pharmacogenetic studies in childhood acute lymphoblastic

Linköping University Medical Dissertations No. 1302

Pharmacogenetic studies in childhood acute lymphoblastic leukaemia

with primary focus on methotrexate

Jannie Gregers

Faculty Logo

Department of Clinical Pharmacology

Linköping University, Sweden

Linköping 2012

Pharmacogenetic studies in childhood acute lymphoblastic leukaemia with primary focus on methotrexate

Jannie Gregers, 2012

Cover/picture/Illustration/Design: Jannie Gregers and Per Lagman

Published article has been reprinted with the permission of the copyright holder.

Printed in Sweden by LiU-Tryck, Linköping, Sweden, 2012

ISBN 978-91-7519-929-0

ISSN 0345-0082

Pharmacogenetic studies in childhood acute lymphoblastic leukaemia with primary focus on methotrexate Abstract ................................................................................................. 4 Populärvetenskaplig sammanfattning (SE) ........................................... 6 Populærvidenskabelig sammenfatning (DK) ........................................ 8 Papers included in the thesis ............................................................... 10 Abbreviations ...................................................................................... 11 Introduction ......................................................................................... 13

Acute lymphoblastic leukaemia ...................................................... 13 History and epidemiology ........................................................... 14 Medical treatment ....................................................................... 15 Risk group assignment ................................................................ 18

Methotrexate ................................................................................... 19 Mechanism of action ................................................................... 20 Pharmacokinetics ........................................................................ 20 Clinical use .................................................................................. 21 Clinical aspects of MTX in ALL ................................................ 21 Drugs interacting with MTX ....................................................... 22

Doxorubicin and vincristine ............................................................ 22 Individualisation of therapy ............................................................ 23 Pharmacogenetics and pharmacogenetic terms ............................... 23

Haplotypes .................................................................................. 24 Linkage disequilibration ............................................................. 24 Polymorphism ............................................................................. 24 Significance of SNPs .................................................................. 25 Phenotyping and genotyping ....................................................... 25 Pharmacogenetics in ALL ........................................................... 26

Folic acid metabolism - Metabolic pathways ................................. 26 Genetic polymorphisms in drug metabolising enzymes and transporters ...................................................................................... 28

Folylpolyglutamate synthetase (FPGS G1037T) ........................ 28 Aminoimidazol carboxamid ribonucleotid transformylase (ATIC 347C>G) ..................................................................................... 29

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Methylenetetrahydrofolate reductase (MTHFR 677C>T, 1298G>A) ................................................................................... 29 Thymidylate synthase (TS TSER*2/TSER*3) ........................... 29 Serine hydroxymethyltransferase (SHMT1 1420C>T)............... 30 Reduced folate carrier (SLC19A1 80G>A) ................................ 30 Multi drug resistance (ABCB1 1199G>A, 1236C>T, 2677G>A/T and 3435C>T) ............................................................................. 30

Aims of the thesis ................................................................................ 32 Material and methods .......................................................................... 33

Patients and healthy volunteers ....................................................... 33 Methodology overview ................................................................... 34 DNA isolation ................................................................................. 34 TaqMan® allelic discrimination ..................................................... 34 DNA sequencing ............................................................................. 36 Pyrosequencing ............................................................................... 37 Monitoring of MTX ........................................................................ 38 MTX determination in erythrocytes ................................................ 38 MTX determination in plasma ........................................................ 39 Flow cytometry ............................................................................... 39 Statistics .......................................................................................... 40

Results and discussion ........................................................................ 41 Impact of genetic variation in SLC19A1 on MTX uptake.............. 41 Correlation between genetic variation in SLC19A1 and effect of MTX in ALL ................................................................................... 44

Chromosome 21 copy number, SLC19A1 80G>A and risk of relapse in ALL ............................................................................ 45 SLC19A1 80G>A and pharmacokinetics ................................... 47 SLC19A1 80G>A and toxicity after HD-MTX .......................... 48

Genetic variation in the ABCB1 gene and effect on ALL treatment ......................................................................................................... 50

ABCB1 polymorphisms and linkage disequilibria ..................... 50 ABCB1 1199G>A and risk of relapse ........................................ 50 ABCB1 3435C>T and risk of relapse ......................................... 53 ABCB1 1236C>T, ABCB1 2677C>T and risk of relapse .......... 54 Polymorphisms in ABCB1 and MTX pharmacokinetics ............ 54 Polymorphisms in ABCB1 and toxicity...................................... 54

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Correlation between genetic variation in ATIC, MTHFR, and SHMT and effect in MTX therapy .............................................................. 56

ATIC, MTHFR, SHMT, outcome and pharmacokinetics ........... 56 ATIC, MTHFR, SHMT and toxicity .......................................... 56

Polymorphisms and risk of acute lymphoblastic leukaemia ........... 59 Impact of gene-gene interaction and the role of MTX in efficacy and toxicity ...................................................................................... 61

Conclusion .......................................................................................... 63 Future aspects ...................................................................................... 65 Acknowledgements ............................................................................. 67 References ........................................................................................... 69 Appendix (Paper I-IV) ........................................................................ 85

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Abstract Childhood acute lymphoblastic leukaemia is the most common type of cancer in children. Improvement in treatment has increased survival to approximately 85 per cent. Pharmacogenetics can influence the disposition of anticancer agents and can ideally be used as tool to further improve treatment based on the individual child’s pharmacogenetic profile. The hypothesis in this thesis was that polymorphisms in genes responsible for MTX influx (SLC19A1), efflux (ABCB1, studies with MTX monotherapy have demonstrated effect of variations in this gene) or other MTX pathways (ATIC, MTHFR and SHMT) could have impact on efficacy in childhood acute lymphoblastic leukaemia. The uptake of MTX and impact of SLC19A1 80G>A was investigated in vitro and showed that SLC19A1 80GG had decreased uptake in CD+ T cells and B cells caused by reduced capacity on receptor-to-receptor basis. In more than 500 patients the clinical effect of SLC19A1 80G>A genotype was evaluated and showed that patients with the SLC19A1 80AA had better survival, more bone marrow toxicity, but less liver toxicity than patients with SLC19A1 80GG or 80GA variants. Furthermore, it was demonstrated that SLC19A1 80G>A interacts with chromosome 21 copy number in the leukemic clone. The clinical impact of ABCB1 1199G>A, 1236C>T, 2677G<T/A and 3435C>T on the treatment was evaluated. Patients with either the 1199GA or the 3435CC variant had increased risk of relapse compared to patients with the 1199GG or 3435CT/TT variants, respectively. Toxicity was also affected by the ABCB1 polymorphisms. No association between polymorphisms in the ATIC, MTHFR and SHMT genes and outcome was seen. However the 677C>T and 1298 C>A in the MTHFR gene were associated with toxicity.

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The genotype frequencies between healthy donors and patients were compared, but no association to risk of developing cancer was seen in the investigated polymorphisms.

The results in this thesis emphasise the importance of including pharmacogenetic markers in attempts to improve outcome and reduced side effects in childhood ALL.

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Populärvetenskaplig sammanfattning (SE) Cancer är näst efter olyckor den vanligaste dödsorsaken hos barn och akut lymfoblastisk leukemi (ALL) är den vanligaste cancerformen hos barn. Avhandlingen handlar om normala variationer i människans arvsmassa, DNA, och hur de kan påverka läkemedelsbehandlingen av barn med ALL. En kohort på över 500 barn med ALL diagnosticerade mellan 1992 och 2006 har undersökts vad gäller olika normala genetiska varianter i relation till behandlingsutfallet. Metotrexat (MTX) är ett av de mesta använda läkemedlen under hela den 2 – 2,5 års långa behandlingstiden och avhandlingen fokuserar i första hand på normala ärftliga variationer som kan tänkas påverka effekter och biverkningar av MTX-behandling. I avhandlingen har undersökts om varianter av genen SLC19A1 påverkar transporten av MTX in i cellerna. I laboratorieförsök på normala lymfocyter visas att genvarianten 80AA gav högre intracellulära koncentrationer än övriga varianter efter inkubation med MTX. Hos barn med ALL fick individer med denna genvariant färre återfall men mera biverkningar än patienter med varianterna 80GA eller GG. Ca 25 % av barn med ALL har mer DNA än normalt i de sjuka cellerna, och i avhandlingen visas att detta påverkar behandlingsresultaten så att individer med 80GA eller 80GG- varianter får samma goda behandlingseffekter som individer med 80AA. Det verkar alltså som att mer DNA kan upphäva de negativa effekterna av GG eller 80GA varianterna. Genen ABCB1 är involverad i uttransport av många cancerläkemedel ut ur cellerna. I avhandlingen finns belägg för att även uttransporten av MTX kan påverkas. Det visade sig att patienter med genvarianten 1199GA eller 3435CC hade flera återfall men färre biverkningar än patienter med andra genvarianter. Genom olika statistiska test visas att genvarianterna som påverkar uttransporten av läkemedel inte hade så stor betydelse i den patientgrupp, som inte har en hög intransport av MTX. Däremot, i den patientgrupp med den genetiska variant som ger hög intransport, var det 10 gånger sämre att ha en variant med hög uttransportförmåga än

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med låg. Detta beror sannolikt på att MTX får en kortare tid att utöva sina effekter i cellerna. SLC19A1-genen påverkar bara intransporten av MTX medan data tyder på att ABCB1-genen är involverad i uttransporten även av MTX eftersom de olika genetiska varianterna påverkar behandlingsresultaten. Då MTX är ett cellgift som ska döda tumörceller kan det vara svårt att hitta den rätta balansen för att döda alla cancerceller utan att döda många friska celler, vilket leder till biverkningar. Denna avhandling ger oss några ytterligare redskap för att kunna individualisera behandlingen av barn-ALL med ledning av normal ärftliga skillnader så att bättre effekter och mindre biverkningar kan erhållas.

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Populærvidenskabelig sammenfatning (DK) Cancer er næst efter ulykker den hyppigste dødsårsag hos børn, og akut lymfoblastær leukæmi (ALL) er den hyppigste form for børnecancer. Dette studie omhandler normale varianter i det menneskelige arvemateriale DNA, som har betydning for medicinsk behandling af børn med ALL. Mere end 500 børn, der fik stillet diagnosen ALL imellem 1992 og 2006, er blevet undersøgt for forskellige normale varianters relation til effekt af behandling. Methotrexate (MTX) er et af de mest brugte medikamenter gennem hele den 2 til 2½ år lange behandling for ALL, og dette studie fokuserer primært på arvelige variationer, der kan tænkes at påvirke enten virkningen af MTX eller bivirkninger efter MTX behandling. I studiet er det undersøgt om varianter i genet SLC19A1 kunne påvirke transporten af MTX ind i kroppens celler. I et laboratorieforsøg med normale celler blev det vist at varianten 80AA var bedre til få MTX ind i cellerne. Hos børn med ALL fik patienterne med denne variant færre tilbagefald, men flere bivirkninger end patienter med enten 80GA eller 80GG varianterne. Cirka 25% af børn med ALL har mere DNA end normalt i deres syge celler, og i studiet blev det vist, at dette påvirkede den undersøgte variant, idet den patientgruppe med 80GA eller 80GG varianter, der skulle give flere tilbagefald af sygdom, ikke fik lige så mange tilbagefald, hvis de havde mere DNA i de syge celler. Dette skyldes formentligt, at selvom 80GG og 80GA varianterne er dårligere end 80AA varianten til at transportere MTX ind i cellerne, vil mere DNA og dermed flere 80GG eller 80GA varianter kunne ophæve den dårlige indflydelse.

Genet ABCB1 er involveret i at transportere mange former for medikamenter ud af cellerne og måske også i at transportere MTX ud af cellerne. I studiet blev det undersøgt, om forskellige varianter i genet ABCB1 kunne påvirke transporten af medikamenter, og i særdeleshed om varianterne ville påvirke transporten af MTX ud af cellerne. Det viste sig, at patienter med enten varianten 1199GA eller

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varianten 3435CC havde flere tilbagefald, men færre bivirkninger end patienter uden disse varianter. Gennem forskellige statistiske tests viste det sig, at varianterne, der påvirker transport af medikamenter ud af cellerne, ikke havde så stor betydning i den patientgruppe, der havde varianter, som ikke er gode til at få MTX ind i cellerne. Hvorimod det i patientgruppen med den variant, der er god til at få MTX ind i cellerne, var 10 gange dårligere at have en variant, der er god til at transportere medikamenter ud af cellerne end at have en variant, der er længere tid om at transportere medikamenter ud af cellerne. Dette skyldes formentlig, at medikamenterne ikke får så lang tid til at udøve deres virkning inde i cellerne. Fordi SLC19A1 genet kun er involveret i, at lige præcis MTX kommer ind i cellen, og der ses en større forskel af påvirkning på transport ud af cellerne imellem patienter med forskellige varianterne i ABCB1 i den patientgruppe, der bedst får MTX ind i cellerne, så er det sandsynliggjort, at genet ABCB1 er involveret i at få lige præcis MTX ud af cellen. Da MTX er en cellegift, der skal slå cancerceller ihjel, kan det være svært at finde den balance, hvor man får slået alle cancercellerne ihjel uden at slå raske celler ihjel (bivirkninger). Dette studie giver os nogle redskaber til at kunne individualisere patientbehandling ud fra vore arveanlæg, så bedre virkning af MTX kan opnås og/eller færre bivirkninger kan undgås.

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Papers included in the thesis

I. Baslund B, Gregers J, Nielsen CH. Reduced folate carrier polymorphism determines methotrexate uptake by B cells and CD4+ T cells. Rheumatology (Oxford). 2008 Apr;47(4):451-3. Epub 2008 Mar 3.

II. Gregers J, Christensen IJ, Dalhoff K, Lausen B, Schroeder H, Rosthoej S, Carlsen N, Schmiegelow K, Peterson C. The association of reduced folate carrier 80G>A polymorphism to outcome in childhood acute lymphoblastic leukemia interacts with chromosome 21 copy number. Blood. 2010 Jun 10;115 (23):4671-7. Epub 2010 Mar 24.

III. Gregers J, Gréen H, Christensen IJ, Peterson C, Dalhoff K,

Schroeder H, Carlsen N, Rosthoej S, Laursen B and Schmiegelow K. Polymorphisms in the ABCB1 gene affect outcome and toxicity in childhood acute lymphoblastic leukaemia. Submitted.

IV. Gregers J, Christensen IJ, Dalhoff K, Lausen B, Schroeder H,

Rosthoej S, Carlsen N, Schmiegelow K, Peterson C. Pharmacogenetic polymorphisms in folate metabolism affect toxicity after high dose methotrexate in childhood acute lymphoblastic leukemia. Manuscript.

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Abbreviations Abbreviations used in this thesis: ABCB1 ATP-binding cassette, sub-family B, the gene encoding

P-glycoprotein ALAT Alanine amino transferase ALL Acute lymphoblastic leukaemia ATIC 5-Aminoimidazole-4-carboxamide-ribonucleotide-

formyltransferase/IMP-cyclohydrolase ATP Adenosine triphosphate

CA Candida albicans CR Complete remission CI Confidence interval dATP deoxyadenosine triphosphate dATP-S deoxyadenosine alfa-thio triphosphate ddNTP Dideoxyribonucleotide triphosphate DHFp Dihydrofolate polyglutamates DHFR Dihydrofolate reductase DNA Deoxyribonucleic acid dNTP Deoxyribonucleotide triphosphate dTMP Deoxythymidine monophosphate dUMP Deoxyuridine monophosphate FPGS Folylpolyglutamate synthase GART Glycinamide ribonucleotide formyltransferase HD-MTX High dose methotrexate HR Hazard rate i.t. Intrathecal (into the spinal canal)

6-MP 6-Mercaptopurine MDR-1 Multi-drug resistance, earlier name for the gene

encoding P-glycoprotein 5-MeTHF 5-Methyltetrahydrofolate MFI Mean fluorescence intensity MGB Minor groove binder MS Methionine synthase MT Methyl transferase

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MTHFR Methylene tetrahydrofolate reductase MTHFD Methylene tetrahydrofolate dehydrogenase MTX Methotrexate MTXp Methotrexate polyglutamates (of different length) NFQ Non-fluorescent quencher NOPHO Nordic society of Paediatric Haematology and Oncology P-gp P-glycoprotein PCR Polymerase chain reaction RFC1 Reduced folate carrier protein tRNA transfer RiboNucleric Acid SHMT Serine hydroxymethyltransferase 1 SLC19A1 Solute carrier family 19 (folate transporter) member 1,

the gene encoding reduced folate carrier SNP Single nucleotide polymorphism TDM Therapeutic drug monitoring THFp Tetrahydrofolate polyglutamates TPMT Thiopurine methyltransferase TS Thymidylate synthetase TT Tetanus toxoid WBC White blood cells

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Introduction Second only to accidents, cancer is the most common course of death in children. Although the survival rate has increased to almost 80% in the Nordic countries, we still need to improve treatment protocols for the 20% non-survivors and reduce the side effects for those cured with the current protocols. Individualised treatment based on pharmacogenetics could be important to achieve this goal. The current enthusiasm for pharmacogenetics draws much of its inspiration from the examples of polymorphisms that have marked clinically relevant effects on drug response. In childhood leukaemia, polymorphism in the enzyme thiopurine methyltransferase (TPMT) has been shown to play a significant role in the effect and toxicity of 6-mercaptopurine treatment [Relling et al., 1999]. As methotrexate (MTX) is the most widely used drug for leukaemia treatment, pharmacogenetic individualization of MTX therapy could thus improve outcome and reduce toxicities for the individual child.

Acute lymphoblastic leukaemia Acute lymphoblastic leukaemia (ALL) is a condition where genetic alterations in a single lymphoblast are inherited in all the cell’s descendants. The genetic alterations lead to accumulation of these leukemic clone cells with uncontrolled proliferation, which causes dysfunction of the bone marrow leading to mono- or pancytopenia and ultimately, if not treated, death. Multiple genetic hits to DNA are necessary to cause cancer and when cancer strikes in childhood it is probably due to only a few severe genetic hits. Thus in childhood ALL we see the same genetic alterations in more than half of the children (hyperdiploidy 35% and t(12;21) translocation 25%). However these alterations alone are not enough to cause cancer; 0.5% of adults harbour the t(12;21) translocation and have never had childhood ALL [Olsen et al., 2006]. We do not know the cause of the initiating genetic alteration. Suggestions include chemicals, ionising radiation, food, smoking, many infections (the immune system going berserk) or few infections (the immune system does not mature and goes berserk after the first

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infection late in childhood). The latter hypothesis by Greaves [Greaves, 2006] is supported by a study showing that children in day-care have reduced risk of childhood cancer compared to children with lesser contact to other and thus lesser exposure to infections [Urayama et al., 2010]. In the industrialized parts of the world, we see more cases of childhood ALL; this could also support Greaves’s hypotheses as children in the Western world have fewer infections due to for example vaccinations programmes.

History and epidemiology Rudolf Virchow from Germany was the first to use the term leukaemia in 1847, only a few years after he, as well as J.H Bennett and D. Craigie from Scotland, had first described cases of the disease [Bennett, 1980;Kampen, 2012]. Once Ehrlich had introduced staining methods, the classification into acute lymphoid leukaemia became possible in 1913 [Pui, 2006], and in 1973 ALL was divided into origin from B or T-lymphocytes [Borella and Sen, 1973]. Until the 1940’s there were no effective treatments for leukaemia in children. However after recognising that folic acid seemed to accelerate the disease, Sidney Farber introduced the folate antagonist, aminopterin, into the treatment in 1948 and was the first to induce remission in children with ALL [Miller, 2006]. Today we individualize treatment in childhood leukaemia based on pharmacology, cytomorphology, immunology, cytogenetics and molecular biology (minimal residual disease) [Synold et al.,

Hyperdiploidy is the phenomenon with more than 51 chromosomes in the leukemic clone (46 is normal). t(12;21) is a translocation, where some of the DNA material on chromosome 12 and chromosome 21 have exchanged places. Children harbouring these genetic alterations have a better prognosis than the other children with ALL [McLean et al., 1996;Pui et al., 1990].

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1994;Barredo et al., 1994;Whitehead et al., 1992;Coustan-Smith et al., 2000;Evans et al., 1998] and, as mentioned earlier with the example with TPMT and 6-mercaptopurine, pharmacogenetics. ALL is the most common cancer in children, accounting for 75-80% of all acute leukaemias in children. Approximately half to two-third of ALL cases occur in children. An incident peak is seen between 2 and 5 years among children living in the Western world [Greaves, 2006]. Every year approximately 180-200 children are diagnosed with ALL in the Nordic countries (Denmark, Finland, Iceland, Norway and Sweden), of which 35-40 are Danish children. The annual incidence is 3.9 children under 15 years per 100 000 [Gustafsson et al., 2000].

Medical treatment Paediatric haematologists in the Nordic countries have a long tradition for sharing experience across borders, and reflecting this the Nordic society of Paediatric Haematology and Oncology (NOPHO) was founded in 1981. Because of the Nordic collaboration, the treatment of ALL is identical in all Nordic countries. The first uniform Nordic protocol was NOPHO ALL-92 where cranial irradiation was replaced with intravenous high-dose chemotherapy for all but the highest risk patients (Table 1). The second uniform Nordic protocol was NOPHO ALL-2000, which retained the basic concepts in the NOPHO-ALL 1992 protocol, except for minor changes during different phases (Table 2). As a result of treatment intensification the long-term survival for Nordic children has increased to 83% [Schmiegelow et al., 2010].

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Table 1. NOPHO ALL-92 protocol Induction therapy.

All patients received prednisolone (60 mg/m2/day on days 1–36, then tapered), weekly VCR (2.0mg/m2 six times, maximum 2.0mg), doxorubicin (40mg/m2 three times (SR and IR) or four times (HR)), Erwinia asparaginase (30.000 IU/m2 daily on days 37–46) and intrathecal MTX on four occasions.

Early intensification Immediately after induction therapy, IR- and HR-patients received two doses of cyclophosphamide (1000 mg/m2 two times, 4 weeks apart) with low-dose cytarabine (75 mg/m2 daily for two 4-day periods after each cyclophosphamide dose) and oral 6MP.

Consolidation For SR–ALL, consolidation therapy included three courses of high-dose MTX (HD– MTX) 5g/m2/24 h with i.t. MTX and leucovorin rescue. Patients with IR–ALL received oral 6MP (25 mg/m2/day) with four courses of HD–MTX 5 g/m2/24 h with i.t. MTX and leucovorin rescue at 2 weeks intervals. Patients with HR– or VHR–ALL received HD–MTX 8 g/m2/24 h with i.t. MTX and leucovorin rescue, alternating with high-dose cytarabine (12 g/m2) two times (VHR) or four times (HR) with two 2-month intervening periods of oral weekly MTX and daily 6MP with two VCR/prednisolone re-inductions per period. Delayed intensification

Patients with IR-, HR- or VHR-ALL received delayed intensification with dexamethasone (10mg/m2/day for 3 weeks, then tapered), weekly VCR (2.0mg/m2 four times), weekly anthracycline (30mg/m2/day doxorubicin three times (HR) or daunorubicin four times (IR)) and Erwinia asparaginase (30.000 IU/m2 four times) followed by cyclophosphamide 1000mg/m2, low-dose cytarabine and 6-thioguanine.

6-MP/MTX maintenance therapy This therapy was initiated at treatment weeks 13 (SR), 32 (IR) or 63 (HR) and continued until 2 (IR and HR) or 2½ years (SR) after diagnosis. During the first year of maintenance therapy, patients with SR– or IR–ALL received alternate pulses at 4-week intervals of (i) VCR (2.0 mg/m2 once) and prednisolone (60 mg/m2/day for 1 week) and (ii) HD–MTX 5 g/m2/24 h with i.t. MTX and leucovorin rescue until five courses of HD–MTX had been given. Every 8 weeks throughout maintenance therapy, HR patients received reinductions of VCR (1.5 mg/m2 once) and prednisolone (40 mg/m2/day for 5 days) with i.t. MTX.

[Schmiegelow et al., 2010].

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Table 2. Changes in NOPHO-ALL 2000 compared to NOPHO-ALL 92. Patients with unfavourable features such as WBC > 50 x109/L at diagnosis, T-cell immunophenotype, hypodiploid karyotype (<45 chromosomes or DNA-index < 0.95), hyperhaploid karyotype (<34 chromosomes), 11q23/MLL rearrangements, t(9;22)(q34;q11)/BCR-ABL, t(1;19)(q23;p13)/E2A-PBX1, CNS-involvement at diag-nosis, testicular leukaemia at diagnosis or poor response to therapy The doxorubicin dose on day 8 is omitted. This is a reduction in total anthracycline

dose from 160 to 120 mg/m2 during the first induction phase. Patients with WBC>=200 x 109/L at diagnosis, and/or MLL rearrangement

(age>=10 yrs) and/or t(9;22)(q34;q11) /BCR-ABL fusion and/or hypodiploidy (< 34 chromosomes) and/or very poor response (M3 BM on day 29) are primarily selected for BMT in first remission.

The first dose of Leukovorin rescue after HDM-8 gr/m2 is reduced to 15 mg/m2. The first rescue dose is given at 36 hours from start of HDM-course as in previous protocol.

One interim maintenance block is excluded from the earlier “high-risk” protocols. The LSA2L2 regimes are included as a part of the maintenance therapy in the

intensive protocol (2 cycles). In the very intensive protocols the number of cycles is reduced from 6 to 3 and the maintenance therapy is continued with oral 6-MP/Mtx treatments.

Patients without unfavourable features The doxorubicin dose on day 36 is omitted. This is a reduction in total anthracycline

dose from 120 to 80 mg/m2 during the first induction phase. The intervals between HDM-courses during the consolidation phase are increased to

4 weeks. Cytarabine injections are given during the 2nd and 3rd week after the HDM-infusion. 6-MP is added during the consolidation phase for the SI group.

The first leukovorin-rescue dose is given at 42 hours (earlier 36 hours) from start of HDM-infusion.

The delayed intensification block has been modified and is given after the consolidation block in the intermediate intensive protocol.

Dexamethasone 6 mg/m2 will replace prednisolone in the pulses of vincristine during maintenance-1 phase.

All patients are randomised during the maintenance II phase into two arms, one arm with 6-MP/Mtx and one arm with 6-MP/Mtx + pulses of dexamethasone/vincristine.

Treatment duration for intermediate intensity protocol will be increased from 2 to 2.5 years from initial diagnosis.

All Patients The dose of vincristine is 2.0 mg/m2 as in ALL-92, but the maximum dose is

increased from 2.0 mg to 2.5 mg. Each dose of doxorubicin is infused over 4 hours instead of 24 hours. The asparaginase preparation and dose is standardised; Asparaginase MEDAC

6.500 IU/m2 twice weekly. www.nopho.org

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Risk group assignment Both in NOPHO-92 and NOPHO-2000 the children were assigned to risk groups with specified treatment according to age and white blood cell count (WBC) at diagnosis. In the NOPHO-92 protocol the assignment was as followed: Standard risk (SR): age 2.0–9.9 years and WBC <10.0*109/L. Intermediate risk (IR): age 1.0–1.9 or >10.0 years and/or WBC >10–49.9*109/L. High risk (HR or very high risk (VHR)): WBC>50.0*109/L and the presence of unfavourable features such as T-ALL, the presence of CNS or testicular involvement, translocations t(9;22)(q34;q11) or t(4;11)(q21;q23), lymphomatous leukaemia, mediastinal lymphoma, and/or poor response to therapy. The children were assigned to the VHR risk group, if they were at least 5 years of age at diagnosis and in addition had either T-cell ALL with one or more additional unfavourable features, CNS leukaemia, lymphomatous leukaemia and/or were assigned to HR risk group at diagnosis and showed poor response to therapy in bone marrow at day 15 or day 29. The assignment to risk group in the NOPHO-2000 protocol was very similar to NOPHO-92 except that all children aged 1.0–9.9 years were assigned to the SR risk group, if their WBC was <10*109/L and they had no unfavourable features (in the NOPHO-2000 protocol, t(1;19)(q23;p13), hypodiploidy (<45 chromosomes) and all MLL-rearrangements were included in unfavourable features). Furthermore the high risk group patients were stratified into three treatment groups: HR, VHR and extra HR. Children with unfavourable features were assigned to the VHR risk group, if they were at least 5 years of age at diagnosis and in addition had WBC of 100–199*109/L, and/or T-cell ALL with mediastinal mass and/or CNS leukaemia. Children with WBC>200*109/L, MLL-rearrangement and age >10 years, hypodiploidy <34 chromosomes, translocation t(9;22)(q34;q11), and/or a poor response to treatment in bone marrow, were stratified to the extra HR group and offered allogeneic stem cell transplantation in first complete remission (CR). All other patients with unfavourable

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features were stratified to the HR–ALL group [Schmiegelow et al., 2010].

Methotrexate MTX (4-amino-10-methylpteroyl-L-glutamic acid) is an analogue to the folic acid antagonist aminopterin (Fig.1), the first drug to induce remissions in children with ALL [Schornagel and McVie, 1983]. Today MTX is the most widely used drug in chemotherapy and is used throughout the 2-2½ years of therapy in childhood ALL. MTX has increased affinity for its target enzymes when MTX is polyglutamated intracellularly and the polyglutamated MTX (MTXp) is intracellularly retained far longer than the administered monoglutamated MTX. The antileukemic effect of MTX is well documented [Burke et al., 1999;Evans et al., 1998] and it has been shown that intracellular and extracellular concentrations of MTX and its active polyglutamylated metabolites are significant for the antileukemic effect and cure rate [Masson et al., 1996]. Treatment efficiency is assessed by the number of lymphoblasts in bone marrow (minimal residual disease MRD) and outcome [van Dongen et al., 1998;Coustan-Smith et al., 2000;Schmiegelow et al., 2001].

O

C NH

COOH

COOHN

N N

N

H2N

OH

NH

Folic Acid

O

C NH

COOH

COOHN

N N

N

H2N

OH

NH

Folic Acid

O

C NH

COOH

COOHN

N N

N

H2N

N2H

CH3

N

Methotrexate - a Folic Acid antagonist

O

C NH

COOH

COOHN

N N

N

H2N

N2H

CH3

N

Methotrexate - a Folic Acid antagonist

Figure 1. Folic acid and methotrexate only differ in an amino and a methyl-group

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Mechanism of action MTX and MTXp exert their effect by inhibiting enzymes essential for thymidylate synthesis and de novo purine synthesis, which will affect DNA synthesis and cellular proliferation by primarily inhibiting the enzyme dihydrofolate reductase (DHFR), leading to depletion of 5-10 methylene tetrahydrofolic acid and N-10 formyl tetrahydrofolic acid. As these tetrahydrofolates function as co-factors to one-carbon transfer reactions, various configurations and synthetic reactions, which are dependent on one-carbon addition, are inhibited. Both the purine de novo synthesis and the thymidylate synthesis are dependent on one-carbon addition. For example, the thymidylate synthesis receives a one-carbon group from 5,10-methylene tetrahydrofolate to deoxyuridine monophosphate (dUMP) for the conversion to deoxythymine monophosphate (dTMP), one of the precursors essential for DNA-synthesis. In this process, the 5,10-methylene tetrahydrofolate is oxidized to dihydrofolate and DFHR would, if not inhibited by MTX and MTXp, reduce it to tetrahydrofolate again. The inhibition of DHFR also prevents DHFR from reducing MTXp to MTX. As MTXp is retained longer inside the cell, the accumulation of MTXp will extend the toxic effect to the cell. MTXp inhibits MTHFR, TS, GAR-Tase and AICAR-Tase, all essential for either the thymidylate synthesis or the de novo purine synthesis [Schornagel and McVie, 1983;Schroder, 1990]. It is also likely that MTX has inhibitory effects on the intracellular transport of glucose. MTX kills cells during the S phase of the cell cycle and has the highest efficacy on rapidly dividing cells. In high-dose MTX treatment, the cells are depleted and the patient will die, if leucovorin rescue is not given. Leucovorin, a reduce folate coenzyme, repletes the intracellular pool of tetrahydrofolate cofactors. The effect of low-dose MTX treatment is probably more due to long-lasting effect of the polyglutamation.

Pharmacokinetics The absorption of MTX in the proximal jejunum is variable from 40 to 100%. In doses less than 25 mg/m2, MTX is readily absorbed from the gastrointestinal tract, but larger doses are absorbed incompletely and

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thus often given intravenously. MTX is rapidly incorporated into various tissues, including the cerebral spinal fluid, although in that particular case only high-dose MTX intravenous or intrathecal treatment insure therapeutic levels [Brunton et al., 2006]. Transport of MTX in cells is mediated by the reduced folate carrier and opposed by independent exit pumps [Belkov et al., 1999;Matherly and Taub, 1999;Moscow, 1998]. In the cells the enzyme folylpolyglutamate synthetase (FPGS) metabolises MTX to MTXp with up to seven long chain glutamate groups. MTXp is intracellularly accumulated and the rate of efflux from cells is inversely related to the number of glutamate residues [Schroder, 1990]. Between 50-60% of plasma MTX is bound to proteins, and at low doses this may be up to 95% [Schornagel and McVie, 1983]. Between 80-90% of low-dose MTX is eliminated unmetabolised by renal excretion within 48 hours. The plasma-MTX half-live is 3 to 10 hours after low oral doses. After high intravenous doses, MTX disappears in a triphasic way: a rapid distribution phase, followed by the second phase reflecting renal clearance with a half-life of 2 to 3 hours, and the third phase with a half-life of 8 to 15 hours.

Clinical use Apart from leukaemias and other cancer diseases, MTX is used in low doses in several illnesses, such as rheumatoid arthritis, inflammatory bowel diseases, psoriasis and other skin diseases.

Clinical aspects of MTX in ALL Almost every child with ALL throughout the world is treated with MTX. In the Nordic ALL protocol, MTX is given as intravenous 5 or 8 g/m2 high dose infusions (HD-MTX), as intrathecal (i.t.) injections and as low oral doses (20 mg/m2 weekly). Life-threatening situations such as severe infections and toxicity are mainly seen during treatment with HDMTX. Other common side effects are nausea, vomiting, diarrhoea, stomatitis, megaloblastic anaemia, leucopenia, trombocytopenia, transient elevation of the hepatic transaminases and bone marrow suppression. Lowering or

21

postponing the doses can reduce the toxic side effects. In both intravenous and intrathecal therapy, neurological toxicity can occur.

Drugs interacting with MTX Delayed renal excretion can be caused by concurrent use of drugs, that either reduce renal blood flow, are nephrotoxic or are weak organic acids (e.g. nonsteroidal anti-inflammatory agents, cisplatin and aspirin/piperacillin, respectively) and can lead to severe myelosuppression [Thyss et al., 1986]. 6-Mercaptopurine (6-MP) is used in ALL therapy together with MTX and gives a synergistic in-vivo effect on both toxicity and efficacy [Schmiegelow et al., 1994;Schmiegelow et al., 1995;Schmiegelow and Bretton-Meyer, 2001;Nygaard and Schmiegelow, 2003;Bokkerink et al., 1988].

Doxorubicin and vincristine MTX is not a known substrate for p-glycoprotein encoded by ABCB1, but well-known substrates such as doxorubicin and vincristine are also important drugs in ALL treatment. Doxorubicin is an anthracycline antibiotic, derived from the fungus Streptococcus peucetius. Anthracyclines were introduced in anti-leukemic therapy in 1966 [Jacquillat et al., 1966]. Doxorubicin is rapidly absorbed and is eliminated after hepatic conversion to inactive products and biliary excreted, disappearing in a multiphasic way with half-lives between 3 and 30 hours [Twelves et al., 1998]. Doxorubicin enters the cell through passive diffusion and exerts its effect by intercalating with DNA, thus affecting DNA transcription and replication. Doxorubicin also forms complexes with DNA and topoisomerase, thus inhibiting re-ligation of broken DNA strands, and causing apoptosis [Osheroff et al., 1994;Bachur et al., 1992]. Vincristine is an alkaloid derived from the Periwinkle plant and has been used in anti-leukemic therapy since 1963 [Johnson, 1968]. Vincristine, like doxorubicin, enters the cell through passive diffusion and is metabolised in the liver and excreted through the bile.

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Vincristine has plasma half-lives of between 1 and 20 hours [Zhou and Rahmani, 1992]. Vincristine binds to β -tubulin and exerts its effect by preventing β -tubulin from polymerising with α-tubulin into microtubules. This arrests the cell division in metaphase and leads eventually to apoptosis [Jordan et al., 1998].

Individualisation of therapy Traditionally, the same kind of drug is given to patients with the same disease, and the dose is based on the patients’ weight or body surface area (m2). However, response to treatment can vary greatly, even though they all are treated with the same drug and the same dose per square meter [Eichelbaum et al., 2006]. This variability in individual response can be caused by non-genetic factors, such as age affecting kidney function, liver function, environment, food, and concomitant diseases. However genetics is responsible for typically 15 to 30%, and in rare cases up to 95%, of individual differences in drug metabolism and treatment effect. These genetic differences can affect both pharmacokinetics (e.g drug-metabolising enzymes) and pharmacodynamics (e.g. drug targets or target related proteins) and thus affect both efficacy and toxicity [Nebert et al., 2008]. One way of individualising treatment is therapeutic drug monitoring (TDM), where drug concentration or a biological marker of drug effect is measured to ensure treatment effect without toxicity, also called the therapeutic window, for example monitoring of patients on warfarin treatment. Another way is to screen the patient for known pharmacogenetic factors before treatment, for example TPMT in childhood ALL.

Pharmacogenetics and pharmacogenetic terms In this thesis the word pharmacogenetics is used as a general term for genetics involving both pharmacokinetics and pharmacodynamics, while pharmacogenomics involves a broader perspective of pharmacogenetic variants in the genome.

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Pharmacogenetics is the term for those genetic alterations where a relationship between the genetic variant and clinical effect is seen. The term was first introduced by Fridrich Vogel in 1959, however the first known pharmacogenetic observation was done by Pythagoras about 510 B.C, when he talked about the danger of eating the fava bean [Nebert et al., 2008]. To be of use in daily practice, pharmacogenetic variants need to have either economic (for example early shift from ineffective treatment, reduction in drug doses) or treatment related advantages. Pharmacogenetic variants should also not occur too infrequently.

Haplotypes The mapping of the humane genome has contributed to our knowledge of genes and we know that drug efficacy often depends on interaction between several genes [Crawford and Nickerson, 2005]. Thus it can be necessary to look at haplotypes. The term haplotypes is sometimes used for genetic variants in linkage disequilibration or at the same chromosome. In this thesis, haplotypes is primary used for combinations of genetic variants with the same effect on drug response. These genetic variants can be located on different genes and chromosomes.

Linkage disequilibration Linkage disequilibration is the phenomenon where two or more genetic variant combinations are inherited together, resulting in fewer haplotypes than expected. In humans this is often seen in genetic variants with a small physical distance between loci, resulting in fewer meiotic recombinations between the genetic variants.

Polymorphism Polymorphism (Greek: multiple forms) is the phenomenon of alternative DNA sequences between individuals at a locus in the genome. There are different types of polymorphisms: single base polymorphism (SNP), deletions, or insertions of a section of DNA, the latter includes repeated sequences. The majority of human sequence variations are due to substitutions that have occurred once in the

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history of mankind at individual base pairs. SNP is the most common form of polymorphisms, found in approximately 1 of every 600 base pairs [Patil et al., 2001]. In polymorphisms where a sudden variant causes diseases, the variant is often referred to as a mutation. The most frequent variant, which obviously does not cause disease, is called wildtype. In pharmacogenetics a variant can be most frequent in one ethnic population but not in another ethnic population, hence the term wildtype is avoided in the thesis. Instead, the specific nucleotides from each allele are mentioned (e.g. 3435CC, 3435TT or 3435CT, if the variant is heterozygous).

Significance of SNPs The significance of a SNP depends on its location. A SNP located in an intron, for instance, could be of significance if located in a splice-site or in the promoter region of the gene in question, or if the SNP functions as a marker for a phenotype because of linkage disequilibration with the functional SNP. A SNP located in an exon can also function as a marker for phenotype, but the altered DNA sequence often results in an amino acid change leading to a functional change. Sometimes the altered DNA sequence does not result in an amino acid change, these variants are called silent variants/mutations or synonymous variants/mutations. These silent variants were earlier thought only to have relevance as markers for phenotypes, but today it is thought that silent mutations such as ABCB1 3435C>T could be of significance, even though mRNA and protein levels are unaffected in the different variants. The altered DNA sequence in 3435C>T requires a rare transfer RNA (tRNA), which is thought to slow down the translation in a specific location to allow the peptide chain to bend into an unusual conformation and thus affect functionality [Kimchi-Sarfaty et al., 2007].

Phenotyping and genotyping Genotype is the inherited genetic code defined by the DNA sequence. Phenotype is the physical manifestation of the genotype in combination with environmental factors. Gene activity status can be determined by phenotyping or genotyping. Phenotyping measures the

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current status of the gene activity. This can be useful / advantageous, however phenotyping of TPMT activity is largely influenced by bone marrow suppression and/or medical enzyme induction [Brouwer et al., 2005]. This is probably due to the correlation between younger cells and increased enzyme activity [Lennard et al., 2001]. Genotyping identifies variations in the inherited genetic code and is unaffected by transportation time, storage temperature and temporary biological changes.

Pharmacogenetics in ALL Whilst pharmacogenetics have been used in childhood ALL for several years, the only genetic variants routinely tested today are in the gene encoding TPMT. TPMT is an enzyme involved in the metabolism of 6-MP; it catalyses the conversion of 6-MP to the less cell toxic 6-methyl mercaptopurine. To prevent severe bone marrow toxicity in children with genotypes coding for reduced TPMT enzyme activity, scheduled 6-MP doses are reduced before treatment start. However, treatment of childhood ALL involves a variety of drugs. Identifying other pharmacogenetic variants that are significant for treatment efficacy could therefore be of great benefit to patients. One method of identifying genes relevant for a specific disease is to perform whole genome sequencing in a large group of patients, examining patterns between genetic variants and treatment outcome. This approach is used in ongoing ALL research projects in Nordic children [Wesolowska et al., 2011]. Relevant polymorphisms are found in drug target genes or in genes responsible for transport or metabolism. Examining the metabolism pathways could help identify genes relevant for a specific drug. In this thesis focus is on the folic acid antagonist MTX and the metabolic pathway of MTX is the folic acid metabolism.

Folic acid metabolism - Metabolic pathways The conversion of folic acid or vitamin B9 to tetrahydrofolates is called the folic acid metabolism (Fig. 2). The reduced folate carrier is responsible for transport of the plasma form of folic acid, 5-methyl tetrahydrofolate (5-MeTHF), into the cell. Inside the cell 5-MeTHF is

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polyglutamated by folylpolyglutamate synthetase (FPGS) into 5-MeTHF polyglutamates (5-MeTHFp). The impact of polyglutamylation from two to seven glutamate residues does not seem to influence the activity to carry one-carbon groups, but 5-MeTHFp is retained longer inside the cell than 5-MeTHF. The 5-MeTHFp is reduced to THFp, when giving a one-carbon group to the homocysteins conversion to methionine. Methionine is converted to S-adenosylmethionine, the one-carbon carrier to more than hundred reactions, included DNA synthesis [Devlin, 1986;Schornagel and McVie, 1983;Schroder, 1990]. THFp is converted to 5,10-methylene-THFp, the one-carbon carrier for thymidylate synthesis. The reaction is followed by the oxidation of 5,10-methylene-THFp to 5,10-methenyl-THFp, which reversibly hydrolysed to 10-formyl-THFp, the one-carbon carrier for de novo purine synthesis. 5,10-methylene-THFp is reduced to either dihydrofolate polyglutamate (DHFp) or 5-methyl-THFp. Multi-drug-resistance protein (MDR) is involved in efflux of folic acid. Because of their significance for the thymidylate, de novo purine and thus the DNA synthesis, folate-requiring enzymes can play an essential role for the efficacy of folate antagonist therapy like MTX. In the figure below the grey bubbles with MTX indicate, where MTX and MTXp inhibit. As MTX and folic acid only differ from each other by a methyl-group and an alcohol to an amino-group, MTX will compete with folic acid in this metabolism.

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Figure 2. The folic acid metabolism

Genetic polymorphisms in drug metabolising enzymes and transporters In this thesis, the following key enzymes harbouring well characterised polymorphisms with possible clinical impact on MTX efficacy in childhood ALL were selected for further study. This was based on a review of literature focused upon enzymes relevant to the folic acid metabolism and polymorphisms, which had shown possible clinical relevance in MTX treatments for example in rheumatoid arthritis, psoriasis or cancers.

Folylpolyglutamate synthetase (FPGS G1037T) A polymorphism G1037T, has been identified in the gene encoding the enzyme FPGS, which metabolises MTX to MTXp [Liani et al., 2003]. Two studies have reported a relationship between FPGS activity and the concentration of MTXp in lymphoblastic bone marrow samples [Rots et al., 1999], including one in-vitro study [Galpin et al., 1997]. However one study with only eight patients could not demonstrate this relationship [Longo et al., 1997]. The frequencies and association to response to MTX therapy and outcome was unknown. When analysing the donor cohort for the

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polymorphism only one variant was present and since this could be a spontaneous mutation in a cell line in Liani et al’s study, no further evaluation of the “polymorphism” was conducted in this thesis.

Aminoimidazol carboxamid ribonucleotid transformylase (ATIC 347C>G) The enzyme ATIC or AICART is essential for de novo purine synthesis. A polymorphism C347G has been identified and shown to affect MTX therapy in patients with rheumatoid arthritis [Dervieux et al., 2004a] and psoriasis [Campalani et al., 2007]. More recent research suggests that other polymorphisms could also be of potential interest [Hinks et al., 2011;Owen et al., 2012].

Methylenetetrahydrofolate reductase (MTHFR 677C>T, 1298G>A) The irreversible process, which reduces 5,10-methylene-tetrahydrofolate polyglutamate to 5-methyltetrahydrofolate polyglutamate is catalysed by the enzyme MTHFR. The enzyme is inhibited by S-adenosylmethionine [Bagley and Selhub, 1998]. A polymorphism C677T, allele frequency 0,30, and a polymorphism, allele frequency 0,32 have been identified [Ogino and Wilson, 2003]. Correlation has been shown between MTHFR polymorphisms 677C>T and 1298G>A and treatment efficacy [Chiusolo et al., 2002].

Thymidylate synthase (TS TSER*2/TSER*3) The thymidylate synthesis is catalysed by the enzyme TS with 5,10 methylenetetrahydrofolate as one-carbon donor. A polymorphism in the TS promoter enhancer region (TSER) has been shown to contain either two (TSER*2) or three (TSER*3) 28 bp tandem repeats. The allele frequency is 0.54 in Caucasian populations [Marsh et al., 2000]. Two studies have investigated the correlation between TS-polymorphisms and treatment effect with conflicting results [Krajinovic et al., 2002;Lauten et al., 2003]. However, it has not been possible to establish a functional method for analysing TS and therefore this polymorphism could not be evaluated in the thesis.

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Serine hydroxymethyltransferase (SHMT1 1420C>T) The reversible conversion of tetrahydrofolate to methylenetetrahydrofolate is catalysed by SHMT. SHMT is involved in providing one-carbon units for purine and thymidylate synthesis. A study has found that SHMT1 1420C>T is related to MTX resistance [de Jonge et al., 2005].

Reduced folate carrier (SLC19A1 80G>A) Reduced folate carrier is involved in influx of folate and MTX into the cell. The reduced folate carrier gene is located at chromosome 21. A polymorphism G80A has been identified in the protein RFC1, which mediates the transport of MTX (and serum-folate) into cells. The allele frequency is 0,48 [Chango et al., 2000;Laverdiere et al., 2002]. A study showed correlations between RFC1 polymorphisms and plasma-MTX concentrations and outcome [Laverdiere et al., 2002]. Recent research suggests other polymorphisms of interest [Owen et al., 2012].

Multi drug resistance (ABCB1 1199G>A, 1236C>T, 2677G>A/T and 3435C>T) ABCB1 (also called MDR1) encodes for P-glycoprotein, which is suggested to play an important role in membrane transport and drug resistance [Woodahl and Ho, 2004;Sakaeda et al., 2003]. Several groups have studied the silent polymorphism C3435T and its relationship to leukaemia - with divergent results. One study found no influence on overall survival [Efferth et al., 2003] while two studies have found influence on susceptibility, a lower event free survival/overall survival [Jamroziak et al., 2004] and reduced risk of CNS relapse [Stanulla et al., 2005]. Even though MTX is not a known substrate for P-gp, studies with patients in MTX monotherapy have shown that polymorphisms in the ABCB1 gene can play a role in MTX treatment [Grabar et al., 2010;Kato et al., 2011]. Recent research suggests other polymorphisms of potential interest for evaluation of impact in MTX treatment efficacy, for example

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polymorphisms in the DHFR [Chandran et al., 2010;Hayashi et al., 2011] and polymorphisms in the CGH gene [Owen et al., 2012;Yanagimachi et al., 2011].

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Aims of the thesis The objective of this study is to clarify the role of pharmacogenetics affecting transport and metabolism of chemotherapeutic drugs in the treatment of childhood ALL with focus on MTX. Thereby it might be possible to give more individualised treatment to improve therapeutic and reduce toxic effects. The study will focus on ALL protocols with extensive use of HD-MTX therapy. Specific aims 1) To establish methods and determine genotypes for the

polymorphisms named below. 2) To clarify the influence of polymorphism 80G>A in the reduced

folate carrier gene SLC19A1 on MTX uptake in cells and on the effect of MTX in childhood ALL with special focus on children with hyperdiploidy.

3) To evaluate the impact of 1199G>A, 1236C>T, 2677G>T/A and

3435C>T in the ABCB1 gene on treatment effects in childhood ALL.

4) To evaluate the effect of 677C>T and 1298G>A in the MTHFR gene, in the ATIC/AICART gene, and in the SHMT gene on response to MTX in childhood ALL.

5) To determine the risk of ALL and association with the above

selected polymorphisms.

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Material and methods

Patients and healthy volunteers For Paper I, blood was collected from 25 healthy volunteers employed at the University Hospital in Copenhagen, Denmark. For Papers II-IV blood from 202 healthy volunteers was collected during a three-month period from blood donors at the University Hospital in Copenhagen, Denmark. All healthy volunteers were anonymously included after informed consent. For Papers II-IV, all children (n=563) diagnosed with ALL between January 1, 1992 and December 31, 2006 were included if they were >=1 year and <15 year at the time of diagnosis and had T-cell or non-mature B immunophenotype (children with infant ALL or a mature B-cell immunophenotype ALL have different treatment protocols). The children’s parents gave written informed consent. The patients were treated according to the NOPHO-92 protocol (n=346) or NOPHO-2000 (n=217), either with a low-risk (n=388) or high-risk protocol (n=175). The low-risk group comprised standard risk (n=199) and intermediate risk (n=189). The high-risk group comprised high risk (n=109), very high risk (n=47) and extra high risk (n=19). There were 246 girls and 317 boys with a median age of 4.5 years at the time of diagnosis. The median follow-up time was 7.9 years (50% range: 4.1–12.1 years). Seventy-four children (13%) had a relapse within 0.2–8.3 years from the diagnosis (median: 2.6 years). Five patients died in first remission and five developed a second malignancy. Twenty-two patients died before the first HDMTX was given, and five patients did not achieve remission during induction treatment and thus changed protocol before the first HDMTX. More than 95% of the patients were of Nordic Caucasian origin. DNA was extracted from all patients where blood or bone marrow was available, and all genotypes for the SNPs were analysed if possible. In order to assess the risk of developing ALL, all children or healthy volunteers with a genotype measurement of the relevant SNP

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were included in the statistical analysis. For evaluation of treatment response, subgroups of patients were analysed as described in the papers II-IV. The Ethic’s Committee of Copenhagen (j.nr. 01-259108) as well as the Danish Data Protection Authority (j.nr. 2005-41-4808) approved the study design and protocol.

Methodology overview Table 3. Overview of methods used in this thesis Technique Papers DNA extraction I-IV TaqMan® allelic discrimination I-IV DNA sequencing (validation of TaqMan®) I-IV Pyrosequencing III Determination of MTX concentrations II-IV

DNA extraction 1-5 ml EDTA-stabilized blood or isolated lymphocytes were mixed with a high concentration sucrose buffer to haemolyse erythrocytes. The isolated pellet was treated with a buffer containing proteinase K to digest contaminating proteins and degrade nucleases. Finally DNA was extracted and purified by NaCl- and ethanol-precipitation.

TaqMan® allelic discrimination TaqMan® allelic discrimination from Applied Biosystem (Life), Denmark is based on a PCR reaction with primers amplifying a polymorphic sequence of interest and two probes. Each probe is complementary to only one allele and releases fluorescent light with a probe specific wavelength, allowing detection of both alleles in the same reaction. If the probe hybridises perfectly to an allele, DNA polymerase cleaves the probe and a fluorescent signal with one wavelength will be released from the probe (Fig. 3). If there is just a single nucleotide mismatch between probe and an allele, it reduces the hybridisation of the probe, and the DNA polymerase is more likely to replace the

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mismatched probe without cleaving it. In both cases the release of fluorescent signals will be inhibited. During the PCR cycles, the cleavage of one or both probes will produce exponentially increasing fluorescent signals.

Each probe consists of a short nucleotide sequence complementary to one of the two possible patient’s alleles. Either a VIC® or a FAMTM

fluorescent reporter dye is linked to the 5’ end of the probe. A non-fluorescent quencher (NFQ) and a minor groove binder (MGB) are attached to the 3’ end of the probe. The MGB increases the melting temperature for the probe allowing shorter probes, which results in greater difference in melting temperature between matched and mismatched probes and thus produces a very stable allelic discrimination [Afonina et al., 1997;Haque et al., 2003;Kutyavin et al., 1997]. An example of sample results is shown in figure 4.

Applied biosystems

Figure 3. The figure shows a patient’s two alleles. In allele 1 the probe hybridises with VIC (V) reporter dye, the probe is cleaved and the fluorescent released. The probe with the FAM (F) reporter dye does not match allele 1, thus cannot hybridise and the probe is not cleaved nor is the fluorescent released.

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Figure 4. Allelic discrimination – Output. Each dot represents one patient or control. The cluster marked with blue represents homozygous alleles labelled with FAM, the cluster marked with red represents homozygous alleles labelled with VIC and the cluster marked with green represents patients with heterozygous alleles, one labelled with FAM and another labelled with VIC.

DNA sequencing In this thesis DNA sequencing is used to validate the Taqman® SNP assays. Fred Sanger developed in 1976 a method for DNA sequencing with chain-terminating inhibitors [Sanger et al., 1977]. Today the method is often used with only minor moderations; The Klenow fragment is substituted with a more robust DNA polymerase and the dideoxyribonucleotides (ddNTP) is labelled with four different fluorescents, which allows a one-tube reaction instead of four separated reactions. The principle is based on an ordinary PCR reaction with primers amplifying a sequence of interest. The PCR amplicon is used in an additional reaction with a new primer and DNA polymerase incorporating deoxyribonucleotides (dNTP) and ddNTPs. The only difference between ddNTP and dNTP is that ddNTP lacks a 3’-hydroxyl group, which terminates further incorporations and stops the elongation of the DNA chain. A fluorescent reporter dye with specific colour/wavelengths for each of the four ddNTP is linked to the 3’ end

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of the ddNTP. The ratio of the terminating ddNTPs added is a 100-fold lower than the dNTPs. This results in multiple DNA fragments of various lengths. The PCR amplicons are injected into a capillary gel, which separates the fragments according to size. The fluorescence in the gel is then detected and the signal is stored in a computer and thus output like the one in figure 5 can be achieved. The output can be seen as an image of the gel, where the DNA fragments are listed according to size, with the smallest fragments to the left. Each terminating ddNTP’s fluorescence is detected and the nucleotide it represents is shown at the top and by the colour of the curve.

Figure 5. Electropherogram (Sanger sequencing). The blue line in the middle of the electropherogram marks a location in the DNA sequence where the alleles have different nucleotides in this case thymine and cytosine, which could be caused by a polymorphism or a mutation.

Pyrosequencing Pyrosequencing is a sequencing method based on real-time monitoring of DNA synthesis [Ronaghi et al., 1998]. The principle is based on an ordinary PCR reaction with primers amplifying a sequence of interest. The PCR amplicon is used in an additional reaction with a new primer and DNA polymerase incorporating deoxyribonucleotides (dNTP). The dNTP is added sequentially. If the first dNTP is not complementary to the patients PCR amplicon, the enzyme apyrase will degrade the unincorporated dNTP and the next dNTP will be added. When a dNTP is incorporated, pyrophosphate (PPi) in a quantity equimolar to the amount of incorporated nucleotide will be released. Ppi is converted into ATP and ATP catalyses the conversion

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of luciferin to oxyluciferin, which generates visible light. The light is detected and shown as a peak, the height of which is proportional to the numbers of the specific dNTP incorporated (Figure 6). Because ATP is used in the reaction, the dNTP deoxyadenosine triphosphate (dATP) is substituted with deoxyadenosine alfa-thio triphosphate (dATP-S) [Ahmadian et al., 2006].

www.pyrosequencing.com

Figure 6. Pyrogram (Pyrosequencing). The DNA sequence is seen at the top, the missing T indicates a deletion.

Monitoring of MTX The HD-MTX courses are lethal if not followed by leucovorin rescue in sufficient doses and duration. Plasma MTX is therefore monitored frequently from the end of MTX fusion and until the plasma concentration is below 200 nmol/L. If the MTX clearance is delayed, for example by renal insufficiency, gastrointestinal obstruction, co-administration of other drugs [Nygaard and Schmiegelow, 2003] or just elevated transaminase levels, the doses/duration of leucovorin should be increased to avoid severe toxicity. During maintenance therapy low oral doses of MTX are given weekly, and dose adjustments according to pharmacokinetic measurements, including MTX in erthrocytes, have been attempted [Schmiegelow et al., 1994;Schmiegelow et al., 2003].

MTX determination in erythrocytes For determination of low-dose MTX a radio-immuno assay was used. The method is based on the chemical reaction of DHFR and MTX

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forming stable complexes when nicotinamide adenine dinucleotide phosphate (NADPH) is present. NADPH, DHFR and the patient sample are mixed and incubated, allowing all MTX of the patient to form stable complexes with DHFR. Then tritium labelled MTX (3H-MTX) is added and 3H-MTX will bind the rest of the DHFR in stable complexes. Activated charcoal precipitates the remaining unbounded 3H-MTX, leaving only the radioactive stable complexes to be measured. Thus the measurement of 3H is inversely proportional to the amount of MTX in the sample [Kamen et al., 1976].

MTX determination in plasma For determination of high concentrations of MTX, the radio-immuno assay described above was used, with a shift to an enzyme-multiplied immunoassay technique (EMIT) based upon an enzymatic assay for glucose-6-phosphate dehydrogenase (G6PDH). The principle in the competitive reductase-binding assay is based on an antibody binding competition between the patient’s MTX and MTX labelled with the enzyme G6PDH derived from bacteria. When MTX labelled with G6PDH (MTX-G6PDH) is bound to the antibody, the G6PDH enzyme activity is decreased. The bacterial enzyme G6PDH reduces Nicotinamide adenine dinucleotide (NAD) to NADH and induces an alteration in the absorbance, which can be spectrofotometrically measured, i.e. higher MTX concentration in the patient’s plasma is directly porportional with increased G6PDH activity [Moyer TP, 2005].

Flow cytometry Flow cytometry or fluorescence activated cell sorting (FACS) is a method for determination of cell-membrane proteins, intracellular proteins, peptides and DNA. The principle behind FACS is an antigen-antibody reaction, where the antibodies are labelled with fluorescence. The suspension with the labelled cells pass through a flow-cell by hydrodynamic forces, which allow passage for only one cell at a time. The stream of liquid suspension is directed through a beam of laser light and several detectors including fluorescence detectors pick up

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the combination of both scattered and fluorescent light emitted. By analysing the fluctuations in brightness at each detector, it is then possible to derive various types of information about the physical and chemical structure of each individual cell.

Statistics SAS software version 9.1.3 (Paper I-II) and 9.2 (Paper III-IV) from SAS Institute, Cary, N.Y., USA, was used for the statistical analysis. All statistical analyses were two-tailed and p<<0.05 was considered significant. Unpaired and paired t-tests were used for comparison of groups in the cell study (Paper I). In the statistical tests in Paper II-IV, all blood measurements were logarithmically transformed, and in all multivariate analyses, adjustment variables were gender, protocol (ALL92/ALL2000), risk group (high/low) and phenotype (pre-B/T).

Chi2 test was used for tests of independence to assess each polymorphism and risk of developing leukaemia. Relapse and outcome probabilities were estimated using the log rank and Kaplan-Meier methods. Univariate Cox regression and multivariate Cox regression analyses with stratification by risk group were used to identify potential risk factors for an event. Model assumptions, including the proportionality assumption, were assessed using Schoenfeld and martingale residuals. Hazard ratios (HR) with 95% confidence intervals were calculated when appropriate. A general linear model was used for exploring toxicity and pharmacokinetics after the first HDMTX course. In Paper II, a general linear mixed model with repeated measures was used to explore toxicity and pharmacokinetics after all HDMTX courses, and also in Paper III the same model was used to explore toxicity after induction therapy. In Paper IV, Bonferoni’s correction for multiple testing was applied, if any initial p-values were below 0.05.

40

Results and discussion

Impact of genetic variation in SLC19A1 on MTX uptake In Paper I the influence of polymorphism 80G>A in the reduced folate carrier gene SLC19A1 on MTX uptake in CD4+ T cells and B cells from healthy individuals was investigated. Cells were stimulated with Candida albicans (CA) and tetanus toxoid (TT) to induce cell proliferation as MTX has higher uptake [Nielsen et al., 2007] and the highest efficacy in dividing cells. Fluorescence labelled MTX was added at day 6, where a high degree of uptake occurs [Nielsen et al., 2007]. The study demonstrated that individuals with the SLC19A1 80GG variant had decreased uptake of MTX in both T cells (Fig. 7A black bars) and B cells (Fig. 7B black bars) when using CA as stimulating agent. When using TT as stimulating agent the same effect could only be demonstrated in CD4+ T cells (Fig. 7 A+B white bars). To ensure that differences in uptake capacity were specific for MTX, MTX was substituted with fluorescence labelled 5-FAM-lysine with a molecular weight similar to the labelled MTX in a parallel experiment (Fig. 7 C). It seems improbable that 5-FAM-lysine was taken up via the reduced folate carrier since it is unaffected by the SLC19A1 80G>A polymorphism. The alternative route used by 5-FAM-lysine may also have been used for some unspecific uptake of MTX, leading to underestimation of the difference in MTX transport capacity between the SLC19A1 80G>A variants. The possibility, however unlikely, remains that unspecific uptake accounts for the entire uptake observed in SLC19A1 80GG variants, due to non-functional gene products.

41

The decreased uptake of MTX in CD4+ cells from individuals with the SLC19A1 80GG variant was not associated with decreased expression of the receptor, as the level of expression did not differ between the SLC19A1 80G>A variant groups (Fig. 8A). However, an estimation of uptake per receptor for each individual was done by relating the MTX uptake by CA-stimulated CD4+ T cells to the numbers of RFC1 molecules expressed by that individual’s CD4+ T cells (Fig. 8B). As can be seen in figure 8B, individuals with SLC19A1 80GG variant took up significantly less MTX per receptor than cells from individuals with the AA variant. Thus reduced capacity to take up MTX on receptor-to-receptor basis was the reason for the decreased uptake of MTX in CD4+ cells from individuals with the SLC19A1 80GG variant. The findings in this paper are in agreement with previous studies of rheumatoid arthritis patients demonstrating that patients with the SLC19A1 80AA variant have higher erythrocyte MTX polyglutamates levels than patients with other variants [Dervieux et al., 2004b] and that the probability of remission was more than 3 times higher in patients with the SLC19A1 80AA variant than in patients with the SLC19A1 80GG variant [Drozdzik et al., 2007]. Another study of

Figure 7. Uptake of MTX in A. CD4+ T lymphocytes and B. B lymphocytes. C shows uptake of the control 5-FAM-lysine, with no statistically difference between the SLC19A180G>A variants.

42

rheumatoid arthritis patients found no association between SLC19A1 80G>A variants and toxicity or effect on the outcome [Wessels et al., 2006]. There is no clear explanation for the differing results from these studies. However, the results demonstrated here are also supported by the findings in Paper II.

Figure 8. Expression and uptake efficiency in CD4+ T cells

43

Correlation between genetic variation in SLC19A1 and effect of MTX in ALL In Paper II the clinical impact of the 80G>A polymorphism in the reduced folate carrier/SLC19A1 gene was investigated. To test the effect of SLC19A1 80G>A on outcome, SLC19A1 80G>A genotypes were compared with outcome and it showed that patients with the SLC19A1 80AA variant had a 50% lower risk of relapse, death or second malignancy (HR 0.5 [95%CI: 0.25-1.00]; p=0.046) compared to patients with other variants (Fig 9).

In a backward stepwise Cox regression model adjusted for risk group, phenotype, protocol and chromosome 21 copy numbers, the SLC19A1 AA variant still had a better prognosis (p=0.10), but only risk group (HR 2.83 [95%CI: 1.83-4.47]) had a significant effect on outcome (Table 3).

Figure 9. SLC19A1 polymorphism and outcome. The Kaplan-Meier survival curve is shown to visualize the difference between AA variant and GG/GA variants (log rank p=0.046).

44

Table 3. Cox regression analysis Univariate Multivariate Covariate

Hazard ratio (95% CI)

p-value Hazard ratio (95% CI)

p-value

SLC19A180 AA vs GA/GG

0.50 (0.25-1.00) 0.046 0.56 (0.28-1.13) 0.101

Pre B vs T 2 0.97 (0.51-1.87) 0.94 0.943

Copy no. Chr21 >2 vs 2 0.80 (0.46-1.39) 0.44 0.713

Risk group High vs low 2.97 (1.90-4.63) <0.0001 2.86 (1.83-4.47) <0.0001 Protocol 2000 vs 1992 0.90 (0.55-1.48) 0.68 0.323

1If only relapse was considered as an event, then p=0.13. 2Low risk patients were excluded from the model, because no T-ALL were assigned to low risk therapy 3P-value of covariate if included in the final model.

Another study found that patients with SLC19A1 80AA or 80GA had a worse outcome in childhood leukaemia [Laverdiere et al., 2002] However, in their study only one 4 g/m2 HDMTX course and 30mg/m2 per week after induction was given instead of the four to nine courses of 5 or 8 g/m2 HDMTX courses and 20mg/m2 per week after induction used in the NOPHO protocols. Furthermore, the present study includes twice as many patients and the median follow up time is much longer (7.9 versus 4 years), which is important since relapses tend to come late in many low risk ALL patients such as the high-hyperdiploid cases and those with t(12;21)[Forestier et al., 2008]. This is also in conformity with the results in Paper I, showing that the SLC19A1 80AA variant takes up MTX more efficiently,

Chromosome 21 copy number, SLC19A1 80G>A and risk of relapse in ALL The SLC19A1 gene is located at chromosome 21 and patients with hyperdiploidy, which often involves chromosome 21, have better prognosis than others [Pui et al., 1990]. Therefore the interaction between the SLC19A1 80G>A variants and chromosome 21 copy numbers was examined. In 303 patients with two copies of chromosome 21 in their leukemic clone, 59 patients with the SLC19A1 80AA variant had a 64% reduced risk of relapse compared to the 244 patients with other variants (p=0.048 HR 0.36 [95%CI: 0.13-0.99])

45

(Figure 10). However, no significant differences in the risk of relapse between the SLC19A1 80G>A variant groups (p=0.80) were showed among the 126 patients with three or more copies of chromosome 21 in their leukemic clone.

These findings are in concordance with other studies, which found that higher mRNA levels of reduced folate carrier were related to the chromosome 21 copy number [Belkov et al., 1999] and higher mRNA levels were related to the SLC19A1 80AA variant and to chromosome 21 copy number [Jansen et al., 1998]. Children with either the SLC19A1 80GG or GA variant had a better prognosis if they had more than two chromosomes 21 in their leukemic clone. However in children with the SLC19A1 80AA variant the chromosome copy number did not influence the prognosis (Fig. 11).

Figure 10. SLC19A1 polymorphism and outcome in patients with a normal copy number of chromosome 21. Patients with an increased copy number of chromosome 21 (expected higher MTX influx) had no significant differences between SLC19A1 variants (p=0.94) (data not shown).

46

SLC19A1 80G>A and pharmacokinetics In a subgroup of 182 patients, plasma MTX levels were measured at 20-24 hours after initiation of the HD-MTX infusion (n=608 HD-MTX courses). These patients did not differ significantly from the remaining total study cohort with respect to gender, treatment protocol, immunophenotype or relapse rate. Patients with the SLC19A1 GG-variant had lower end-of-infusion plasma MTX-levels (Table 4) than the others variant groups both at the first HDMTX course (p=0.0365, 123 patients stratified for low/high risk ALL), and after all HDMTX courses (p=0.0122, 608 HDMTX courses, 182 patients). This finding confirmed the association between the SLC19A1 GG variant and lower MTX plasma concentrations reported in another study [Laverdiere et al., 2002].

Nopho92 Nopho-2000 Nopho92 Nopho-2000

Ë > Two chromosome 21, Ï Two chromosome 21

Figure 11. Different hazard ratios compared to patients with a normal copy number of chromosome 21 and SLC19A1GA/GG variant according to the Nopho92 protocol.

Table 4. SLC19A1 80G>A polymorphism and plasma levels of methotrexate after HDMTX (nmol/L)

First HDMTX course, 123 patients. (GG vs. GA/AA, p=0.037, n=123)

All HDMTX courses, 182 patients. (GG vs. GA/AA, p=0.012, n=608)

GG (n=37)

GA (n=58)

AA (n=28)

GG (n=173)

GA (n=307)

AA (n=128)

Low risk 82207 89554 90300 67818 79585 79074

High risk 91524 122684 148458 100160 105373 157403

47

SLC19A1 80G>A and toxicity after HD-MTX To investigate the impact of SLC19A1 80G>A on toxicity after HDMTX, the highest level of ALAT and the nadir of neutrophils, platelets and haemoglobin were measured in the same subgroup as in the previous section concerning pharmacokinetics. Low-risk patients with the SLC19A1 80AA variant had more pronounced bone marrow suppression with significantly lower platelets (p=0.004/0.002) and haemoglobin nadirs (p=0.004/0.001) compared to the other variants. The same trends were seen in high-risk patients although it did not reach statistical significance. Patients with the SLC19A1 80AA variant had both more toxicity (bone marrow suppression) and higher efficacy of MTX treatment (better prognosis). This correlates with the finding in Paper I that MTX is taken up more efficiently by the SLC19A1 80AA variant. However, low-risk patients with the SLC19A1 80GG variant had more liver toxicity with significantly higher levels of ALAT compared to the other variants (p=0.030/0.049) (Table 5). The same trends were seen in high-risk patients although it did not reach statistical significance. The biological background for SLC19A1 80GG variant having more liver toxicity is unclear. An explanation could be that under normal conditions high levels of folic acid polyglutamates are stored in liver cells. Since the gene dosage of A-alleles would be expected to correlate with increased levels of folic acid polyglutamates in liver cells, this could protect the cells from MTX toxicity. In addition, higher folic acid polyglutamate levels in liver cells in A-alleles may also decrease the influx of MTX into the hepatocytes, where a significant fraction of MTX during HDMTX is eliminated, which could explain that patients with A-allele have a slower elimination of MTX and thus higher MTX plasma concentrations.

48

Table 5. Nadir of platelets, hemoglobin and lymphocytes and highest ALAT value after high dose methotrexate and relation to SLC19A180G>A in low risk ALL patients SLC19A1 80G>A - genotype AA GA GG Ratio (95% CI) p-value Platelets Patients 29 72 39 (109/L) HDMTX courses 116 279 153 Mean (geometric) 73 99 105 Confidence-interval 55-95 78-125 81-136 GG vs. AA 1.44[1.14-1.82] 0.002 GA vs. AA 1.36[1.10-1.68] 0.004 GG vs. GA 1.06[0.88-1.28] 0.546 Time to count recovery

(>150) after first HDMTX in days, geometric mean

3.4 2.4 2.4

Hemoglobin Patients 29 72 39 (mmol/L) HDMTX courses 116 279 153 Mean (geometric) 5.6 5.9 6.0 Confidence interval 5.4-5.8 5.7-6.1 5.8-6.2 GG vs. AA 1.06[1.02-1.10] 0.001 GA vs. AA 1.05[1.01-1.08] 0.004 GG vs. GA 1.01[0.98-1.04] 0.395 Neutrophiles Patients 28 72 38 (109/L) HDMTX courses 111 262 149 Mean (geometric) 0.7 0.8 0.8 Confidence interval 0.6-0.9 0.7-1.0 0.7-0.9 GG vs. AA 1.07[0.86-1.32] 0.551 GA vs. AA 1.11[0.92-1.35] 0.286 GG vs. GA 0.96[0.81-1.14] 0.652 Time to count recovery

(>0.5) after first HDMTX in days, geometric mean

4.4 3.4 2.4

ALAT Patients 28 71 38 (U/L) HDMTX courses 102 227 132 Mean (geometric) 123.8 127.0 167.1 Confidence interval 86-177 93-174 119-

236

GG vs. AA 1.35[1.00-1.82] 0.049 GA vs. AA 1.02[0.78-1.34] 0.851 GG vs. GA 1.31 [1.03-

1.69] 0.030

p values are adjusted for repeated measurements

49

Genetic variation in the ABCB1 gene and effect on ALL treatment In Paper III the focus was on polymorphisms in the ABCB1 gene, which is responsible for cell efflux of many drugs.

ABCB1 polymorphisms and linkage disequilibria To get an overview of linkage disequilibria between the ABCB1 polymorphisms, the distribution of genotypes was mapped in haplotypes (Table 6). Since the haplotype frequencies are non-randomly distributed, as only 5 out of 40 possible haplotypes have more than 5% patients and count for more than 80% of all patients, ABCB1 polymorphisms are in linkage disequilibrium. The 2677G>T/A and 1236C>T polymorphisms are in strong linkage disequilibrium, as only three haplotypes have more than 5% patients (GG/CC, GT/CT and TT/TT). These findings are in agreement with a French study [Jeannesson et al., 2007]. Table 6. Distribution of ABCB1 haplotypes. 230 patients from the induction therapy toxicity study with all genotypes measured. 2677GG 2677GA 2677GT 2677TT 2677TA 3435CC/1236CC 35 - 15% ** 4 - <2%* 0 0 0 3435CC/1236CT 2 - <1% 0 3 - <2%* 1 - <1% 0 3435CC/1236TT 0 0 1 - <1% 0 0 3435CT/1236CC 26 - 11%* 3 - <2% 4 - <2% 0 0 3435CT/1236CT 1 - <1% 1 - <1% 70 - 30%* 1 - <1% 1 - <1% 3435CT/1236TT 1 - <1% 0 3 - <2% 3 - <2% 0 3435TT/1236CC 5 – 2% 1 - <1% 2 - <1% 0 0 3435TT/1236CT 0 0 16 - 7% 2 - <1% 1 - <1% 3435TT/1236TT 0 0 2 - <1% 41 - 18% 0 Haplotypes with more than 5% patients are in boldface There were 92% patients with 1199GG and 8% with 1199GA. *6% of 1199GA (1 patient) **75% of 1199GA (12 patients)

ABCB1 1199G>A and risk of relapse No patient had the ABCB1 1199AA variant. The 41 patients with the 1199GA variant had more than two-fold increased risk of relapse (HR

50

2.86 [95%: 1.52-5.26] p=0.001) compared to the 477 patients with the 1199GG variant (Fig.12). The 5 year overall probability of event-free survival (pEFS5y) for patients with the 1199GA variant was 68% [95%CI: 50-80] and for patients with the 1199GG variant 83% [95%CI: 79-86].

Within the high risk group (Fig.13), the 15 patients with the 1199GA variant had more than four-fold increased risk of relapse compared to the 149 patients with the 1199GG variant in both univariate (relapse=37, HR 4.55 [95%: 2.08-10] p=0.0001 and multivariate analysis adjusted for protocol, gender and immunophenotype (HR 4.34 [95%: 2.04-9.09] p=0.0001).

144

Ris

k of

Rel

apse

0.0

0.2

0.4

0.6

0.8

1.0

0 24 48 72 96 120

Log rank p = 0.0006

GG

GA

1116213341GA

185248311409479GG

9672482401199G>A

Time (months)All riskgroup

Time (Months) Figure 12. ABCB1 1199G>A polymorphism and relapse in both low and high risk group. The Kaplan-Meier survival curve is shown to visualize the difference between GA and AA variants (the only variants found). The small inserted table shows number of patients in each variant group at specific times.

51

No statistically significant differences in risk of relapse in the low-risk group were found, although the data did not indicate significant interactions between the genotypes and risk groups. No deaths or second malignancies were registered in the patient group with the 1199GA variant compared to sixteen deaths and five second malignancies in the 1199GG group. This is the first study to explore the association between ABCB1 1199G>A polymorphism and risk of relapse in childhood ALL. The pronounced increase in relapse rates for high risk ALL patients with the 1199GA variant is likely to reflect, that these patients are more exposed to P-gp substrates (glucocorticosteroids, vincristine, anthracyclines and alkylating agents) than low risk patients (Table 1 and 2). In accordance with these findings, the 1199GG genotype has also been associated with a superior outcome among acute myeloid leukaemia patients [Green et al., 2010]. Furthermore, in vitro studies of HEK cells and LLC-PK1 epithelial cells have showed increased drug resistance to doxorubicin and/or vincristine for the 1199GA variants when compared to the 1199GG variant [Crouthamel et al., 2006;Woodahl et al., 2004;Woodahl et al., 2009]. Lower efflux of

Ris

k of

rel

apse

0.0

0.2

0.4

0.6

0.8

1.0

Time (Months)

0 24 48 72 96 120 144 168 192

Log rank p< 0.0001

GG

GA

123715GA

394967103149GG

9672482401199G>A

Time (months)High risk

123715GA

394967103149GG

9672482401199G>A

Time (months)High risk

Figure 13. ABCB1 1199G>A polymorphism and relapse in the high risk group The Kaplan-Meier survival curve is shown to visualize the difference between GA and AA variants (the only variants found). There were 28 (19%) and 9 (60%) events in the high risk GG and GA variant group, respectively´. The small inserted table shows number of patients in each variant group at specific times.

52

vincristine in patients with the 1199GG variants compared to patients with the 1199GA variant may thus explain the effect on relapse.

ABCB1 3435C>T and risk of relapse Compared to 96 patients with the 3435CC variant, the 421 patients with the 3435TT or 3435CT variants had respectively 61 % (HR 0.39 [95%CI: 0.20-0.76], p=0.006) and 40% (HR 0.60 [95%CI: 0.34-1.03], p=0.06) reduced risks of relapse in multivariate analysis (Figure 14). Only one death and no second malignancy were found in the 3435CC variant group compared to eight deaths (3 in first remission) and four second malignancies in the 3435CT variant group, and six deaths (1 in first remission) and one second malignancy in the 3435TT variant group. This led to a pEFS5y of 78% [95%CI: 68-86] for the 3435CC patient group and 83% [95%CI: 79-86] for the 3435CT/TT patient group.

Ris

k of

Rel

aps

144

0.0

0.2

0.4

0.6

0.8

1.0

Time (months)0 24 48 72 96 120

Log rank p = 0.03

TT

CT

CC

153043568296CC

68100133169224263CT

436486105134158TT

1209672482403435C>T

Time (months)

153043568296CC

68100133169224263CT

436486105134158TT

1209672482403435C>T

Time (months)

Figure 14. ABCB1 3435C>T polymorphism and relapse The Kaplan-Meier survival curve is shown to visualize the difference between TT, CT and CC variants. There were 15 (9%), 34 (13%) and 20 (21%) events in the TT, CT and CC variant groups, respectively. The small inserted table shows number of patients in each variant group at specific times. There was no difference in risk of relapse between high and low risk group. The results in this study are in agreement with other studies, where inferior outcome for patients with the 3435CC variant also were found [Yang et al., 2010;Rao et al., 2010;Jamroziak et al., 2004]. These clinical observations are supported by in vitro studies of CD56+ cells

53

and duodenum, which have shown lower P-gp expression and/or P-gp function in 3435TT [Drescher et al., 2002;Hoffmeyer et al., 2000]. However, as seen with the 1199G>A polymorphism, the reduced relapse rates for patients with the 3435CT and 3435TT variant were jeopardized by their higher frequency of death in remission and second malignancies. It has been hypothesized that even if the 3435C>T nucleotide substitution does not result in an amino acid change, the C>T substitution may cause an alteration in co-translational folding, which requires a rare tRNA and thereby alters P-gp activity [Kimchi-Sarfaty et al., 2007]. A study found that in spite of the assumed linkage disequilibrium between 1236C>T, 2677G>A/T and 3435C>T, it appears that only 3435C>T accounts for altered RNA expression levels [Wang et al., 2005]. This is consistent with the finding that there is a strong association with the 3435C>T polymorphism and risk of relapse, but not with the 2677G>A/T and the 1236C>T polymorphisms (see below).

ABCB1 1236C>T, ABCB1 2677C>T and risk of relapse In risk group stratified analyses, no statistically significant differences in relapse risk were found for either the 1236C>T polymorphism (p=0.37) or 2677G>A/T polymorphism (p=0.98).

Polymorphisms in ABCB1 and MTX pharmacokinetics Both univariate and multivariate analyses showed no statistical difference in end-of-infusion MTX plasma levels in relation to any of the ABCB1 variants (p>0.20 in all univariate and multivariate analyses). No pharmacokinetic studies were carried out for doxorubicin, prednisolone and vincristine.

Polymorphisms in ABCB1 and toxicity ABCB1 polymorphisms significantly influenced the risk of toxicities both after induction therapy and HD-MTX, being most pronounced for 3435C>T. During induction therapy patients with the 3435TT variant had more pronounced bone marrow toxicity (lower haemoglobin and platelet

54

levels) than patients with the 3435CT (multivariate p=0.01 and p=0.0002) or 3435CC variants (multivariate p=0.01 and p<0.0001). Similar effects were seen for neutrophils when comparing patients with the 3435TT variant and patients with the 3435CT variant. When looking at haplotypes involving the two polymorphisms with strongest linkage disequilibrium (1236C>T and 2677G>T/A), their combined impact on bone marrow toxicity was more pronounced than for any of them individually. In the haplotype with strongest linkage disequilibrium 2677GG/1236CC, 2677GT/1236CT and 2677TT/1236TT, no statistically significant difference in haemoglobin values (p=0.11, multivariate p=0.16) was seen, but platelets and neutrophils nadir during induction therapy were statistically significantly lower in patients with 2677TT/1236TT genotype compared to patients with the 1236CC/2677GG genotype (platelets: p=0.01, multivariate p=0.02. Neutrophils: p=0.006, multivariate p=0.06). The more profound bone-marrow toxicity found in patients with the 3435TT variant after the doxorubicin-containing induction therapy is in accordance with their reduced risk of relapse and increased risk of death or second cancer. After the first HD-MTX course patients with the 3435CC variant had statistically significant higher ALAT levels (univariate p=0.03, multivariate p=0.06), when compared to patients with 3435CT or 3435TT variants. Including end-of-infusion plasma MTX levels and the SLC19A180G>A polymorphisms in the models did not significantly alter this effect of 3435C>T (Table 8). Although MTX plasma levels after high dose MTX did not differ significantly between subsets of patients defined by their ABCB1 variants, the 3435CC variant was associated with more liver toxicity after first HD-MTX treatment. In Paper II, higher levels of ALAT among the patients with the highest risk of relapse were similarly reported. It remains to be clarified whether this reflects intracellular hepatic MTX exposure, a shift in the metabolism in the liver due to the genetic variant or differences in folate disposition or other pathways.

55

Correlation between genetic variation in ATIC, MTHFR, and SHMT and effect in MTX therapy In Paper IV the clinical impact of polymorphisms in three enzymes involved in the folic acid metabolism were evaluated.

ATIC, MTHFR, SHMT, outcome and pharmacokinetics No association between the relapse risk or event-free survival and the polymorphisms was found in either univariate or multivariate test. Only a single statistically significant difference in MTX-values for the heterozygous variant ATIC347CG versus ATIC347CC was found (MTX Steady-state mean: 60220 versus 69700 nmol/L, p=0.02, p=0.08, when applying Bonferroni's correction for multiple testing). However ATIC247GG (67074 nmol/L) versus ATIC347CC showed no difference at all (p=0.76). The two homozygous variants had almost identical levels indicating no gene dose effect and thus it is likely a random type 1 error. Other studies have found that the homozygous variant genotype ATIC347GG was associated with better therapeutic response to methotrexate [Dervieux et al., 2004a] and that MTHFR variants were associated with outcome in ALL [Aplenc et al., 2005]. The reason for these different results is probably due to lack of power (too few individuals) in some studies, different protocols or perhaps different folic acid status before and under MTX treatment.

ATIC, MTHFR, SHMT and toxicity When looking at maximum ALAT levels after all HD-MTX courses in a multivariate test (Table 7), 34-51% higher maximum ALAT-levels were found in 100 patients with either MTHFR677CT or MTHFR677TT variants versus 79 patients with the MTHFR677CC variant (p=0.049). A tendency to higher maximum ALAT-levels in 78 patients with the MTHFR1298AA versus 25 patients with the MTHFR1298CC variant was also seen (144 versus 108 U/L, p=0.04). When using Bonferroni's correction for multiple testing, the p-values were no longer significant. In Paper II, an association with liver toxicity was seen for one variant whereas bone marrow toxicity was associated with another variant. In

56

Paper IV a tendency to higher liver toxicity in patients with MTHFR1298AA versus MTHFR1298CC was found. This could reflect intracellular hepatic MTX exposure, different liver metabolism due to the genetic variant or differences in folate disposition or other pathways. When looking at bone marrow toxicity after all HD-MTX courses, lower platelets and haemoglobin levels were found in 26 patients with MTHFR1298CC versus 154 patients with either MTHFR1298CA or MTHFR1298AA variants (Median nadir: 72 versus 109/93, p=0.0001 and 5.7 versus 5.9/6.0, p=0.03, respectively). When applying Bonferroni's correction for multiple testing, the p-value remained significant for platelets (p=0.0004). The evidence of higher liver toxicity (ALAT values) in patients with the MTHFR677 T allele, and the more pronounced bone marrow toxicity in patients with MTHFR1298CC found in this study are partly supported by several other studies [Chiusolo et al., 2011;Huang et al., 2008;Kantar et al., 2009;Ongaro et al., 2009;Tantawy et al., 2010]. Yet others studies found no association between toxicity and MTHFR variants [Kishi et al., 2007;Erculj et al., 2012]. No relationship between either SHMT1-1420C>T or ATIC347C>G polymorphisms and toxicity in childhood ALL could be found in this study. Other studies have found that the ATIC347G allele was associated with discontinued MTX therapy due to intolerable side effects in patients with psoriasis [Campalani et al., 2007] and higher toxicity in patients with rheumatoid arthritis [Dervieux et al., 2006]. One explanation could be that MTX exerts its effect differently in leukaemia as compared to autoimmune diseases. Another explanation could be that different folate status as folate supplementation during MTX treatment often is given in both rheumatoid arthritis and psoriasis.

57

Tab

le 7

. T

oxic

ity

afte

r H

D-M

TX

AL

AT

U/L

P

late

lets

*10

9 /L

Hae

mog

lobi

n m

mol

/L

F

irst

HD

-MT

X

All

HD

-MT

X

Fir

st H

D-M

TX

A

ll H

D-M

TX

F

irst

HD

-MT

X

All

HD

-MT

X

MT

HFR

677C

>T

All

P

atie

nts

(n)

111

(111

) 17

9 (5

19)

126

(126

) 18

6 (6

16)

126

(126

) 18

6 (6

16)

Uni

vari

ate

M

ultiv

aria

te

p=0.

42

p=0.

86

p=0.

007*

p=

0.04

9*

p=0.

51

p=0.

38

p=0.

23

p=0.

14

p=0.

28

p=0.

11

p=0.

53

p=0.

31

CC

B

asel

ine

- -

- -

- -

Mea

n 12

7 [8

8-18

2]

115

[84-

158]

88

[66

-118

] 10

1 [8

2-12

4]

5.7

[5.5

-5.9

] 5.

9 [5

.7-6

.0]

CT

H

azar

d R

atio

1.

39[0

.85-

2.28

] 1.

34[1

.09-

1.65

] 0.

86[0

.58-

1.29

] 0.

91[0

.77-

1.07

] 0.

99[0

.94-

1.04

] 1.

0[0.

97-1

.02]

M

ean

177

[125

-250

] 15

4 [1

12-2

12]

76 [

58-1

01]

91 [

74-1

12]

5.6

[5.4

-5.8

] 5.

9 [5

.7-6

.0]

p-va

lue

0.19

0.

005*

0.

46

0.23

0.

69

0.72

TT

H

azar

d R

atio

1.

14[0

.50-

2.61

] 1.

51[1

.05-

2.18

] 0.

71[0

.39-

1.32

] 0.

81[0

.62-

1.06

] 0.

94[0

.86-

1.02

] 0.

98[0

.94-

1.02

] M

ean

145

[68-

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58

Polymorphisms and risk of acute lymphoblastic leukaemia In Papers II-IV, the association of risk of development of ALL and the following polymorphisms was investigated: 80G>A in the reduced folate carrier gene/SLC19A1 (Paper II), 1199G>A, 1236C>T, 2677G>T/A and 3435C>T in the multi-drug resistance/ABCB1 gene (Paper III), and 347C>G in the ATIC gene, 677C>T and 1298A>C in the MTHFR gene and 1420C>T in the SHMT1 gene (Paper IV). Table 8. Patient and controls in risk studies Patients Healthy donors P values SLC19A1 80G>A 516 200 0.44 ABCB1 1199G>A 518 200 0.38 ABCB1 1236C>T 518 200 0.63 ABCB1 2677G>T/A 520 200 0.51 ABCB1 3435C>T 517 200 0.22 ATIC 347C>G 514 202 0.66 MTHFR 677C>T 532 202 0.85 MTHFR 1298A>C 515 202 0.64 SHMT1 1420C>T 470 201 0.72 No significant differences in the genotype frequencies between the patients and controls (healthy adult blood donors) in any of the selected polymorphisms were found (Table 8). The genotype frequencies in the donor and patient cohorts were all in agreement with Hardy-Weinberg equilibrium (HWE), except for SHMT1 1420C>T, where the patient cohort deviated (n=470, p=0.04). Although SHMT1 deviates from HWE, it is notable that two more patients with the heterozygous variant would have resulted in no deviation. It is also notable that the donor and patient cohorts do not differ significantly from each other. This is probably a random type 1

59

error. Another explanation could be that the analysis was influenced by the SHMT pseudogene on chromosome 1. Although some studies have found a correlation between one of the polymorphisms investigated (SLC19A1 80G>A [de Jonge et al., 2009], SHMT1 1420C>T [Skibola et al., 2002]) and risk of ALL, other studies support the findings in this thesis (SHMT1 1420C>T [de Jonge et al., 2009;Lightfoot et al., 2010]). Minor studies have found some effect of MTHFR polymorphisms on risk of ALL development; however a large meta-analysis study [Zintzaras et al., 2011] concludes that current evidence is not sufficient to draw definite conclusions regarding this association. The lack of statistically significant associations between the ABCB1 variants and risk of ALL is in agreement with a previously published Hungarian study [Semsei et al., 2008], although other studies with Indian (n=147, controls=246) or Polish (n=113, controls=175) individuals found higher incidences of ALL among patients with the 3435TT variant [Jamroziak et al., 2004;Rao et al., 2010]. However, the frequency of 3435TT among patients in the Polish study, but not their controls, was very similar to the case and control frequencies found in this thesis and in other studies with white individuals, such as the 1000genom project (n=60), HapMap studies (n=113, n=59 and n=59), and the Hungarian study (396 patients and 192 controls) [Semsei et al., 2008].

60

Impact of gene-gene interaction and the role of MTX in efficacy and toxicity The complex drug combinations currently applied to cure children with ALL, emphasize that multiple genetic variants need to be tested to understand host-related causes for treatment failure [Davidsen et al., 2008;Rocha et al., 2005].

The 22 patients harbouring both the ABCB1 1199GA and the 3435CC variants had an almost three-fold greater risk of relapse compared to the remaining 402 patients (HR=2.96 [95%CI: 1.36-6.49] p=0.007), which was approximately the same effect seen in both 1199G>A and 3435C>T independently (Paper III). Since other studies [Grabar et al., 2010;Kato et al., 2011] have indicated that MTX could be a substrate for P-gp and SLC19A1 encodes for a protein involved in influx of MTX into the cell, and since HD-MTX is widely used in NOPHO protocols [Schmiegelow et al., 2010;Skarby et al., 2006] interactions between SLC19A1 80G>A and both 1199G>A and 3435C>T with respect to risk of relapse were evaluated in Paper III. A potential interaction between 1199G>A and SLC19A1 80G>A polymorphisms was not found to be statistically significant (p=0.14), and a test for interaction between 3435C>T and SLC19A1 80G>A was not conducted since none of the 32 patients with SLC19A1 80AA and 3435TT had a relapse. Instead an additive model including SLC19A1 80G>A and 3435C>T as covariates was used, and showed that both polymorphisms had an effect on outcome (p=0.024). When combining these two polymorphisms, the 78 patients with SLC19A1 80GA/GG and 3435CC had an almost five-fold higher risk of relapse (HR 4.75[95%: 1.70-13.26], and the 207 patients with SLC19A1 80GA/GG and 3435CT had almost three-fold higher risk of relapse (HR 2.87[95%: 1.08-7.66]) when compared to the 32 patients with both SLC19A1 80AA and 3435TT. Multivariate analysis including these polymorphisms, risk group, immunophenotype and protocol gave hazard ratios very similar to those above (Paper III).

61

Since SLC19A1 80GA/GG had a two-fold higher risk of event than the other variant (Paper II) and the 3435CT/TT had a three-fold higher risk of relapse than the other variant, it appears that the five-fold higher risk found by combining the two polymorphisms is additive. It remains to be clarified whether the additive predictive effect of variants of the reduced folate carrier (encoded by SLC19A1) and the 3435C>T polymorphism reflects their impact on MTX versus other drugs. Since it was shown that SLC19A1 80GA and SLC19A1 80GG had similar effects on outcome in Paper II, a new statistical analysis has been made, where SLC19A1 variants are grouped in only two groups (80AA and 80GA/GG). The ABCB1 1199GA and the 3435CC combined gave the same hazard rate as each independently (Paper III) and were therefore grouped in one group, and the remaining variants, 1199GG, 3435CT and 3435TT were grouped together. The multivariate Cox regression analysis showed an interaction between polymorphisms in the ABCB1 and SLC19A1 genes (p=0.048). Patients with SLC19A1 80GG/GA and ABCB1 1199GA/3435CC had almost two-fold higher risk of relapse as compared to patients with other ABCB1 variants (HR=1.89 [95%CI: 1.10-3.27]). However, patients with SLC19A1 80AA and ABCB1 1199GA/3435CC had more than ten-fold higher risk of relapse than patients with other ABCB1 variants (HR=10.89 [95%CI: 2.10-56.38]). This indicates a synergistic rather than an additive effect of the ABCB1 and SLC19A1 genes and implies that both genes have an impact on MTX. Thus MTX could be a substrate for P-gp. This is supported by studies showing impact of ABCB1 3435C>T variants on the toxicity or disease score in MTX monotherapy studies [Grabar et al., 2010;Kato et al., 2011] which suggest that ABCB1 variants influence MTX efflux from leukemic cells.

62

Conclusion Based upon the findings in Paper I-IV and new statistical calculations in the section above, the following conclusions can be drawn: Genotypes for specific polymorphisms in the ABCB1, ATIC, MTHFR, SLC19A1 and SHMT genes have been determined and methods have been established, except for ABCB1, where methods already were established. The polymorphism SLC19A1 80G>A affects MTX uptake in CD+ T cells and B cells. The different uptake in the SLC19A1 80G>A variants are caused by reduced capacity on receptor-to-receptor basis and not by receptor expression levels. The SLC19A1 80G>A polymorphism has a significant impact on MTX treatment efficacy in childhood ALL, and this impact can only be fully appreciated within the karyotypic background of the leukemic cells as higher numbers of chromosome 21 seem to neutralize the effect of SLC19A1 variants. The ABCB1 genetic variants 1199G>A and 3435C>T are associated with outcome in childhood ALL and, as a synergistic rather than an additive effect of the ABCB1 and SLC19A1 genes was shown, this implies that ABCB1 genetic variants 1199G>A and 3435C>T are associated not only with the effect of known p-glycoprotein substrates (doxorubicin and vincristine), but of MTX, indicating that MTX is a substrate for p-glycoprotein. The MTHFR variants were not associated with outcome, but may be important for both bone marrow and liver toxicity, and should be considered as markers for individualization of treatment in childhood ALL in combination with other pharmacogenetic markers. No effect of polymorphisms of the ATIC and SHMT genes could be found.

63

Due to the size of the present study with more than 750 individuals included, it can be concluded that the explored polymorphisms do not seem to be associated with the risk of ALL. Even though only Danish children were included in the study, it is expected that these data would apply directly for children in the other Nordic countries as well, as the genetic differences are few and the treatment regimen is identical to the one used in Denmark.

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Future aspects This population-based cohort study emphasizes the need to add pharmacogenetic profiling to the already extensive biological exploration of childhood ALL (e.g. leukaemia karyotype or post-remission minimal residual disease). Both these and previously published data [Schmiegelow et al., 2009] support that constitutional variations in genes that influence the disposition of anticancer agents may be as important for prediction of relapse and toxicity risks as the genetic aberrations in the leukemic clone. The study underlines the delicate balance between efficacy and toxicity when treating children with ALL as SNPs associated with reduced relapse rates may lead to increased risk of toxicities or even second cancers which ultimately can jeopardize the beneficial effects. Further prospective studies are needed to determine if dose adjustments according to host pharmacogenetics can significantly increase the efficacy of the antileukemic treatment without unacceptable increments in toxicity. Among patients with a favourable prognosis due to the variants they harbour, future studies are needed to explore which additional genetic polymorphisms cause a small subset of these patients to die in remission or develop a second cancer. Such inherited genetic variants may involve glutathione S-transferases, cytochrome P-450 enzymes, quinine oxoreductase, or the folate pathway [Bolufer et al., 2007;Stanulla et al., 2007;Guillem et al., 2007;Woo et al., 2000]. To further elucidate the role of pharmacogenetics and the biological mechanisms involved, it is recommended including pharmacokinetic studies with intracellular drug level measurements. As demonstrated in this thesis, the reduced folate carrier plays an essential role in efficacy of the ALL treatment. It could be interesting to see if novel folate antagonists such as pemetrexed (MTA) could have an even better effect in ALL. A preclinical study showed that pemetrexed had a higher potency index than MTX [Norris and Adamson, 2010]. Pemetrexed appears to be a better substrate for the

65

reduced folate carrier and when polyglutamated intracellularly, it primarily and more potently inhibits GART and TS. If the primary effect of MTX lies on the inhibition of DNA and Thymidylate synthesis instead of depletion of other enzymes in the folic acid metabolism, pemetrexed could be a possible new drug in ALL treatment.

66

Acknowledgements First of all I wish to thank all children for their participation in the study. Many people have been involved in the studies included in this thesis and it is difficult to thank them all. However, I would like to express my gratitude to my supervisor Professor Curt Peterson and co-supervisors chief consultants Birgitte Lausen and Kim Dalhoff for making it possible for me to conduct this study. A special thanks to Curt for always encouraging me, for opening your and Eva’s home to me, and in every way making my study life as problem free as possible. Also special thanks to senior researcher and statistician Ib Jarle Christensen for many hours of discussions and help with statistics and to Professor Kjeld Scmiegelow for fruitful discussions and to chief consultant Bo Baslund for supporting me with good advice or humour, whenever needed. For all the people I have met at the Department of Clinical Pharmacology, Linköping, especially Henrik Gréen, Malin Linquist (even though you don’t understand me, when I speak Danish ), Britt Sigfridsson, Karin Skoglund, and Svante Vikingsson - thank you for making me feel very welcome in Sweden. Thanks to Ingrid Jakobsen Falk from the Department of Clinical Pharmacology, Linköping, to Bodil Studsgaard and Michael Timm from the Childhood Cancer Laboratory, and to Vibeke Blaabjerg, Vibeke Trandbohus, Sherukh Jamil and Dorte Pedersen from Genomic Medicine, Rigshospitalet, Denmark for excellent laboratory assistance. Thanks to my boss Finn Cilius Nielsen and the staff at Genomic Medicine for your patience, I am looking forward to giving the

67

department my full attention……. until autumn, when I start my leader education. Also thanks to Thomas van Overeem Hansen and Lars Jønsson for listening and giving advice about molecular genetics and absolutely non-work related subjects. Thanks to my parents for always encouraging me to reach my goals, for your love and for having taught me to look on the bright side of life. A special thanks to my daughters Lea and Emilie and my son Simon for your love, help and support during especially the first three years. Too bad, you have all left home in the last year; now that I am finally free to provide excellent service with food, homemade cookies and laundry for children living at home…To my bonus children Jonna and Viktor, thanks for being very quiet during the last phase of writing, but don’t get too excited over the homemade cookies, it was a joke! To all friends and family thanks for asking and appearing interested whenever I started talking about polymorphisms, pharmacogenetic and cancer. A special thanks to my knight in shining armour, Darrin Bayliss, for support, encouragement, and for making my life special. Also thanks for proof reading, now you all know who is to blame if something is misspelled . The projects presented in this thesis were supported by grants from the Danish Childhood Cancer Foundation, the Swedish Childhood Cancer Society, the Swedish Cancer Society, the Danish Cancer research Foundation, The Dagmar Marshall Foundation, The Otto Christensen’s Foundation, the Chief Consultant Anders Hasselbalch’s Foundation, DBIO’s research foundation, LSB’s research grant, the University Hospital Rigshospitalet, Denmark and the Danish Arthritis Foundation.

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