de Yucatán, Yucatán, Mexico; Servicio de Oncología Pediátrica del Hospital ÓHorán, SS, Yucatán, Mexico
| | | | | | - Nora Nancy Núñez-Villegas
- Servicio de Hematología Pediátrica, Hospital General "Gaudencio González Garza", CMN "La Raza", IMSS, Ciudad de México, México
| | - Maria Luisa Pérez-Saldivar
- Unidad de Investigación Médica en Epidemiología Clínica, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, México
| | - Francisco Xavier Guerra-Castillo
- Unidad de Investigación en Inmunología e Infectología Hospital de Infectologia, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, México
| | - Luz Victoria Flores-Villegas
- Servicio de Hematología Pediátrica, CMN "20 de Noviembre", Instituto de Seguridad Social al Servicio de los Trabajadores del Estado (ISSSTE), Ciudad de México, México
| | - María Teresa Ramos-Cervantes
- Unidad de Investigación en Inmunología e Infectología Hospital de Infectologia, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, México
| | - José Manuel Fragoso
- Departamento de Biología Molecular, Instituto Nacional de Cardiología, Ignacio Chávez, Ciudad de México, Mexico
| | - María Guadalupe García-Escalante
- Laboratorio de Genética, Centro de Investigaciones Regionales Dr. Hideyo Noguchi, Universidad Autónoma de Yucatán, Yucatán, México
| | - Doris Del Carmen Pinto-Escalante
- Laboratorio de Genética, Centro de Investigaciones Regionales Dr. Hideyo Noguchi, Universidad Autónoma de Yucatán, Yucatán, México
| | - Julián Ramírez-Bello
- Laboratorio de la Unidad de Investigación en Enfermedades Metabólicas y Endócrinas del Hospital Juárez de México, Ciudad de México, Mexico
| | - Alfredo Hidalgo-Miranda
- Laboratorio de Genómica del Cáncer, Instituto Nacional de Medicina Genómica, Mexico City, México.
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Abaji R, Krajinovic M. Thiopurine S-methyltransferase polymorphisms in acute lymphoblastic leukemia, inflammatory bowel disease and autoimmune disorders: influence on treatment response. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2017; 10:143-156. [PMID: 28507448 PMCID: PMC5428801 DOI: 10.2147/pgpm.s108123] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The thiopurine S-methyltransferase (TPMT) gene encodes for the TPMT enzyme that plays a crucial role in the metabolism of thiopurine drugs. Genetic polymorphisms in this gene can affect the activity of the TPMT enzyme and have been correlated with variability in response to treatment with thiopurines. Advances in the pharmacogenetics of TPMT allowed the development of dosing recommendations and treatment strategies to optimize and individualize prescribing thiopurine in an attempt to enhance treatment efficacy while minimizing toxicity. The influence of genetic polymorphisms in the TPMT gene on clinical outcome has been well-documented and replicated in many studies. In this review, we provide an overview of the evolution, results, conclusions and recommendations of selected studies that investigated the influence of TPMT pharmacogenetics on thiopurine treatment in acute lymphoblastic leukemia, inflammatory bowel disease and autoimmune disorders. We focus mainly on prospective studies that explored the impact of individualized TPMT-based dosing of thiopurines on clinical response. Together, these studies demonstrate the importance of preemptive TPMT genetic screening and subsequent dose adjustment in mitigating the toxicity associated with thiopurine treatment while maintaining treatment efficacy and favorable long-term outcomes. In addition, we briefly address the cost-effectiveness of this pharmacogenetics approach and its impact on clinical practice as well as the importance of recent breakthrough advances in sequencing and genotyping techniques in refining the TPMT genetic screening process.
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Affiliation(s)
| | - Maja Krajinovic
- Departments of Pediatrics and Pharmacology, CHU Sainte-Justine Research Center, University of Montreal, Montreal, QC, Canada
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7
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Tamm R, Mägi R, Tremmel R, Winter S, Mihailov E, Smid A, Möricke A, Klein K, Schrappe M, Stanulla M, Houlston R, Weinshilboum R, Mlinarič Raščan I, Metspalu A, Milani L, Schwab M, Schaeffeler E. Polymorphic variation in TPMT is the principal determinant of TPMT phenotype: A meta-analysis of three genome-wide association studies. Clin Pharmacol Ther 2017; 101:684-695. [PMID: 27770449 DOI: 10.1002/cpt.540] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 09/02/2016] [Accepted: 10/17/2016] [Indexed: 12/20/2022]
Abstract
Thiopurine-related hematotoxicity in pediatric acute lymphoblastic leukemia (ALL) and inflammatory bowel diseases has been linked to genetically defined variability in thiopurine S-methyltransferase (TPMT) activity. While gene testing of TPMT is being clinically implemented, it is unclear if additional genetic variation influences TPMT activity with consequences for thiopurine-related toxicity. To examine this possibility, we performed a genome-wide association study (GWAS) of red blood cell TPMT activity in 844 Estonian individuals and 245 pediatric ALL cases. Additionally, we correlated genome-wide genotypes to human hepatic TPMT activity in 123 samples. Only genetic variants mapping to chromosome 6, including the TPMT gene region, were significantly associated with TPMT activity (P < 5.0 × 10-8 ) in each of the three GWAS and a joint meta-analysis of 1,212 cases (top hit P = 1.2 × 10-72 ). This finding is consistent with TPMT genotype being the primary determinant of TPMT activity, reinforcing the rationale for genetic testing of TPMT alleles in routine clinical practice to individualize mercaptopurine dosage.
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Affiliation(s)
- R Tamm
- Department of Biotechnology, Institute of Molecular and Cell Biology, University of Tartu, Tartu, Estonia.,Estonian Genome Center, University of Tartu, Tartu, Estonia
| | - R Mägi
- Estonian Genome Center, University of Tartu, Tartu, Estonia
| | - R Tremmel
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany, and University of Tuebingen, Germany
| | - S Winter
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany, and University of Tuebingen, Germany
| | - E Mihailov
- Estonian Genome Center, University of Tartu, Tartu, Estonia
| | - A Smid
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - A Möricke
- Department of Pediatrics, University Hospital Schleswig-Holstein, Kiel, Germany
| | - K Klein
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany, and University of Tuebingen, Germany
| | - M Schrappe
- Department of Pediatrics, University Hospital Schleswig-Holstein, Kiel, Germany
| | - M Stanulla
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - R Houlston
- Division of Genetics and Epidemiology, Institute of Cancer Research, Sutton, UK
| | - R Weinshilboum
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | | | - A Metspalu
- Department of Biotechnology, Institute of Molecular and Cell Biology, University of Tartu, Tartu, Estonia.,Estonian Genome Center, University of Tartu, Tartu, Estonia
| | - L Milani
- Estonian Genome Center, University of Tartu, Tartu, Estonia
| | - M Schwab
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany, and University of Tuebingen, Germany.,Department of Clinical Pharmacology, University Hospital Tuebingen, Tuebingen, Germany.,Department of Pharmacy and Biochemistry, University of Tuebingen, Tuebingen, Germany
| | - E Schaeffeler
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany, and University of Tuebingen, Germany
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8
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Mlakar V, Huezo-Diaz Curtis P, Satyanarayana Uppugunduri CR, Krajinovic M, Ansari M. Pharmacogenomics in Pediatric Oncology: Review of Gene-Drug Associations for Clinical Use. Int J Mol Sci 2016; 17:ijms17091502. [PMID: 27618021 PMCID: PMC5037779 DOI: 10.3390/ijms17091502] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 08/02/2016] [Accepted: 08/15/2016] [Indexed: 02/07/2023] Open
Abstract
During the 3rd congress of the European Society of Pharmacogenomics and Personalised Therapy (ESPT) in Budapest in 2015, a preliminary meeting was held aimed at establishing a pediatric individualized treatment in oncology and hematology committees. The main purpose was to facilitate the transfer and harmonization of pharmacogenetic testing from research into clinics, to bring together basic and translational research and to educate health professionals throughout Europe. The objective of this review was to provide the attendees of the meeting as well as the larger scientific community an insight into the compiled evidence regarding current pharmacogenomics knowledge in pediatric oncology. This preliminary evaluation will help steer the committee’s work and should give the reader an idea at which stage researchers and clinicians are, in terms of personalizing medicine for children with cancer. From the evidence presented here, future recommendations to achieve this goal will also be suggested.
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Affiliation(s)
- Vid Mlakar
- Cansearch Research Laboratory, Geneva University Medical School, Avenue de la Roseraie 64, 1205 Geneva, Switzerland.
| | - Patricia Huezo-Diaz Curtis
- Cansearch Research Laboratory, Geneva University Medical School, Avenue de la Roseraie 64, 1205 Geneva, Switzerland.
| | | | - Maja Krajinovic
- Charles-Bruneau Cancer Center, Centre hospitalier universitaire Sainte-Justine, 4515 Rue de Rouen, Montreal, QC H1V 1H1, Canada.
- Department of Pediatrics, University of Montreal, 2900 Boulevard Edouard-Montpetit, Montreal, QC H3T 1J4, Canada.
- Department of Pharmacology, Faculty of Medicine, University of Montreal, 2900 Boulevard Edouard-Montpetit, Montreal, QC H3T 1J4, Canada.
| | - Marc Ansari
- Cansearch Research Laboratory, Geneva University Medical School, Avenue de la Roseraie 64, 1205 Geneva, Switzerland.
- Pediatric Department, Onco-Hematology Unit, Geneva University Hospital, Rue Willy-Donzé 6, 1205 Geneva, Switzerland.
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9
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Fakhoury M, Jacqz-Aigrain E, de Beaumais T, Médard Y. [Not Available]. Therapie 2016; 65:187-93. [PMID: 27392985 DOI: 10.2515/therapie/2010031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Accepted: 03/23/2010] [Indexed: 12/25/2022]
Abstract
6-mercaptopurine, a key drug for the treatment of acute lymphoblastic leukaemia in children, is a prodrug metabolized into 6-thioguanine (6-TGN) which are the active compounds and into methylated metabolites, primary by thiopurine S-methyltransferase enzyme (TPMT). This enzyme displays important inter subject variability linked to a genetic polymorphism: when treated with standard doses of thiopurine, TPMT-deficient and heterozygous patients are at great risk for developing severe and potentially life-threatening toxicity (hematopoietic, hepatic, mucositis. . . ) but show a better survival rate while patients with high TPMT activity (wild type) present lower peripheral red blood cells 6-TGN concentrations and a higher risk of leukemia relapse. Genotyping remains crucial before 6-MP administration at diagnosis to identify patients with homozygous mutant TPMT genotype and therefore prevent severe and life-threatening toxicity, and to individualize therapy according to TMPT genotype. Follow-up of ALL treatment should preferentially be based on repeated determinations of intracellular active metabolites (6-thioguanine nucleotides) and methylated metabolites in addition to haematological surveillance.
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Affiliation(s)
- May Fakhoury
- Laboratoire de Pharmacologie Pédiatrique et Pharmacogénétique, Hôpital Robert Debré, Paris, France
| | - Evelyne Jacqz-Aigrain
- Laboratoire de Pharmacologie Pédiatrique et Pharmacogénétique, Hôpital Robert Debré, Paris, France.
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10
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Asselin BL, Devidas M, Chen L, Franco VI, Pullen J, Borowitz MJ, Hutchison RE, Ravindranath Y, Armenian SH, Camitta BM, Lipshultz SE. Cardioprotection and Safety of Dexrazoxane in Patients Treated for Newly Diagnosed T-Cell Acute Lymphoblastic Leukemia or Advanced-Stage Lymphoblastic Non-Hodgkin Lymphoma: A Report of the Children's Oncology Group Randomized Trial Pediatric Oncology Group 9404. J Clin Oncol 2015; 34:854-62. [PMID: 26700126 DOI: 10.1200/jco.2015.60.8851] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To determine the oncologic efficacy, cardioprotective effectiveness, and safety of dexrazoxane added to chemotherapy that included a cumulative doxorubicin dose of 360 mg/m(2) to treat children and adolescents with newly diagnosed T-cell acute lymphoblastic leukemia (T-ALL) or lymphoblastic non-Hodgkin lymphoma (L-NHL). PATIENTS AND METHODS Patients were treated on Pediatric Oncology Group Protocol POG 9404, which included random assignment to treatment with or without dexrazoxane given as a bolus infusion immediately before every dose of doxorubicin. Cardiac effects were assessed by echocardiographic measurements of left ventricular function and structure. RESULTS Of 573 enrolled patients, 537 were eligible, evaluable, and randomly assigned to an arm with or without dexrazoxane. The 5-year event-free survival (with standard error) did not differ between groups: 77.2% (2.7%) for the dexrazoxane group versus 76.0% (2.7%) for the doxorubicin-only group (P = .9). The frequencies of severe grade 3 or 4 hematologic toxicity, infection, CNS events, and toxic deaths were similar in both groups (P ranged from .26 to .64). Of 11 second malignancies, eight occurred in patients who received dexrazoxane (P = .17). The mean left ventricular fractional shortening, wall thickness, and thickness-to-dimension ratio z scores measured 3 years after diagnosis were worse in the doxorubicin-alone group (n = 55 per group; P ≤ .01 for all comparisons). Mean fractional shortening z scores measured 3.5 to 6.4 years after diagnosis remained diminished and were lower in the 21 patients who received doxorubicin alone than in the 31 patients who received dexrazoxane (-2.03 v -0.24; P ≤ .001). CONCLUSION Dexrazoxane was cardioprotective and did not compromise antitumor efficacy, did not increase the frequencies of toxicities, and was not associated with a significant increase in second malignancies with this doxorubicin-containing chemotherapy regimen. We recommend dexrazoxane as a cardioprotectant for children and adolescents who have malignancies treated with anthracyclines.
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Affiliation(s)
- Barbara L Asselin
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI.
| | - Meenakshi Devidas
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Lu Chen
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Vivian I Franco
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Jeanette Pullen
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Michael J Borowitz
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Robert E Hutchison
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Yaddanapudi Ravindranath
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Saro H Armenian
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Bruce M Camitta
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Steven E Lipshultz
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
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Tanaka Y, Kato M, Hasegawa D, Urayama KY, Nakadate H, Kondoh K, Nakamura K, Koh K, Komiyama T, Manabe A. Susceptibility to 6-MP toxicity conferred by aNUDT15variant in Japanese children with acute lymphoblastic leukaemia. Br J Haematol 2015; 171:109-15. [DOI: 10.1111/bjh.13518] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 04/16/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Yoichi Tanaka
- Department of Clinical Pharmacy; Centre for Clinical Pharmacy and Sciences; School of Pharmacy; Kitasato University; Tokyo Japan
| | - Motohiro Kato
- Department of Paediatrics; The University of Tokyo; Tokyo Japan
| | - Daisuke Hasegawa
- Department of Paediatrics; St. Luke's International Hospital; Tokyo Japan
| | - Kevin Y. Urayama
- Department of Human Genetics and Disease Diversity; Tokyo Medical and Dental University; Tokyo Japan
- Centre for Clinical Epidemiology; St. Luke's Life Science Institute; Tokyo Japan
| | - Hisaya Nakadate
- Department of General Paediatrics & Interdisciplinary Medicine; National Centre for Child Health and Development; Tokyo Japan
| | - Kensuke Kondoh
- Department of Paediatrics; St. Marianna University School of Medicine; Kanagawa Japan
| | - Kozue Nakamura
- Department of Paediatrics; Teikyo University Hospital; Tokyo Japan
| | - Katsuyoshi Koh
- Department of Haematology/Oncology; Saitama Children's Medical Centre; Saitama Japan
| | - Takako Komiyama
- Department of Clinical Pharmacy; Centre for Clinical Pharmacy and Sciences; School of Pharmacy; Kitasato University; Tokyo Japan
| | - Atsushi Manabe
- Department of Paediatrics; St. Luke's International Hospital; Tokyo Japan
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12
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Treatment-related myelodysplastic syndrome in a child with acute myeloid leukemia and TPMT heterozygosity. J Pediatr Hematol Oncol 2015; 37:e242-4. [PMID: 25000470 DOI: 10.1097/mph.0000000000000211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION We describe a patient diagnosed with acute myeloid leukemia (AML) and low activity of thiopurine methyltransferase (TPMT) who developed secondary myelodysplastic syndrome after treatment. OBSERVATION A 10-year-old boy presented with AML-M2 with t(8;21)(q22;q22) and genotyping revealing 3*B TPMT heterozygosity. The patient was treated according to the NOPHO-AML 2004 protocol. Two years after the treatment, the patient presented with neutropenia and thrombocytopenia. Bone marrow, including fluorescent in situ hybridization and retrospective aCGH analysis, verified therapy-related myelodysplastic syndrome with ring chromosome 6. DISCUSSION The clinical course of this patient raises the possibility that low-activity TPMT genotypes may influence 6TG toxicity in patients with AML and lead to an increased risk of developing secondary malignant neoplasms.
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Linga VG, Patchva DB, Mallavarapu KM, Tulasi V, Kalpathi KI, Pillai A, Gundeti S, Rajappa SJ, Digumarti R. Thiopurine methyltransferase polymorphisms in children with acute lymphoblastic leukemia. Indian J Med Paediatr Oncol 2014; 35:276-80. [PMID: 25538405 PMCID: PMC4264274 DOI: 10.4103/0971-5851.144989] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Introduction: Acute lymphoblastic leukemia (ALL) is the most common malignancy in children. 6-mercaptopurine (6-MP) and methotrexate are backbone drugs for maintenance phase of treatment. Purine Analogs 6-MP/6-thioguanine/azathiopurine are metabolized to its inactive form by the enzyme thiopurine methyltransferase (TPMT). Ninety percent of the population harbor wild type on both alleles (TPMT wild/wild), 10% are heterozygous, that is, one allele is mutant (TPMT wild/mutant) and 0.3% are homozygous, that is, both allele are mutant (TPMT mutant/mutant). In heterozygous and homozygous variant, activity of enzyme is low, leading to a higher incidence of toxicity (myelosuppression). Aim: The primary objective was to access the polymorphism of the enzyme, TPMT, in Children with ALL. Secondary objective was to correlate TPMT genotype with 6-MP toxicities. Materials and Methods: Seventy-two children with newly diagnosed ALL during first maintenance phase were serially enrolled after obtaining consent. Five ml of peripheral blood was drawn and DNA extracted. TPMT 2 polymorphisms were performed using Allele specific polymerase chain reaction (PCR) and TPMT 3B and 3C are performed by PCR-restriction fragment length polymorphism. Results: Sixty-nine children of 72 (95.8%) were wild for TPMT polymorphism and 3 (4.2%) were heterozygous for TPMT. Among the heterozygous variant one each (33.3%) were heterozygous for 2A, 3A, 3C. Febrile neutropenia was the most common toxicity in both wild and heterozygous group. Conclusion: The frequency of TPMT polymorphisms in children with ALL is 4.2%. Heterozygous variant is this study are one each (33%) of 2A, 3A, 3C.
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Affiliation(s)
- Vijay Gandhi Linga
- Department of Medical Oncology, Nizams Institute of Medical Science, Hyderabad, Telangana, India
| | - Dorra Babu Patchva
- Department of Pharmacology, Apollo Institute of Medical Science and Reasearch, Hyderabad, Telangana, India
| | | | - Venkata Tulasi
- Department of Medical Oncology, Basavatarakam Indo American Cancer Institute and Research, Hyderabad, Telangana, India
| | | | - Ashok Pillai
- Department of Medical Oncology, Nizams Institute of Medical Science, Hyderabad, Telangana, India
| | - Sadashivudu Gundeti
- Department of Medical Oncology, Nizams Institute of Medical Science, Hyderabad, Telangana, India
| | - Senthil J Rajappa
- Department of Medical Oncology, Basavatarakam Indo American Cancer Institute and Research, Hyderabad, Telangana, India
| | - Raghunadharao Digumarti
- Director and Head, Department of Medical Oncology, Tata Memorial Hospital, Aganampudi, Vishakapatnam, Andra Pradesh, India
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Host thiopurine methyltransferase status affects mercaptopurine antileukemic effectiveness in a murine model. Pharmacogenet Genomics 2014; 24:263-71. [PMID: 24710003 DOI: 10.1097/fpc.0000000000000044] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thiopurines are used for many cancers, including acute lymphoblastic leukemia (ALL). Patients with an inherited host defect in thiopurine methyltransferase (TPMT) are at high risk for life-threatening toxicity if treated with conventional dosages, but the impact on antileukemic efficacy is less clear. MATERIALS AND METHODS We treated thiopurine-sensitive BCR-ABL+Arf-null Tpmt+/+ ALL in Tpmt+/+, +/-, or -/- recipient mice to test the impact of the host polymorphism on antileukemic efficacy. RESULTS Median survival was similar in untreated mice of different Tpmt genotypes (16-18 days). However, in mice treated with low-dose mercaptopurine (such as tolerated by TPMT-/- patients), the difference in 30-day leukemia-free survival by Tpmt genotype was profound: 5% (±9%) for Tpmt+/+ mice, 47% (±26%) for Tpmt+/- mice, and 85% (±14%) for Tpmt-/- mice (P=5×10), indicating a substantial impact of host Tpmt status on thiopurine effectiveness. Among Tpmt+/+ recipient mice, leukemia-free survival improved with higher doses of mercaptopurine (similar to doses tolerated by wild-type patients) compared with lower doses, and at higher doses was comparable (P=0.6) to the survival of Tpmt-/- mice treated with the lower dose. CONCLUSIONS These findings support the notion that germline polymorphisms in Tpmt affect not only host tissue toxicity but also antitumor effectiveness.
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Lennard L, Cartwright CS, Wade R, Vora A. Thiopurine dose intensity and treatment outcome in childhood lymphoblastic leukaemia: the influence of thiopurine methyltransferase pharmacogenetics. Br J Haematol 2014; 169:228-40. [PMID: 25441457 PMCID: PMC4737107 DOI: 10.1111/bjh.13240] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 11/04/2014] [Indexed: 12/02/2022]
Abstract
The impact of thiopurine methyltransferase (TPMT) genotype on thiopurine dose intensity, myelosuppression and treatment outcome was investigated in the United Kingdom childhood acute lymphoblastic leukaemia (ALL) trial ALL97. TPMT heterozygotes had significantly more frequent cytopenias and therefore required dose adjustments below target levels significantly more often than TPMT wild‐type patients although the average dose range was similar for both genotypes. Event‐free survival (EFS) for patients heterozygous for the more common TPMT*1/*3A variant allele (n = 99, 5‐year EFS 88%) was better than for both wild‐type TPMT*1/*1 (n = 1206, EFS 80%, P = 0·05) and TPMT*1/*3C patients (n = 17, EFS 53%, P = 0·002); outcomes supported by a multivariate Cox regression analysis. Poor compliance without subsequent clinician intervention was associated with a worse EFS (P = 0·02) and such non‐compliance may have contributed to the poorer outcome for TPMT*1/*3C patients. Patients prescribed escalated doses had a worse EFS (P = 0·04), but there was no difference in EFS by dose intensity or duration of cytopenias. In contrast to reports from some USA and Nordic trials, TPMT heterozygosity was not associated with a higher rate of second cancers. In conclusion, TPMT*1/*3A heterozygotes had a better EFS than TPMT wild‐type patients. Thiopurine induced cytopenias were not detrimental to treatment outcome.
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Affiliation(s)
- Lynne Lennard
- Academic Unit of Clinical Pharmacology, University of Sheffield, Sheffield, UK
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Levinsen M, Rosthøj S, Nygaard U, Heldrup J, Harila-Saari A, Jonsson OG, Bechensteen AG, Abrahamsson J, Lausen B, Frandsen TL, Weinshilboum RM, Schmiegelow K. Myelotoxicity after high-dose methotrexate in childhood acute leukemia is influenced by 6-mercaptopurine dosing but not by intermediate thiopurine methyltransferase activity. Cancer Chemother Pharmacol 2014; 75:59-66. [PMID: 25347948 DOI: 10.1007/s00280-014-2613-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 10/14/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE Through enhancement of 6-mercaptopurine (6MP) bioavailability and inhibition of purine de novo synthesis, high-dose methotrexate (HD-MTX) may increase incorporation into DNA of 6-thioguanine nucleotides, the cytotoxic metabolites of 6MP. Patients with intermediate activity of thiopurine methyltransferase (TPMT(IA)) have higher cytosol 6-thioguanine nucleotide levels. We investigated toxicity following HD-MTX during MTX/6MP maintenance therapy in relation to 6MP and TPMT. METHODS Using linear mixed models, we explored myelo- and hepatotoxicity in relation to 6MP dosage and TPMT phenotype following 1,749 HD-MTX courses to 411 children with acute lymphoblastic leukemia on maintenance therapy. RESULTS The degree of myelosuppression following HD-MTX was similar for patients with TPMT(IA) and patients with high TPMT activity (TPMT(HA)), when HD-MTX started with same blood counts and 6MP doses. However, since TPMT(IA) had lower blood counts at initiation of HD-MTX compared with TPMT(HA) patients (median WBC 2.8 vs. 3.3 × 10⁹/L, P = 0.01; median ANC 1.4 vs. 1.7 × 10⁹/L, P = 0.02), TPMT(IA) continued to have lower WBC and ANC levels compared with TPMT(HA) during all 28 days after HD-MTX [relative difference 9 % (95 % CI 2-17), P = 0.02 and 21 % (95 % CI 6-39), P = 0.005]. Still, the fractional decrease in WBC and ANC levels after HD-MTX did not differ between TPMT(IA) and TPMT(HA) patients (P = 0.47; P = 0.38). The degree of leukopenia, neutropenia, thrombocytopenia and rise in aminotransferases were all significantly related to 6MP dose (P < 0.001 for all analyses). CONCLUSION For both TPMT(IA) and TPMT(HA) patients, dose of 6MP prior to HD-MTX should be guided by pre-HD-MTX blood counts, but not by TPMT activity.
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Affiliation(s)
- Mette Levinsen
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
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Abstract
The antileukemic mechanisms of 6-mercaptopurine (6MP) and methotrexate (MTX) maintenance therapy are poorly understood, but the benefits of several years of myelosuppressive maintenance therapy for acute lymphoblastic leukemia are well proven. Currently, there is no international consensus on drug dosing. Because of significant interindividual and intraindividual variations in drug disposition and pharmacodynamics, vigorous dose adjustments are needed to obtain a target degree of myelosuppression. As the normal white blood cell counts vary by patients' ages and ethnicity, and also within age groups, identical white blood cell levels for 2 patients may not reflect the same treatment intensity. Measurements of intracellular levels of cytotoxic metabolites of 6MP and MTX can identify nonadherent patients, but therapeutic target levels remains to be established. A rise in serum aminotransferase levels during maintenance therapy is common and often related to high levels of methylated 6MP metabolites. However, except for episodes of hypoglycemia, serious liver dysfunction is rare, the risk of permanent liver damage is low, and aminotransferase levels usually normalize within a few weeks after discontinuation of therapy. 6MP and MTX dose increments should lead to either leukopenia or a rise in aminotransferases, and if neither is experienced, poor treatment adherence should be considered. The many genetic polymorphisms that determine 6MP and MTX disposition, efficacy, and toxicity have precluded implementation of pharmacogenomics into treatment, the sole exception being dramatic 6MP dose reductions in patients who are homozygous deficient for thiopurine methyltransferase, the enzyme that methylates 6MP and several of its metabolites. In conclusion, maintenance therapy is as important as the more intensive and toxic earlier treatment phases, and often more challenging. Ongoing research address the applicability of drug metabolite measurements for dose adjustments, extensive host genome profiling to understand diversity in treatment efficacy and toxicity, and alternative thiopurine dosing regimens to improve therapy for the individual patient.
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Levinsen M, Rotevatn EØ, Rosthøj S, Nersting J, Abrahamsson J, Appell ML, Bergan S, Bechensteen AG, Harila-Saari A, Heyman M, Jonsson OG, Maxild JBC, Niemi M, Söderhäll S, Schmiegelow K. Pharmacogenetically based dosing of thiopurines in childhood acute lymphoblastic leukemia: influence on cure rates and risk of second cancer. Pediatr Blood Cancer 2014; 61:797-802. [PMID: 24395436 DOI: 10.1002/pbc.24921] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 11/05/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND Previous studies have indicated that patients with thiopurine methyltransferase (TPMT) low activity (TPMT(LA)) have reduced risk of relapse but increased risk of second malignant neoplasm (SMN) compared to patients with TPMT wild-type (TPMT(WT)) when treated with 6 MP maintenance therapy starting doses of 75 mg/m(2)/day. To reduce SMN risk, 6MP starting doses were reduced to 50 mg/m(2)/day for patients with TPMT heterozygosity in the Nordic Society of Paediatric Haematology and Oncology (NOPHO) ALL2000 protocol. PROCEDURE We explored the pattern of SMN and relapse in the NOPHO ALL2000 protocol (n = 674) and NOPHO ALL92 protocol (n = 601) in relation to TPMT pheno- and/or genotype. RESULTS The overall risk of any event did not differ significantly between the two protocols. However, in event pattern analyses considering only the patients with TPMT(LA) who experienced relapse or SMN, the risk of SMN versus leukemia relapse was significantly lower in the ALL2000 cohort for patients with a 6MP starting dose <75 mg/m(2)/day when compared to the patients in ALL92 (relapse (n = 11) and SMN (n = 0) in ALL2000 versus relapse (n = 5) and SMN (n = 4) in ALL92, P = 0.03). Furthermore, the 8-year cumulative incidence of relapse for patients with TPMT(LA) was significantly higher in the ALL2000 compared to the ALL92 cohort (19.7% (11.6-33.3%) vs. 6.7% (2.9-15.5%), P = 0.03). CONCLUSION This study indicates that reducing 6MP starting dose for patients with TPMT(LA) may reduce SMN risk but lead to a relapse risk similar to that of patients with TPMT(WT).
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Affiliation(s)
- Mette Levinsen
- Department of Pediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
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Schmiegelow K, Levinsen MF, Attarbaschi A, Baruchel A, Devidas M, Escherich G, Gibson B, Heydrich C, Horibe K, Ishida Y, Liang DC, Locatelli F, Michel G, Pieters R, Piette C, Pui CH, Raimondi S, Silverman L, Stanulla M, Stark B, Winick N, Valsecchi MG. Second malignant neoplasms after treatment of childhood acute lymphoblastic leukemia. J Clin Oncol 2013; 31:2469-76. [PMID: 23690411 DOI: 10.1200/jco.2012.47.0500] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
PURPOSE Second malignant neoplasms (SMNs) after diagnosis of childhood acute lymphoblastic leukemia (ALL) are rare events. PATIENTS AND METHODS We analyzed data on risk factors and outcomes of 642 children with SMNs occurring after treatment for ALL from 18 collaborative study groups between 1980 and 2007. RESULTS Acute myeloid leukemia (AML; n = 186), myelodysplastic syndrome (MDS; n = 69), and nonmeningioma brain tumor (n = 116) were the most common types of SMNs and had the poorest outcome (5-year survival rate, 18.1% ± 2.9%, 31.1% ± 6.2%, and 18.3% ± 3.8%, respectively). Five-year survival estimates for AML were 11.2% ± 2.9% for 125 patients diagnosed before 2000 and 34.1% ± 6.3% for 61 patients diagnosed after 2000 (P < .001); 5-year survival estimates for MDS were 17.1% ± 6.4% (n = 36) and 48.2% ± 10.6% (n = 33; P = .005). Allogeneic stem-cell transplantation failed to improve outcome of secondary myeloid malignancies after adjusting for waiting time to transplantation. Five-year survival rates were above 90% for patients with meningioma, Hodgkin lymphoma, thyroid carcinoma, basal cell carcinoma, and parotid gland tumor, and 68.5% ± 6.4% for those with non-Hodgkin lymphoma. Eighty-nine percent of patients with brain tumors had received cranial irradiation. Solid tumors were associated with cyclophosphamide exposure, and myeloid malignancy was associated with topoisomerase II inhibitors and starting doses of methotrexate of at least 25 mg/m(2) per week and mercaptopurine of at least 75 mg/m(2) per day. Myeloid malignancies with monosomy 7/5q- were associated with high hyperdiploid ALL karyotypes, whereas 11q23/MLL-rearranged AML or MDS was associated with ALL harboring translocations of t(9;22), t(4;11), t(1;19), and t(12;21) (P = .03). CONCLUSION SMNs, except for brain tumors, AML, and MDS, have outcomes similar to their primary counterparts.
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Affiliation(s)
- Kjeld Schmiegelow
- Department of Paediatric and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.
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Rassekh SR, Ross CJD, Carleton BC, Hayden MR. Cancer pharmacogenomics in children: research initiatives and progress to date. Paediatr Drugs 2013; 15:71-81. [PMID: 23529868 DOI: 10.1007/s40272-013-0021-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Over the last few decades, cure rates for pediatric cancer have increased dramatically, and now over 80 % of children with cancer are cured of their disease. This improvement in cure has come with a significant cost, with many children suffering irreversible, life-threatening, or long-lasting toxicities due to the medications required during their treatment. In the last 2 decades, major technological advances in genomics and the mapping of the human genome have made it possible to identify genetic differences between children in order to investigate differing responses to cancer therapy and to help explain why children treated with the same medications can have different outcomes. The emerging field of pharmacogenomics has had many important findings in pediatric cancer. The focus of this review is drug toxicity in pediatric cancer and the use of pharmacogenomics to reduce these adverse drug reactions, with a specific focus on thiopurines, methotrexate, cisplatin, vincristine and anthracyclines. Future areas of research and the need for international collaboration are discussed.
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Affiliation(s)
- Shahrad Rod Rassekh
- Department of Pediatrics, Division of Pediatric Hematology/Oncology/BMT, University of British Columbia, Vancouver, BC, Canada.
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Erčulj N, Faganel Kotnik B, Debeljak M, Jazbec J, Dolžan V. DNA repair polymorphisms influence the risk of second neoplasm after treatment of childhood acute lymphoblastic leukemia. J Cancer Res Clin Oncol 2012; 138:1919-30. [DOI: 10.1007/s00432-012-1265-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 06/05/2012] [Indexed: 11/28/2022]
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Hosni-Ahmed A, Barnes JD, Wan J, Jones TS. Thiopurine methyltransferase predicts the extent of cytotoxicty and DNA damage in astroglial cells after thioguanine exposure. PLoS One 2011; 6:e29163. [PMID: 22216194 PMCID: PMC3244435 DOI: 10.1371/journal.pone.0029163] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 11/22/2011] [Indexed: 01/11/2023] Open
Abstract
Thiopurine methyltransferase (Tpmt) is the primary enzyme responsible for deactivating thiopurine drugs. Thiopurine drugs (i.e., thioguanine [TG], mercaptopurine, azathioprine) are commonly used for the treatment of cancer, organ transplant, and autoimmune disorders. Chronic thiopurine therapy has been linked to the development of brain cancer (most commonly astrocytomas), and Tpmt status has been associated with this risk. Therefore, we investigated whether the level of Tpmt protein activity could predict TG-associated cytotoxicity and DNA damage in astrocytic cells. We found that TG induced cytotoxicity in a dose-dependent manner in Tpmt+/+, Tpmt+/− and Tpmt−/− primary mouse astrocytes and that a low Tpmt phenotype predicted significantly higher sensitivity to TG than did a high Tpmt phenotype. We also found that TG exposure induced significantly more DNA damage in the form of single strand breaks (SSBs) and double strand breaks (DSBs) in primary astrocytes with low Tpmt versus high Tpmt. More interestingly, we found that Tpmt+/− astrocytes had the highest degree of cytotoxicity and genotoxicity (i.e., IC50, SSBs and DSBs) after TG exposure. We then used human glioma cell lines as model astroglial cells to represent high (T98) and low (A172) Tpmt expressers and found that A172 had the highest degree of cytoxicity and SSBs after TG exposure. When we over-expressed Tpmt in the A172 cell line, we found that TG IC50 was significantly higher and SSB's were significantly lower as compared to mock transfected cells. This study shows that low Tpmt can lead to greater sensitivity to thiopurine therapy in astroglial cells. When Tpmt deactivation at the germ-line is considered, this study also suggests that heterozygosity may be subject to the greatest genotoxic effects of thiopurine therapy.
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Affiliation(s)
- Amira Hosni-Ahmed
- Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
- Department of Chemistry, College of Science, Fayoum University, Fayoum, Egypt
| | - Joseph D. Barnes
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
| | - Jim Wan
- Division of Biostatistics and Epidemiology, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
| | - Terreia S. Jones
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
- Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
- * E-mail:
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Abstract
PURPOSE OF REVIEW The purpose of this review is to update knowledge on therapy-related myeloid neoplasms (t-MN), taking into account the new 2008 WHO classification, new genome-wide approaches for the definition of susceptibility towards t-MN and the introduction of new more aggressive treatments in cancer patients. RECENT FINDINGS t-MN are an increasing matter in cancer survivors treated with chemoradiotherapy. One of the major concerns in hematologic malignancies is childhood acute lymphoblastic leukemia, in which the leukemogenic role of extended etoposide/teniposide treatment, concomitant intensive antimetabolite and asparaginase, granulocyte colony-stimulating factor (G-CSF) and prophylactic cranial radiotherapy use have been established. In high-risk Hodgkin lymphoma, 3% t-MN have been observed at 10-year follow-up with the escalated bleomycin/etoposide/doxorubicin/cyclophosphamide/vincristine/procarbazine/prednisone (BEACOPP) schedule, versus 0.4% with doxorubicin/bleomycin/vinblastine/dacarbazine (ABVD). In lymphoproliferative diseases the new drugs fludarabine and lenalidomide may increase the risk of second tumors, when associated to other cytotoxic therapies. Among solid tumors, breast cancer is most frequently associated to t-MN. The risk is correlated to higher chemotherapy doses, radiotherapy, use of G-CSF, but also independent from treatment, suggesting a genetic predisposition to both diseases. Radiotherapy plays a role also in female pelvic tumors and in testicular cancer, when associated to cisplatin. SUMMARY The risk of t-MN is not negligible, although below 2% in most series. This is particularly significant for younger cancer patients and during the first 5 years after the primary malignancies. Efforts should be maximized to identify susceptibility factors to identify patients at risk, in whom more leukemogenic drugs and schedules should be avoided.
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Epidemiology of therapy-related myeloid neoplasms after treatment for pediatric acute lymphoblastic leukemia in the nordic countries. Mediterr J Hematol Infect Dis 2011; 3:e2011020. [PMID: 21713078 PMCID: PMC3113279 DOI: 10.4084/mjhid.2011.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 05/03/2011] [Indexed: 11/08/2022] Open
Abstract
Of 1614 Nordic children with ALL that were treated according to the NOPHO ALL92 protocol, 20 developed an SMN (cumulative risk at 12 years: 1.6%). Sixteen of the twenty SMNs were acute myeloid leukemias or myelodysplasias, and 9 of these had either monosomy 7 (n=7) or 7q deletions (n=2). In Cox multivariate analysis longer duration of oral MTX/6MP maintenance therapy (p=0.02; being longest for standard risk patients) and presence of high-hyperdiploidy (p=0.07) were related to an increased risk of SMN. In 524 patients we determined the erythrocyte activity of thiopurine methyltransferase (TPMT), which methylates 6MP and its metabolites, and thus reduces cellular levels of cytotoxic 6-thioguanine nucleotides. The TPMT activity was significantly lower in those that did compared to those that did not develop an SMN (Median: 12.1 vs 18.1 IU/ml; p=0.02). Among 427 TPMT wild type patients, those who developed SMN received higher 6MP doses than the remaining (69.7 vs 60.4 mg/m2, p=0.03), which may reflect increased levels of methylated metabolites that inhibit purine de novo synthesis and thus enhance incorporation of 6-thioguanine nucleotides into DNA. In conclusion, the duration and intensity of 6MP/MTX maintenance therapy of childhood ALL may influence the risk of SMN.
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Thiopurine S-methyltransferase gene polymorphism and 6-mercaptopurine dose intensity in Indian children with acute lymphoblastic leukemia. Leuk Res 2010; 34:1023-6. [DOI: 10.1016/j.leukres.2010.01.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Revised: 01/21/2010] [Accepted: 01/26/2010] [Indexed: 11/23/2022]
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Fotoohi AK, Coulthard SA, Albertioni F. Thiopurines: factors influencing toxicity and response. Biochem Pharmacol 2010; 79:1211-20. [PMID: 20096268 DOI: 10.1016/j.bcp.2010.01.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Revised: 12/22/2009] [Accepted: 01/12/2010] [Indexed: 11/17/2022]
Abstract
Thiopurines are the backbone of current anti-leukemia regimens and have also been effective immunosuppressive agents for the past half a century. Extensive research on their mechanism of action has been undertaken, yet many issues remain to be addressed to resolve unexplained cases of thiopurine toxicity or treatment failure. The aim of this review is to summarize current knowledge of the mechanism of thiopurine action in experimental models and put into context with clinical observations. Clear understanding of their metabolism will contribute to maximizing efficacy and minimizing toxicity by individually tailoring therapy according to the expression profile of relevant factors involved in thiopurine activation pathway.
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Affiliation(s)
- Alan Kambiz Fotoohi
- Department of Oncology and Pathology, Cancer Center Karolinska, Karolinska Institutet, SE-17176 Stockholm, Sweden
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Stocco G, Crews KR, Evans WE. Genetic polymorphism of inosine-triphosphate-pyrophosphatase influences mercaptopurine metabolism and toxicity during treatment of acute lymphoblastic leukemia individualized for thiopurine-S-methyl-transferase status. Expert Opin Drug Saf 2010; 9:23-37. [PMID: 20021291 DOI: 10.1517/14740330903426151] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE OF THE FIELD Although genetic polymorphisms in the gene encoding human thiopurine methyltransferase (TPMT) are known to have a marked effect on mercaptopurine metabolism and toxicity, there are many patients with wild-type TPMT who develop toxicity. Furthermore, when mercaptopurine dosages are adjusted in patients who are heterozygous at the TPMT locus, there are still some patients who develop toxicity for reasons that are not fully understood. Therefore, we recently studied the effects of a common polymorphism in another gene encoding an enzyme involved in mercaptopurine metabolism (SNP rs1127354 in inosine-triphospate-pyrophosphatase, ITPA), showing that genetic polymorphism of ITPA is a significant determinant of mercaptopurine metabolism and of febrile neutropenia following combination chemotherapy of acute lymphoblastic leukemia (ALL) in which mercaptopurine doses are individualized based on TPMT genotype. AREA COVERED IN THIS REVIEW In this review, we summarize the knowledge available about the effect and clinical relevance of TPMT and ITPA on mercaptopurine pharmacogenomics, with a particular focus on the use of this medication in pediatric patients with ALL. WHAT THE READER WILL GAIN Reader will gain insights into: i) the effects of pharmacogenomic traits on mercaptopurine toxicity and efficacy for the treatment of ALL and ii) individualization strategies that can be used to mitigate toxicity without compromising efficacy in pediatric patients with ALL. TAKE HOME MESSAGE Mercaptopurine dose can be adjusted on the basis of TPMT genotype to mitigate toxicity in pediatric patients with ALL. As treatment is individualized in this way for the most relevant genetic determinant of drug response (i.e., for mercaptopurine, TPMT), the importance of other genetic polymorphisms emerges (e.g., ITPA).
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Affiliation(s)
- Gabriele Stocco
- St. Jude Children's Research Hospital, Department of Pharmaceutical Sciences, 262 Danny Thomas Place MS 272, Memphis, TN 38105, USA
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Incidence and susceptibility to therapy-related myeloid neoplasms. Chem Biol Interact 2009; 184:39-45. [PMID: 20026017 DOI: 10.1016/j.cbi.2009.12.013] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Revised: 12/09/2009] [Accepted: 12/11/2009] [Indexed: 02/05/2023]
Abstract
Therapy-related myeloid neoplasms (t-MN) include acute myeloid leukemias and myelodysplastic syndromes arising in patients who have been treated with chemotherapy, radiation therapy, immunosuppressive agents or after documented exposure to environmental carcinogen. t-MN are defined according to the primary treatment and the corresponding genetic and molecular lesions. Chromosome(s) 7 and/or 5 monosomies or deletions are typical of alkylating agent-induced AML, while balanced translocations involving chromosome bands 11q23 and 21q22 are associated to preceeding therapy with DNA-topoisomerase II inhibitors. Antimetabolites, and in particular the immunosuppressive agents azathioprine and fludarabine, have also been recently associated to t-MN. Leukemias developing after benzene exposure are similar to t-MN and are characterized by chromosomal aberrations, which have been also observed among otherwise healthy benzene-exposed workers. Individual predisposing factors, including polymorphisms of detoxification and DNA-repair enzymes have been identified. Two genetic variants in key metabolizing enzymes, myeloperoxidase and NAD(P)H:quinone oxidoreductase, have been shown to influence susceptibility to benzene hematotoxicity. Combination of polymorphisms impairing detoxification and DNA repair may significantly increase therapy-related myeloid neoplasm risk. Among hematological malignancies, long-term survivors of Hodgkin's lymphoma are exposed to an increased t-MN risk, particularly when receiving MOPP-based and escalated-BEACOPP regimens, and when alkylators are combined to radiotherapy. Patients with lymphoma are at highest risk if total body irradiation followed by autologous stem cell transplantation is used as rescue or consolidation. The addition of granulocyte-colony stimulating factor (G-CSF) and radiotherapy plays a significant role in t-MN following treatment of childhood acute lymphoblastic leukemia. In solid tumors, treatment for breast cancer and germ-cell tumors has been associated with a 1-5% lifetime risk of t-MN.
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Long-term results of five consecutive trials in childhood acute lymphoblastic leukemia performed by the ALL-BFM study group from 1981 to 2000. Leukemia 2009; 24:265-84. [PMID: 20010625 DOI: 10.1038/leu.2009.257] [Citation(s) in RCA: 360] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Between 1981 and 2000, 6609 children (<18 years of age) were treated in five consecutive trials of the Berlin-Frankfurt-Münster (BFM) study group for childhood acute lymphoblastic leukemia (ALL). Patients were treated in up to 82 centers in Germany, Austria and Switzerland. Probability of 10-year event-free survival (EFS) (survival) improved from 65% (77%) in study ALL-BFM 81 to 78% (85%) in ALL-BFM 95. In parallel to relapse reduction, major efforts focused on reducing acute and late toxicity through advanced risk adaptation of treatment. The major findings derived from these ALL-BFM trials were as follows: (1) preventive cranial radiotherapy could be safely reduced to 12 Gy in T-ALL and high-risk (HR) ALL patients, and eliminated in non- HR non-T-ALL patients, if it was replaced by high-dose and intrathecal (IT) MTX; (2) omission of delayed re-intensification severely impaired outcome of low-risk patients; (3) 6-month-less maintenance therapy caused an increase in systemic relapses; (4) slow response to an initial 7-day prednisone window was identified as adverse prognostic factor; (5) condensed induction therapy resulted in significant improvement of outcome; (6) the daunorubicin dose in induction could be safely reduced in low-risk patients and (7) intensification of consolidation/re-intensification treatment led to considerable improvement of outcome in HR patients.
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Frequency of TPMT alleles in Indian patients with acute lymphatic leukemia and effect on the dose of 6-mercaptopurine. Med Oncol 2009; 27:1046-9. [DOI: 10.1007/s12032-009-9331-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Accepted: 09/29/2009] [Indexed: 10/20/2022]
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