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Methotrexate polyglutamate levels and co-distributions in childhood acute lymphoblastic leukemia maintenance therapy

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Abstract

Purpose

Methotrexate polyglutamates (MTXpg) facilitate incorporation of thioguanine nucleotides into DNA (DNA-TG, the primary cytotoxic thiopurine metabolite and outcome determinant in MTX/6-mercaptopurine treatment of childhood ALL). We hypothesized that mapping erythrocyte levels of MTXpg with 1–6 glutamates and their associations with DNA-TG formation would facilitate future guidelines for maintenance therapy dosing.

Methods and results

Summed MTX with 1–6 glutamates resolved by LCMS [median (interquartile): 5.47 (3.58–7.69) nmol/mmol hemoglobin] was in agreement with total MTX by radio ligand assay. In 16,389 blood samples from 1426 ALL maintenance therapy patients, MTXpg3 21.0 (15.2–27.4)% was the predominant metabolite, and MTXpg1 (the maternal drug) constituted 38.6 (27.2–50.2)% of MTXpg1–6. All subsets correlated; the strongest associations were between metabolites with similar polyglutamate lengths. Correlations of MTXpg1 with MTXpg2 and MTXpg3,4,5,6 were rs = 0.68 and rs = 0.25–0.42, respectively. Intercorrelations of MTXpg3,4,5,6 were all rs ≥ 0.51. MTXpg4 accounted for 29.8 (24.7–33.3)% of MTXpg3–6, yet explained 96% of the summed MTXpg3–6 variation. MTXpg1–4, MTXpg1–6, MTXpg2–6 and MTXpg3 were all associated with DNA-TG levels (p < 0.00001), but collinearity precluded identification of the most informative subset.

Conclusions

Measuring erythrocyte MTXpg4 simplifies and can replace longer chain MTXpg monitoring. Resolving individual MTXpg identifies samples that are unsuitable for dose guidance due to high levels of MTXpg1 remaining in the plasma fraction because of recent MTX intake. All tested MTXpg subsets correlated with DNA-TG and may be used for ALL maintenance therapy dose adjustments, but the most informative subset remains to be identified.

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Abbreviations

DHFR:

Dihydrofolate reductase

DNA-TG:

DNA (-incorporated) thioguanine nucleotides

Ery-:

Erythrocyte

G:

Guanine

HD:

High dose

HR:

High-risk

IR:

Intermediate-risk

LCMS:

Liquid chromatography tandem mass spectrometry

MP:

Mercaptopurine

MT1/2:

Early and late maintenance therapy phases

MTX:

Methotrexate

MTXpgX:

Polyglytamated MTX with X γ-linked glutamates

SR:

Standard-risk

MTXtot :

Total MTX determined by radio ligand assay

RLA:

Radio ligand assay

TG:

Thioguanine

TGN:

Thioguanine nucleotides

WBC:

White blood cell count

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Acknowledgements

The authors thank the dedicated staff at the laboratory of Pediatric Oncology, Copenhagen for their valuable work.

Funding

The Danish Childhood Cancer Foundation (Grant nos. 2012/13, PROJ12/059), The Danish Cancer Society, The Nordic Cancer Union, The Swedish Childhood Cancer Foundation, Otto Christens Foundation, University Hospital Rigshospitalet, and Novo Nordic Foundation.

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Authors and Affiliations

  1. Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark

    Jacob Nersting, Stine Nygaard Nielsen, Kathrine Grell, Maria Paerregaard & Kjeld Schmiegelow

  2. Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark

    Kathrine Grell

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

    Jonas Abrahamsson

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

    Bendik Lund

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

    Olafur Gisli Jonsson

  6. Tallinn Children’s Hospital, Tallinn, Estonia

    Kaie Pruunsild

  7. University Hospital Santariskiu Klinikos, Vilnius, Lithuania

    Goda Vaitkeviciene

  8. Children’s Hospital, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland

    Jukka Kanerva

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

    Kjeld Schmiegelow

Authors
  1. Jacob Nersting
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  2. Stine Nygaard Nielsen
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  3. Kathrine Grell
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  4. Maria Paerregaard
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  6. Bendik Lund
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  7. Olafur Gisli Jonsson
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  8. Kaie Pruunsild
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  9. Goda Vaitkeviciene
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  10. Jukka Kanerva
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  11. Kjeld Schmiegelow
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Consortia

the Nordic Society of Paediatric Haematology and Oncology (NOPHO)

Contributions

JN drafted the manuscript, developed, implemented, supervised all pharmacological analyses and performed together with MP the statistical analysis in the method comparison and co-distribution study. SNN and KG compiled data and did the statistical analysis of associations of DNA-TG with MTXpg subsets and cytoplasmic metabolites. JA, BL, JK, OGJ, GV, and KP developed the study protocol and coordinated the national blood sample and data collection for each country. KS initiated, supervised, and was the principal investigator for this study and of the NOPHO ALL2008 protocol. All authors approved the final manuscript.

Corresponding author

Correspondence to Jacob Nersting.

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The authors declare no conflict of interest.

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Nersting, J., Nielsen, S.N., Grell, K. et al. Methotrexate polyglutamate levels and co-distributions in childhood acute lymphoblastic leukemia maintenance therapy. Cancer Chemother Pharmacol 83, 53–60 (2019). https://doi.org/10.1007/s00280-018-3704-7

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