Thiopurine methyltransferase (TPMT) risk alleles (mainly *2,*3B, *3C and *3A) are the major determinants of interindividual differences in the severe toxicity or efficacy of 6-mercaptopurine (6MP) during the treatment of childhood acute lymphoblastic leukemia (ALL). The frequencies of these risk alleles, known to functionally impair TPMT activity, were investigated among 167children with ALL and 206 healthy adult controls in Turkish population by using allele specific PCR and PCRRFLP methods. TPMT*3A and TPMT*3C were the only deficiency alleles detected in Turkish population with an allele frequency of 0.5% for both. The total frequency of mutant TPMT alleles in Turkish population (1.0%) was found to be significantly lower than those of other Caucasian populations (5.3-7.0%), but it was found to be very similar to Kazak population (1.2%) which is also Caucasian in ethnic origin. v In the patient group, two individuals were found to be heterozygote for *3C and *3A allele. One individual was homozygous mutant (*3B/*3C). In this study, the clinical histories of the patients with TPMT defects were examined retrospectively from hospital records. The patients with heterozygous or homozygous mutant genotypes had systematically developed severe neutropenia, infection and some other specific conditions (like lesions around mouth, oral herpes and high fever) when they were administered with 6MP during the therapy. This study provides the first data on the frequency of common TPMT risk alleles in the Turkish population, based on analysis of pediatric patients with ALL. The results would contribute valuable information to the public health, as more clinicians and patients become aware of the importance of TPMT polymorphisms, less patients will suffer from 6MP related adverse effects. In addition, in this study two genes EPHX1-microsomal epoxide hydrolase (exon 3 and exon 4 polymorphisms) and SULT1A1*2 variant &ndash / sulfotransferase 1A1, either alone or in combination were investigated as risk modifiers in the development of childhood acute lymphoblastic leukemia due to their dual role (activation/detoxification) in the metabolism of various carcinogens. Also interactions of these polymorphisms with non-genetic risk factors (parental smoking exposure and parental age at conception) were investigated. The conclusion inferred from results was that only genetically reduced EPHX1 activity (homozygous mutant genotype for EPHX1 exon 3 polymorphism and some specific genotype combinations with exon 4 polymorphism) was found to be significantly associated with the risk of childhood ALL.

In this study, the role of two DNA repair genes, X-ray repair cross complementing group 3 (XRCC3) Thr241Met and Rad51 G135C polymorphisms were investigated in the risk of development of childhood ALL in Turkish population among 193 healthy controls and 184 ALL patients, by using PCR-RFLP technique. For XRCC3 Thr241Met polymorphism, the frequencies of both heterozygous and homozygous mutant genotypes were found to be higher in the controls compared to ALL patients (OR: 0.59, p = 0.02 / OR: 0.48, p = 0.02, respectively). In addition, either heterozygous (Thr/Met) or homozygous mutant (Met/Met) genotypes were significantly more common in the controls than the ALL patients (OR: 0.55, p =0.005). In case of Rad51 G135C polymorphism, no significant associations have been found with the risk of childhood ALL. Combination of XRCC3 heterozygote and Rad51 heterozygote genotypes increased the protective effect for risk of childhood ALL. (OR=0.35 / p =0.02). Combination of homozygote mutant genotype of XRCC3 with homozygote wild type genotype of Rad51 gave a highly statistically proved protective effect for the development of disease (OR= 0.36 / p= 0.004). To our knowledge, this is the first study showing the protective role of XRCC3 Thr241Met polymorphism either alone or in combination with Rad51 G135C variant on the risk of development of childhood ALL. In addition, interactions of these polymorphisms with non-genetic risk factors were investigated. Only in terms of paternal exposure, the heterozygote (Thr/Met) genotype for XRCC3 gene in children whose father exposed to cigarette smoke demonstrated a significant risk of 3.0 fold (p=0.05). Moreover, the frequency of Rad51 135C allele was determined for the first time in Turkish population. The frequency of the mutant allele was found to be very similar to that observed in other Caucasian populations.

Die akute lymphoblastische Leukämie (ALL) ist die häufigste maligne Erkrankung im Kindesalter. Trotz risikoadaptierter Chemotherapie erleiden 25 - 30 % der Kinder mit ALL ein Rezidiv. Im Rezidivfall liegen die Heilungschancen trotz intensivierter Therapie nur bei 35- 40%. In retrospektiven und prospektiven Analysen konnten wir einerseits prognostisch-relevante, genetische Merkmale in den Leukämiezellen von Kindern mit ALL-Rezidiv erstmals identifizieren. Diese leukämiespezifischen Merkmale umfassen sowohl Translokations-assoziierte Fusionsgene (TEL-AML1, BCR-ABL, MLL-Aberrationen, E2A-PBX1), Deletionen von Tumorsuppressorgenen (p15, p16, p18) als auch Mutationen in DNA-Reparaturgenen (NBS1). Zusammen mit der sensitiven molekularen Bestimmung der Kinetik der Leukämiezellreduktion (Reaktion auf die Therapie, (MRD, minimal residual disease)) läßt sich die Prognose der Kinder mit ALL-Rezidiv durch die Verwendung dieser Marker zuverlässiger bewerten. Andererseits zeigen unsere Analysen, dass das Ansprechen auf die Therapie und die Prognose von wirtseigenen Faktoren (medikamenten metabolisierenden Enzyme) und von der Interaktion zwischen Leukämie- und Stromazellen und löslichen Wachstumsfaktoren (Zytokinen) abhängt. Eine adäquatere Behandlung dieser Patientengruppe, die bereits eine intensive Therapie erhalten hat und wesentlich risikoreichere, mit einer hohen Akut- und Spättoxizität behaftete Therapieverfahren einschließt, lässt sich durch die Berücksichtigung dieser Ergebnisse erreichen. Die genetische Typisierung und die sensitive Quantifizierung des molekularen Ansprechens auf die Therapie ergänzen heute die klinischen Determinanten zur Risikostratifizierung der Kinder mit ALL-Rezidiv der derzeitigen Therapieoptimierungsstudie ALL-REZ BFM 2002 (Berlin-Frankfurt-Münster). / Acute lymphoblastic leukemia is the most common malignancy in childhood. Although the prognosis for pediatric ALL with risk-adapted chemotherapy has improved dramatically, 25-30% of the children suffer a relapse. The prognosis for relapsed ALL remains poor (35-40%). In retrospective and prospective studies, we identified prognostic-relevant genetic features in leukemic blasts from children with ALL relapse. These leukemia-specific aberrations include translocation-associated fusion genes (TEL-AML1, BCR-ABL, MLL changes, E2A-PBX1), deletions of tumor suppressor genes (p15, p16, p18) and point mutations in DNA repair genes (NBS1). Together with the sensitive quantitative assessment of the molecular response to therapy (MRD, minimal residual disease), prediction of outcome is now more reliable. Furthermore, response to therapy and, thus, prognosis is significantly dependent on modifying host factors (drug-metabolizing enzymes) and interactions between leukemic and stromal cells as well as soluble growth factors (cytokines). Today, the genetic characterization of leukemic cells as well as the molecular quantification of response to therapy complement prognostic significant clinical determinants allowing a more precise risk stratification of children with ALL relapse in the relapse trial ALL-REZ BFM 2002 of the BFM (Berlin-Frankfurt-Münster) study group.

L’ostéonécrose (ON) et les fractures (FR) sont des complications qui prennent de plus en plus place dans le traitement pédiatrique de la leucémie aiguë lymphoblastique (LAL). L’ON peut être causée par différents facteurs, dont principalement l’utilisation de glucocorticoïdes. Les glucocorticoïdes sont administrés lors du traitement de la leucémie dans le but d’initier l’apoptose des cellules malignes tout en ayant un effet anti-inflammatoire. Cependant, l’utilisation de ces corticostéroïdes comprend des effets secondaires sérieux, notamment le développement d’ostéonécrose. Des variantes génétiques peuvent mettre certains patients plus à risque que d’autres. Plusieurs gènes ont déjà été signalés comme régulés par les actions glucocorticoïdes (GC). Les variations génétiques présentes dans les régions régulatrices de ces gènes peuvent affecter leur fonctionnement normal et, en fin de compte, de déterminer un risque accru de développer l’ON associé au traitement contre la leucémie. Pour cette raison, plusieurs polymorphismes ont été identifiés et étudiés dans la cohorte QcALL de Ste-Justine, concernant les gènes suivants : ABCB1, ACP1, BCL2L11, NFKB1, PARP1, et SHMT1. Ces gènes jouent majoritairement un rôle dans les mécanismes d’action des glucocorticoïdes, mais quelques-uns ont plutôt un effet direct sur le développement d’ostéonécrose. Nos recherches ont démontré une corrélation entre ces polymorphismes et l’apparition d’ostéonécrose chez les patients de la cohorte QcALL, traités aux glucocorticoïdes. L'incidence cumulative de l'ostéonécrose a été évaluée rétrospectivement chez 305 enfants atteints de la leucémie qui ont subi un traitement à l’hôpital Ste-Justine selon les protocoles DFCI de Boston (87-01, 91-01, 95-01 et 2000-01). Parmi les huit polymorphismes de BCL2L11 étudiés, les 891T> G (rs2241843) et 29201C> T (rs724710) ont été significativement associés à ON (p = 0.01 et p = 0.03, respectivement). L'association du polymorphisme 891T> G a été modulée par le type de corticostéroïde (CS), l’âge, le sexe et le groupe à risque (p ≤ 0,05). Le polymorphisme 29201C> T était particulièrement apparent chez les patients à haut risque (p = 0,003). La même étude était conduite en parallèle sur des patients de la cohorte DFCI de Boston (N = 192), et montrait des résultats significatifs pour les polymorphismes étudiés. En conclusion, les résultats de cette étude permettront de confirmer l’association de ces polymorphismes au développement d’ON chez les patients de LLA traités aux GC. / Osteonecrosis (ON) and fractures (FR) are complications that take place in the treatment of children acute lymphoblastic leukemia (cALL). They can be caused by various factors, mainly using glucocorticoids. The corticosteroids, dexamethasone (DXM) and prednisone (PDN) are administered during the treatment of leukemia to initiate apoptosis of malignant cells; while having an anti-inflammatory effect. However, the use of these corticosteroids has severe side effects, including the development of osteonecrosis. Moreover, some patients develop resistance to treatment, and are at risk of developing side effects. The genetic variants predispose some patients at higher risk than others. Several genes have been previously reported as up- or down regulated by the GCs actions. The genetic variations present in gene coding or regulatory regions can affect their function and ultimately determine an increased risk of developing ON associated to ALL therapy. Therefore, we investigated the association between several single nucleotide polymorphisms (SNPs) in six candidate genes: BCL2L11, NFKB1, PARP1, ABCB1, ACP1, and SHMT1. These genes play a role in the mechanisms of action of glucocorticoids, but some have more of a direct effect on the development of osteonecrosis. Our research has shown a correlation between these polymorphisms and the occurrence of osteonecrosis in patients in the QCALL cohort, treated with glucocorticoids. Cumulative incidence of osteonecrosis was assessed retrospectively in 305 children with ALL who underwent treatment with DFCI protocols (87-01, 91-01, 95-01 and 2000-01) in childhood ALL cohort from Quebec (QcALL). Among the eight tag BCL2L11 polymorphisms studied the 891T>G (rs2241843) and 29201C>T (rs724710) were significantly associated with ON (p = 0.01 and p = 0.03, respectively). Association of 891T>G polymorphism was modulated by type of corticosteroid (CS), age, sex and risk group (p ≤ 0.05 and that of 29201C>T was particularly apparent among high risk (p = 0.003) patients. These polymorphisms have shown significant ON association in several QcALL risk groups, mainly in corticosteroid groups, age < 10 years, and high risk (HR) group. Furthermore, the same study was conducted in parallel with patients in the replication (DFCI) cohort (N = 192), and we showed significant genetic association results for all studied polymorphisms. In conclusion, this study identifies that some ALL children have a high incidence of ON during the treatment that is highly associated with polymorphisms in different genes regulated by corticosteroids and ALL prognostic factors.