Study of the Pathogenic Mechanisms of Metabolic Syndrome at the Background of Genetically Determined Insulin Resistance in Childhood Cancer Survivors
Conditions: Metabolic Syndrome
Sponsor: Federal Research Institute of Pediatric Hematology, Oncology and Immunology

 
 
 
 
 
 
 
Study of the pathogenic mechanisms of metabolic syndrome at the 
background of genetically determined insulin resistance in childhood cancer 
survivors 
 
 
Approval Number : 10э/3-18 
 
 
 
 
 
 
 
Dmitry Rogachev National Research Center of Pediatric Hematology, 
Oncology and Immunology 
1 Samory Mashela str., 117997, Moscow, Russia 
 
 
 
 
 
 
 
Principal investigator: Elena V. Zhukovskaya, PhD, Prof. 
Telephone:   +79154145145 
Email:   elena_zhukovskay@mail.ru 
 
 

Study Title:  Study of the pathogenic mechanisms of metabolic syndrome at the background 
of genetically determined insulin resistance in childhood cancer survivors  
IND Holder: Not Applicable 
 
Brief Overview: 
The remarkable progress in developing curative therapy for childhood cancer over the last 4 to 5 
decades has increased awareness of the serious cancer treatment-related late effects experienced by 
long-term survivors such as premature mortality early deaths, second primary cancers, organ 
dysfunction (heart, lung, endocrine system), fertility impairment, cognitive deficits, and reduced 
quality of life. Endocrine disorders, which occur in 30% to 70% of childhood cancer survivors, are 
among the most frequent late effects of anticancer therapy. Survivors treated with radiation and 
alkylating agent chemotherapy for hematological malignancies and CNS tumors are at a 
particularly high risk for endocrine dysfunction.  
Most anticancer drugs act directly or indirectly by modifying intracellular metabolism. Therefore, 
high frequency of acute and late cancer treatment-related organ toxicity can result in metabolic 
disorders. For example, steroid-induced hypercortism blocks glycolysis and results in insulin 
resistance of tissues. Insulin resistance is associated with earlier manifestation of diabetes mellitus, 
obesity etc. The clinical sequelae of metabolic syndrome developing in childhood cancer survivors 
may include insulin resistance, fasting hyperglycemia, endothelial failure, obesity, dyslipidemia, 
hypertension, chronic fatigue syndrome, motor and behavioral disorders.  
Modern genetics make it possible to create a basis for a personalized approach to the prevention of 
early and late toxic effects caused by anticancer therapy and the rehabilitation of the childhood 
cancer survivors. 
Objectives: 
Specific Aim 1. Evaluate the frequency and clinical features of the metabolic syndrome in 
childhood cancer survivors.  
Hypothesis 1A: Components of the metabolic syndrome are realizing in children and adolescents 
at all stages of   therapy of leukemia and lymphomas, can influence the development of 
complications and late toxic effects. 
Hypothesis 1B: Initial health conditions (abnormal IBM, family history, comorbid diseases); 
drug’s toxicity could influence to the appearance of early manifestation of metabolic syndrome. 
 
Specific Aim 2: Evaluate the contribution of functional polymorphisms in candidate genes to 
metabolic syndrome outcomes among childhood cancer patients. 
Hypothesis 2A: Genetic polymorphisms involved in the regulation of the insulin resistance and 
cancer medications during treatment contribute to the development of metabolic syndrome in 
childhood cancer survivors. 
 
Specific Aim 3: Assess the extent to which genetic predictors, doses of drugs, risk factors improve 
the discriminatory performance of standard clinical prediction models for metabolic syndrome 
outcomes among childhood cancer survivors. 
Hypothesis 3 A: Development of metabolic syndrome in cancer patients depends of genetic 
determinants and toxic effects of antitumor therapy. 
 
Secondary Aim 1: Assess the definition of metabolic syndrome in cohort of patients of leukemia 
and lymphoma and survivors. 
Hypothesis 1A: Episodes of triglyceridemic, insulin resistance (Hyperglycemia, HOMA>2,7, 
Steroid Diabetes) during the treatment could be the base evidence marker of Metabolic Syndrome 
in patients treated by antitumor therapy. 
Hypothesis 1 B: Endothelial dysfunction as a clinical component of metabolic syndrome is 
responsible for cardio-vascular abnormalities in cancer survivors. 
 

Exploratory aim 1: Assess the association of biomarkers and genetic predictors among childhood 
cancer survivors with therapeutic exposures (chemotherapy and/or radiation therapy) and 
metabolic syndrome. 
 
Evaluation: 
Eligible persons who consent to participate in this trial will be asked to do the following: 
 Vital sign measurement including resting heart rate, blood pressure, height, and weight. 
 A total of 12 mL of blood will be collected in 3 test tubes. Biomarker analysis will be 
completed by Laboratory of Dmitry Rogachev National Medical Research Center. 
 A Total of 4 mL of blood in 1 test tube will be used for genotyping for the presence of 
polymorphic variants in genes involved in biotransformation of xenobiotics, insulin 
resistance and carbohydrate metabolism in the biomolecular laboratory of Dmitry 
Rogachev National Medical Research Center. 
 An echocardiogram and ultrasound will be performed to assess cardiac function. 
 CAVI and ABI pulse wave velocity will be non-invasively measured by using the 
SphygmoCor VaSera VS-1500N. Arterial pressure waveforms will be recorded with a 
strain gauge pressure sensor placed lightly over the radial artery before and after “6-minites 
physical activity”. 
Study Design: Longitudinal 
Sample Size: Aims of this study will be accomplished using a longitudinal assessment of 400 
patients with ALL/NHL from Dmitry Rogachev National Medical Research Center and other 
Regional Clinics will be recruiting to the cohort at the start of the therapy MB-ALL/ BFM-NHL. 
Potentially 2100 survivors ALL/NHL will be treating in “Russkoe Pole”2018-2021. 
 
Cases: Participants for this study will be patients of “Russkoe Pole” cohort (RPC), a longitudinal 
study designed to evaluate health among children and adolescents survivors of childhood leukemia 
and lymphoma as they age. Participants in RPC undergo risk-based medical screening according to 
the Standards of Medical Insurance for rehabilitation of Cancer treated patients.  Cases will be 
stratified by survival time (1-4, 5-9, and ≥ 10years).  
To be eligible for RPC, cancer survivors must have been treated in Russian children oncology 
clinics by MB-ALL/ BFM-NHL and be 15 years of age or younger , and at least 6 months from the 
completion of the therapy .All the patients will have exhaustively full epicrisis of medical history 
with cumulative doses of medications. Because RPC is a retrospective cohort study with ongoing 
recruitment (additional survivors become eligible over time). 
 
 
Study Population:  
 
Eligibility criteria:  
 Cancer survivors: 
 Treatment with chemotherapy and/or radiation therapy for a primary ALL/NHL diagnosed 
prior to age 17 years.  
 ≤ 15 years of age at time of enrollment.  
  No cytostatic drugs uptake during the study.  
Exclusion criteria: 
 Diagnosis of diabetes mellitus types 1 or 2 types before antitumor therapy 
 Active oncological disease 
 History of allogeneic hematopoietic cell transplant 
 Absence of written consent for participation from the patient or legally authorized 
representative 
 

 
 
 
Appendix 1 Genetic testing  
 
The table summarizes specific polymorphisms that are candidate genes underlying 
genetic risk factors for metabolic syndrome after childhood cancer.  
i) A candidate gene approach, rather than genome-wide polymorphism detection, will be 
used, 
ii) Functional polymorphisms will be targeted, and 
iii) Genes will be identified by virtue of the fact that they have been associated with 
metabolic syndrome outcomes in adults, or with similar “de novo” diseases, or they are 
likely to affect the pharmacogenetics or pharmacodynamics of the most important drug-
related risk factors for the adverse event. 
Randomization: N/A 
Anticipated Primary Objective Completion Date: 10/09/2018 
Anticipated Study Completion Date: 10/12/2021 
Analysis of objectives: 
Aims 1 and 2: Descriptive statistics will be used to summarize prior cancer therapy, collected from 
formal medical record abstraction.  Epidemiological, clinical and laboratory variables, including 
genetic variants will be tested for their association with metabolic syndrome. McNemar's   test for 
paired data will be used to compare the unmatched general characteristics of cases and controls. 
Allele frequencies will be estimated by two-side Fisher exact test, and the Chi-square test will be 
used to check for departures from Hardy-Weinberg equilibrium.  
Aim 3:  The crude disease-exposure association will be determined by estimating the OR and its 
95% confidence interval (CI). This will be done by univariate conditional logistic regression, to 
account for the matched design. The significance of the OR will be assessed by the Wald test. 
Exposures for which the P-value is less than 0.25 in univariate analysis will be entered into a 
multivariate conditional logistic regression model. Backward stepwise regression procedures will 
be used to develop the final multivariate model and possible interactions will be examined. The fit 
of the model will be assessed by the logistic regression diagnostics procedure.  Haplotypes will be 
constructed where applicable, and pathway analysis will be used to construct multilocus genotypic 
groups, rather than a "one-gene-at-a-time" approach, where possible. 
Exploratory Aim:  The multiple regression approach as described above (plan for primary 
Aims 1 and 2) will be implemented to assess the relationship between biomarker levels (HOMA 
index, triglyceridemic) and endothelial dysfunction (rigidness of arteries and positive biomarkers) 
with metabolic syndrome in cancer treated patients. 
Data management: Data management for this study will be supervised by the Department of the 
study late effects of antitumor therapy, medical record data are contained in the data base of 
registry information of Dmitry Rogachev National Medical Research Center. 
Human Subjects: The risk of harm anticipated in the proposed research is not greater than that 
encountered during daily activities. All assessments will be performed by the clinical practitioners 
and researches who has experience in their own scientific technology. Participants will not be 
required to complete any assessments they wish to omit. Dr. Zhukovskaya will be available to 
answer any questions participants have regarding their treatment or medical late effects. If a 
participant experiences undue discomfort during any of the testing, the test will be stopped 
immediately. 

 
Gene 
   SNP ID 
Protein’ function 
INSR  
rs2059806 
The insulin receptor gene is a member of insulin signal 
transduction pathway which regulates the absorption and 
release of glucose, synthesis and storage of carbohydrates, 
lipids and protein. Mutations in the gene are associated 
with autosome-recessive hereditary syndromes, such as 
syndrome 
Donohue 
(leprechaunizm) 
and 
Rabson-
Mendenhall syndrome. It is possible that the heterozygote 
carriers of the mutations associated with these syndromes 
have hereditary predisposition to a metabolic syndrome. 
rs1051691 
rs52800171 
IRS1 
rs2943641 
Binding of insulin to its receptor induces phosphorylation 
of the cytosolic substrates IRS1 and IRS2. The insulin 
receptor substrate 1 gene (IRS1) variants ( rs2972146, 
rs2943641, and rs2943634) are related to body fat 
percentage (BF%) and multiple metabolic traits. 
PPARG 
rs1801282  
The protein PPAR-gamma is the regulator of adipocytes 
differentiation. 
KCNJ11 
rs5219 
The protein KCNJ11 is a part of ATP-dependent K + - 
channels of pancreatic beta cells, which play a key role in 
insulin secretion. As a result of 67A>G nucleotide 
change, the lysine in the position 23 is replaced with 
glutamine (Lys23Gln). The change in protein structure 
interferes with closing of channels and leads to decrease 
in insulin secretion from beta cells and to violation of 
blood sugar level control. 
TCF7L2  
rs7903146 
Protein is a member of the TCF family (transcription 
factors with high mobility group domain). TCF7L2 can 
influence several biological pathways, including the Wnt 
signaling pathway. The single nucleotide polymorphism 
(SNP) within the TCF7L2 gene, rs7903146, is, to date, 
the most significant genetic marker associated with Type 
2 diabetes mellitus (T2DM) risk. SNPs in this gene are 
especially known to be linked to higher risk to develop 
type 2 diabetes, gestational diabetes, and multiple other 
diseases. 
FTO 
rs9939609 
Fat mass and obesity-associated protein also known as 
alpha-ketoglutarate-dependent dioxygenase FTO is an 
enzyme that in humans is encoded by the FTO gene. 
Certain variants of the FTO gene appear to be correlated 
with obesity in humans.  
APOB 
rs676210 
The main apolipoprotein of chylomicrons and low-density 
lipoproteins. The polymorphism has protective effect, in 
the presence of a minor allele A dyslipidemia associated 
with methotrexate intake less often develops.  
APOE  
rs429358 
The ApoE gene makes a protein which, when combined 
with fat, becomes a lipoprotein. The lipoprotein ApoE is a 
very low-density lipoprotein, responsible in part for 
removing cholesterol from the bloodstream. Variations in 
ApoE affect cholesterol metabolism. 
rs7412 
ADIPOQ 
rs2241766 
Adiponectin is a hormone secreted by adipocytes that 

rs266729 
regulates energy homeostasis and glucose and lipid 
metabolism. It is an adipose tissue-specific plasma 
protein, the polymorphisms are associated with serum 
adiponectin concentrations. 
NR3C1 
rs56149945 
The glucocorticoid receptor (GR, or GCR) also known as 
NR3C1 (nuclear receptor subfamily 3, group C, member 
1) is the receptor to which cortisol and other 
glucocorticoids bind. The variant 1088A>G is associated 
with increase of sensitivity to glucocorticosteroids. 
CYP2D6 
rs3892097 
Protein 
CYP2D6 
responsible 
for 
1 
phase 
of 
biotransformation of a large number of exogenous and 
endogenous compounds. Gene polymorphisms may result 
in decrease in enzyme activity. 
rs35742686 
CYP2C9 
rs1799853 
It has been estimated that CYP2C9 is responsible for the 
metabolic clearance of up to 15-20% of all drugs 
undergoing phase I metabolism. Genetic variations cause 
changes in metabolic activity. 
rs1057910 
CYP2C19 
rs4244285 
The protein, a member of the cytochrome P450 mixed-
function oxidase system, is involved in the metabolism of 
xenobiotics, including many proton pump inhibitors and 
antiepileptic. Genetic variations cause changes in 
metabolic activity. 
NAT2 
rs1801280 
The gene encodes an enzyme N-acetyltransferase 2 that 
functions to both activate and deactivate arylamine and 
hydrazine drugs and carcinogens. Polymorphisms in this 
gene are responsible for the N-acetylation polymorphism 
in which human populations segregate into rapid, 
intermediate, and slow acetylator phenotypes. Allele T 
(341 T>C) is associated with increase insulin resistance. 
rs1799930 
rs1799931 
MTHFR 
rs1801133 
The protein encoded by this gene catalyzes the conversion 
of 
5,10-methylenetetrahydrofolate 
to 
5-
methyltetrahydrofolate, a co-substrate for homocysteine 
remethylation to methionine. The polymorphism 677 C>T 
is known, substituting an alanine (A) for a valine (V), 
where the T(V) allele results in a thermolabile enzyme 
with reduced activity. The carriers of genotype Т/Т have 
higher plasma homocysteine level. 
 
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