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Acute lymphoblastic leukemia

NT5C2 germline variants alter thiopurine metabolism and are associated with acquired NT5C2 relapse mutations in childhood acute lymphoblastic leukaemia

Leukemia volume 32, pages 2527–2535 (2018)Cite this article

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Abstract

The antileukaemic drug 6-mercaptopurine is converted into thioguanine nucleotides (TGN) and incorporated into DNA (DNA-TG), the active end metabolite. In a series of genome-wide association studies, we analysed time-weighted means (wm) of erythrocyte concentrations of TGN (Ery-TGN) and DNA-TG in 1009 patients undergoing maintenance therapy for acute lymphoblastic leukaemia (ALL). In discovery analyses (454 patients), the propensity for DNA-TG incorporation (wmDNA-TG/wmEry-TGN ratio) was significantly associated with three intronic SNPs in NT5C2 (top hit: rs72846714; P = 2.09 × 10−10, minor allele frequency 15%). In validation analyses (555 patients), this association remained significant during both early and late maintenance therapy (P = 8.4 × 10−6 and 1.3 × 10−3, respectively). The association was mostly driven by differences in wmEry-TGN, but in regression analyses adjusted for wmEry-TGN (P < 0.0001), rs72846714-A genotype was also associated with a higher wmDNA-TG (P = 0.029). Targeted sequencing of NT5C2 did not identify any missense variants associated with rs72846714 or wmEry-TGN/wmDNA-TG. rs72846714 was not associated with relapse risk, but in a separate cohort of 180 children with relapsed ALL, rs72846714-A genotype was associated with increased occurrence of relapse-specific NT5C2 gain-of-function mutations that reduce cytosol TGN levels (P = 0.03). These observations highlight the impact of both germline and acquired mutations in drug metabolism and disease trajectory.

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Acknowledgements

This work was supported by The Danish Cancer Society, The Danish Childhood Cancer Foundation, The Swedish Childhood Cancer Foundation, The Nordic Cancer Union, The Otto Christensen Foundation, University Hospital Rigshospitalet and The Novo Nordic Foundation.

Author contributions

MT compiled the data and handled bioinformatics analyses with MG, SNN, BOW and RG. MT and KG handled statistical analyses. MT drafted the manuscript. PSW, OGJ, BL, AH-S, JA, GV, KP, NT, MH, EH, SL, LG and MP developed the study protocol and coordinated the national blood sample and data collection for each country. JW and WLC assisted with data and analyses from the TARGET database. ZZ designed the probes for the sequencing panel. MDD designed and performed the DNA library preparation for targeted gene sequencing. JN supervised all pharmacological analyses. KS initiated and supervised the study, was the principal investigator for this study and the NOPHO ALL2008 protocol, and had responsibility for the final submission for publication. All authors approved the final manuscript

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Authors and Affiliations

  1. Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark

    Morten Tulstrup, Stine Nygaard Nielsen, Kathrine Grell, Benjamin Ole Wolthers, Jacob Nersting & Kjeld Schmiegelow

  2. Department of Bio and Health Informatics, Technical University of Denmark, Kongens Lyngby, Denmark

    Marie Grosjean, Zeyu Zhang, Marlene D. Dalgaard & Ramneek Gupta

  3. Section of Biostatistics, Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

    Kathrine Grell

  4. Department of Pediatric Hematology and Oncology, H. C. Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark

    Peder Skov Wegener

  5. Department of Pediatrics, Landspitali University Hospital, Reykjavík, Iceland

    Olafur Gisli Jonsson

  6. Department of Pediatrics, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway

    Bendik Lund

  7. Department of Laboratory Medicine, Faculty of Medicine and Health sciences, Children’s and Women’s Health, Norwegian University of Science and Technology, Trondheim, Norway

    Bendik Lund

  8. Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden

    Arja Harila-Saari

  9. Department of Pediatrics, Institution for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

    Jonas Abrahamsson

  10. Clinic of Children’s Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania

    Goda Vaitkeviciene

  11. Department of Onco-haematology, Talinn Children’s Hospital, Talinn, Estonia

    Kaie Pruunsild

  12. Department of Hematology, University Hospital Rishospitalet, Copenhagen, Denmark

    Nina Toft

  13. Department of Haematology, Aarhus University Hospital, Aarhus, Denmark

    Mette Holm

  14. Department of Hematology and Coagulation, Sahlgrenska University Hospital, Göteborg, Sweden

    Erik Hulegårdh

  15. Department of Hematology, Ullevål University Hospital, Faculty Division Ullevål University Hospital, University of Oslo, Oslo, Norway

    Sigurd Liestøl

  16. Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania

    Laimonas Griskevicius

  17. Hematology, Oncology and Transfusion Medicine Center, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania

    Laimonas Griskevicius

  18. Clinic of Hematology and Oncology, Tartu University Clinic, Tartu, Estonia

    Mari Punab

  19. Masonic Cancer Center, Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA

    Jinhua Wang

  20. Department of Pediatrics, New York University Medical Center, Perlmutter Cancer Center, New York, NY, USA

    William L. Carroll

  21. Sino-Danish Center for Education and Research, University of Chinese Academy of Sciences, Beijing, China

    Zeyu Zhang

  22. Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark

    Kjeld Schmiegelow

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  1. Morten Tulstrup
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Correspondence to Kjeld Schmiegelow.

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Tulstrup, M., Grosjean, M., Nielsen, S.N. et al. NT5C2 germline variants alter thiopurine metabolism and are associated with acquired NT5C2 relapse mutations in childhood acute lymphoblastic leukaemia. Leukemia 32, 2527–2535 (2018). https://doi.org/10.1038/s41375-018-0245-3

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