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MTHFR1298 genotype, CSF p-Tau and intellectual performance in adult childhood leukemia survivors

Iris J. Elens1, 2, Jurgen Lemiere2, 3, Sabine Deprez4, Thibo Billiet5, Charlotte Sleurs3, 4, Anne Uyttebroeck3, Veerle Labarque3, Stefaan Van Gool6, Patricia Bijttebier7, Marina Danckaerts2 and Rudi D'Hooge1*
  • 1 KU Leuven, Psychology and Educational sciences, Belgium
  • 2 University Psychiatric Centre Leuven, Child and adolescent psychiatry, Belgium
  • 3 University Hospital Leuven, Pediatrics, Belgium
  • 4 University Hospital Leuven, Radiology, Belgium
  • 5 icoMetrix, Belgium
  • 6 Immunologisch Onkologisches Zentrum, Germany
  • 7 KU Leuven, Psychology and educational sciences, Belgium

Introduction Developmentally adverse cranial irradiation for the treatment of acute lymphoblastic leukemia (ALL) and non-Hodgkin lymphoma (NHL)was successfully replaced by intrathecal and high-dose intravenous administration of the anti-folate agent methotrexate. However, neurocognitive sequelae continue to be a concern in pharmacologically treated survivors as well (1). Little is however known about moderators of methotrexate -induced toxicity. Increased levels of Tau and phosphorylated Tau (pTau) in cerebrospinal fluid (CSF) during treatment were observed following intrathecal administration of methotrexate (2, 3). In parallel, methyltetrahydrofolate reductase (MTHFR) deficiency was reported to enhance methotrexate toxicity in mice (4) as well as to increase the risk of executive dysfunction in child survivors of leukemia (5, 6). A common A1298-to-C substitution in the MTHFR gene reduces the activity of this enzyme (7) and thus the conversion of folate to its biologically active form, possibly aggravating methotrexate neurotoxicity. Besides challenging folate levels, reduced MTHFR-activity also constitutes a major cause of hyperhomocysteinemia which was linked with increased brain levels of pTau (8), suggesting a biochemical link between altered MTHFR function, pTau and cognitive dysfunction. We investigated whether or not MTHFR1298 genotype of childhood leukemia patients influenced their (1) CSF levels of Tau and pTau during treatment, and (2) adult performance IQ (PIQ), which has been shown to be vulnerable to methotrexate exposure (9). Materials and methods Childhood leukemia patients (ALL: n= 27, NHL: n= 4; mean age at diagnosis 6.4) were treated according to the EORTC 58881 (1994-1998) or 58951 (1998-2004) protocol, consisting of an induction, interval, reinduction and maintenance phase (table 1). Cerebrospinal fluid levels of Tau and pTau were determined at fixed time-points during treatment (5, 4, 1 and 5 for induction, interval, reinduction and maintenance phase, respectively). Fifteen (11.6 – 19.5) years after diagnosis, MTHFR1298 genotype was analyzed in 33 survivors and intelligence was determined using the Wechsler Adult Intelligence Scale. We opted for one-sided testing given the small sample size and since it has been well established that reduced folate heightens CSF Tau and pTau levels (2, 10), and that cognitive performance is reduced in some survivors of childhood leukemia (6, 11). Results We observed a significantly different response to the first intrathecal methotrexate administration between genotypes (p= 0.019 and 0.031 for CSF Tau and pTau, respectively). Intrathecal methotrexate had a higher impact on fluctuations in CSF biomarkers in MTHFR1298CC genotypes compared to MTHFR1298AA genotypes (p= 0.007 and 0.028 for CSF tau and pTau, respectively), while heterozygotes depicted an intermediate response. During the entire induction phase, MTHFR1298CC genotypes established highest concentrations of CSF Tau and pTau (figures 1-2) while MTHFR1298CC genotypes were situated in between the two other ones (p= 0.004 and 0.028 for CSF Tau and pTau, respectively with post-doc LSD test comparing 1/ MTHFR1298AA versus MTHFR1298CC genotypes: p= 0.002 and 0.009 for CSF Tau and Tau, respectively, 2/ MTHFR1298AC versus MTHFR1298CC genotypes: p= 0.057 and 0.037 for CSF Tau and Tau, respectively and 3/ MTHFR1298AC versus MTHFR1298AA genotypes: p= 0.012 and 0.117). Systemic folic acid administration abolished the differences in CSF Tau levels between genotypes (figure 3); one-sided, one-way ANOVA yielded p = 0.012 and 0.086 for CSF Tau before versus after folic acid administration, respectively, and one-sided repeated measures ANOVA comparing CSF Tau before versus after folic acid administration demonstrated no significant influence of time (p= 0.131) but did show a significant effect of genotype (p= 0.032) and genotype*methotrexate (p= 0.044). During the maintenance phase CSF pTau but not Tau did no longer distinguish between the three genotypes while CSF pTau did (p = 0.035 and 0.109, respectively) with significantly higher CSF pTau concentrations in MTHFR1298CC compared with MTHFR1298AA (p= 0.012) and MTHFR1298AC genotypes (p= 0.034) but no significant differences between MTHFR1298AC and AA genotypes (p= 0.208) (figures 4-5). We found a significant correlation between genotype and both pooled (i.e. entire treatment) CSF Tau and pTau concentrations (p = 0.002 and 0.020 ; Spearman’s rho = -0.497 and -0.406, respectively). Finally, CSF pTau but not Tau was correlated with adult PIQ (p = 0.044 and 0.085 ; Spearman’s rho= -.441 and -0.331) and MTHFR1298AA individuals performed significantly better on intellectual testing compared with MTHFR1298CC and AC individuals (p = 0.028, 0.038 and 0.010 for main effect, post-hoc LSD test comparing MTHFR1298CC versus AA and AA versus AC, respectively). Discussion Our data confirm that genetic constitution plays a role in chemotherapy-induced brain toxicity (5, 6, 12). Indeed, MTHFR1298CC genotypes – establishing the most compromised MTHFR metabolism – presented with the highest levels of CSF Tau and pTau, followed by heterozygotes. Moreover, levels of both Tau and pTau were correlated with the respective genotypes. Interestingly, the discrepancies in biomarker levels between genotypes disappeared after folic acid administration despite concomitant intravenous and intrathecal methotrexate administration. Since folate receptor alfa has a higher affinity for folic acid than for methotrexate (13), systemic folic acid might saturate these receptors, diminish intracellular uptake of methotrexate and prevent acute toxicity. Our observations possibly imply that especially MTHFR1298CC genotypes benefit from this intervention. Cerebrospinal fluid levels of pTau but no longer Tau discriminated MTHFR1298AA from MTHFR1298CC genotypes during maintenance phase, confirming the observation that CSF homocysteine – and accordingly Tau phosphorylation – raises later during treatment (14). Besides, CSF pTau was linked with adult PIQ. We postulate a synergism between chemotherapy-induced neurotoxicity and lower MTHFR activity, ultimately affecting pTau levels. Excessive Tau phosphorylation triggers the formation of neurofibrillary tangles, a hallmark of neurodegenerative disorders (15). Furthermore, homocysteine is an excitotoxic and vasculotoxicity (16) agent. Polymorphisms in the MTHFR gene could aggravate the toxicity of the anti-folate agent methotrexate, which explicating the differences in adult PIQ in childhood leukemia survivors. Conclusions We demonstrated that 1/ MTHFR1298A>C homozygosity predicts fluctuations in CSF Tau and pTau in response to intrathecal methotrexate, 2/ differences in CSF biomarker level disappear after folic acid supplementation, 3/ CSF pTau but not Tau is correlated with intelligence in adult childhood leukemia survivors and 4/ MTHFR1298AA homozygotes presented with higher adult PIQ.

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Acknowledgements

We are grateful to the participants who contributed to this study, and researchers Elise Bossuyt, Charlotte van Soest, Trui Vercruysse, Linde Van den Wyngaert, Femke Pauwels and Lien Solie, who made this work possible. The authors are also grateful to Prof. Dr. Koen Luyckx for statistical advice, Dr. Hugo Vanderstichele and Fujirebio Europe NV for practical and logistic help with collecting and analyzing the CSF samples, Prof. Dr. Jan Cools and Nicole Menten

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Keywords: Methotrexate, MTHFR1298, Leukemia, Children, tau Proteins, chemotherapy-induced adverse effects

Conference: 12th National Congress of the Belgian Society for Neuroscience, Gent, Belgium, 22 May - 22 May, 2017.

Presentation Type: Poster Presentation

Topic: Disorders of the Nervous System

Citation: Elens IJ, Lemiere J, Deprez S, Billiet T, Sleurs C, Uyttebroeck A, Labarque V, Van Gool S, Bijttebier P, Danckaerts M and D'Hooge R (2019). MTHFR1298 genotype, CSF p-Tau and intellectual performance in adult childhood leukemia survivors. Front. Neurosci. Conference Abstract: 12th National Congress of the Belgian Society for Neuroscience. doi: 10.3389/conf.fnins.2017.94.00034

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Received: 28 Apr 2017; Published Online: 25 Jan 2019.

* Correspondence: PhD. Rudi D'Hooge, KU Leuven, Psychology and Educational sciences, Leuven, 3000, Belgium, rudi.dhooge@kuleuven.be