Elsevier

The Lancet Oncology

Volume 10, Issue 7, July 2009, Pages 663-671
The Lancet Oncology

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Predicting outcomes for children with neuroblastoma using a multigene-expression signature: a retrospective SIOPEN/COG/GPOH study

https://doi.org/10.1016/S1470-2045(09)70154-8Get rights and content

Summary

Background

More accurate prognostic assessment of patients with neuroblastoma is required to better inform the choice of risk-related therapy. The aim of this study is to develop and validate a gene-expression signature to improve outcome prediction.

Methods

59 genes were selected using an innovative data-mining strategy, and were profiled in the largest neuroblastoma patient series (n=579) to date using real-time quantitative PCR starting from only 20 ng of RNA. A multigene-expression signature was built using 30 training samples, tested on 313 test samples, and subsequently validated in a blind study on an independent set of 236 tumours.

Findings

The signature has a performance, sensitivity, and specificity of 85·4% (95% CI 77·7–93·2), 84·4% (66·5–94·1), and 86·5% (81·1–90·6), respectively, to predict patient outcome. Multivariate analysis indicates that the signature is a significant independent predictor of overall survival and progression-free survival after controlling for currently used risk factors: patients with high molecular risk have a higher risk of death from disease and higher risk of relapse or progression than patients with low molecular risk (odds ratio 19·32 [95% CI 6·50–57·43] and 3·96 [1·97–7·97] for overall survival and progression-free survival, respectively, both p<0·0001). Patients at an increased risk of an adverse outcome can also be identified in the current treatment groups, showing the potential of this signature for improved clinical management. These results were confirmed in the validation study, in which the signature was also independently statistically significant in a model adjusted for MYCN status, age, International Neuroblastoma Staging System stage, ploidy, International Neuroblastoma Pathology Classification grade of differentiation, and mitosis karyorrhexis index (odds ratios between 4·81 and 10·53 depending on the model for overall survival and 3·68 [95% CI 2·01–6·71] for progression-free survival).

Interpretation

The 59-gene expression signature is an accurate predictor of outcome in patients with neuroblastoma. The signature is an independent risk predictor, identifying patients with an increased risk of poor outcome in the current clinical-risk groups. The method and signature is suitable for routine laboratory testing, and should be evaluated in prospective studies.

Funding

The Belgian Foundation Against Cancer, the Children Cancer Fund Ghent, the Belgian Society of Paediatric Haematology and Oncology, the Belgian Kid's Fund and the Fondation Nuovo-Soldati (JV), the Fund for Scientific Research Flanders (KDP, JH), the Fund for Scientific Research Flanders, the Institute for the Promotion of Innovation by Science and Technology in Flanders, Strategisch basisonderzoek, the Fondation Fournier Majoie pour l'Innovation, the Instituto Carlos III, the Italian Neuroblastoma Foundation, the European Community under the FP6, and the Belgian programme of Interuniversity Poles of Attraction.

Introduction

Few tumours have engendered as much fascination and frustration for clinicians and scientists as neuroblastoma. This tumour is one of the most frequent solid malignancies in children and, by contrast with many other paediatric malignancies, is fatal in almost half of the patients diagnosed, despite advances in multimodal anticancer therapies. Current therapeutic stratification of patients with neuroblastoma is based on risk estimation according to combinations of age, tumour stage, MYCN status, DNA ploidy status, and histopathology.1 Clinical experience with this system suggests that the stratification of patients for treatment is useful, but patients with the same clinicopathological parameters, receiving the same treatment, can have markedly different clinical courses. As a consequence, patients with an intrinsic poor prognosis but who are classified as low risk or intermediate risk on the basis of the current stratification system, will receive inappropriately mild treatment, and this could lead to a loss of valuable time before starting the required, more intensive treatment. Alternatively, patients with an intrinsic good prognosis but recognised as high risk with the current system of stratification will undergo a toxic therapy, putting them at an unnecessary risk of long-term side-effects. Additionally, survival rates remain disappointingly low in the current high risk treatment group. Therefore, the challenge remains to identify additional tumour-specific prognostic markers for improved risk estimation at the time of diagnosis. Only then can patients receive the most appropriate therapy, be monitored more intensively if appropriate, and become eligible for new experimental therapies.

To emulate the successful identification of gene-expression signatures for other tumour types,2, 3, 4, 5 we sought to develop, validate, and implement a robust multigene-expression signature to accurately assess prognosis in children with neuroblastoma. By contrast with gene-expression studies in neuroblastoma published previously, we aimed for a high patient–gene ratio, testing a carefully selected small number of genes on a large panel of tumour samples. We further validated the signature in an independent set of tumours.

Section snippets

Patients

The initial cohort consisted of 343 patients with neuroblastoma taken from the International Society of Pediatric Oncology, European Neuroblastoma Group (SIOPEN) and from the Gesellschaft fuer Paediatrische Onkologie und Haematologie (GPOH). Patients were only included if primary untreated neuroblastoma tumour RNA (at least 60% tumour cells and confirmed histological diagnosis of neuroblastoma) was available and of sufficient quality. Almost all patients (324; 95%) were treated according to the

Results

A set of 59 genes with prognostic power in at least two independent studies was selected based on a re-analysis of seven published microarray gene-expression studies6, 7, 8, 9, 10, 11, 12 combined with an extensive screening of previously published reports for single candidate prognostic genes (table 1, webappendix). A prognostic multigene signature was subsequently built based on the expression of the 59 genes using 15 deceased high-risk and 15 low-risk patients with a long progression-free

Discussion

Identification of more specific and sensitive markers for outcome prediction and response to therapy is required to further improve the choice of risk-related therapy for children with neuroblastoma. Using a carefully selected set of 59 prognostic genes based on an innovative data-mining strategy, we did a gene-expression study on the largest neuroblastoma patient series to date, covering 579 patients in total. Our robust prognostic multigene expression signature was tested on a large set of

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