Which Clinical and Biological Tumor Markers Proved Predictive in the Prospective Multicenter Trial HIT’91 - Implications for Investigating Childhood Medulloblastoma

Abstract

Background: Most recent studies analyzing candidate biological prognostic factors in childhood medulloblastoma (MB) are limited by small patient numbers due to dependence on fresh-frozen tumor material. By contrast, large archives of formalin-fixed, paraffin-embedded MB samples exist from homogeneously treated patients.

Patients and Methods: We have optimized RNA and DNA isolation from formalin-fixed paraffin-embedded MB samples. We then analyzed ar-chived tumor samples from well-documented pa-tients treated within the prospective randomized multicenter trial HIT’91 for DNA amplification of c-myc and N-myc, and mRNA expression of c-myc and trkC.

Results: TrkC and c-myc mRNA expression were identified as independent prognostic factors by multivariate analysis. Three risk groups were identified: 1) Favorable risk group: All 8 patients (2 metastatic) with elevated trkC and reduced c-myc mRNA expression (compared to levels of human cerebellum) remained relapse-free (7-year EFS 100%). 2) Poor risk group: 10 of 15 patients with metastatic disease and high c-myc and low trkC mRNA expression relapsed (7-year EFS 33%). 3) Intermediate risk group: The 7-year EFS of the remaining 78 patients was 65%.

Conclusions: While the collection of fresh-frozen tumor samples is remaining a major challenge in large clinical trials, routinely processed paraffin-embedded tissue samples can be used to quantitate biological prognostic factors on the DNA and RNA level. Upon prospective validation of cut-off levels, this may lead to better risk-based stratification systems for children with medulloblastoma.

Zusammenfassung

Hintergrund: Die aktuellen Studien zur Untersuchung potenzieller biologischer prognostischer Faktoren bei Kindern mit Medulloblastom (MB) sind häufig durch die geringe Zahl verfügbarer unfixierter schockgefrorener Tumorproben limitiert. Im Gegensatz dazu sind große Serien formalinfixierter, paraffineingebetteter Tumorproben homogen behandelter Patienten verfügbar.

Patienten und Methoden: Zunächst zeigten wir, dass die Expression von trkC- und c-myc-mRNA nach Optimierung der RNA- und DNA-Isolation aus formalinfixierten, paraffineingebetteten Tumorproben mit den aus unfixiertem schockgefrorenem Tumormaterial gewonnenen Werten korrelierte. Anschließend wurden formalinfixierte Tumorproben von Patienten der prospektiven randomisierten multizentrischen Studie HIT’91 auf DNA-Amplifikation von c-myc- und N-myc- und mRNA-Expression von c-myc und trkC untersucht.

Ergebnisse: TrkC- und c-myc-mRNA-Expression wurden durch multivariable Analyse als unabhängige prognostische Faktoren identifiziert. Es zeigten sich 3 Gruppen mit unterschiedlichem Rezidivrisiko. 1) Geringes Rezidivrisiko: Alle 8 Patienten (2 mit metastatischer Erkrankung) mit erhöhter mRNA-Expression trkC (verglichen mit humanem Kleinhirn) und erniedrigter c-myc-mRNA (verglichen mit humanem Kleinhirn) blieben rückfallsfrei (7-Jahres-EFS 100%). 2) Hohes Rezidivrisiko: 10 von 15 Patienten mit Metastasierung und hoher mRNA-Expression von c-myc- und niedriger trkC-mRNA-Expression hatten ein Rezidiv (7-Jahres-EFS 33%). 3) Mittleres Risiko: Das 7-Jahres-EFS der übrigen 78 Patienten betrug 65%.

Schlussfolgerung: Während die Sammlung von schockgefrorenem Tumormaterial in größeren klinischen Studien noch besser implementiert werden muss, können biologische prognostische Faktoren auf DNA- und RNA-Ebene an besser verfügbaren paraffineingebetteten Tumorschnitten quantifiziert werden. Nach prospektiver Validierung von Grenzwerten können diese Ergebnisse zu einer Verbesserung der risikoadaptierten Therapiestratifizierung für Kinder mit Medulloblastom beitragen.

brain tumor - medulloblastoma - prognosis - risk stratification

Hirntumor - Medulloblastom - Prognose - Risikostratifikationen

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1 Both authors contributed equally.

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