Polymorphisms in Genes of Folate Metabolism and Response to High-Dose Methotrexate in Patients with Primary Central Nervous System Lymphoma.

The antifolate methotrexate (MTX) was shown to be the single most-effective agent in first-line treatment of patients with primary central nervous system lymphoma (PCNSL) when given intravenously in high doses. MTX inhibits 5,10-methylentetrahydrofolate reductase (MTHFR) as well as thymidylate synthase (TS) in target cells what eventually results in decreased DNA synthesis. Intracellular uptake of both folate and MTX is mediated by the reduced folate carrier (RFC). Genetic polymorphisms for all three proteins were described: a C to T base transition at nucleotide 667 (C677T) and an A to C transition at 1298 (A1298C) of MTHFR; a 28-base pair (bp) tandemly repeated sequence polymorphic in the numbers of the repeat (2R/2R; 3R/3R; and 2R/3R) in the 5′-UTR of TS; a 6bp insertion-(+6bp)/deletion(−6bp)-polymorphism in the 3′-UTR of TS; and a polymorphism at nucleotide 80 (G80A) of RFC. We hypothesized that these polymorphisms may be directly linked to response, survival and toxicity in patients with PCNSL who are treated with single high-dose MTX. We prospectively collected blood from 152 subjects who were enrolled into a German multicenter PCNSL trial. They were scheduled to receive HD-MTX 4 g/m² every 2 weeks. Genomic DNA was extracted from mononuclear cells using QIAGEN DNA Blood Mini Kit®. Genotyping of the two MTHFR (C677T; A1298C) and the RFC (G80A) single nucleotide polymorphisms (SNPs) was performed by melting point analysis with Master Hybridization Probes® using the Light Cycler® technology. Genotyping of the TS 28bp tandem/triplet repeats in the 5′-UTR was performed by conventional PCR followed by high resolution agarose gel electrophoresis. The TS +6bp/−6bp polymorphism in the 3′-UTR was analyzed with PCR, followed by restriction enzyme digest with draI and agarose gel electrophoresis. The fragment sizes were 70 bp and 88 bp for the 6 bp insertion allele and 152 bp for the 6 bp deletion allele. Allele frequencies for heterozygosity and for homozygous mutations of the two MTHFR and the RFC SNPs as well as of the two TS polymorphisms were as expected for a Caucasian population. For the currently 120 evaluable patients logistic regression analysis, Armitage Trend test and Kaplan-Meier survival curves were performed to analyze the role of the polymorphisms as potential predictors for MTX response. Up to now, we only found a trend for an association between response to treatment and survival for the 2 MTHFR mutations. We will analyze haematological and non-haematological toxicities which will be presented at the meeting with updated results for survival and response in the patients who will have completed treatment until then.