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\begin{document}

\title{BRAF Mutation in Neuroblastoma: A Rare Finding}



\author[1]{Sara Hutchins}%
\author[1]{Sara Ferguson R}%
\author[2]{Geling Li}%
\author[3]{Elizabeth Beierle}%
\author[1]{Elizabeth Alva}%
\affil[1]{The University of Alabama at Birmingham Department of Pediatrics}%
\affil[2]{The University of Alabama at Birmingham Department of Pathology}%
\affil[3]{The University of Alabama at Birmingham Department of Surgery}%


\vspace{-1em}



  
  \date{June 08, 2024}


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\textbf{Title:} \emph{BRAF}Mutation in Neuroblastoma: A Rare Finding

\textbf{Authors:} Sara C Hutchins\textsuperscript{1}, Sara R
Ferguson\textsuperscript{1}, Geling Li\textsuperscript{2}, Elizabeth A
Beierle\textsuperscript{3}*, Elizabeth Alva\textsuperscript{1}

\textbf{Affiliations:}

\textsuperscript{1}Division of Pediatric Hematology-Oncology, Department
of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
35233, USA.

\textsuperscript{2}Department of Pathology, Children's of Alabama,
Birmingham, AL 35233, USA.

\textsuperscript{3}Division of Pediatric Surgery, Department of Surgery,
University of Alabama at Birmingham, Birmingham, AL 35233, USA.

\textbf{*Corresponding author:}

Elizabeth A. Beierle

1600 7\textsuperscript{th} Ave South

Lowder, Room 300

Birmingham, AL 35233

Email: elizabeth.beierle@childrensal.org

\textbf{Word count:} Main Text: 817

\textbf{Figures:} 2

\textbf{Short running title:} \emph{BRAF} mutation in neuroblastoma

\textbf{Keywords:} neuroblastoma, BRAF, Stage MS, Stage M

\textbf{Abbreviations key:}

ALK; anaplastic lymphoma kinase

HVA; homovanillic acid

INRG; International Neuroblastoma Risk Group

LOH; loss of heterozygosity

MIBG; meta-iodobenzylguanidine

VMA; vanillylmandelic acid

\textbf{To the Editor:}

We report the rare finding of a MS neuroblastoma harboring a mutation
in\emph{BRAF} . Briefly, a healthy 5 month old female presented with
fever, tachycardia and Escherichia coli bacteremia. Imaging evaluation
revealed a right-sided adrenal mass and liver lesions (Fig. 1A).
Homovanillic acid (HVA) was mildly elevated to 34.1 mg/g creatinine and
vanillylmandelic acid (VMA) was increased to 82.2 mg/g creatinine. She
underwent right adrenalectomy, liver biopsy, and bone marrow aspirates.
Pathology of the adrenal mass was consistent with poorly differentiated
neuroblastoma with favorable histology, liver biopsy revealed metastatic
neuroblastoma, and bone marrow aspirates revealed minimal marrow
involvement (Fig. 1B). She was diagnosed with Stage MS neuroblastoma and
was managed with observation. Six months later, follow-up imaging
revealed a left adrenal mass, stable liver lesions, and bony disease
(Fig. 2A). Bone marrow aspirates showed increased marrow disease (5\%,
previously \textless{}1\%) (Fig. 2B), Curie score was 7 and HVA and VMA
were elevated (59.6 and 90.6 mg/g creatinine, respectively). Molecular
genetic testing revealed \emph{BRAF} V600E mutation and loss of
heterozygosity (LOH) at 1p and copy number gain at 17q. She was treated
with 6 cycles of intermediate-risk therapy per Children's Oncology
Group, ANBL0531. End of therapy disease evaluation showed resolution of
the adrenal mass, decreased liver lesions, negative bone marrows, normal
VMA and HVA, and Curie score of 0. She is currently fifteen months out
from therapy without evidence of recurrence.

A unique subset of neuroblastoma patients diagnosed in infancy is
categorized as Stage MS according to the International Neuroblastoma
Risk Group (INRG) Staging System using diagnostic criteria that include
age less than 18 months at the time of diagnosis and metastatic disease
confined to liver, skin and/or bone marrow (\textless{}10\%) {[}1{]}.
Most children with MS disease will have spontaneous regression, but
10-15\% will experience disease progression {[}2{]}.

Multiple genetic mutations occur in neuroblastoma. Amplification of
the\emph{MYCN} gene is the most common mutation in patients with poor
prognosis {[}3{]}. Segmental chromosome abnormalities including
deletions of 1p and 11q and gain of 17q are common in high-risk
neuroblastoma, while whole chromosomal gains are found in low-risk
disease {[}4, 5{]}. The most frequently mutated gene is anaplastic
lymphoma kinase (\emph{ALK} ) {[}6{]}.

The \emph{BRAF} V600E mutation is a hyper-activating missense mutation
in codon 600 of exon 15 of the \emph{BRAF} gene that allows BRAF to
function in a Ras dispensable manner {[}7, 8{]}. \emph{BRAF} mutations
are rare in pediatric solid tumors and are not thought to play a role in
the development of these neoplasms {[}9{]}. Recent studies have
identified \emph{BRAF} mutations in neuroblastoma. Shahid et al.
identified \emph{BRAF} V600E mutations in two patients with high-risk
neuroblastoma that developed vasoactive intestinal peptide (VIP)-induced
diarrhea during induction therapy {[}10{]}. In another study,
investigators found a \emph{BRAF} V600E mutation to be present in 1 of
192 neuroblastoma cases, revealing its occurrence in less than 1\% of
cases {[}11{]}. An alternate \emph{BRAF} F595L mutation was discovered
in another neuroblastoma sample. \emph{BRAF} mutations were identified
in 1.7\% of embryonal rhabdomyosarcoma samples and 1.3\% of Ewing
sarcomas {[}11{]}. These findings suggest \emph{BRAF} mutations may play
an oncogenic role in a small group of neuroblastomas pediatric sarcomas.

BRAF inhibitors have been developed to target tumors
harboring\emph{BRAF} mutations. Vemurafenib was one of the first
inhibitors specific for \emph{BRAF} V600E mutations. Other BRAF
inhibitors are now available {[}12{]}. Shahid et al. combined dabrafenib
with trametinib, a MEK inhibitor, as an adjunct to conventional
high-risk therapy to treat VIP-induced diarrhea in two children with
\emph{BRAF} V600E mutations. They concluded that this targeted therapy
was compatible with conventional high-risk neuroblastoma therapy and
yielded minimal additional toxicities {[}10{]}. For the patient in the
current report, BRAF inhibition was reserved for the treatment of
relapsed disease.

We present a case of an infant with Stage MS neuroblastoma
with\emph{BRAF} V600E mutation, which, to our knowledge has not been
reported previously in the literature. Furthermore, the patient
progressed from Stage MS to Stage M disease, a phenomenon that occurs in
only 10-15\% of patients diagnosed with MS disease. This case offers
further evidence for \emph{BRAF} mutations as oncogenic drivers in some
pediatric tumors, and highlights the importance of sequencing for tumors
that do not respond to standard therapies.

\textbf{Fig 1: CT and MIBG scans and bone marrow aspirates at
presentation.} (\textbf{A} ) CT scan demonstrating right adrenal mass
(\emph{open arrow, left panel} ) with MIBG avidity (\emph{closed arrow,
right panel} ). (\textbf{B} ) Immunohistochemistry of right (\emph{left
panel} ) and left (\emph{right panel} ) iliac bone marrow aspirates
demonstrating large atypical cells (\emph{star} ) and clumps of atypical
cells \emph{(star} )\emph{,} consistent with neuroblastoma constituting
less than 10\% of the specimen. Scale bars represent 10 \selectlanguage{greek}µ\selectlanguage{english}m.

\textbf{Fig 2: MIBG scan and bone marrow aspirates at
relapse.}(\textbf{A} ) MIBG scan showing left adrenal mass (\emph{open
arrows} ) and bilateral pelvic and femur bony disease (\emph{closed
arrows} ). (\textbf{B} ) Bilateral right (\emph{left panel} ) and left
(\emph{right panel} ) iliac bone marrow aspirates with large atypical
cells\emph{(star} ) consistent with neuroblastoma. Scale bars represent
10 \selectlanguage{greek}µ\selectlanguage{english}m.

The authors have nothing to disclose.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Monclair T, Brodeur GM, Ambros PF, Brisse HJ, Cecchetto G, Holmes K,
  Kaneko M, London WB, Matthay KK, Nuchtern JG, von Schweinitz D, Simon
  T, Cohn SL, Pearson AD; INRG Task Force. The International
  Neuroblastoma Risk Group (INRG) staging system: an INRG Task Force
  report. J Clin Oncol. 2009 Jan 10;27(2):298-303. doi:
  10.1200/JCO.2008.16.6876. Epub 2008 Dec 1. PMID: 19047290; PMCID:
  PMC2650389.
\item
  Parodi S, Sorrentino S, Cataldo AD, Tondo A, Fagnani AM, Perri P,
  Gigliotti AR, Erminio G, Corrias MV, De Bernardi B. Metastatic
  progression in infants diagnosed with stage 4S neuroblastoma. A study
  of the Italian Neuroblastoma Registry. Pediatr Blood Cancer. 2021
  May;68(5):e28904. doi: 10.1002/pbc.28904. Epub 2021 Jan 18. PMID:
  33459514.
\item
  Tolbert VP, Matthay KK. Neuroblastoma: clinical and biological
  approach to risk stratification and treatment. Cell Tissue Res. 2018
  May;372(2):195-209. doi: 10.1007/s00441-018-2821-2. Epub 2018 Mar 23.
  PMID: 29572647; PMCID: PMC5918153.
\item
  Mlakar V, Jurkovic Mlakar S, Lopez G, Maris JM, Ansari M, Gumy-Pause
  F. 11q deletion in neuroblastoma: a review of biological and clinical
  implications. Mol Cancer. 2017 Jun 29;16(1):114. doi:
  10.1186/s12943-017-0686-8. PMID: 28662712; PMCID: PMC5492892.
\item
  Guan J, Hallberg B, Palmer RH. Chromosome Imbalances in
  Neuroblastoma-Recent Molecular Insight into Chromosome 1p-deletion,
  2p-gain, and 11q-deletion Identifies New Friends and Foes for the
  Future. Cancers (Basel). 2021 Nov 24;13(23):5897. doi:
  10.3390/cancers13235897. PMID: 34885007; PMCID: PMC8657310.
\item
  Moss\selectlanguage{ngerman}é YP, Laudenslager M, Longo L, Cole KA, Wood A, Attiyeh EF,
  Laquaglia MJ, Sennett R, Lynch JE, Perri P, Laureys G, Speleman F, Kim
  C, Hou C, Hakonarson H, Torkamani A, Schork NJ, Brodeur GM, Tonini GP,
  Rappaport E, Devoto M, Maris JM. Identification of ALK as a major
  familial neuroblastoma predisposition gene. Nature. 2008 Oct
  16;455(7215):930-5. doi: 10.1038/nature07261. Epub 2008 Aug 24. PMID:
  18724359; PMCID: PMC2672043.
\item
  Davies H, Bignell GR, Cox C, Stephens P, Edkins S, Clegg S, Teague J,
  Woffendin H, Garnett MJ, Bottomley W, Davis N, Dicks E, Ewing R, Floyd
  Y, Gray K, Hall S, Hawes R, Hughes J, Kosmidou V, Menzies A, Mould C,
  Parker A, Stevens C, Watt S, Hooper S, Wilson R, Jayatilake H,
  Gusterson BA, Cooper C, Shipley J, Hargrave D, Pritchard-Jones K,
  Maitland N, Chenevix-Trench G, Riggins GJ, Bigner DD, Palmieri G,
  Cossu A, Flanagan A, Nicholson A, Ho JW, Leung SY, Yuen ST, Weber BL,
  Seigler HF, Darrow TL, Paterson H, Marais R, Marshall CJ, Wooster R,
  Stratton MR, Futreal PA. Mutations of the BRAF gene in human cancer.
  Nature. 2002 Jun 27;417(6892):949-54. doi: 10.1038/nature00766. Epub
  2002 Jun 9. PMID: 12068308.
\item
  Loo E, Khalili P, Beuhler K, Siddiqi I, Vasef MA. BRAF V600E Mutation
  Across Multiple Tumor Types: Correlation Between DNA-based Sequencing
  and Mutation-specific Immunohistochemistry. Appl Immunohistochem Mol
  Morphol. 2018 Nov/Dec;26(10):709-713. doi:
  10.1097/PAI.0000000000000516. PMID: 29271794.
\item
  Miao J, Kusafuka T, Fukuzawa M. Hotspot mutations of BRAF gene are not
  associated with pediatric solid neoplasms. Oncol Rep. 2004
  Dec;12(6):1269-72. PMID: 15547749.
\item
  Shahid S, Kushner BH, Modak S, Basu EM, Rubin EM, Gundem G,
  Papaemmanuil E, Roberts SS. Association of BRAF V600E mutations with
  vasoactive intestinal peptide syndrome in MYCN-amplified
  neuroblastoma. Pediatr Blood Cancer. 2021 Oct;68(10):e29265. doi:
  10.1002/pbc.29265. Epub 2021 Jul 31. PMID: 34331515.
\item
  Shukla N, Ameur N, Yilmaz I, Nafa K, Lau CY, Marchetti A, Borsu L,
  Barr FG, Ladanyi M. Oncogene mutation profiling of pediatric solid
  tumors reveals significant subsets of embryonal rhabdomyosarcoma and
  neuroblastoma with mutated genes in growth signaling pathways. Clin
  Cancer Res. 2012 Feb 1;18(3):748-57. doi:
  10.1158/1078-0432.CCR-11-2056. Epub 2011 Dec 5. PMID: 22142829; PMCID:
  PMC3271129.
\item
  Zaman A, Wu W, Bivona TG. Targeting oncogenic BRAF: past, present, and
  future. Cancers (Basel). 2019 Aug 16;11(8):1197. doi:
  10.3390/cancers11081197. PMID: 31426419; PMCID: PMC6721448.
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