Medical Oncology

, Volume 29, Issue 3, pp 2053–2062 | Cite as

Study of the pharmacokinetic and pharmacogenetic contribution to the toxicity of high-dose methotrexate in children with acute lymphoblastic leukemia

  • Noha M. EL-KhodaryEmail author
  • Sahar M. EL-Haggar
  • Manal A. Eid
  • Emad N. Ebeid
Original Paper


Methotrexate inhibits the conversion of 5,10-methylenetetrahydrofolate to 5-methyltetrahydrofolate by methylenetetrahydrofolate reductase (MTHFR). MTHFR has a common functional polymorphism C677T. The present study aimed to investigate the prevalence of MTHFR polymorphisms in Egyptian children with ALL and the relation to MTX-related toxicity, relapse, and MTX pharmacokinetic parameters. Forty patients with ALL were included in the study. They were treated according to ALL-NCI total XIII protocol. MTX-related toxicity and MTX pharmacokinetic parameters were assessed during therapy. MTHFR genotyping was done with a PCR-based restriction fragment length polymorphism assay, and MTX pharmacokinetic parameters were assessed by HPLC. The MTHFR C677T polymeric allele frequencies were 55, 35, and 10% for CC, CT, and TT genotypes, respectively, among the studied patients with ALL. MTX therapy was significantly associated with toxicity signs in TT genotype: elevated transaminases (P < 0.0001), elevated serum alpha 1-microglobulin protein (P < 0.0001), anemia (P < 0.0001), neutropenia (P < 0.0001), thrombocytopenia (P < 0.0001), and elevated CSF-β-glucuronidase activity (P < 0.0001). Patients with TT genotype showed significant increase in MTX t ½ and AUC (P < 0.0001), while MTX elimination rate and total body clearance were significantly decreased (P < 0.0001 and P < 0.05, respectively) compared with CC genotype. The TT genotype was significantly associated with relapse in 2 years in 50% compared with 28.57% in CT and 13.64% in CC alleles. The overall 2-year survival was significantly lower in TT genotype (50%) compared with CC genotype (90.91%; P = 0.01). MTHFR TT genotype is significantly associated with increased toxicity during methotrexate therapy as well as increased relapse rate in pediatric patients with ALL. In future, MTX dose adjustment in ALL treatment protocols should be considered based on patient’s genotype.


Methotrexate MTHFR Polymorphism ALL 



All authors gave substantial contributions to the conception and design of the study, analysis and interpretation of the data, drafting and revising the article. We thank the Tanta Cancer Center for help in obtaining samples and the patients and their families for participating.


  1. 1.
    Kishi S, Cheng C, French D, et al. Ancestry and pharmacogenetics of antileukemic drug toxicity. Blood. 2007;109:4151–7.PubMedCrossRefGoogle Scholar
  2. 2.
    Costea I, Moghrabi A, Laverdiere C, et al. Folate cycle gene variants and chemaotherapy toxicity in pediatric patients with acute lymphoblastic leukemia. Haematologica. 2006;91:1113–6.PubMedGoogle Scholar
  3. 3.
    De Jonge R, Hooijberg JH, van Zelst BD, et al. Effect of polymorphisms in folate-related genes on in vitro methotrexate sensitivity in pediatric acute lymphoblastic leukemia. Blood. 2005;106(2):717–20.PubMedCrossRefGoogle Scholar
  4. 4.
    Ulrich CM, Yasui Y, Storb R, et al. Pharmacogenetics of methotrexate: toxicity among marrow transplantation patients varies with the methylenetetrahydrofolate reductase C677T polymorphism. Blood. 2001;98(1):231–4.PubMedCrossRefGoogle Scholar
  5. 5.
    Kishi S, Griener J, Cheng C, et al. Homocysteine, pharmacogenetics and neurotoxicity in children with leukemia. J Clin Oncol. 2003;21(16):3084–91.PubMedCrossRefGoogle Scholar
  6. 6.
    van Ede AE, Laan RF, Blom HJ, et al. The C677T mutation in the methylenetetrahydrofolate reductase gene: a genetic risk factor for methotrexate-related elevation of liver enzymes in rheumatoid arthritis patients. Arthritis Rheum. 2001;44(11):2525–30.PubMedCrossRefGoogle Scholar
  7. 7.
    World Health Organization. WHO handbook for reporting results of cancer treatment. WHO Offset Puplication no. 48. Geneva: World Health Organization; 1979.Google Scholar
  8. 8.
    Liu X, Liu J, Huang Y, et al. Determination of methotrexate in human serum by high-performance liquid chromatography combined with pseudotemplate molecularly imprinted polymer. J Chromatogr A. 2009;1216(44):7533–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Beratis NG, Mavromatis T, Hatiris I, et al. Increased activity of lysosomal acid hydrolases in the cell-free cerebrospinal fluid of bacterial meningitis. Pediatr Res. 1997;41:235–41.PubMedCrossRefGoogle Scholar
  10. 10.
    Rosenblatt DS. Methylenetetrahydrofolate reductase. Clin Invest Med. 2001;24:56–9.PubMedGoogle Scholar
  11. 11.
    Martin DN, Boersma BJ, Howe TM. Association of MTHFR gene polymorphisms with breast cancer survival. BMC Cancer. 2006;6:257–66.PubMedCrossRefGoogle Scholar
  12. 12.
    Chiusolo P, Reddiconto G, Casorelli I, et al. Preponderance of methylenetetrahydrofolate reductase C677T homozygosity among leukemia patients intolerant to methotrexate. Ann Oncol. 2002;13:1915–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Widemann BC, Balis FM, Kempf-Bielack B, et al. High-dose methotrexate-induced nephrotoxicity in patients with osteosarcoma. Incidence, treatment, and outcome. Cancer. 2006;100(10):2222–32.CrossRefGoogle Scholar
  14. 14.
    Grönroos MH, Jahnukainen T, Möttönen M, et al. Long-term follow-up of renal function after high-dose methotrexate treatment in children. Pediatr Blood Cancer. 2008;51(4):535–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Ongaro A, De Mattei M, Della Porta MG, et al. Gene polymorphisms in folate metabolizing enzymes in adult acute lymphoblastic leukemia: effects on methotrexate-related toxicity and survival. Haematologica. 2009;94(10):1319–98.CrossRefGoogle Scholar
  16. 16.
    Chiusolo P, Reddiconto G, Farina G, et al. MTHFR polymorphisms’ influence on outcome and toxicity in acute lymphoblastic leukemia patients. Leukemia Res. 2007;31:1669–74.CrossRefGoogle Scholar
  17. 17.
    Vlacha V, Eliopoulou M, Haidas S, et al. Correlation of cerebrospinal fluid Β-glucuronidase activity with plasma methotrexate concentrations in leukemic children receiving high-dose methotrexate. Pediatr Blood Cancer. 2004;42:350–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Mahadeo KM, Dhall G, Panigrahy A, et al. Subacute methotrexate neurotoxicity and cerebral venous sinus thrombosis in a 12-year-old with acute lymphoblastic leukemia and methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism: homocysteine-mediated methotrexate neurotoxicity via direct endothelial injury. Pediatr Hematol Oncol. 2010;27(1):46–52.PubMedCrossRefGoogle Scholar
  19. 19.
    Imanishi H, Okamura N, Yagi M, et al. Genetic polymorphisms associated with adverse events and elimination of methotrexate in childhood acute lymphoblastic leukemia and malignant lymphoma. J Hum Genet. 2007;52(2):166–71.PubMedCrossRefGoogle Scholar
  20. 20.
    Aplenc R, Thompson J, Han P, et al. Methylenetetrahydrofolate reductase polymorphism and therapy response in pediatric acute lymphoblastic leukemia. Cancer Res. 2005;65(5):2482–7.PubMedCrossRefGoogle Scholar
  21. 21.
    Shimasaki N, Mori T, Samejima H, et al. Effects of methylenetetrahydrofolate reductase and reduced folate carrier 1 polymorphisms on high-dose methotrexate-induced toxicities in children with acute lymphoblastic leukemia or lymphoma. J Pediatric Hematol Oncol. 2006;28(2):64–8.CrossRefGoogle Scholar
  22. 22.
    Seidemann K, Book M, Zimmermann M, et al. MTHFR 677 (C  T) polymorphism is not relevant for prognosis or therapy-associated toxicity in pediatric NHL: results from 484 patients of multicenter trial NHL-BFM 95. Ann Hematol. 2006;85:291–300.PubMedCrossRefGoogle Scholar
  23. 23.
    Krajinovic M, Lemieux-Blanchard E, Chiasson S, et al. Role of polymorphisms in MTHFR and MTHFD1 genes in the outcome of childhood acute lymphoblastic leukemia. Pharmacogenomics J. 2004;4(1):66–72.PubMedCrossRefGoogle Scholar
  24. 24.
    Chiusolo P, Reddiconto G, Farina G, et al. MTHFR polymorphisms’ influence on outcome and toxicity in acute lymphoblastic leukemia patients. Leuk Res. 2007;31:1669–74.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Noha M. EL-Khodary
    • 1
    Email author
  • Sahar M. EL-Haggar
    • 1
  • Manal A. Eid
    • 2
  • Emad N. Ebeid
    • 3
  1. 1.Department of Clinical Pharmacy, Faculty of PharmacyTanta UniversityTantaEgypt
  2. 2.Department of Clinical Pathology, Faculty of MedicineTanta UniversityTantaEgypt
  3. 3.Department of Pediatric Oncology and Hematology, National Cancer InstituteCairo UniversityCairoEgypt

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