PURPOSE: In neuroblastoma (NB), the ALK receptor tyrosine kinase can be constitutively activated through activating point mutations or genomic amplification. We studied ALK genetic alterations in high-risk (HR) patients on the HR-NBL1/SIOPEN trial to determine their frequency, correlation with clinical parameters, and prognostic impact. MATERIALS AND METHODS: Diagnostic tumor samples were available from 1,092 HR-NBL1/SIOPEN patients to determine ALK amplification status (n = 330), ALK mutational profile (n = 191), or both (n = 571). RESULTS: Genomic ALK amplification (ALKa) was detected in 4.5% of cases (41 out of 901), all except one with MYCN amplification (MNA). ALKa was associated with a significantly poorer overall survival (OS) (5-year OS: ALKa [n = 41] 28% [95% CI, 15 to 42]; no-ALKa [n = 860] 51% [95% CI, 47 to 54], [P < .001]), particularly in cases with metastatic disease. ALK mutations (ALKm) were detected at a clonal level (> 20% mutated allele fraction) in 10% of cases (76 out of 762) and at a subclonal level (mutated allele fraction 0.1%-20%) in 3.9% of patients (30 out of 762), with a strong correlation between the presence of ALKm and MNA (P < .001). Among 571 cases with known ALKa and ALKm status, a statistically significant difference in OS was observed between cases with ALKa or clonal ALKm versus subclonal ALKm or no ALK alterations (5-year OS: ALKa [n = 19], 26% [95% CI, 10 to 47], clonal ALKm [n = 65] 33% [95% CI, 21 to 44], subclonal ALKm (n = 22) 48% [95% CI, 26 to 67], and no alteration [n = 465], 51% [95% CI, 46 to 55], respectively; P = .001). Importantly, in a multivariate model, involvement of more than one metastatic compartment (hazard ratio [HR], 2.87; P < .001), ALKa (HR, 2.38; P = .004), and clonal ALKm (HR, 1.77; P = .001) were independent predictors of poor outcome. CONCLUSION: Genetic alterations of ALK (clonal mutations and amplifications) in HR-NB are independent predictors of poorer survival. These data provide a rationale for integration of ALK inhibitors in upfront treatment of HR-NB with ALK alterations.

Center for Genomic Medicine Rigshospitalet Copenhagen University Hospital Copenhagen Denmark

Clinical and Translational Oncology Research Group Health Research Institute La Fe Valencia Spain

Departamento de Genética Humana Instituto Nacional de Saúde Doutor Ricardo Jorge Lisbon Portugal

Département d'Oncologie Pédiatrique Gustave Roussy Villejuif France

Department for Studies and Statistics and Integrated Research St Anna Children's Hospital St Anna Children's Cancer Research Institute Vienna Austria

Department for Studies and Statistics and Integrated Research Vienna Austria

Department of Clinical Genetics Children's Health Ireland at Crumlin Dublin Ireland

Department of Paediatric Haematology and Oncology 2nd Faculty of Medicine Charles University and University Hospital Motol Prague Czech Republic

Department of Paediatric Haematology and Oncology Princess Elisabeth Children's Hospital Ghent University Hospital Ghent Belgium

Department of Paediatrics Medical University of Vienna Vienna Austria

Department of Pathology IRCCS Istituto Giannina Gaslini Genova Italy

Department of Pathology Medical School University of Valencia Incliva Health Research Institute CIBERONC Madrid Spain

Department of Pathology Oslo University Hospital and Medical Faculty University of Oslo Oslo Norway

Department of Pediatric Oncology and Hematology Institute of Pediatrics Jagiellonian University Medical College Krakow Poland

Division of Clinical Studies The Institute of Cancer Research London United Kingdom

Equipe SiRIC RTOP Recherche Translationelle en Oncologie Pédiatrique Institut Curie Paris France

Ghent University Ghent Belgium

INSERM U830 Laboratoire de Génétique et Biologie des Cancers Institut Curie Paris France

Institut Curie Genomics of Excellence Platform Research Center Institut Curie Paris France

Instituto de Investigación Sanitaria La Fe Valencia Spain

Karolinska University Hospital Stockholm Sweden

Laboratory of Molecular Biology IRCCS Istituto Giannina Gaslini Genova Italy

Leeds Children's Hospital Leeds General Infirmary Leeds United Kingdom

Northern Genetics Service The Newcastle upon Tyne Hospitals NHS Foundation Trust Newcastle upon Tyne United Kingdom

Paediatric Oncology Fondazione IRCCS Istituto Nazionale dei Tumori Milan Italy

Paediatric Tumour Biology Division of Clinical Studies The Institute of Cancer Research Sutton United Kingdom

Pediatric Hematology Oncology Research Laboratory Lausanne University Hospital and University of Lausanne Lausanne Switzerland

Pediatric Hematology Oncology Unit Lausanne University Hospital and University of Lausanne Lausanne Switzerland

Ruth Rappaport Children's Hospital Rambam Health Care Campus Haifa Israel

Sahlgrenska University Hospital Göteborg Sweden

Schneider Children's Medical Center of Israel Tel Aviv University Tel Aviv Israel

Service de Génétique des tumeurs; Institut Gustave Roussy Villejuif France

SIREDO Care Innovation and Research for Children Adolescents and Young Adults with Cancer Institut Curie Paris France

St Anna Children's Cancer Research Institute Vienna Austria

Translational Research Laboratory Centre Léon Bérard Lyon France

Unité de Génétique Somatique Service de Génétique Hospital Group Institut Curie Paris France

Wolfson Childhood Cancer Research Centre Newcastle Centre for Cancer Translational and Clinical Research Institute Newcastle University Newcastle upon Tyne United Kingdom

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