European Journal of Medical Genetics xxx (2016) 1e7

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European Journal of Medical Genetics

journal homepage: http://www.elsevier.com/locate/ejmg

Clinical course and therapeutic implications for lymphoid

malignancies in Nijmegen breakage syndrome
Agata Pastorczak a, Tomasz Szczepanski b, Wojciech Mlynarski a, *, on behalf of the
International Berlin-Frankfurt-Munster (I-BFM) ALL host genetic variation working group
a
Department of Pediatrics, Hematology, Oncology and Diabetology, Medical University of Lodz, Poland
b
Department of Pediatric Hematology and Oncology, Medical University of Silesia, Zabrze, Poland

a r t i c l e i n f o a b s t r a c t

Article history: Nijmegen breakage syndrome (NBS, MIM #251260) is an autosomal recessive chromosomal instability
Received 17 August 2015 disorder. Majority of patients affected are of Slavic origin and share the same founder mutation of
Received in revised form 657del5 within the NBN gene encoding protein involved in DNA double-strand breaks repair. Clinically,
14 January 2016
this is characterized by a microcephaly, immunodeficiency and a high incidence of pediatric malig-
Accepted 24 January 2016
Available online xxx
nancies, mostly lymphomas and leukemias. Anticancer treatment among patients with NBS is chal-
lenging because of a high risk of life threatening therapy-related toxicity including severe infections,
bone marrow failure, cardio- and nephrotoxicity and occurrence of secondary cancer. Based on systemic
Keywords:
Nijmegen-breakage syndrome
review of available literature and the Polish acute lymphoblastic leukemia database we concluded that
Leukemia among patients with NBS, these who suffered from clinically proven severe immunodeficiency are at risk
Lymphoma of the complications associated with oncological treatment. Thus, in this group it reasonable to reduce
Treatment chemotherapy up to 50% especially concerning anthracyclines methotrexate, alkylating agents and
epipodophyllotoxines, bleomycin and radiotherapy should be omitted. Moreover, infection prophylaxis
using intravenous immunoglobulin supplementation together with antifungal and antibacterial agent is
recommended. To replace radiotherapy or some toxic anticancer agents targeted therapy using mono-
clonal antibodies and kinase inhibitors or bone marrow transplantation with reduced-intensity condi-
tioning should be considered in some cases, however, this statement needs further studies.
© 2016 Elsevier Masson SAS. All rights reserved.

1. Introduction nibrin (NBN gene), containing two modules found in cell cycle
checkpoint proteins, a forkhead-associated domain adjacent to a
Nijmegen-breakage syndrome (NBS, MIM #251260) is an breast cancer carboxy-terminal domain. A truncating 5 bp deletion
autosomal recessive chromosomal instability syndrome charac- (c.657_661del5, pK219fsX19) was identified in the majority of NBS
terized by a very distinct phenotype (microcephaly, growth patients. In the original report, more than 200 NBS cases were
retardation, immunodeficiency) associated with increased pre- described, the majority among Slavic populations and with a
disposition to develop malignancies, particularly of lymphoid founder mutation in the NBN gene (c.657_661del5). The preva-
origin. The first NBS patients were described in Nijmegen in 1981 lence of this mutation in the Slavic countries (Poland, Ukraine,
by Weemaes et al. (Weemaes et al., 1981) and the genetic back- Czech Republic) was subsequently analyzed, revealing unexpect-
ground of this disease was discovered by Varon et al. (1998) and edly high (1/177) carrier frequency of the founder mutation (Varon
Gorski et al. (2003). They cloned a gene encoding a novel protein, et al., 2000).
The principal clinical manifestations of the syndrome are
microcephaly, present at birth and progressive with age, dysmor-
phic facial features, mild growth retardation, mild-to-moderate
* Corresponding author. Department of Pediatrics, Oncology, Hematology and intellectual disability, and in females, primary ovarian insuffi-
Diabetology, Medical University of Lodz, 36/50 Sporna St., 91-738, Lodz, Poland. ciency (hypergonadotropic hypogonadism) (Chrzanowska et al.,
E-mail address: [email protected] (W. Mlynarski).

http://dx.doi.org/10.1016/j.ejmg.2016.01.007
1769-7212/© 2016 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Pastorczak, A., et al., Clinical course and therapeutic implications for lymphoid malignancies in Nijmegen
breakage syndrome, European Journal of Medical Genetics (2016), http://dx.doi.org/10.1016/j.ejmg.2016.01.007
2 A. Pastorczak et al. / European Journal of Medical Genetics xxx (2016) 1e7

2012). Sometimes clinical manifestations are rather discrete and mutation among patients of European Caucasian origin
the diagnosis of NBS is made only on the occasion of diagnostic (Chrzanowska et al., 2012).
work-up of associated malignancy. With time, most patients
develop profound immunodeficiency both of humoral and cellular 4. Risk of lymphoid malignancy in NBS
type. This is frequently associated with recurrent sinopulmonary
infections. The spectrum of humoral immunodeficiency is variable Since by the age of 20 years, over 40% of NBS patients develop
ranging from agammaglobulinemia to a moderate reduction in the cancer, relevant markers predicting malignant transformation have
immune response (Gregorek et al., 2002). Immunological studies been widely investigated. Kruger at al observed significant associ-
reveal mild-to-moderate lymphopenia in nearly half of the patients ation between lymphoma incidence and the low expression level of
with an evident decrease of T-cells, particularly CD4þ and the truncated p70-nibrin in NBS patients who were homozygous
CD45RA þ naïve subsets (Michalkiewicz et al., 2003). for a founder hypomorphic mutation (c.657_661del5) (Kruger et al.,
Another particular feature of NBS is the occurrence of spon- 2007). Based on the study performed on mouse models and cell
taneous chromosome instability, detected via cytogenetic anal- lines the protective value of the increased p70-nibrin expression
ysis of standard PHA-stimulated peripheral blood T cells. probably results from the ability of p70 protein to uphold some
Inversions and translocations, involving two different loci in function of p95-nibrin such as binding to MRE11 and RAD50 and
chromosomes 7 and 14 are particularly characteristic for NBS stimulation of ATM (Tauchi et al., 2001; Difilippantonio et al., 2005).
(Stumm et al., 2001) and are found in the vast majority of cases Moreover, Gregorek at al. prospectively searched for non-
followed by breakpoints located in chromosome bands 7p13, invasive laboratory biomarkers preceding malignancy in NBS pa-
7q35, 14q11, and 14q32, which are the sites of the T-cell receptor tients by PCR analysis of the presence of viral genome, monoclonal
genes (TCRG, TCRB, TCRA/D), and the immunoglobulin heavy gammapathy and clonal rearrangements of Ig/TCR genes in pe-
chain gene (IGH), respectively. Since the MRN complex plays a ripheral lymphocytes (Gregorek et al., 2010). Both EBV DNA, clonal
role in normal Ig/TCR gene rearrangements, its dysfunction in Ig (IgH, IgK, or IgL) and TCR (B, G and/or D) gene rearrangements
NBS patients can be further confirmed by molecular detection of were found in 68% and 73% of NBS patients respectively, and pre-
Ig/TCR cross-rearrangements and trans-rearrangements. ceded the diagnosis of lymphoma, on average, by 3 years. However,
It was also demonstrated that biallelic 657del5 NBN mutation there is a discrepancy between results of this study and study
leads to a quantitative defect in V(D)J recombination through loss of performed by Dura-Gladkowska in a large cohort of NBS patients,
juxtaposition of recombination activating gene-induced DNA ends. which proved that EBV is not essential driver in NBS lymphoma
This quantitative defect affects the B-cell receptor repertoire, thus formation (Gładkowska-Dura et al., 2008).
contributing to the observed immunodeficiency in NBS patients Nevertheless, none of predictive marker has been applied into
(van der Burg et al., 2010). clinical practice, probably because of the lack of well-established
diagnostic and therapeutic procedure towards NBS patients
2. Molecular background of NBS exhibiting precancerous status.

The majority of NBS patients identified to date (about 70%) 5. Biological features of primary and secondary lymphoid
had homozygous five base pair deletion in NBN gene malignancy in NBS
(c.657_661del5, pK219fsX19) with founder effect observed in
Caucasian European populations, especially of Slavic origin The adaptive component of immune system depends on ge-
(Varon et al., 2000). Similar founder phenomenon was described netic diversity resulting from genomic rearrangements and point
among Pakistani patients with NBS features who were homo- mutations which occur physiologically throughout V(D)J recom-
zygous for c.C1089A mutation in NBN (New et al., 2005). Other bination, class switch recombination (CSR) and somatic hyper-
mutations are uncommon (Chrzanowska et al., 2012). NBN gene mutation (SHM) during lymphocyte development (Moses, 2001).
product, nibrin protein forms a triheteromeric complex with Deficiency of DNA repair proteins affecting these processes
MRE11 and RAD50 (the MRN complex). The complex is a primary reduce fidelity of replication and may lead to malignant trans-
sensor of DNA double-strand breaks (DSB) and is required for the formation. Since NBN is involved in CSR and alternative end
effective monomerization and autophosphorylation of ATM after joining (alt-EJ) DNA repair pathway, its defect contributes to the
DNA DSB damage (Varon et al., 1998; Lee and Paull, 2005). This is specific targeting of B cells by genomic instability (de Miranda
an initial process in two major pathways of DNA DSB repair, e.g. et al., 2011). Moreover, a quantitative disturbance of V(D)J
homologous recombination and non-homologous end joining. recombination, characterized by impaired resolution of RAG-
Thus, all patients with biallelic hypomorphic mutation in NBN induced IgH breaks, may promote formation of complex trans-
gene have defective DSB repair machinery, which leads to clinical locations involving IgH locus in NBS lymphomas (van der Burg
features of the syndrome and are prone to develop malignancies. et al., 2010; Difilippantonio et al., 2005).
Therefore, immunological lineage of lymphomas in NBS
3. Diagnosis of NBS significantly differ from Non-Hodgkin Lymphomas (NHL) entities
observed in general pediatric population as well as in primary
The diagnosis of Nijmegen breakage syndrome is based on immunodeficiencies. There is a strong predominance of diffuse
clinical features including microcephaly with no or very mild large B-cell lymphoma (DLBCL) and T cell lymphoblastic lym-
psychomotor and neurological lesions, recurrent infections and phoma (T-LBL/ALL), all showing clonal Ig/TCR rearrangements
occurrence of lymphoid malignancies. Patients presenting these (Gładkowska-Dura et al., 2008; Seidemann et al., 1999a;
clinical characteristics should be subjected for genetic evaluation, Dembowska-Baginska et al., 2009). The distribution of lym-
which includes family history, cytogenetic abnormalities involving phoma between T and B cell origins in the Polish Registry of NBS
mostly two loci on chromosomes 7 (TCR genes cluster) and 14 is almost equal and achieve 55% and 45% respectively
(immunoglobulin heavy chain gene cluster) and search for biallelic (Chrzanowska et al., 2012). Regarding other lymphoma subtypes,
mutations in NBN gene with the specific focus on c.657_661del5 a few cases of ALCL, Hodgkin's lymphoma, AILT-like B cell and

Please cite this article in press as: Pastorczak, A., et al., Clinical course and therapeutic implications for lymphoid malignancies in Nijmegen
breakage syndrome, European Journal of Medical Genetics (2016), http://dx.doi.org/10.1016/j.ejmg.2016.01.007
 A. Pastorczak et al. / European Journal of Medical Genetics xxx (2016) 1e7 3

Burkitt e like lymphomas in NBS patients have been also docu- therapy of secondary ALCL in NBS patient who showed good
mented (Gładkowska-Dura et al., 2008; Engel et al.,). tolerance of the drug and long-term remission (Stockklausner
The common feature of lymphomas in NBS patients is et al., 2008). On the other hand, reduced doses of anthracy-
advanced stage of disease and multiorgan involvement resulting clines induced severe cardiotoxicity in NBS child treated due to
from delayed diagnosis of malignancy (Dembowska-Baginska AML according to AML BFM87 protocol (Barth et al., 2003). Acute
et al., 2009; Bienemann et al., 2011). Non-specific symptoms cardiomiopathy appeared after a total dose of anthracyclines of
such as fever, nodal enlargement and gastrointestinal signs are 190 mg/m2, which is far below the level considered toxic
frequently thought to be infection-related in NBS children. (400e450 mg/m2). However, anthracyclines are DNA damaging
Another characteristic feature of NBS lymphoma is high inci- agents acting through additional mechanisms: intercalation into
dence of disease recurrence (Seidemann et al., 1999a). Less DNA, DNA unwinding and alkylation, DNA cross-linking, inter-
intensive treatment is considered as a main contribution to high ference with DNA unwinding or DNA separation, helicase activity,
relapse rate but the specific role of tumor biology linked with cellular senescence as well as inhibition of topoisomerase II and
genomic instability is probably underestimated. This assumption generation of free radicals (Gewirtz, 1999). Impaired repair of
is supported by the comparable risk of T-NHL recurrence be- oxydative DNA damage produced by free radicals may contribute
tween NBS patients who received over 80% of drug doses and to the toxic effect of anthracyclines in NBS as well.
those with dosage reduction (Dembowska-Baginska et al., 2009). Although reduction of chemotherapy in NBS patients was
Acute lymphoblastic leukemia is far less frequent type of expected to limit severe complications of the treatment, influ-
lymphoproliferation in NBS and as in Ataxia Telangiectasia, strong ence positively on compliance with time schedules of chemo-
prevalence of T-cell immunophenotype is observed (Bienemann therapy and prevent second malignancies, the largest studies
et al., 2011; Michallet et al., 2003; Pasic et al., 2004). Interest- performed among NBS patients did not consistently confirm this
ingly, central nervous system involvement at ALL diagnosis was notion (Dembowska-Baginska et al., 2009; Bienemann et al.,
frequently found in children with NBS analyzed by the Polish 2011). Whereas Bienemann K et al. did observe that dosage-
Pediatric Leukemia and Lymphoma Study Group but this could be reduction of chemotherapeutic drugs diminish toxic side effects
not be entirely explained by T-cell immunophenotype only of the treatment in NBS patients without negative impact on
(Pastorczak et al., 2011). disease outcome, the same was not true for NBS cohort described
Another hallmark of NBS is a high risk of developing secondary by Dembowska-Baginska et al. In the Polish study, the frequency
malignancy, mainly lymphomas, but ALL and AML have been also of severe toxicity was comparable between patients receiving
described (Gładkowska-Dura et al., 2008; Bienemann et al., 2011; greater or less than 80% of drug doses but administration of full
Barth et al., 2003; Resnick et al., 2002; Pastorczak et al., 2014). drug doses was feasible and treatment related complications
The second cancer was considered to occur in even up to 33% of NBS manageable (Dembowska-Baginska et al., 2009). The most
patients diagnosed with lymphoma, particularly in cases of initial apparent risk factors of toxic side effects identified in NBS pa-
B-cell lineage (Gładkowska-Dura et al., 2008). Summarizing data tients during intensive chemotherapy were: immunodeficiency,
derived from all NBS patients described in literature, about 23% of recurrent sinopulmonary infections and massive dental caries
patients develop malignancy more than once, with median time 11 (Dembowska-Baginska et al., 2009). Additionally, congenital
years to the second cancer. Rarely, even third limfoproliferation renal hypoplasia/aplasia as well as urinary tract defects (dupli-
may be diagnosed in course of NBS (Gładkowska-Dura et al., 2008; cation of renal pelvis and ureter, hydronephrosis) are commonly
Bienemann et al., 2011). noted in NBS patients and should be taken into consideration
during individual modifications of drug dosages (Chrzanowska
et al., 2012).
6. Chemotherapy of primary malignancy in NBS

NBS patients diagnosed with lymphoproliferative disorders 7. Immunotherapy in NBS

receive modified dosages of chemotherapy due to reduced
treatment tolerance and high risk of life-threatening infectious In order to limit toxicity of chemotherapy in NBS patients
complications. However, any defined modifications of standard exhibiting severe adverse events of the standard treatment as well
protocols have been designed for patients treated due to leuke- as in case of relapsed and refractory disease, targeted drugs should
mia or lymphoma in course of chromosomal instability disorders. be considered. However, apart from rituximab, most of antibodies
The common approach is starting chemotherapy with reduced and antibody-drug conjugates directed against surface antigens,
dosage and adapting its intensity according to individual toler- antibodies directed against immune checkpoint proteins and small
ance (Dembowska-Baginska et al., 2009; Pasic et al., 2004; molecule inhibitors directed against cell signaling pathways were
Seidemann et al., 1999b). Non-Hodgkin Lymphoma BFM study not specifically tested among NBS patients. Therefore, there is not
group recommends dose reduction with respect to methotrexate, enough evidence to recommend them in the frontline setting
alkylating agents and epipodophyllotoxines (Seidemann et al., unless substantial part of the standard protocol or indicated
1999b, 2000). Radiomimetics like bleomycin, which directly radiotherapy were omitted. Nevertheless in context of high mor-
induce chromosome aberrations with rearrangements involving tality associated with refractory leukemia or lymphoma in NBS
chromosomes 7 and 14, should be omitted due to extreme hy- patients, possible treatment benefits may outweigh the risk of
persensitivity observed in NBS patients (Pe
rez-Vera et al., 1997). complications which should be always taken into consideration.
Therapy with topoisomerase inhibitors, which block the ligation Several second line treatment options refer to the most common
step of the cell cycle by generating single and double stranded type of lymphoid malignancy in NBS patients which is DLBCL (e.g.
DNA break, should also be limited (Dembowska-Baginska et al., Ofatumumab, Polatuzumab vedotin, Epratuzumab, Inotuzumab
2009). However, depending on the specific agent from this ozogamicin, MEDI-551, Anti-CD19 antibodies, Ibrutinib). However,
group, individual tolerance differs among NBS patients signifi- regarding relapsed/refractory ALL or aggressive lymphomas, we
cantly. Low doses of etoposide were successfully administered in may expect less effective action of immunotherapeutical drugs

Please cite this article in press as: Pastorczak, A., et al., Clinical course and therapeutic implications for lymphoid malignancies in Nijmegen
breakage syndrome, European Journal of Medical Genetics (2016), http://dx.doi.org/10.1016/j.ejmg.2016.01.007
4 A. Pastorczak et al. / European Journal of Medical Genetics xxx (2016) 1e7

which stimulate a patient's own immune system to attack cancer prophylaxis during intensive chemotherapy of NBS patients.
cells (bispecific T-cell engager Blinatumomab CD19/CD3 or However, unspecified adjuvant antimicrobial therapy was rec-
chimeric antigen receptor (CAR) T-cell therapy) due to intrinsic ommended by BFM-NHL study group in children with primary
immunodeficiency. immunodeficiency treated due to Non-Hodgkin Lymphoma
(Seidemann et al., 1999b). The prophylaxis with fluoroquinolone
8. Radiotoxicity in NBS antibiotics have been widely used in adult oncology patients.
Since long-term exposure to fluoroquinolone may result in
Hypersensitivity to ionizing radiation (IR), X and g, has been cartilage toxicity in children, we recommend short time oral
demonstrated in the majority of NBS patients (Jaspers et al., prophylaxis in the most immunodeficient NBS patients, during
1988). Its molecular manifestations such as high level of the induction and reinduction protocol in case of ALL/T-LBL as well as
radioresistant DNA synthesis (RDS) and decreased colony- during all courses of B-NHL.
forming ability after exposure to IR were used in the diagnostic Another fundamental aim of supportive care is to reduce the
procedure of NBS in the past (Chrzanowska et al., 1995). Irradi- risk of invasive fungal infections which are important causes of
ation of NBS patient may certainly contribute to life-threatening morbidity and mortality in NBS patients, particularly during in-
toxicity and malignant transformation, therefore it should be duction of remission (Seidemann et al., 1999b). Antifungal pro-
avoided for both therapeutic and diagnostic purpose. Bakhsi et al. phylaxis seems to be also rationale since even without
described a boy with undiagnosed NBS who developed radiation- antineoplasmatic treatment, NBS patients are frequent carrier of
induced dermatitis and gastroesophagitis leading to uncontrolled Candida sp. in their oral cavity (Gregorek et al., 2009). Therefore,
and unresponsive to treatment bleeding after two courses of consistently with ECIL-4 (European Conference on Infections in
craniospinal irradiation (Bakhshi et al., 2003). Additionally, Leukaemia) guidelines, posaconazole would be preferred agent
considering the risk of the iatrogenic DNA damage associated for prevention of invasive fungal in immunocompromised NBS
with CT or PET/CT, the standard staging of lymphomas, moni- patients (Groll et al., 2014). However, there are limitations of
toring of response to therapy, and detection of disease recurrence presented approach. Firstly, posaconasole is recommended in
should be performed using magnetic resonance imaging (MRI) or children older than 12 years of age (Groll et al., 2014). Secondly,
ultrasound (US). concomitant administration of vincristine with antifungal azoles
may lead to the wide range of severe adverse events including
9. Infections during oncologic treatment neurotoxicity (Moriyama et al. 2012). Therefore withholding the
antifungal azole before vincristine chemotherapy and using a
Deficient humoral and cellular immunity predisposing to non-azole antifungal agent during the withholding period should
recurrent infections is a clinical hallmark of NBS. Defects in primary be considered (Moriyama et al. 2012).
and secondary antibody production, low level of serum immuno-
globulin and poor response to vaccination have been attributed to
reduced B cell counts and impairment of B and T cells function, 10. Outcome of lymphoma and leukemia in NBS
particularly insufficient cooperation in immunoglobulin class
switching due to low number of T helper lymphocyte counts Although remission can be achieved by the vast majority of NBS
(Gregorek et al., 2002; Michalkiewicz et al., 2003; Gregorek et al., patients treated due to lymphoid malignancy with reduced in-
2010; van Engelen et al., 2001). Additionally, NBS patients tensity protocol, the prognosis of long-term survival remains
demonstrate abnormal composition of peripheral B-cell compart- poorer compare to patients without DNA repair defects
ment resulting from aberrant maturation of B-cell, with predomi- (Dembowska-Baginska et al., 2009; Bienemann et al., 2011;
nance of the natural effector B-lymphocytes compare to naive and Seidemann et al., 1999b). The main reason of the inferior
memory B-cell (Pia˛ tosa et al., 2012). Since abnormalities of immune outcome is progressive disease, relapse and second malignancy
system result in profound deficiency of several subclasses of which account for death in about 30% of NBS patients with leuke-
immunoglobulin (IgG1, IgG2, IgG4 and IgA) in the majority of NBS mias or lymphomas. Recently, Bienemann et al. showed that using
patients, humoral immunity is more deregulated in NBS than in more-risk adapted therapy protocol, definitive cure of malignancy
other known chromosomal instability syndromes (Gregorek et al., is possible in more than 50% of patients with chromosomal insta-
2002). bility syndromes (Bienemann et al., 2011). One possible ther-
In practice, immunodeficiency is considerably heterogeneous apeutical option is addition of monoclonal antibodies such as anti-
feature among NBS patients with a tendency to progress over CD20 antibody to standard protocol in a group of NBS patients
time, therefore monitoring of the immune system is highly rec- diagnosed with CD20-positive B-NHL or HL. The beneficial role of
ommended and should be performed at least once a year anti-CD20 antibody results from its targeted anticancer property
(Chrzanowska et al., 2012; Gregorek et al., 2002). Despite of associated with reduced risk of severe toxicity and secondary ma-
confirmed immunodeficiency, the majority of NBS patients do lignancy (Bienemann et al., 2011; Stockklausner et al., 2008; Dumic
not develop opportunistic infections without oncological treat- et al., 2007).
ment and some of them do not need immunoglobulin supple- Escalation of drug doses over 80% was suggested as another
mentation until development of malignancy. On the other hand, alternative therapeutical approach which may improve outcome
fatal infectious complications are relatively common during in NBS patients treated due to lymphoma (Dembowska-
intensive chemotherapy. Therefore, history of previous severe Baginska et al., 2009). This strategy may be supported by the
infections of respiratory tract, otitis, meningitis or encephalitis, fact that the possibility of secondary malignancy was indepen-
which reflect immunodeficiency should influence on the decision dent of treatment intensity in both largest NBS cohorts
of additional supportive care. According to current guidelines for (Dembowska-Baginska et al., 2009; Bienemann et al., 2011).
immunoglobulin supplementation in primary immunodefi- Moreover, rationale supportive care as well as effective therapy
ciencies, NBS patient should receive IVIG to maintain a serum IgG of second and third malignancy and successful allogeneic stem
level over 5.0 g/l if IgG deficiency is observed (Orange et al., cell transplantation in NBS children encourage to apply full drug
2006). doses unless clear indications for drug reduction appear (See
Sparse evidence supports beneficial role of antibiotic Fig. 1).

Please cite this article in press as: Pastorczak, A., et al., Clinical course and therapeutic implications for lymphoid malignancies in Nijmegen
breakage syndrome, European Journal of Medical Genetics (2016), http://dx.doi.org/10.1016/j.ejmg.2016.01.007
 A. Pastorczak et al. / European Journal of Medical Genetics xxx (2016) 1e7 5

Fig. 1. Proposed algorithm for diagnostic and therapeutic procedure among NBS patients with lymphoid malignancy. HSCT e hematopoietic stem cell transplantation; dotted frame
e further clinical evidence required.

11. Bone marrow transplantation as a method of treatment in predominantly donor chimeras. The underlying immunodeficiency
NBS was corrected in the six surviving patients with disappearance of
frequent pulmonary infections and T-cell numbers restored back to
Primary immunodeficiency diseases and lymphoid malignancy normal levels. T-cell proliferation was normal in all six patients.
observed in NBS characterized by increased chromosomal insta- One patient remains on intravenous immunoglobulin replacement
bility or radiosensitivity pose a significant therapeutic challenge after rituximab treatment for immune mediated thrombocyto-
when bone marrow transplantation is considered. Hematopoietic penia, the others have normal immunoglobulin levels and antibody
stem cell transplantation (HSCT) has traditionally not been responses to vaccine antigens (Albert et al., 2010).
attempted in NBS because of concerns about excessive chemo- or In line with the observation that there seems to be a high rate of
radiotherapy induced toxicity. Additionally, transplant related treatment failures or secondary lymphoid malignancies in NBS, all
toxicity such as graft versus host disease and the secondary im- four reported patients with malignant diseases had resistant, re-
munodeficiency that accompanies it can further increase the risk lapsing or secondary malignant disease. Thus, HSCT will often
for secondary malignancy. present as a last treatment option in NBS patients in whom stan-
In literature seven patients with NBS who had undergone allo- dard chemotherapy regimens have failed. Long term follow up will
geneic HSCT were identified (Albert et al., 2010; Wozniak et al., need to show whether the risk of lymphoid malignancy in these
2015; Gennery et al., 2005). Three patients were transplanted for patients is abolished, but it is encouraging that HSCT might offer a
immunodeficiency and rest of these for cancer treatment. A wide viable treatment option.
range of different donors, conditioning regimens, graft versus host Furthermore, these reports revealed that the cellular and hu-
disease prophylaxis and stem cell sources were used. Of note, six of moral immunodeficiency in NBS could be also corrected by HSCT.
the seven patients received a reduced intensity-conditioning But before real long term safety data are available, this procedure
regimen based on either fludarabine or low dose thor- should not be recommended as a standard treatment approach for
acoabdominal irradiation, combined with T-cell depleting anti- NBS patients in whom the immunodeficiency can be controlled
bodies. The remaining patient had a fully myeloablative, busulfan with conservative measures, but should be considered in select
based conditioning regimen. GVHD prophylaxis was cyclosporine A cases with severe immunodeficiency where an HLA identical donor
based with the exception of one patient who received a T-cell is available. Summarizing the experience of allogeneic HSCT in
depleted graft from a haploidentical parental donor. At a median of seven NBS patients worldwide it demonstrates that this procedure
22.5 years of follow-up 6/7 patients were alive. Acute transplant is feasible and that reduced intensity conditioning can reduce
related toxicity differed widely but was manageable. One patient regimen related toxicity in these patients.
who had received myeloablative conditioning died from bacterial
sepsis before engraftment. GVHD was also manageable (Gennery
et al., 2005). All evaluable patients were either complete or

Please cite this article in press as: Pastorczak, A., et al., Clinical course and therapeutic implications for lymphoid malignancies in Nijmegen
breakage syndrome, European Journal of Medical Genetics (2016), http://dx.doi.org/10.1016/j.ejmg.2016.01.007
6 A. Pastorczak et al. / European Journal of Medical Genetics xxx (2016) 1e7

12. Future directions Kowalczyk, D., Gladkowska-Dura, M., Grajkowska, W., Chrzanowska, K.H., 2009.
Non-Hodgkin lymphoma (NHL) in children with Nijmegen breakage syndrome
(NBS). Pediatr. Blood Cancer 52, 186e190.
Since several therapeutical strategies regarding cancer treat- Difilippantonio, S., Celeste, A., Fernandez-Capetillo, O., Chen, H.T., Reina San
ment in NBS patients have been published yet, retrospective anal- Martin, B., Van Laethem, F., Yang, Y.P., Petukhova, G.V., Eckhaus, M.,
ysis of such miscellaneous studies do not lead to clear and precise Feigenbaum, L., Manova, K., Kruhlak, M., Camerini-Otero, R.D., Sharan, S.,
Nussenzweig, M., Nussenzweig, A., 2005. Role of Nbs1 in the activation of the
conclusions. For further optimization of cancer treatment, inter- Atm kinase revealed in humanized mouse models. Nat. Cell Biol. 7, 675e685.
national registry for NBS patients with malignancies should be Dumic, M., Radman, I., Krnic, N., Nola, M., Kusec, R., Begovic, D., Labar, B., Rados, M.,
created as well as designed treatment protocol including drug 2007. Successful treatment of diffuse large b-cell non-hodgkin lymphoma with
modified CHOP (Cyclophosphamide/Doxorubicin/Vincristine/Prednisone)
doses modifications and supportive care advises is needed. There- chemotherapy and rituximab in a patient with nijmegen syndrome. Clin.
fore, these objectives became one of the main task of the I-BFM Lymphoma Myeloma 7, 590e593.
workgroup on cancer predisposition syndromes with respect to Engel K, Rudelius M, Meinel F, Peschel C, Keller U An adult patient with Nijmegen
breakage syndrome and Hodgkin's lymphoma, BMC Hematol. 14, 2.
DNA repair syndromes. Gennery, A.R., Slatter, M.A., Bhattacharya, A., Jeggo, P.A., Abinun, M., Flood, T.J.,
Cant, A.J., 2005. Bone marrow transplantation for Nijmegan breakage syn-
drome. J. Pediatr. Hematol. Oncol. 27, 239.
13. Clinical recommendations Gewirtz, D., 1999. A critical evaluation of the mechanisms of action proposed for the
antitumor effects of the anthracycline antibiotics adriamycin and daunorubicin.
1. Molecular detection of common hypomorphic founder mutation Biochem. Pharmacol. 57, 727e741.
Gorski, B., Debniak, T., Masojc, B., Mierzejewski, M., Medrek, K., Cybulski, C.,
(c.657_661del5) in NBN gene should be considered before
Jakubowska, A., Kurzawski, G., Chosia, M., Scott, R., Lubinski, J., 2003. Germline
oncologic treatment always if at least single phenotypic feature 657del5 mutation in the NBS1 gene in breast cancer patients. Int. J. Cancer 106,
suggestive for this condition appear. 379e381.
2. Patients with NBS treated due to leukemia/lymphoma may Gregorek, H., Chrzanowska, K.H., Dzierzanowska-Fangrat, K., Wakulinska, A.,
Pietrucha, B., Zapasnik, A., Zborowska, M., Pac, M., Smolka-Afifi, D.,
receive standard doses of chemotherapy on condition that Kasztelewicz, B., Piekutowska-Abramczuk, D., Maldyk, J., 2010. Nijmegen
neither history of severe infections nor immunoglobulin sup- breakage syndrome: long-term monitoring of viral and immunological bio-
plementation was noted in the past. markers in peripheral blood before development of malignancy. Clin. Immunol.
135, 440e447.
3. Antibacterial oral prophylaxis with fluoroquinolone antibiotics Gregorek, H., Chrzanowska, K.H., Michalkiewicz, J., Syczewska, M., Madalinski, K.,
should be administered in severe immunodeficient NBS patients 2002. Heterogeneity of humoral immune abnormalities in children with Nij-
at least during induction and reinduction protocol in case of ALL/ megen breakage syndrome: an 8-year follow-up study in a single centre. Clin.
Exp. Immunol. 130, 319e324.
T-LBL as well as during all courses of B-NHL. Gregorek, H., Olczak-Kowalczyk, D., Dembowska-Baginska, B., Pietrucha, B.,
4. Posaconazole would be preferred agent for prevention of inva- Wakulinska, A., Gozdowski, D., Chrzanowska, K.H., 2009. Oral findings in pa-
sive fungal in NBS patients during whole treatment protocol of tients with Nijmegen breakage syndrome: a preliminary study. Oral Surg. Oral
Med. Oral Pathol. Oral Radiol. Endod. 108, s e39es e45.
leukemia and lymphoma excluding maintenance phase. Groll, A.H., Castagnola, E., Cesaro, S., Dalle, J.-H., Engelhard, D., Hope, W., Roilides, E.,
5. MRI or US should be applied instead of CT when diagnostics Styczynski, J., Warris, A., Lehrnbecher, T., 2014. Fourth european conference on
imaging is necessary. infections in leukaemia (ECIL-4): guidelines for diagnosis, prevention, and
treatment of invasive fungal diseases in paediatric patients with cancer or
6. HSCT or targeted therapy may be considered for NBS patients
allogeneic haemopoietic stem-cell transplantation. Lancet Oncol. 15,
who omitted substantial drugs or radiotherapy and for NBS e327ee340.
patient with secondary cancer. _
Gładkowska-Dura, M., Dzierzanowska-Fangrat, K., Dura, W.T., van Krieken, J.,
Chrzanowska, K.H., van Dongen, J.J.M., Langerak, A.W., 2008. Unique morpho-
logical spectrum of lymphomas in Nijmegen breakage syndrome (NBS) patients
Appendix A. Supplementary data with high frequency of consecutive lymphoma formation. J. Pathol. 216,
337e344.
Jaspers, N.G., Gatti, R.A., Baan, C., Linssen, P.C., Bootsma, D., 1988. Genetic comple-
Supplementary data related to this article can be found at http:// mentation analysis of ataxia telangiectasia and Nijmegen breakage syndrome: a
dx.doi.org/10.1016/j.ejmg.2016.01.007. survey of 50 patients. Cytogenet Cell Genet. 49, 259e263.
Kruger, L., Demuth, I., Neitzel, H., Varon, R., Sperling, K., Chrzanowska, K.H.,
Seemanova, E., Digweed, M., 2007. Cancer incidence in Nijmegen breakage
References syndrome is modulated by the amount of a variant NBS protein. Carcinogenesis
28, 107e111.
Albert, M.H., Gennery, A.R., Greil, J., Cale, C.M., Kalwak, K., Kondratenko, I., Lee, J.H., Paull, T.T., 2005. ATM activation by DNA double-strand breaks through the
Mlynarski, W., Notheis, G., Fuhrer, M., Schmid, I., Belohradsky, B.H., 2010. Suc- Mre11-Rad50-Nbs1 complex. Science 308, 551e554.
cessful SCT for Nijmegen breakage syndrome. Bone Marrow Transpl. 45, Michalkiewicz, J., Barth, C., Chrzanowska, K., Gregorek, H., Syczewska, M.,
622e626. Weemaes, C.M.B., Madalinski, K., Dzierzanowska, D., Stachowski, J., 2003. Ab-
Bakhshi, S., Cerosaletti, K.M., Concannon, P., Bawle, E.V., Fontanesi, J., Gatti, R.A., normalities in the T and NK lymphocyte phenotype in patients with Nijmegen
Bhambhani, K., 2003. Medulloblastoma with adverse reaction to radiation breakage syndrome. Clin. Exp. Immunol. 134, 482e490.
therapy in nijmegen breakage syndrome. J. Pediatr. Hematol. Oncol. 25, Michallet, A.S., Lesca, G., Radford-Weiss, I., Delarue, R., Varet, B., Buzyn, A., 2003. T-
248e251. cell prolymphocytic leukemia with autoimmune manifestations in Nijmegen
Barth, E., Demori, E., Pecile, V., Zanazzo, G.A., Malorgio, C., Tamaro, P., 2003. breakage syndrome. Ann. Hematol. 82, 515e517.
Anthracyclines in Nijmegen breakage syndrome. Med. Pediatr. Oncol. 40, Moriyama, B., Henning, S.A., Leung, J., Falade-Nwulia, O., Jarosinski, P., Penzak, S.R.,
122e124. Walsh, T.J., 2012. Adverse interactions between antifungal azoles and vincris-
Bienemann, K., Burkhardt, B., Modlich, S., Meyer, U., Mo €ricke, A., Bienemann, K., tine: review and analysis of cases. Mycoses 55, 290e297.
Mauz-Ko €rholz, C., Escherich, G., Zimmermann, M., Ko€rholz, D., Janka-Schaub, G., Moses, R.E., 2001. DNA damage processing defects and disease. Annu. Rev. Geno-
Schrappe, M., Reiter, A., Borkhardt, A., 2011. Promising therapy results for mics Hum. Genet. 2, 41e68.
lymphoid malignancies in children with chromosomal breakage syndromes New, H.V., Cale, C.M., Tischkowitz, M., Jones, A., Telfer, P., Veys, P., D'Andrea, A.,
(Ataxia teleangiectasia or Nijmegen-breakage syndrome): a retrospective sur- Mathew, C.G., Hann, I., 2005. Nijmegen breakage syndrome diagnosed as Fan-
vey. Br. J. Haematol. 155, 468e476. coni anaemia. Pediatr. Blood Cancer 44, 494e499.
Chrzanowska, K.H., Kleijer, W.J., Krajewska-Walasek, M., Bialecka, M., Orange, J.S., Hossny, E.M., Weiler, C.R., Ballow, M., Berger, M., Bonilla, F.A.,
Gutkowska, A., Goryluk-Kozakiewicz, B., Michalkiewicz, J., Stachowski, J., Buckley, R., Chinen, J., El-Gamal, Y., Mazer, B.D., Nelson, R.P., Patel, D.D.,
Gregorek, H., Lyson-Wojciechowska, G., Janowicz, W., Jozwiak, S., 1995. Eleven Secord, E., Sorensen, R.U., Wasserman, R.L., Cunningham-Rundles, C., 2006.
polish patients with microcephaly, immunodeficiency, and chromosomal Primary immunodeficiency committee of the American academy of allergy,
instability: the Nijmegen breakage syndrome. Am. J. Med. Genet. 57, 462e471. asthma and immunology: use of intravenous immunoglobulin in human dis-
Chrzanowska, K., Gregorek, H., Dembowska-Baginska, B., Kalina, M., Digweed, M., ease: a review of evidence by members of the primary immunodeficiency
2012. Nijmegen breakage syndrome (NBS). Orphanet. J. Rare Dis. 7, 13. committee of the American academy of allergy, asthma and immunology.
de Miranda, N.F.C.C., Bjo€rkman, A., Pan-Hammarstro € m, Q., 2011. DNA repair: the link J. Allergy Clin. Immunol. 117, S525eS553.
between primary immunodeficiency and cancer. Ann. N. Y. Acad. Sci. 1246, Pasic, S., Vujic, D., Fiorini, M., Notarangelo, L., 2004. T-cell lymphoblastic leukemia/
50e63. lymphoma in Nijmegen breakage syndrome. Haematologica 89. ECR27.
Dembowska-Baginska, B., Perek, D., Brozyna, A., Wakulinska, A., Olczak- Pastorczak, A., Szczepanski, T., Trelinska, J., Finalet Ferreiro, J., Wlodarska, I.,

Please cite this article in press as: Pastorczak, A., et al., Clinical course and therapeutic implications for lymphoid malignancies in Nijmegen
breakage syndrome, European Journal of Medical Genetics (2016), http://dx.doi.org/10.1016/j.ejmg.2016.01.007
 A. Pastorczak et al. / European Journal of Medical Genetics xxx (2016) 1e7 7

Mycko, K., Polucha, A., Sedek, L., Meyer, C., Marschalek, R., Młynarski, W., 2014. High frequency of spontaneous translocations revealed by FISH in cells from
Secondary acute monocytic leukemia positive for 11q23 rearrangement in patients with the cancer-prone syndromes ataxia telangiectasia and Nijmegen
Nijmegen breakage syndrome. Pediatr. Blood Cancer 61, 1469e1471. breakage syndrome. Cytogenet Cell Genet. 92, 186e191.
Pastorczak, A., Stolarska, M., Trelin
ska, J., Zawitkowska, J., Kowalczyk, J., Tauchi, H., Kobayashi, J., Morishima, K-i, Matsuura, S., Nakamura, A., Shiraishi, T.,
Mlynarski, W., on behalf of the Polish Pediatric Leukemia/Lymphoma Study G, Ito, E., Masnada, D., Delia, D., Komatsu, K., 2001. The forkhead-associated
2011. Nijmegen breakage syndrome (NBS) as a risk factor for CNS involvement domain of NBS1 is essential for Nuclear Foci formation after irradiation but
in childhood acute lymphoblastic leukemia. Pediatr. Blood Cancer 57, 160e162. ^
not essential for hRAD50A$hMRE11 ^
A$NBS1 complex DNA repair activity. J. Biol.

rez-Vera, P., Gonza
Pe
lez-del Angel, A., Molina, B., Go
mez, L., Frías, S., Gatti, R.A., Chem. 276, 12e15.
Carnevale, A., 1997. Chromosome instability with bleomycin and x-ray hyper- van der Burg, M., Pac, M., Berkowska, M.A., Goryluk-Kozakiewicz, B., Wakulinska, A.,
sensitivity in a boy with Nijmegen breakage syndrome. Am. J. Med. Genet. 70, Dembowska-Baginska, B., Gregorek, H., Barendregt, B.H., Krajewska-
24e27. Walasek, M., Bernatowska, E., van Dongen, J.J., Chrzanowska, K.H.,
Pia˛ tosa, B., van der Burg, M., Siewiera, K., Pac, M., van Dongen, J.J.M., Langerak, A.W., Langerak, A.W., 2010. Loss of juxtaposition of RAG-induced immunoglobulin
Chrzanowska, K.H., Bernatowska, E., 2012. The defect in humoral immunity in DNA ends is implicated in the precursor B-cell differentiation defect in NBS
patients with Nijmegen breakage syndrome is explained by defects in periph- patients. Blood 115, 4770e4777.
eral B lymphocyte maturation. Cytom. Part A 81A, 835e842. 
van Engelen, B.G.M., Hiel, J.A.P., GabreA«ls, F.J.M., van den Heuvel, L.P.W.J., van
Resnick, I.B., Kondratenko, I., Togoev, O., Vasserman, N., Shagina, I., Evgrafov, O., Gent, D.C., Weemaes, C.M.R., 2001. Decreased immunoglobulin class switching
Tverskaya, S., Cerosaletti, K.M., Gatti, R.A., Concannon, P., 2002. Nijmegen in nijmegen breakage syndrome due to the DNA repair defect. Hum. Immunol.
breakage syndrome: clinical characteristics and mutation analysis in eight 62, 1324e1327.
unrelated russian families. J. Pediatr. 140, 355e361. Varon, R., Vissinga, C., Platzer, M., Cerosaletti, K.M., Chrzanowska, K.H., Saar, K.,
Seidemann, K., Tiemann, M., Henze, G., Sauerbrey, A., Müller, S., Reiter, A., 1999. Beckman, G., Seemanova, E., Cooper, P.R., Nowak, N.J., Stumm, M.,
Therapy for non-Hodgkin lymphoma in children with primary immunodefi- Weemaes, C.M.R., Gatti, R.A., Wilson, R.K., Digweed, M., Rosenthal, A.,
ciency: analysis of 19 patients from the BFM trials. Med. Pediatr. Oncol. 33, Sperling, K., Concannon, P., Reis, A., 1998. Nibrin, a novel DNA double-strand
536e544. break repair protein, is mutated in Nijmegen breakage syndrome. Cell 93,
Seidemann, K., Tiemann, M., Henze, G., Sauerbrey, A., Muller, S., Reiter, A., 1999. 467e476.
Therapy for non-hodgkin lymphoma in children with primary immunodefi- Varon, R., Seemanova, E., Chrzanowska, K., Hnateyko, O., Piekutowska-
ciency: analysis of 19 patients from the BFM Trials. Med. Pediatr. Oncol. 33, Abramczuk, D., Krajewska-Walasek, M., Sykut-Cegielska, J., Sperling, K., Reis, A.,
536e544. 2000. Clinical ascertainment of Nijmegen breakage syndrome (NBS) and
Seidemann, K., Henze, G., Beck, J.D., Sauerbrey, A., Kuhl, J., Mann, G., Reiter, A., 2000. prevalence of the major mutation, 657del5, in three Slav populations. Eur. J.
Non- Hodgkin lymphoma in pediatric patients with chromosomal breakage Hum. Genet. 8, 900e902.
syndromes (AT and NBS): experience from the BFM trials. Ann. Oncol. 11, Weemaes, C.M., Hustinx, T.W., Scheres, J.M., van Munster, P.J., Bakkeren, J.A.,
141e145. Taalman, R.D., 1981. A new chromosomal instability disorder: the Nijmegen
Stockklausner, C., Behnisch, W., Mechtersheimer, G., Mo €ller, P., Kulozik, A.E., 2008. breakage syndrome. Acta Paediatr. Scand. 70, 557e564.
Long-term remission of children with relapsed and secondary anaplastic large Wozniak, M., Krzywon, M., Holda, M.K., Gozdzik, J., 2015. Reduced-intensity con-
cell non-Hodgkin lymphoma (ALCL) following treatment with pulsed dexa- ditioning umbilical cord blood transplantation in Nijmegen breakage syndrome.
methasone and low dose etoposide. Pediatr. Blood Cancer 50, 126e129. Pediatr. Transpl. 19, E51eE55.
Stumm, M., Neubauer, S., Keindorff, S., Wegner, R.D., Wieacker, P., Sauer, R., 2001.

Please cite this article in press as: Pastorczak, A., et al., Clinical course and therapeutic implications for lymphoid malignancies in Nijmegen
breakage syndrome, European Journal of Medical Genetics (2016), http://dx.doi.org/10.1016/j.ejmg.2016.01.007