Clinical outcomes and patient-matched molecular composition of relapsed medulloblastoma

original reports Clinical Outcomes and Patient-Matched Molecular Composition of Relapsed Medulloblastoma Rahul Kumar, PhD 1,2 ; Kyle S. Smith, PhD 1 ; Maximilian Deng, MD 3 ; Colt Terhune, BA 4 ; Giles W. Robinson, MD 4 ; Brent A. Orr, MD, PhD 6 ; Anthony P. Y. Liu, MBBS 1,4 ; Tong Lin, PhD 5 ; Catherine A. Billups, MS 5 ; Murali Chintagumpala, MD 7 ; Daniel C. Bowers, MD 8 ; Timothy E. Hassall, MD 9 ; Jordan R. Hansford, MD 10 ; Dong Anh Khuong-Quang, PhD 10 ; John R. Crawford, MD 11 ; Anne E. Bendel, MD 12 ; Sridharan Gururangan, MD 13 ; Kristin Schroeder, MD, MPH 13 ; Eric Bouffet, MD 14 ; Ute Bartels, MD 14 ; Michael J. Fisher, MD 15 ; Richard Cohn, MD 16 ; Sonia Partap, MD 17 ; Stewart J. Kellie, MD 18 ; Geoffrey McCowage, MD 18 ; Arnold C. Paulino, MD 19 ; Stefan Rutkowski, MD 20 ; Gudrun Fleischhack, MD 21 ; Girish Dhall, MD 22 ; Laura J. Klesse, MD, PhD 8 ; Sarah Leary, MD 23 ; Javad Nazarian, PhD 24 ; Marcel Kool, PhD 25 ; Pieter Wesseling, MD 26 ; Marina Ryzhova, MD 27 ; Olga Zheludkova, MD 28 ; Andrey V. Golanov, MD 29 ; Roger E. McLendon, MD 30 ; Roger J. Packer, MD 31 ; Christopher Dunham, MD 32 ; Juliette Hukin, MB 33 ; Maryam Fouladi, MD 34 ; Claudia C. Faria, MD 35 ; Jose Pimentel, MD 36 ; Andrew W. Walter, MD 37 ; Nada Jabado, MD, PhD 38 ; Yoon-Jae Cho, MD 39 ; Sebastien Perreault, MD 40 ; Sidney E. Croul, MD 41 ; Michal Zapotocky, MD, PhD 42 ; Cynthia Hawkins, MD, PhD 43 ; Uri Tabori, MD 43 ; Michael D. Taylor, MD, PhD 43 ; Stefan M. Pfister, MD 27 ; Paul Klimo Jr, MD 44 ; Frederick A. Boop, MD 44 ; David W. Ellison, MD, PhD 6 ; Thomas E. Merchant, DO, PhD 45 ; Arzu Onar-Thomas, PhD 5 ; Andrey Korshunov, MD 46 ; David T. W. Jones, PhD 3,49 ; Amar Gajjar, MD 4 ; Vijay Ramaswamy, MD, PhD 43,48 ; and Paul A. Northcott, PhD 1 abstract PURPOSE We sought to investigate clinical outcomes of relapsed medulloblastoma and to compare molecular features between patient-matched diagnostic and relapsed tumors. METHODS Children and infants enrolled on either SJMB03 (NCT00085202) or SJYC07 (NCT00602667) trials who experienced medulloblastoma relapse were analyzed for clinical outcomes, including anatomic and temporal patterns of relapse and postrelapse survival. A largely independent, paired molecular cohort was analyzed by DNA methylation array and next-generation sequencing. RESULTS A total of 72 of 329 (22%) SJMB03 and 52 of 79 (66%) SJYC07 patients experienced relapse with significant representation of Group 3 and wingless tumors. Although most patients exhibited some distal disease (79%), 38% of patients with sonic hedgehog tumors experienced isolated local relapse. Time to relapse and postrelapse survival varied by molecular subgroup with longer latencies for patients with Group 4 tumors. Postrelapse radiation therapy among previously nonirradiated SJYC07 patients was associated with long-term survival. Reirradiation was only temporizing for SJMB03 patients. Among 127 patients with patient-matched tumor pairs, 9 (7%) experienced subsequent nonmedulloblastoma CNS malignancies. Subgroup (96%) and subtype (80%) stabilities were largely maintained among the remainder. Rare subgroup divergence was observed from Group 4 to Group 3 tumors, which is coincident with genetic alterations involving MYC,MYCN, and FBXW7. Subgroup-specific patterns of alteration were identified for driver genes and chromosome arms. CONCLUSION Clinical behavior of relapsed medulloblastoma must be contextualized in terms of up-front therapies and molecular classifications. Group 4 tumors exhibit slower biological progression. Utility of radiation at relapse is dependent on patient age and prior treatments. Degree and patterns of molecular conservation at relapse vary by subgroup. Relapse tissue enables verification of molecular targets and identification of occult secondary malignancies. J Clin Oncol 00. © 2021 by American Society of Clinical Oncology Creative Commons Attribution Non-Commercial No Derivatives 4.0 License INTRODUCTION Medulloblastoma relapse represents a key determinant of cancer-related mortality in the pediatric population. 1,2 Multimodal therapy that incorporates maximal surgical resection with craniospinal irradiation (CSI; children older than 3 years) and chemotherapy has driven 5-year overall survival rates to 80%-85% for averagerisk disease and 60%-70% for high-risk disease. 3,4 Nevertheless, treatment failure and relapse occur in up to one-third of patients and confers abysmal prognosis, with only approximately 10% of patients surviving beyond 5 years postrelapse. 5-7 Relapsed disease thus remains extremely refractory to existing therapies, whereas rare survivors often experience serious toxicity and devastating neurocognitive sequalae. 8,9 Although no standard approach for treating relapsed ASSOCIATED CONTENT Appendix Data Supplement Author affiliations and support information (if applicable) appear at the end of this article. Accepted on November 16, 2020 and published at ascopubs.org/journal/ jco on January 27, 2021: DOI https://doi. org/10.1200/JCO.20. 01359 1 Downloaded from ascopubs.org by 79.168.162.59 on February 5, 2021 from 079.168.162.059 Copyright © 2021 American Society of Clinical Oncology. All rights reserved. medulloblastoma exists, salvage therapies, including conventional and targeted agents, have largely failed to confer durable survival benefit. 10,11 A deeper clinical and biological understanding of medulloblastoma recurrence is needed for the design and interpretation of next-generation clinical trials for relapsed disease. Although extensive genomic characterization of medulloblastoma has identified four biologically and clinically distinct subgroups (wingless [WNT], sonic hedgehog [SHH], Group 3, and Group 4), most studies have relied on diagnostic samples that have not been exposed to tumor-directed therapies. 12 Comparative molecular studies of diagnostic versus relapsed medulloblastoma have suggested divergent clonal selection, leading to emergence of specific molecular alterations at relapse in the context of subgroup conservation. 13-16 However, the generalizability of such findings is diminished by relatively modest cohort sizes and employment of different molecular assays. Additionally, exclusion of secondary CNS malignancies subsequent to medulloblastoma therapy, particularly high-grade gliomas, requires robust classification methods to prevent inadvertent cross-entity comparisons and may represent a key limitation of previous comparative studies. 17,18 Multiple recent studies have leveraged DNA methylation profiling to describe additional intertumoral heterogeneity within the core medulloblastoma subgroups. 19-21 These subtypes, primarily defined among SHH (a,b,g, and d) and Groups 3 and 4 (I-VIII) tumors, have distinctive genetic and clinical features. 22,23 Furthermore, subtype-defined risk paradigms are an active area of investigation. However, contextualization of these subtypes in relapsed disease and assessment of conservation at relapse are lacking. In this study, subgroup-specific clinical behavior of relapsed medulloblastoma is described for patients enrolled on two, multi-institutional, risk-adapted clinical trials. A largely independent, paired molecular cohort composed of patientmatched diagnostic and relapse tumors is investigated to determine the molecular features of medulloblastoma relapse using DNA methylation profiling and next-generation sequencing. METHODS Patients and Samples Study populations are summarized in the Data Supplement (online only). Eligible patients with relapsed medulloblastoma from two multi-institutional, risk-adapted clinical trials, SJMB03 (NCT00085202; Gajjar et al 24 and SJYC07 (NCT00602667), 23 were included (Appendix Table A1, online only; Data Supplement). Patients with a clinical diagnosis of nonmedulloblastoma subsequent malignancy were excluded. Given the differing eligibility criteria, risk stratifications, and treatment protocols between the trials, patients from each trial were analyzed separately for clinical outcomes based on molecular features garnered from primary tumor specimens. A largely independent, paired molecular cohort of 127 patients with formalin-fixed paraffin-embedded (FFPE) or frozen tissue specimens available from both their histopathologically diagnosed primary medulloblastoma and relapse or subsequent tumors was also assembled (Appendix Table A2, online only; Data Supplement). Comparative molecular analyses were performed among the paired molecular cohort using patient-matched primary and relapsed tumor specimens. Tumor Molecular Profiling Tumor specimens were analyzed using Infinium Methylation EPIC or 450K BeadChip arrays (Illumina, San Diego, CA) from either freshly frozen or FFPE tissue (Data Supplement). Medulloblastoma subgroup and subtype predictions were determined using DNA methylation–based classification of CNS tumors (MolecularNeuropathology, Heidelberg, Germany, version 11b4) and trained random forest predictions. 18 Genome-wide DNA copy number alterations were inferred from DNA methylation arrays using the Conumee R package. Next-generation (whole-exome or targeted gene panel) sequencing was performed on tumor samples with sufficient material available. Additional details regarding bioinformatic processing are given in the Appendix Methods (Data Supplement). Genomic datasets included in this CONTEXT Key Objective To determine the clinical outcomes and molecular features of relapsed medulloblastoma. Knowledge Generated Time to relapse and postrelapse survival are associated with subgroup with Group 4 tumors exhibiting slower biological progression. Utility of radiation therapy at relapse depends on age and previous therapies. Most relapses exhibit concordant subgroup classifications, except in the cases of occult secondary malignancies or rare divergence from group 4 to group 3. Driver gene and chromosome arm alteration patterns vary according to molecular subgroup. Relevance Future trials for relapsed medulloblastoma must be contextualized by molecular subgroup and up-front therapies. Relapse tissue should be acquired and used for confirmation of diagnosis and verification of molecular targets. 2© 2021 by American Society of Clinical Oncology Kumar et al Downloaded from ascopubs.org by 79.168.162.59 on February 5, 2021 from 079.168.162.059 Copyright © 2021 American Society of Clinical Oncology. All rights reserved. study can be freely explored using the online St Jude Cloud pediatric genomic data resource. 25 Statistical Analysis Time-to-event analyses were performed using KaplanMeier methods with log-rank tests. Hazard ratios (HRs) with associated 95% CIs and Pvalues were computed using Cox regression. Distributions of categorical variables were compared using Fisher’s exact or chi-square test. Multiple testing correction was performed using false discovery rate. Statistical analyses were performed using R version 3.5.1 and are further detailed in the Appendix Methods (Data Supplement). RESULTS Incidence of Relapsed Disease An overview of inclusion criteria, risk stratifications, and treatment protocols for SJMB03 and SJYC07 is shown in Figure 1A.Atotalof72of329(22%)patientsfrom SJMB03and52of79fromSJYC07(66%)relapsed(Fig 1B). Appendix Table A1 summarizes the demographic and clinical characteristics of relapsed patients from each trial according to molecular subgroup. Notably, WNT subgroup relapsed medulloblastomas were absent in both trials. Distributions of subgroups across clinical trial risk groups for relapsed patients are shown in Figure 1C. Subgroup distribution between relapsed and nonrelapsed patients was not uniform in either SJMB03 (P5.0019, chi-square test) or SJYC07 (P5.00083, chi-square test; Fig 1B). Compared with Group 3 tumors, Group 4 tumors had a lower relapse rate in SJMB03 (odds ratio [OR], 0.31; 95% CI, 0.16 to 0.61), whereas SHH tumors had a lower relapse rate in SJYC07 (OR, 0.08; 95% CI, 0.01 to 0.33). The distribution of novel subtypes 19,20,22,23 between relapsed and nonrelapsed patients was not uniform for Groups 3 and 4 subtypes in SJMB03 (P,.0001, chisquare test) or SHH subtypes in SJYC07 (P5.0058, chisquare test; Data Supplement). Proportions of relapsed patients between SJMB03 and SJYC07 differed for novel Groups 3 and 4 subtypes IV (P,.0001, Fisher’s exact test) and VII (P,.0001, Fisher’s exact test). Time to Relapse The median time to relapse was 1.64 years (interquartile range [IQR], 0.91-3.03) for SJMB03 and 0.72 year (IQR, 0.47-1.00) for SJYC07 (Data Supplement). For SJMB03, time to relapse varied by molecular subgroup (P5.00087, log-rank test) with a median time to relapse for patients with Group 4 tumor of 2.79 years (IQR, 1.99-3.64) compared with 0.91 year (IQR, 0.68-1.37) for Group 3 (HR, 3.01; 95% CI, 1.67 to 5.41) and 1.23 years (IQR, 0.96-2.34) for patients with SHH (HR, 2.41; 95% CI, 1.20 to 4.81; Fig 1D). For SJYC07, time to relapse also varied by molecular subgroup (P5.039, log-rank test), largely driven by difference between Group 4 and Group 3 tumors (HR, 2.74; 95% CI, 1.14 to 6.60; Fig 1E). Clinical risk group was a significant covariate for time to relapse only among patients with Group 4 tumor in SJMB03 (Data Supplement). Time to relapse according to novel SHH and Groups 3 and 4 subtypes is shown in Data Supplement. Anatomic Patterns of Relapse Relapse occurred with a distant component in 57 (79%) SJMB03 patients (Fig 1F) and 41 (79%) SJYC07 patients (Fig 1G). Of patients with SHH tumors, 43% in SJMB03 and 35% in SJYC07 presented with isolated local relapse compared with only 14% (P5.028, Fisher’s exact test) and 10% (P5.067, Fisher’s exact test) of non-SHH tumors, respectively (Figs 1F and 1G). Distant relapses were significantly associated with shorter time to relapse only for Group 4 tumors in SJMB03 (HR, 5.08; 95% CI, 1.14 to 22.6) and SHH tumors in SJYC07 (HR, 3.48; 95% CI, 1.07 to 11.3; Data Supplement). Survival After Relapse At data cutoff, seven relapsed patients (10%) from SJMB03 and 24 (46%) from SJYC07 were alive. The median postrelapse survival (PRS) was 1.14 years (IQR, 0.30-2.36) for SJMB03 and 2.12 (IQR, 0.39-NA) for SJYC07 (Data Supplement). Clinical trial risk group was not significantly associated with PRS for SJMB03 (P5.43, log-rank test) or SJYC07 (P5.099, log-rank test; Data Supplement). For SJMB03, PRS time varied by molecular subgroup (P5 .016, log-rank) with the median PRS time for patients with Group 4 tumors of 2.27 years (IQR, 1.19-3.89) compared with 0.44 year (IQR, 0.29-1.29) for patients with Group 3 tumors (HR, 2.39; 95% CI, 1.29 to 4.42) and 1.06 years (IQR, 0.27-1.88) for patients with SHH tumors (HR, 1.90; 95% CI, 0.94 to 3.83; Fig 2A). For SJYC07, PRS did not vary significantly by molecular subgroup (P5.88, log-rank test; Fig 2B). Time to relapse was significantly associated with PRS for SJMB03 (HR, 0.65; 95% CI, 0.52 to 0.82) but not for SJYC07 (HR, 0.53; 95% CI, 0.23 to 1.23). Notably, the association of time to relapse and PRS for SJMB03 remained significant with subgroup and clinical trial risk group as additional covariates (HR, 0.67; 95% CI, 0.50 to 0.90). PRS according to novel SHH and Groups 3 and 4 subtypes is shown in the Data Supplement. Twenty-five (35%) relapsed SJMB03 patients (one patient missing data) and 30 (58%) SJYC07 patients received radiation after relapse. For SJMB03 patients, a transient PRS benefit(P5.032, log-rank test; Fig 2C) was observed with additional radiation after relapse (HR, 0.56; 95% CI, 0.33 to 0.96). For SJYC07 patients, postrelapse CSI (median, 36.0 Gy) was significantly associated with long-term survival (P,.0001, log-rank test; Fig 2D), particularly for patients with SHH (HR, 0.04; 95% CI, 0.01 to 0.37) and Group 3 tumors (HR, 0.27; 95% CI, 0.08 to 0.85) (Data Supplement). Journal of Clinical Oncology 3 Clinico-Molecular Experience With Medulloblastoma Relapse Downloaded from ascopubs.org by 79.168.162.59 on February 5, 2021 from 079.168.162.059 Copyright © 2021 American Society of Clinical Oncology. All rights reserved. C 10 (100%) 4 (18%) 11 (50%) 6 (27%) 1 (5%) 6 (30%) 11 (55%) 2 (10%) 1 (5%) 0 5 10 15 20 Low (n = 10) Intermediate (n = 22) High (n = 20) SJYC07 Risk Group No. of Relapsed Patients SJYC07 (n = 52 relapsed patients) 9 (24%) 11 (30%) 10 (27%) 7 (19%) 5 (14%) 15 (43%) 14 (40%) 1 (3%) 0 10 20 30 Average (n = 37) High (n = 35) SJMB03 Risk Group No. of Relapsed Patients SJMB03 (n = 72 relapsed patients) MB Subgroup SHH Group 3 Group 4 Unclassified A Posterior fossa lesion Surgical resection Medulloblastoma 70CYJS30BMJS M0 GTR M+ <GTR M0 GTR DNMB <GTR non-DNMB 3-5 yo* M+M0 HDMTX VCR Cyclo Cisplatin VinblastineBoost 55-58 Gy VCR Cyclo Cisplatin Cyclo Carboplatin Etoposide Focal RT 54 Gy Topotecan Cyclo CSI (> 3 yo) CSI 23.4 Gy CSI 36-39 Gy yparehtomehc noitcudnInoitaidarri lanipsoinarC Cyclo Topotecan Erlotonib Maintenance chemotherapy High-dose chemotherapy Consolidation therapy < 3 yo* ≥ 3-21 yo 3-5 yo with M0, GTR, and DNMB were eligible for inclusion on intermediate-risk arm of SJYC07 Must have all features for inclusion Any listed feature for inclusion Risk stratification criteria: Average risk High risk Low risk Intermediate risk High risk * Relapse No Yes B SJMB03 (n = 329 patients) Non-WNT Chi-square P = .0019 ref. n.s. 0% 40% 17% 29% 33% WNT SHH G3 G4 UC 0 50 100 No. of Patients * SJYC07 (n = 79 patients) Chi-square P = .00083 ref. n.s. 48% 92% 80% 67% 0 10 20 30 40 SHH G3 G4 UC No. of Patients * D 012345 Years Since Diagnosis Cumulative Relapses SJMB03 Time to Relapse by MB Subgroup (n = 74 patients) Log-rank P = .00087 1495200 2694220 24 21 18 12 5 1 885210Unclassified Group 4 Group 3 SHH Number at Risk Median TTR: SHH: 1.23 yrs Group 3: 0.91 yrs Group 4: 2.79 yrs Unclassified: 2.07 yrs P < .05 ** 0.25 0.50 0.75 1.00 E 0.25 0.50 0.75 1.00 01234 Years Since Diagnosis Cumulative Relapses SJYC07 Time to Relapse by MB Subgroup (n = 52 patients) Log-rank P = .039 20 5 1 1 1 22 3 0 0 0 84110 21000Unclassified Group 4 Group 3 SHH Number at Risk P < .05 MedianTTR: SHH: 0.74 Group 3: 0.55 Group 4: 1.08 Unclassified: 0.78 * FIG 1. Relapse patterns for SJMB03 and SJYC07 patients with medulloblastoma. (A) Overview of trial designs and risk stratifications. (B) Apparent relapse rates by medulloblastoma subgroup per trial. (C) Medulloblastoma subgroup distributions per trial risk stratifications. Time to relapse by subgroup for SJMB03 patients (D) and SJYC07 patients (E). Anatomic patterns of relapse per subgroup for SJMB03 (F) and SJYC07 (G) patients. CSI, craniospinal irradiation; DNMB, desmoplastic nodular medulloblastoma; GTR, gross total resection; HDMTX, high-dose methotrexate; MB, medulloblastoma; RT, radiation therapy; SHH, sonic hedgehog; TTR, time to relapse; UC, unclassified; VCR, vincristine; WNT, wingless. 4© 2021 by American Society of Clinical Oncology Kumar et al Downloaded from ascopubs.org by 79.168.162.59 on February 5, 2021 from 079.168.162.059 Copyright © 2021 American Society of Clinical Oncology. All rights reserved. Patient-Matched Molecular Landscapes Given the rarity of tissue availability from relapsed medulloblastoma and with only seven patients from each trial with relapse tissue available, a large multi-institutional, paired molecular cohort of 127 patient-matched diagnostic and relapsed tumors was assembled (Fig 3A; Appendix Table A2; Data Supplement). Sufficient tissue for DNA methylation profiling was required for inclusion, and whole-exome or targeted panel sequencing data were available for both patient-matched samples in 50% (64 of 127) of the paired molecular cohort (Fig 3B). DNA methylation classification identified nine relapse cases (7%) as nonmedulloblastoma subsequent tumors within the paired molecular cohort (Fig 3C; Data Supplement). 18 Molecular Subgroups and Subtypes Among 118 patients with molecularly confirmed relapsed medulloblastoma, diagnostic tumors were classifiedbymethylationasWNTin1(1%),SHHin48 (41%),Group3in22(19%),andGroup4in46(39%). Medulloblastoma subgroup was conserved at relapse in 113 patients (96%) with divergence observed in a total of five patients between Groups 3 and 4 tumors. Novel molecular subtypes within SHH and Groups 3 and 4 tumors were conserved at relapse in 80% of patients (Figs 3D and 3E). 19,20 To assess the degree of molecular conservation between patient-matched diagnostic and relapsed tumors, mutations and copy number alterations of curated medulloblastoma driver genes and chromosomal arms were analyzed (Fig 4A; Data Supplement). 19 Subgroup designation for paired patient-matched cases was based on subgroup at diagnosis. Driver Gene Alteration Patterns The distribution and pattern of driver gene alterations by subgroup are shown in Figure 4B. Subgroup was associated with a significant difference in conservation pattern of driver gene alterations, largely driven by biases in SHH, which were predominantly conserved (P,.0001, analysis of variance). The median number of discordant driver gene alterations between patient-matched tumors was one with no difference between subgroups (P5.10, Kruskal-Wallis test; Data Supplement). A total of 29% of cases had completely conserved driver gene alterations with no statistical difference between subgroups (P5.29, chi-square test). Within subgroups, the number of discordant copy number variations or mutations was not significantly associated with age at diagnosis, time to relapse, or recurrence pattern (Data Supplement). The incidence of shared driver gene alterations was 52% in SHH, 36% in Group 3, and 37% in Group 4 tumors (Figs 4A F Anatomic Patterns of Relapse for SJMB03 Local only versus Distant component Chi-square P = .058 6 (43%) 4 (15%) 3 (12%) 2 (25%) Local only 0 5 10 15 20 SHH n = 14 Group 3 n = 26 Group 4 n = 24 Unclassified n = 8 Subgroup No. of Relapsed Patients 7 (50%) 21 (81%) 20 (83%) 6 (75%) Distant 0 5 10 15 20 SHH n = 14 Group 3 n = 26 Group 4 n =24 Unclassified n = 8 Subgroup No. of Relapsed Patients 1 (7%) 1 (4%) 1 (4%) Local + Distant 0 5 10 15 20 SHH n = 14 Group 3 n = 26 Group 4 n = 24 Unclassified n = 8 Subgroup No. of Relapsed Patients G Anatomic Patterns of Relapse for SJYC07 Local only versus Distant component Chi-square P = .094 7 (35%) 2 (9%) 1 (12%) 1 (50%) Local only 0 5 10 15 SHH n = 20 Group 3 n = 22 Group 4 n = 8 Unclassified n = 2 Subgroup No. of Relapsed Patients 8 (40%) 16 (73%) 7 (88%) Distant 0 5 10 15 SHH n = 20 Group 3 n = 22 Group 4 n = 8 Unclassified n = 2 Subgroup No. of Relapsed Patients 5 (25%) 4 (18%) 1 (50%) Local + Distant SHH n = 20 Group 3 n = 22 Group 4 n = 8 Unclassified n = 2 0 5 10 15 Subgroup No. of Relapsed Patients FIG 1. (Continued). Journal of Clinical Oncology 5 Clinico-Molecular Experience With Medulloblastoma Relapse Downloaded from ascopubs.org by 79.168.162.59 on February 5, 2021 from 079.168.162.059 Copyright © 2021 American Society of Clinical Oncology. All rights reserved. and 4B). Notable shared driver gene alterations included those affecting PTCH1 (10 of 12, 88% shared) and DDX3X (6 of 7, 86%) in SHH tumors. The incidence of relapsespecific driver gene alterations was 29% in SHH, 57% in Group 3, and 40% in Group 4 tumors. Additionally, numerous low incidence relapse-specific alterations, particularly among chromatin modifiers (eg, CREBBP and SMARCA4) and DNA repair machinery (eg, BRCA2), were observed across subgroups. Primary-specific driver gene alterations, such as focal CDK6 amplification in one primary SHH tumor and one primary Group 4 tumor, were rare and comprised the minority in observed patterns of conservation and divergence. Driver genes with increased odds of alteration in relapsed patients were identified using primary tumor molecular data available for the clinical trial cohorts (Data Supplement). Conservation pattern of such alterations, including TP53 mutations and MYC and MYCN amplifications, was then B + ++ + ++ + + + + + + + +++ +++ ++ + ++ 0.25 0.50 0.75 1.00 02468 Years Since Relapse Postrelapse Survival SJYC07 PRS by MB subgroup (n = 52 patients) 20 (0) 9 (3) 3 (6) 1 (8) 0 (9) 22 (0) 9 (3) 7 (4) 3 (7) 0 (10) 8 (0) 2 (3) 1 (4) 1 (4) 0 (5) 2 (0) 0 (0) 0 (0) 0 (0) 0 (0)Unclassified Group 4 Group 3 SHH Number at Risk (number censored) Log-rank P = .88 Median PRS: SHH: Group 3: Group 4: Unclassified: 2.26 2.24 1.61 0.26 SHH: Group 3: Group 4: Unclassified: 3-year OS (95% CI): 38 (20% to 71%) 46% (29% to 74%) 44% (17% to 100%) .. 1-year OS (95% CI): 59% (40% to 85%) 57% (39% to 83%) 67% (38% to 100%) .. D Years Since Relapse ++ + ++ ++ +++ ++ + + ++++ + + + + + + 0.25 0.50 0.75 1.00 02468 Postrelapse Survival SJYC07 PRS by RT (n = 52 patients) 30 (0) 17 (5) 10 (10) 5 (14) 0 (19) 22 (0) 3 (4) 1 (4) 0 (5) 0 (5) Number at Risk (number censored) No Yes Postrelapse RT Postrelapse RT: +Yes +No Log-rank P = 4e-06 3-year OS (95% CI): 62% (46% to 84%) 8% (1% to 49%) 1-year OS (95% CI): 79% (65% to 50%) 25% (11% to 55%) Postrelapse RT: No postrelapse RT: C 0.25 0.50 0.75 1.00 0 2.5 5 7.5 10 Years Since Relapse Postrelapse Survival SJMB03 PRS by RT (n = 71 patients) 25 (0) 12 (0) 5 (1) 2 (1) 1 (2) 46 (0) 4 (2) 2 (3) 2 (3) 2 (3) No Yes Postrelapse RT Number at Risk (number censored) Postrelapse RT: +Yes +No Log-rank P = .032 3-year OS (95% CI): 39% (24% to 64%) 12% (5% to 27%) 1-year OS (95% CI): 68% (52% to 89%) 50% (37% to 67%) Postrelapse RT: No postrelapse RT: + + ++ ++ A 0.25 0.50 0.75 1.00 0 2.5 5 7.5 10 Years Since Relapse Postrelapse Survival SJMB03 PRS by MB Subgroup (n = 72 patients) 14 (0) 2 (0) 1 (1) 1 (1) 1 (1) 26 (0) 1 (2) 1 (2) 1 (2) 1 (2) 24 (0) 11 (1) 4 (1) 2 (1) 1 (2) 8 (0) 2 (0) 1 (0) 0 (0) 0 (0)Unclassified Group 4 Group 3 SHH Number at Risk (number censored) Log-rank P = .016 14% (4% to 52%) 10% (3% to 34%) 38% (22% to 63%) 25% (8% to 83%) 3-year OS (95% CI): 1-year OS (95% CI): 57% (36% to 90%) 35% (20% to 59%) 80% (65% to 97%) 63% (37% to 100%) SHH: Group 3: Group 4: Unclassified: + +++ + + Median PRS: SHH: 1.06 yrs Group 3: 0.44 yrs Group 4: 2.27 yrs Unclassified: 1.07 yrs P < .05 * FIG 2. Postrelapse outcomes for SJMB03 and SJYC07 patients with medulloblastoma. PRS by subgroup for SJMB03 (A) and SJYC07 (B) patients. Postrelapse survival by receipt of radiation therapy after relapse for SJMB03 (C) and SJYC07 (D) patients. MB, medulloblastoma; OS, overall survival; PRS, postrelapse survival; RT, radiation therapy; SHH, sonic hedgehog. 6© 2021 by American Society of Clinical Oncology Kumar et al Downloaded from ascopubs.org by 79.168.162.59 on February 5, 2021 from 079.168.162.059 Copyright © 2021 American Society of Clinical Oncology. All rights reserved. BA Inclusion Criteria: Patients with histopathologically diagnosed MB Sufficient tissue available for both primary and subequent tumors 131 patients 271 tumors 1 primary tumor unclassifiable 3 relapse tumors in normal tissue Methylation profiling 127 patients 262 tumors Paired molecular cohort: 127 patients 254 tumors 3 patients with multiple primary tumors 5 patients multiple relapse tumors Relapsed MBs: 118 patients 236 tumors Subsequent tumors: 9 patients 18 tumors NGS n = 7 patients NGS n = 57 patients Methylation n = 118 patients Methylation n = 9 patients Relapsed Cohort Subsequent Tumor Cohort n = 1 patient n = 5 patients Panel WES WES/Panel n = 7 patients n = 8 patients n = 42 patients n = 1 patient Panel WES WES/Panel C MB, SHH MB, WNT MB, G4 MB, G3 MB, SHH MB, WNT MB, G4 MB, G3 HGG EWS Subsequent tumors Relapsed MB Paired Molecular Cohort (n = 127 Patients) No. of Patients 125 100 75 50 25 0 Primary Relapse D Group 3 and 4 Subtypes (n = 69 patients) VIII VII VI V IV III II I VIII VII VI V IV III II I 0 20 40 60 Primary Relapse No. of Patients E SHH Subtypes (n = 48 patients) γ δ β (iSHH-I) (iSHH-I) α γ δ β α 0 10 20 30 40 50 Primary Relapse No. of Patients (iSHH-II) (iSHH-II) FIG 3. Overview of patient-matched molecular cohort. (A) Flowchart describing assembly of paired molecular cohort composed of patients with truly relapsed medulloblastomas and those with other subsequent CNS malignancies. (B) Methylation and next-generation sequencing data availability for each arm of the paired molecular cohort. (C) Subgroup and entity classification of patient-matched tissue from diagnosis and relapse. Novel Groups 3 and 4 (D) and SHH (E) subtype classifications of patient-matched tissue from diagnosis and relapse. EWS, Ewing sarcoma; HGG, high-grade glioma; iSHH, infant SHH; MB, medulloblastoma; NGS, next-generation sequencing; SHH, sonic hedgehog; WES, whole-exome sequencing; WNT, wingless. Journal of Clinical Oncology 7 Clinico-Molecular Experience With Medulloblastoma Relapse Downloaded from ascopubs.org by 79.168.162.59 on February 5, 2021 from 079.168.162.059 Copyright © 2021 American Society of Clinical Oncology. All rights reserved. Alterations Age Sex Subgroup Instance AMB, WNT (n = 1 pair) MB, SHH (n = 23 pairs) MB, G3 (n = 10 pairs) MB, G4 (n = 23 pairs) 0 5 Data Alteration Pattern Data PTCH1 MYCN DDX3X OTX2 GLI2 KMT2D MYC PTEN TP53 APC BRCA2 KMT2C TERT CDK6 FBXW7 GSE1 SMO FAT1 KDM6A ARID1A CREBBP FMR1 IDH1 SMARCA4 TBR1 Other Driver 1q 2p 2q 3q 6p 6q 7p 9p 9q 10q 17p 17q 21q 05025 25 050 0 25 NA NA NA NA No. of CNV Alterations No. of Driver Alterations Age Sex Subgroup Instance Subtype NA SNV Indel Male Female MB, WNT MB, SHH MB, G3 MB, G4 Primary Relapse Amplification Deletion Infant Child Adult Panel WES Shared Discordant B No. of Cases (paired primary and relapsed tumors) No. of Cases (paired primary and relapsed tumors) No. of Cases (paired primary and relapsed tumors) Other driver TBR1 SMARCA4 IDH1 FMR1 CREBBP ARID1A KDM6A FAT1 SMO GSE1 FBXW7 CDK6 TERT KMT2C BRCA2 APC TP53 PTEN MYC KMT2D GLI2 OTX2 DDX3X MYCN PTCH1 MB, G4 (15/23 pairs) 50 Other driver TBR1 SMARCA4 IDH1 FMR1 CREBBP ARID1A KDM6A FAT1 SMO GSE1 FBXW7 CDK6 TERT KMT2C BRCA2 APC TP53 PTEN MYC KMT2D GLI2 OTX2 DDX3X MYCN PTCH1 MB, G3 (7/10 pairs) 40 MB, SHH (23/23 pairs) Other Driver TBR1 SMARCA4 IDH1 FMR1 CREBBP ARID1A KDM6A FAT1 SMO GSE1 FBXW7 CDK6 TERT KMT2C BRCA2 APC TP53 PTEN MYC KMT2D GLI2 OTX2 DDX3X MYCN PTCH1 110 snoitaretla 03 = nsnoitaretla 41 = nsnoitaretla 86 = n Proportion of Driver Alterations %92%91 52% 57%7% %04%32%63 37% Subgroup Versus Alteration Pattern P < .001 Pattern of alteration: Relapse onlyPrimary onlyShared FIG 4. Molecular landscape of relapsed medulloblastoma. (A) Oncoprint depicting patient characteristics, driver gene alterations, and chromosomal copy number variation for patient-matched tumor pairs with available next-generation sequencing (n 557 patients). (B) Compartment-specific patterns of driver gene alterations by molecular subgroup. (C) Genomic track of chromosome 2 depicting alteration patterns observed for MYCN.(D) Compartment-specific patterns of chromosome arm copy number variation by molecular subgroup for patient-matched tumor pairs (n 5107 patients). Genomic tracks depicting alteration patterns of chromosome 17 (E) and chromosome 10 (F). CNV, copy number variation; G3, Group 3; G4, Group 4; MB, medulloblastoma; SHH, sonic hedgehog; SNV, single nucleotide variant; WES, whole-exome sequencing; WNT, wingless. 8© 2021 by American Society of Clinical Oncology Kumar et al Downloaded from ascopubs.org by 79.168.162.59 on February 5, 2021 from 079.168.162.059 Copyright © 2021 American Society of Clinical Oncology. All rights reserved. C MYCN MYCN MYCN MYCN MYCN MYCN −1.2 −0.8 −0.4 0.0 0.4 0.8 1.2 MYCN MYCN MYCN MYCN MYCN MYCN Instance: Patient: Subgroup: MB-7 MB-28 MB-121 MB-9 MB-70 MB-78 Log2 Ratio Alteration Pattern: MYCN Relapse OnlyPrimary OnlyShared chr2 chr2 chr2 chr2 chr2 chr2chr2 chr2 chr2 chr2 chr2 chr2 E 9 10 11 Instance Subgroup Patient Chromosome F 16 17 18 Instance Subgroup Patient Chromosome MB-128 MB-124 MB-78 MB-17 MB-7 MB-3 MB-37 MB-32 D Pattern of alteration: Relapse onlyPrimary onlyShared No. of Cases (paired primary and relapse tumors) No. of Cases (paired primary and relapse tumors) No. of Cases (paired primary and relapse tumors) MB, G3 (21/21 pairs) MB, G4 (45/46 pairs) Proportion of Altered Chromosomal Arms MB, SHH (33/40 pairs) n = 294 alterationsn = 201 alterationsn = 222 alterations 10% Subgroup Versus Alteration Pattern P = .0047 Chromosomal Arms 1p 1q 2p 2q 3p 3q 4p 4q 5p 5q 6p 6q 7p 7q 8p 8q 9p 9q 10p 10q 11p 11q 12p 12q 13q 14q 15q 16p 16q 17p 17q 18p 18q 19p 19q 20p 20q 21q 22q 0 10 20 30 ** *** * * Chromosomal Arms 1p 1q 2p 2q 3p 3q 4p 4q 5p 5q 6p 6q 7p 7q 8p 8q 9p 9q 10p 10q 11p 11q 12p 12q 13q 14q 15q 16p 16q 17p 17q 18p 18q 19p 19q 20p 20q 21q 22q 0 5 10 15 * * * * * * Chromosomal Arms 1p 1q 2p 2q 3p 3q 4p 4q 5p 5q 6p 6q 7p 7q 8p 8q 9p 9q 10p 10q 11p 11q 12p 12q 13q 14q 15q 16p 16q 17p 17q 18p 18q 19p 19q 20p 20q 21q 22q 0 5 10 15 * 61% 29%17% 42% %82%41%14 58% FIG 4. (Continued). Journal of Clinical Oncology 9 Clinico-Molecular Experience With Medulloblastoma Relapse Downloaded from ascopubs.org by 79.168.162.59 on February 5, 2021 from 079.168.162.059 Copyright © 2021 American Society of Clinical Oncology. All rights reserved. AUTHORS’DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Clinical Outcomes and Patient-Matched Molecular Composition of Relapsed Medulloblastoma The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I 5Immediate Family Member, Inst 5My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/authors/author-center. Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments). Giles W. Robinson Consulting or Advisory Role: Lilly, Roche/Genentech Research Funding: Novartis, Genentech/Roche, Novartis Jordan R. Hansford Consulting or Advisory Role: Bayer John R. Crawford Honoraria: Illumina Speakers’Bureau: AstraZeneca Eric Bouffet Consulting or Advisory Role: Novartis Research Funding: Roche, Bristol-Myers Squibb Michael J. Fisher Honoraria: AstraZeneca Research Funding: AstraZeneca, Array BioPharma, Exelixis Travel, Accommodations, Expenses: AstraZeneca, SpringWorks Sonia Partap Consulting or Advisory Role: Bayer, Gerson Lehrman Group Research Funding: Abbvie Geoffrey McCowage Consulting or Advisory Role: Biogen Research Funding: Novartis, Merck Travel, Accommodations, Expenses: BIOGEN Arnold C. Paulino Employment: MD Anderson Cancer Center Patents, Royalties, Other Intellectual Property: Royalty from Elsevier Inc for book on PET/CT in Radiotherapy Treatment Planning Travel, Accommodations, Expenses: University of Southern California Stefan Rutkowski Consulting or Advisory Role: Bristol-Myers Squibb GmbH & Co KGaA, Germany, Celgene, Roche Pharma AG, Grenzach-Wyhlen Research Funding: Riemser Pharma GmbH, Greifswald, Germany Laura J. Klesse Consulting or Advisory Role: AstraZeneca Travel, Accommodations, Expenses: Springworks, AstraZeneca Sarah Leary Research Funding: Blaze Bioscience Roger E. McLendon Stock and Other Ownership Interests: Gilead Sciences, NantKwest Expert Testimony: Johnson & Johnson Roger J. Packer Honoraria: Novartis Consulting or Advisory Role: Novartis, AstraZeneca Juliette Hukin Stock and Other Ownership Interests: Abbvie Maryam Fouladi Research Funding: PTC therapeutics, Bayer Schering Pharma Sebastien Perreault Leadership: Bayer Stock and Other Ownership Interests: Novocure Honoraria: Bayer Consulting or Advisory Role: Bayer Speakers’Bureau: Bayer Expert Testimony: Bayer Michal Zapotocky Consulting or Advisory Role: Bayer Patents, Royalties, Other Intellectual Property: IP for low grade glioma and sarcoma fusion panels as well as medulloblastoma subgrouping panel Stefan M. Pfister Research Funding: Lilly, Bayer, Roche, PharmaMar, Pfizer Patents, Royalties, Other Intellectual Property: Patent on utilizing DNA methylation profiling for tumor classification Frederick A. Boop Employment: Semmes Murphey Clinic David W. Ellison Patents, Royalties, Other Intellectual Property: Sole inventor of US Patent No. 9,005,907 issued April 14, 2015 “Methods and Compositions for Typing Molecular Subgroups of Medulloblastoma”, 62627291/S88435 1190US.P1 February 2018 “Epigenetic Histone Regulation Mediated by CXorf67”published August 2019 as WO 2019/155387 Thomas E. Merchant Travel, Accommodations, Expenses: Philips Healthcare Arzu Onar-Thomas Consulting or Advisory Role: Roche Research Funding: Novartis, Apexigen, Pfizer, Celgene, Novartis, Merck, Novocure Travel, Accommodations, Expenses: Roche David T. W. Jones Patents, Royalties, Other Intellectual Property: Patent WO 2013075237 A1, titled “Mutations of histone proteins associated with proliferative disorders” Amar Gajjar Consulting or Advisory Role: Roche/Genentech Research Funding: Genentech, Kazia Pharmaceutical Vijay Ramaswamy Honoraria: AstraZeneca No other potential conflicts of interest were reported. © 2021 by American Society of Clinical Oncology Kumar et al Downloaded from ascopubs.org by 79.168.162.59 on February 5, 2021 from 079.168.162.059 Copyright © 2021 American Society of Clinical Oncology. All rights reserved. APPENDIX TABLE A1. Demographics and Diagnostic Clinical Characteristics of Relapsed Patients MB Subgroup SJMB03 (n 572) SJYC07 (n 552) SHH n514 Group 3 n526 Group 4 n524 Unclassified n58 SHH n520 Group 3 n522 Group 4 n58 Unclassified n52 Sex Female 5 (36%) 8 (31%) 4 (17%) 1 (12%) 10 (50%) 12 (55%) 3 (38%) 1 (50%) Male 9 (64%) 18 (69%) 20 (83%) 7 (88%) 10 (50%) 10 (45%) 5 (62%) 1 (50%) Age (IQR) 8.9 (8.4-10.7) 6.4 (4.0-8.5) 7.8 (5.7-10.6) 9.1 (6.3-11.9) 2.0 (1.3-2.5) 2.6 (2.0-2.9) 3.71 (3.0-4.0) 1.1 (1.0-1.2) M stage M0 9 (64%) 12 (46%) 10 (42%) 7 (88%) 14 (70%) 11 (50%) 6 (75%) 1 (50%) M1 0 (0%) 2 (8%) 0 (0%) 0 (0%) 0 (0%) 1 (5%) 0 (0%) 0 (0%) M2 3 (21%) 0 (0%) 6 (25%) 0 (0%) 1 (5%) 1 (5%) 1 (12%) 0 (0%) M3 2 (14%) 12 (46%) 8 (33%) 1 (12%) 5 (25%) 9 (41%) 1 (12%) 1 (50%) Histology Classic 4 (29%) 15 (58%) 21 (88%) 7 (88%) 2 (10%) 17 (77%) 7 (88%) 2 (100%) DN 2 (14%) 0 (0%) 0 (0%) 0 (0%) 15 (75%) 0 (0%) 0 (0%) 0 (0%) LCA 7 (50%) 11 (42%) 3 (12%) 1 (12%) 0 (0%) 5 (23%) 1 (12%) 0 (0%) MBEN ——— —3 (15%) 0 (0%) 0 (0%) 0 (0%) Medullomyoblastoma 1 (7%) 0 (0%) 0 (0%) 0 (0%) —— — — Resection GTR 10 (71%) 19 (73%) 16 (67%) 7 (88%) 15 (75%) 15 (68%) 7 (88%) 2 (100%) NTR 2 (14%) 7 (27%) 7 (29%) 1 (12%) 0 (0%) 4 (18%) 0 (0%) 0 (0%) STR 2 (14%) 0 (0%) 1 (4%) 0 (0%) 5 (25%) 3 (14%) 1 (12%) 0 (0%) Postrelapse therapy Radiation Yes 4 (29%) 4 (15%) 14 (58%) 3 (38%) 9 (45%) 15 (68%) 6 (75%) 0 (0%) No 10 (71%) 21 (81%) 10 (42%) 5 (62%) 11 (55%) 7 (32%) 2 (25%) 2 (100%) Unknown 0 (0%) 1 (4%) 0 (12%) 0 (12%) —— — — Chemotherapy Yes 11 (79%) 17 (65%) 21 (88%) 5 (62%) 16 (80%) 12 (55%) 3 (38%) 0 (0%) No 1 (7%) 3 (12%) 1 (4%) 1 (12%) 4 (20%) 10 (45%) 5 (62%) 2 (100%) Unknown 2 (14%) 6 (23%) 2 (8%) 2 (25%) —— — — Abbreviations: DN, desmoplastic nodular; GTR, gross total resection; IQR, interquartile range; LCA, large cell anaplastic; MBEN, medulloblastoma with extensive nodularity; NTR, near total resection; SHH, sonic hedgehog; STR, subtotal resection. Journal of Clinical Oncology Clinico-Molecular Experience With Medulloblastoma Relapse Downloaded from ascopubs.org by 79.168.162.59 on February 5, 2021 from 079.168.162.059 Copyright © 2021 American Society of Clinical Oncology. All rights reserved. TABLE A2. Demographic and Clinical Parameters of Patient-Matched Molecular Cohort No. of Cases Subgroup (Diagnosis) Data Available N5127 MB, WNT n52 MB, SHH n552 MB, G3 n523 MB, G4 n550 Age, mean (SD) 25.0 (11.3) 15.9 (12.2) 5.87 (4.21) 8.75 (3.40) 124 Sex 127 Female 1 (50.0%) 21 (40.4%) 11 (47.8%) 19 (38.0%) Male 1 (50.0%) 31 (59.6%) 12 (52.2%) 31 (62.0%) Histology 127 Classic 1 (50.0%) 2 (3.85%) 3 (13.0%) 13 (26.0%) DNMB 0 (0.00%) 16 (30.8%) 0 (0.00%) 1 (2.00%) LCA 0 (0.00%) 8 (15.4%) 2 (8.70%) 0 (0.00%) NOS 1 (50.0%) 26 (50.0%) 18 (78.3%) 36 (72.0%) M Stage 86 M11 (100%) 9 (26.5%) 8 (57.1%) 8 (21.6%) M0 0 (0.00%) 25 (73.5%) 6 (42.9%) 29 (78.4%) Resection 79 GTR or NTR 1 (100%) 21 (65.6%) 7 (50.0%) 26 (81.2%) STR 0 (0.00%) 11 (34.4%) 7 (50.0%) 6 (18.8%) Relapse pattern 121 Distant 1 (50.0%) 14 (28.6%) 17 (73.9%) 31 (66.0%) Local 1 (50.0%) 35 (71.4%) 6 (26.1%) 16 (34.0%) Subgroup conservation 127 Conserved 1 (50.0%) 48 (92.3%) 21 (91.3%) 43 (86.0%) Divergent 0 (0.00%) 0 (0.00%) 1 (4.35%) 4 (8.00%) Non-MB subsequent 1 (50.0%) 4 (7.69%) 1 (4.35%) 3 (6.00%) Therapy (diagnosis) Chemotherapy 1 (50.0%) 31 (70.5%) 13 (86.7%) 27 (90.0%) 91 Radiotherapy 2 (100%) 31 (70.5%) 7 (46.7%) 27 (90.0%) 91 Therapy (relapse) Chemotherapy 0 (0.00%) 23 (82.1%) 12 (80.0%) 23 (92.0%) 69 Radiotherapy 1 (100%) 14 (50.0%) 7 (46.7%) 10 (40.0%) 69 NGS data 2 (100%) 26 (50.0%) 11 (47.8%) 25 (50.0%) 64 EFS (SD) 2.79 (1.12) 2.96 (3.49) 1.67 (1.04) 3.42 (2.54) 121 OS (SD) 9.88 (7.25) 5.29 (4.38) 4.08 (3.04) 5.94 (4.30) 97 Abbreviations: DNMB, desmoplastic nodular medulloblastoma; EFS, event-free survival; G3, Group 3; G4, Group 4; GTR, gross total resection; LCA, large cell anaplastic; MB, medulloblastoma; NGS, next-generation sequencing; NOS, not otherwise specified; NTR, near total resection; OS, overall survival; SHH, sonic hedgehog; STR, subtotal resection; WNT, wingless. © 2021 by American Society of Clinical Oncology Kumar et al Downloaded from ascopubs.org by 79.168.162.59 on February 5, 2021 from 079.168.162.059 Copyright © 2021 American Society of Clinical Oncology. All rights reserved.