Lisa Diller

P53 FUNCTIONS AS A CELL CYCLE CONTROL PROTEIN IN OSTEOSARCOMAS

Mutations in the p53 gene have been associated with a wide range of human tumors, including osteosarcomas. Although it has been shown that wild-type p53 can block the ability of E1a and ras to cotransform primary rodent cells, it is poorly understood why inactivation of the p53 gene is important for tumor formation. We show that overexpression of the gene encoding wild-type p53 blocks the growth of osteosarcoma cells. The growth arrest was determined to be due to an inability of the transfected cells to progress into S phase. This suggests that the role of the p53 gene as an antioncogene may be in controlling the cell cycle in a fashion analogous to the check-point control genes in Saccharomyces cerevisiae.

Activating mutations in ALK provide a therapeutic target in neuroblastoma.

Neuroblastoma, an embryonal tumour of the peripheral sympathetic nervous system, accounts for approximately 15% of all deaths due to childhood cancer. High-risk neuroblastomas are rapidly progressive; even with intensive myeloablative chemotherapy, relapse is common and almost uniformly fatal. Here we report the detection of previously unknown mutations in the ALK gene, which encodes a receptor tyrosine kinase, in 8% of primary neuroblastomas. Five non-synonymous sequence variations were identified in the kinase domain of ALK, of which three were somatic and two were germ line. The most frequent mutation, F1174L, was also identified in three different neuroblastoma cell lines. ALK complementary DNAs encoding the F1174L and R1275Q variants, but not the wild-type ALK cDNA, transformed interleukin-3-dependent murine haematopoietic Ba/F3 cells to cytokine-independent growth. Ba/F3 cells expressing these mutations were sensitive to the small-molecule inhibitor of ALK, TAE684 (ref. 4). Furthermore, two human neuroblastoma cell lines harbouring the F1174L mutation were also sensitive to the inhibitor. Cytotoxicity was associated with increased amounts of apoptosis as measured by TdT-mediated dUTP nick end labelling (TUNEL). Short hairpin RNA (shRNA)-mediated knockdown of ALK expression in neuroblastoma cell lines with the F1174L mutation also resulted in apoptosis and impaired cell proliferation. Thus, activating alleles of the ALK receptor tyrosine kinase are present in primary neuroblastoma tumours and in established neuroblastoma cell lines, and confer sensitivity to ALK inhibition with small molecules, providing a molecular rationale for targeted therapy of this disease.

High Risk of Subsequent Neoplasms Continues With Extended Follow-Up of Childhood Hodgkin’s Disease: Report From the Late Effects Study Group

PURPOSE We present an update of a previously reported Late Effects Study Group cohort of 1,380 children with Hodgkins disease (HD) diagnosed between 1955 and 1986 in patients aged 16 years or younger. We describe the pattern and incidence of subsequent neoplasms (SNs) occurring with extended follow-up. PATIENTS AND METHODS Median age at diagnosis of HD was 11.7 years (range, 0.3 to 16.9 years) and at last follow-up was 27.8 years. Median length of follow-up was 17.0 years. RESULTS An additional 103 SNs were ascertained (total SNs = 212). The cohort was at an 18.5-fold increased risk of developing SNs compared with the general population (standardized incidence ratio [SIR], 18.5, 95% CI, 15.6 to 21.7). The cumulative incidence of any second malignancy was 10.6% at 20 years, increasing to 26.3% at 30 years; and of solid malignancies was 7.3% at 20 years, increasing to 23.5% at 30 years. Breast cancer was the most common solid malignancy (SIR, 56.7). Other commonly occurring solid malignancies included thyroid cancer (SIR, 36.4), bone tumors (SIR, 37.1), and colorectal (SIR, 36.4), lung (SIR, 27.3), and gastric cancers (SIR, 63.9). Risk factors for solid tumors included young age at HD and radiation-based therapy. Thirty-two patients developed third neoplasms, with the cumulative incidence approaching 21% at 10 years from diagnosis of second malignancy. CONCLUSION Additional follow-up of this large cohort of HD survivors documents an increasing occurrence of known radiation-associated solid tumors, (breast and thyroid cancers), as well as emergence of epithelial neoplasms common in adults, (colon and lung cancers) at a younger age than expected in the general population, necessitating ongoing surveillance of this high risk population.

Cardiovascular Status in Long-Term Survivors of Hodgkin's Disease Treated With Chest Radiotherapy

PURPOSE Cardiovascular status was assessed in 48 Hodgkins disease (HD) survivors at a median of 14.3 years (range, 5.9 to 27.5 years) after diagnosis because they may be at increased risk for cardiovascular abnormalities. PATIENTS AND METHODS Patients completed the Short-Form 36 quality-of-life instrument and were screened by echocardiography, exercise stress testing, and resting and 24-hour ECG. RESULTS All patients received mediastinal irradiation (median, 40.0 Gy; range, 27.0 to 51.7 Gy) at a median age of 16.5 years (range, 6.4 to 25.0 years). Four patients received an anthracycline. Although every patient described their health as good or better, and none had symptomatic heart disease at screening, all but one had cardiac abnormalities on screening. Restrictive cardiomyopathy was suggested by reduced average left ventricular (LV) dimension (P < .001) and mass (P < .001), without increased LV wall thickness. Significant valvular defects were present in 42%; 75% had conduction defects. One survivor developed complete heart block shortly after the study visit. Autonomic dysfunction was suggested by a monotonous heart rate in 57%, persistent tachycardia in 31%, and blunted hemodynamic responses to exercise in 27%. Peak oxygen uptake (VO2max) during exercise, a predictor of mortality in heart failure, was significantly reduced (< 20 mL/kg/m2) in 30% of survivors. VO2max was correlated with increasing fatigue, increasing shortness of breath (both, r = -0.35; P =. 02), and decreasing physical component score on the SF-36 (r = 0.554; P = .00017). CONCLUSION A variety of unsuspected, clinically significant cardiovascular abnormalities are common in long-term survivors of HD who are treated at a young age with mediastinal irradiation. We recommend serial, comprehensive cardiac screening of HD survivors who fit this profile.

Chronic Disease in the Childhood Cancer Survivor Study Cohort: A Review of Published Findings

A primary objective of the Childhood Cancer Survivor Study (CCSS) is to characterize the major chronic health conditions faced by childhood cancer survivors, and to determine the risk factors for those conditions. In order to characterize these conditions, at entry into the study, participants completed questionnaires that documented self-reported chronic illnesses, symptoms, and medications. Over time, follow-up questionnaires (administered approximately every 2 to 3 years) have allowed analysis of changes in symptoms and disease burden. To date, analyses have been completed which describe the profile of chronic disease in the cohort at first entry into the study and for specific subgroups, defined by primary cancer, by specific exposures, and by demographic factors.1,2 Generally, these analyses estimate risk of chronic disease by calculating a risk estimate for self-reported symptoms or conditions. Relative risks for chronic disease or specific conditions are calculated comparing the survivor cohort with the sibling cohort or population norms. In addition, relative risk for an outcome in a subgroup with a specific treatment exposure or demographic characteristic is calculated relative to a comparison group without that specific factor of interest. Cumulative incidence of specific chronic illnesses is estimated in many of the reports, and analyses of chronic illnesses in each of the survivor groups by primary diagnosis are completed (acute lymphoblastic leukemia [ALL],3 acute myeloid leukemia [AML],4 and rhadbdomyosarcoma5) or in progress (neuroblastoma, bone sarcoma, renal tumors, lymphomas, and brain tumors). This review presents the completed analyses of overall chronic illness in the original cohort and then describes findings by organ system. Specific chronic diseases reported here will include: endocrinologic disorders (including thyroid disease, disorders of growth, weight, and pubertal regulation), osteonecrosis, cardiac disease, pulmonary conditions, and neurosensory/neurologic adverse outcomes. Adverse outcomes in some domains which might be considered chronic illnesses—secondary cancers, emotional and psychological disorders, pain—are not covered herein, but are reviewed separately in other articles within this issue of Journal of Clinical Oncology. For some outcomes, only subsets of the cohort have been analyzed, often because a hypothesis regarding a specific exposure or disease (eg, weight regulation in leukemia survivors or stroke after neck radiation therapy [RT]) has been explored. Analyses in progress, and not included in this report, include risk of renal and urinary disorders, gastrointestinal diseases, and more in depth cohort-wide characterizations of cardiovascular disease. Additional studies to characterize further longitudinal changes in risk as the cohort ages are planned.

Breast Cancer after Childhood Cancer: A Report from the Childhood Cancer Survivor Study

Context Adult survivors of childhood cancer are at risk for developing breast cancer and other secondary cancer. Knowing the risk factors for breast cancer in these women may help to formulate screening policies for them. Contribution Among 6068 women who survived childhood cancer, 95 developed breast cancer at a median age of 35 years. Childhood sarcoma, chest irradiation, family history of breast cancer, and personal history of thyroid disease increased the risk for breast cancer. Implications Women who survived childhood cancer and had sarcoma, chest irradiation, family history of breast cancer, or personal history of thyroid disease should consider early, vigilant screening for breast cancer. The Editors Women treated with chest radiation therapy for childhood and adolescent Hodgkin disease are at increased risk for developing breast cancer at a young age (1-12). However, case reports and preliminary studies indicate that survivors of childhood cancer other than Hodgkin disease may also be at risk for secondary breast cancer (1, 13, 14). Practitioners caring for the growing population of young female survivors of childhood cancer are challenged with assessing breast cancer risk in order to recommend screening and preventive strategies. Although recent studies have shown that the risk for radiation-induced breast cancer is directly related to dose of chest radiation, specific details of previous treatment are not always available to clinicians and may not affect screening decisions (11, 12). In addition, whether primary cancer diagnosis, previous treatment other than chest radiation, or other well-established breast cancer risk factors contribute to a childhood cancer survivors risk for breast cancer is unknown. Studies of Hodgkin disease survivors have shown that clinical examination and screening mammography can detect early-stage secondary breast cancer in young women (15-17), and although treatment options may be limited by previous therapy, early-stage secondary breast cancer is curable (16, 17). Thus, identifying specific groups of childhood cancer survivors who would benefit from early mammographic screening might reduce the morbidity and mortality of breast cancer in these young women. In this study, we analyzed a large series of women with secondary breast cancer from a cohort of childhood cancer survivors, the Childhood Cancer Survivor Study (CCSS), to describe clinical and pathologic features of breast cancer and to determine breast cancer risk relative to the general population. We hypothesized that breast cancer risk would be modified by previous treatment and factors unrelated to treatment. Thus, in this large cohort of women, we assessed the influence of primary cancer, previous treatment, family cancer history, and menstrual and reproductive history on breast cancer risk. Methods Study Sample: Childhood Cancer Survivors Study The CCSS is a follow-up study of childhood cancer survivors established in 1994. Eligibility criteria included diagnosis at an age younger than 21 years with leukemia, brain tumor, Hodgkin disease, non-Hodgkin lymphoma, renal tumor, neuroblastoma, or soft-tissue or bone sarcoma and survival of at least 5 years after diagnosis. The 20276 eligible participants received a diagnosis from 1 January 1970 to 31 December 1986 at 1 of 25 collaborating institutions (Appendix). Participants (n= 14054) completed a self-report questionnaire, providing information about their medical history, family medical history, reproductive history, and socioeconomic status. Follow-up questionnaires were sent to patients reporting second cancer diagnoses. Information on the cohort was updated in 2000. We used data available as of May 2002 for this analysis. No men in the CCSS reported breast cancer by that date; thus, this analysis was restricted to women. Detailed information on the study methods and cohort characteristics has been reported (18). The human subjects committee at each participating institution approved the CCSS protocol. Clinical Data We abstracted treatment data from medical records, including chemotherapeutic agents and dose, and radiation therapy dose, and site for primary cancer and relapses. We asked participants who self-reported breast cancer to sign a medical release to confirm the diagnosis. We confirmed all cases of breast cancer in this report and obtained the tumor size, histologic characteristics, hormone receptor status, involvement of axillary nodes, and metastatic sites from pathology records. Statistical Analysis We compared survivors who had breast cancer with those who did not have breast cancer with respect to primary cancer diagnosis, age at diagnosis, years of follow-up, and therapy for the primary cancer. We calculated standardized incidence ratios for breast cancer by using age-, sex-, and calendar-yearspecific incidence rates of the general population (Surveillance, Epidemiology, and End Results Program [SEER], National Cancer Institute, Bethesda, Maryland [19]). We considered survivors to be at risk for breast cancer from 5 years after the childhood cancer diagnosis until 1 of the following 3 events: death, breast cancer diagnosis, or completion of the CCSS questionnaire. To make the definition of incidence comparable in the calculation of the observed and expected numbers, we included only the first primary breast cancer diagnosis. We calculated cumulative incidences of breast cancer by attained age (20). We used Poisson multiple regression models for standardized incidence ratios to assess the modification of risk for developing breast cancer by several variables chosen a priori (21). We considered the following risk factors for breast cancer: age at and years since primary cancer diagnosis; age at menarche (<12 years or 12 years); age at first live birth (never, <20 years, 20 to 24 years, or 25 years), as queried in the CCSS questionnaire; history of breast cancer in first-degree female relatives (yes or no); exposure to chest radiation (yes or no); exposure to pelvic radiation (yes or no); family history of sarcoma (yes or no); history of thyroid disease (thyroid nodules, overactive or underactive thyroid, or enlarged thyroid); and exposure to an alkylating agent (alkylating agent score, measured as previously described, accounted for several drug exposures and dose) (22). The Poisson multiple regression incorporated all time-dependent factors by splitting each survivors follow-up period into several time intervals, wherein each factor was assumed constant. We initially evaluated the relative rate of developing breast cancer for each risk factor, adjusting for the exposure to chest radiation (yes or no). We then stratified the analysis by the exposure to chest radiation and assessed the modification of risk with age at and years since primary cancer diagnosis, family history of breast cancer or sarcoma, history of thyroid disease, and exposure to pelvic radiation. The years since primary cancer diagnosis variable was the baseline time factor of the model for which we obtained fitted standardized incidence ratios relative to SEER data. For other variables, we calculated relative rates by comparing standardized incidence ratios across categories of each variable. All significance tests were 2-sided. We used SAS software, version 8 (SAS Institute Inc., Cary, North Carolina), and S-PLUS software, version 6 (Insightful Corp.), for this analysis. Role of the Funding Sources The funding sources had no role in the collection, analysis, or interpretation of the data or in the decision to submit the manuscript for publication. Results Cohort Characteristics Of the 20276 survivors eligible for the CCSS cohort, 9062 were women. Of those, 6498 women participated, 6068 of whom had signed medical record release to be eligible for this analysis. Of the 6068 eligible women, 95 women had 111 confirmed cases of breast cancer. Primary cancer diagnosis and age at treatment were similar between participants and nonparticipants (Table 1). Survivors with breast cancer were older at diagnosis of primary cancer and at follow-up than those without breast cancer. As expected, a large proportion of the women with breast cancer (65 of 95 [68%] women) were Hodgkin disease survivors, and all but 2 of the 65 women were known to have received chest radiation therapy. However, 30 of 95 (32%) women with breast cancer were survivors of other childhood cancer, and 20 of 95 (21%) women did not receive chest radiation therapy. The proportion of patients exposed to alkylating agents was similar in both groups (49.5% vs. 49.2%) (Table 1). Table 1. Characteristics of Women Who Did and Did Not Develop Breast Cancer and of Eligible Nonparticipants Since the oldest survivors in this cohort were 51 years of age, all cases of breast cancer were diagnosed in relatively young women (median age at diagnosis, 35 years [range, 20 to 49 years]) (Table 2). However, 19% (18 of 95 women) of the breast cancer cases occurred in women 20 to 29 years of age and 64% (61 of 95 women) of cases occurred in women 30 to 39 years of age. Median time from childhood cancer diagnosis to breast cancer diagnosis was 19 years; however, the range extended from 6 years to 29 years after primary cancer diagnosis (Table 2). Table 2. Clinical and Pathologic Characteristics of Breast Cancer Cases Of the 111 cases of breast cancer, 21 cases were ductal carcinoma in situ (Table 2). Of those 21 cases, 19 were diagnosed in Hodgkin disease survivors and 2 in soft-tissue sarcoma survivors. Table 2 shows the distribution of histologic characteristics in the invasive cases. We determined the stage in 66 of 90 (73%) invasive cases from pathology reports (Table 2). Twenty-six (29%) cases involved axillary lymph nodes, and 5 (6%) cases involved distant metastatic disease. Estrogen receptor status was available in 37 cases, and 76% of those were positive. There was no predominant laterality. Sixteen cases (17%) were bilateral, 5 were syn

Germline p53 mutations are frequently detected in young children with rhabdomyosarcoma.

We investigated the possibility that a proportion of children with sporadic rhabdomyosarcoma (RMS) carry constitutional mutations of the p53 tumor suppressor gene. 33 patients with sporadic RMS at two large outpatient pediatric oncology clinics submitted blood samples. Genomic DNA was extracted from peripheral blood leukocytes and PCR was used to amplify exons 2-11 of the p53 gene. Amplified genomic DNA was screened for the presence of germline p53 mutations using single-strand conformation polymorphism (SSCP) analysis. The DNA sequence of those samples that showed aberrant migration of bands on SSCP analysis was determined to identify the precise nature of the gene mutations. Patient records were reviewed to assess clinical correlates of the mutant p53 carrier state. Heterozygous constitutional mutations were detected in 3/33 patient samples screened. Two of these missense mutations are located in exon 7 and one in exon 8 of the p53 gene. The presence of mutations was not correlated with tumor histology, stage, or site. However, an association between young age at diagnosis and presence of a constitutional p53 mutation was noted: 3/13 children under the age of 3 yr at diagnosis carried mutations, whereas none of 20 children over 3 yr of age at diagnosis harbored a detectable constitutional mutation. These results in children with RMS corroborates previous findings in other clinical settings suggesting that the mutant p53 carrier state may predispose individuals to malignancy at an early age. Although this study did not assess whether the mutations were preexisting or new germline alterations, assessment of close relatives of RMS patients for cancer risk and predictive genetic testing may be indicated.

Radiation Dose and Breast Cancer Risk in the Childhood Cancer Survivor Study

PURPOSE The purpose of this study was to quantify the risk of breast cancer in relation to radiation dose and chemotherapy among survivors of childhood cancer. METHODS We conducted a case-control study of breast cancer in a cohort of 6,647 women who were 5-year survivors of childhood cancer and who were treated during 1970 through 1986. One hundred twenty patients with histologically confirmed breast cancer were identified and were individually matched to four selected controls on age at initial cancer and time since initial cancer. Medical physicists estimated radiation dose to the breast tumor site and ovaries on the basis of medical records. RESULTS The odds ratio for breast cancer increased linearly with radiation dose, and it reached 11-fold for local breast doses of approximately 40 Gy relative to no radiation (P for trend < .0001). Risk associated with breast irradiation was sharply reduced among women who received 5 Gy or more to the ovaries (P = .002). The excess odds ratio per Gy was 0.36 for those who received ovarian doses less than 5 Gy and was 0.06 for those who received higher doses. Radiation-related risk did not vary significantly by age at exposure. Borderline significantly elevated risks were seen for doxorubicin, dactinomycin, dacarbazine, and carmustine. CONCLUSION Results confirm the radiation sensitivity of the breast in girls age 10 to 20 years but do not demonstrate a strong effect of age at exposure within this range. Irradiation of the ovaries at doses greater than 5 Gy seems to lessen the carcinogenic effects of breast irradiation, most likely by reducing exposure of radiation-damaged breast cells to stimulating effects of ovarian hormones.

Predictors of Smoking Initiation and Cessation Among Childhood Cancer Survivors: A Report From the Childhood Cancer Survivor Study

PURPOSE To examine the determinants of smoking behavior among participants in the Childhood Cancer Survivors Study (CCSS). METHODS This retrospective cohort survey study was conducted among 9,709 childhood cancer survivors. Main outcomes included smoking initiation and cessation. RESULTS Twenty-eight percent of patients reported ever smoking and 17% reported being current smokers. Standardized to United States population rates, the observed to expected (O/E) ratios and corresponding 95% confidence limits (95% CL) of cigarette smoking were 0.72 (95% CL, 0.69, 0.75) among all survivors and 0.71 (95% CL, 0.68 to 0.74) and 0.81 (95% CL, 0.70, 0.93) among whites and nonwhites, respectively. Significantly lower O/E ratios were present among both males (O/E, 0.73) and females (O/E, 0.70). Factors independently associated with a statistically significant relative risk of smoking initiation included older age at cancer diagnosis, lower household income, less education, not having had pulmonary-related cancer treatment, and not having had brain radiation. Blacks were less likely to start smoking. Survivors who smoked were significantly more likely to quit (O/E, 1.22; 95% CL, 1.15, 1.30). Among ever-smokers, factors associated with the likelihood of being a current smoker included age less than 13 years at smoking initiation, less education, and having had brain radiation; those age less than 3 years at cancer diagnosis were significantly more likely to be ex-smokers. CONCLUSIONS Although survivors in the CCSS cohort seem to be smoking at rates below the general population, interventions are needed to prevent smoking initiation and promote cessation in this distinct population.

High-Risk Neuroblastoma Treated With Tandem Autologous Peripheral-Blood Stem Cell–Supported Transplantation: Long-Term Survival Update

PURPOSE To provide an update on long-term survival of patients with high-risk neuroblastoma treated with tandem cycles of myeloablative therapy and peripheral-blood stem-cell rescue (PBSCR). PATIENTS AND METHODS Ninety-seven patients with high-risk neuroblastoma were treated between 1994 and 2002. Patients underwent induction therapy with five cycles of standard agents, resection of the primary tumor and local radiation, and two consecutive courses of myeloablative therapy (including total-body irradiation) with PBSCR. RESULTS Fifty-one patients have experienced relapse or died. Median follow-up time among the 46 patients who remain alive without progression is 5.6 years (range, 15.1 months to 9.9 years). Progression-free survival (PFS) rate at 5 years from diagnosis was 47% (95% CI, 36% to 56%), and PFS rate at 7 years was 45% (95% CI, 34% to 55%). Overall survival rate was 60% (95% CI, 48% to 69%) and 53% (95% CI, 40% to 64%) at 5 and 7 years, respectively. The 5- and 7- year PFS rates from time of first transplantation for 82 patients who completed both transplants were 54% (95% CI, 42% to 64%) and 52% (95% CI, 40% to 63%), respectively. Five patients died from treatment-related toxicity after tandem transplantation. Relapse occurred in 37 (42%) of 89 patients, mainly within 3 years of transplantation and primarily in diffuse osseous sites. No primary CNS relapse or secondary leukemia was seen. One patient developed synovial cell sarcoma 8 years after therapy. CONCLUSION High-dose therapy with tandem autologous stem-cell rescue is effective for treating high-risk neuroblastoma, with encouraging long-term survival. CNS relapse and secondary malignancies are rare after this therapy.