HHS Public Access

Author manuscript
Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
Author Manuscript

Published in final edited form as:

Crit Rev Oncog. 2015 ; 20(3-4): 227–243.

Pediatric Rhabdomyosarcoma
Jack F. Sherna,b, Marielle E. Yohea,b, and Javed Khana,b,*

aGenetics Branch, Oncogenomics Section, Center for Cancer Research, National Institutes of
Health, Bethesda, Maryland bPediatric Oncology Branch, Center for Cancer Research, National
Institutes of Health, Bethesda, Maryland
Author Manuscript

Abstract
Rhabdomyosarcoma is the most common soft-tissue sarcoma of childhood, and despite clinical
advances, subsets of these patients continue to suffer high levels of morbidity and mortality
associated with their disease. Recent genetic and molecular characterization of these tumors using
sophisticated genomics techniques, including next-generation sequencing experiments, has
revealed multiple areas that can be exploited for new molecularly targeted therapies for this
disease.

Keywords
Rhabdomyosarcoma; Alveolar Rhabdomyosarcoma; Embryonal Rhabdomyosarcoma; Targeted
Therapy; Genomics; Epigenetics; Development
Author Manuscript

I. INTRODUCTION
Rhabdomyosarcoma (RMS) is the most common soft-tissue sarcoma of childhood, with an
annual incidence of 4.5 cases per 1 million children, making it the third most prevalent
extracranial solid tumor of childhood after neuroblastoma and Wilms tumor.1 RMS tumors
typically are associated with the skeletal muscle lineage, and approximately 50% of cases
are diagnosed in the first decade of life. RMS is currently categorized by histopathology into
distinct subtypes, including embryonal, alveolar, pleomorphic, and sclerosing/spindle cell
pathology, which have distinct molecular and clinical correlates.2 In the 1970s and 1980s a
multimodal chemotherapy backbone of vincristine, actinomycin, and cyclophosphamide was
established as an effective treatment for RMS.3 Through a series of collaborative group
Author Manuscript

clinical trials, dose modification of this backbone, coupled with improvements in local
control and supportive care, have led to impressive gains in survival over the past decades.
Patients with low-risk disease now have a 5-year survival that approaches 90%, and current
efforts are focused on dose reduction to avoid long-term effects.4 Relapse-free survival for
patients with localized disease has improved to 70–80%, albeit with significant toxicity.4
Despite these impressive and important gains, several clinical trends have emerged. First,

*
Address all correspondence to Dr. Javed Khan, Oncogenomics Section Genetics Branch, National Cancer Institute, National Institutes
of Health, 37 Convent Dr., Room 2016, Bethesda, MD 20892; Tel. (Office): 301-435-2937; Tel. (Lab): 301-402-9031; Fax:
301-480-0314;; [email protected].
 Shern et al. Page 2

there has been a general flattening in the improvement in outcome for all patients. This is
Author Manuscript

likely because, despite several randomized studies to evaluate dosing and schedule, the
systemic chemotherapy backbone has remained largely unchanged since the 1970s. This
effect is most pronounced for patients with intermediate and high-risk disease who, in a
series of trials, experienced escalating dose intensification and compression of cytotoxic
therapy with minimal gains.5,6 Second, patients with high-risk disease or recurrent disease
continue to suffer a dismal prognosis (5-year survival <30% and 17%, respectively).5,7
Finally, clinical trials that integrate the growing knowledge of the oncogenic mechanisms of
these tumors with novel therapies have been slow to emerge. This review summarizes recent
advances in the understanding of the genetic and molecular basis of RMS and highlights
how investigators and clinicians are using this information in an effort to improve outcomes
for patients with RMS.
Author Manuscript

II. RMS GENETICS

The association of RMS with familial cancer syndromes, most notably Li-Fraumeni
syndrome,8 neurofibromatosis,9 Beckwith-Wiedemann syndrome,10 and Costello
syndrome,11 has made the genetics of RMS an area of intense study. Decades of targeted
sequencing and microarray methods have led to the discovery of loss of heterozygosity at
11p15.512; mutations in TP53,13 NRAS, KRAS, HRAS,14 PIK3CA, CTNNB1,15 and
FGFR416; and the characteristic translocations involving the PAX3 or PAX7 genes with
FOXO117 that have defined the genomic characteristics frequently associated with histologic
and clinical features of this disease.

Several more recent large-scale, next-generation sequencing studies of primary RMS tumors
have been reported.18–20 These studies revealed in a comprehensive manner the landscape of
Author Manuscript

mutations, copy number changes, and genomic rearrangements that define these tumors.
These studies each show that primary RMS has a low overall mutation rate (0.31 protein-
coding mutations/Mb) and is characterized by 2 distinct genotypes, which can clearly be
defined by the presence or absence of a PAX gene rearrangement (Fig. 1). Next-generation
sequencing studies have confirmed that RMS should not be solely diagnosed by histology
but by the presence (fusion-positive RMS) or absence (fusion-negative RMS) of a PAX3/7
gene fusion.18

A. PAX Fusion–Positive RMS

In RMS, the PAX3 or PAX7 gene fusions were originally found through physical mapping
and cloning studies, which revealed the rearrangement of chromosome 2 or 1 in a reciprocal
translocation with FOXO1, found on chromosome 13.17,21 Follow-up studies have
Author Manuscript

confirmed that juxtaposition of the N-terminus of the paired box genes with the C-terminus
of the forkhead transcription factor characterizes a distinct subset of RMS genotypes. Other
infrequent rearrangements of the PAX3 gene also have been observed in tumors with
alveolar histology, including the in-frame fusion with the nuclear receptor coactivator
NCOA1,22,23 or the chromatin remodeling gene INO80D.18 The tumors that harbor these
fusions retain the expression signature characteristic of the canonical fusions PAX3-FOXO1

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 3

and PAX7-FOXO1 and define a subset of tumors previously described as fusion-negative

Author Manuscript

alveolar histology.

In general, tumors that have a PAX gene translocation have an extremely low overall
mutation rate (0.1 protein-coding mutation/Mb) and, interestingly, no recurring genes with
single nucleotide mutations18 (Fig. 2). While recurrent collaborating point mutations have
not been found in these tumors, regions of focal genomic amplification are frequently
observed (Table 1). Multiple genome-wide analyses of copy number alterations in RMS to
date have been completed using the single nucleotide polymorphism array technology. The
most commonly amplified genomic regions observed in PAX gene fusion–positive tumors
are 2p24, containing the MYCN oncogene, and 12q13-q14, which includes CDK4.26 The
amplification of MYCN, which occurs in 28% of fusion-positive cases, has been confined to
a genomic region less than 1 Mb, including the same region frequently observed in
neuroblastoma cases.27 This region includes only 2 genes (MYCN and DDX1) and is
Author Manuscript

observed most commonly in PAX3-FOXO1 fusion–positive RMS. While the number of

cases remains small, no correlation between 2p24 amplification and RMS clinical outcome
has been shown, in contrast to neuroblastoma.25 Amplifications of 12q13-q14, however,
have been associated with significantly worse failure-free and overall survival independent
of PAX gene fusion status.25 This amplicon also is observed in multiple other tumor types,
including lung cancer, glioblastoma, and osteosarcoma. The observed region has been
confined to a common region, 0.55 Mb in length, that contains 27 genes, including CDK4.
Expression analysis confirms that the genomic amplification results in overexpression of
CDK4. Other amplified regions in fusion-positive tumors include 15q24-26, 1p36, 13q31,
1q21, and 8q13-21.26 The regions of 1p36, which encompasses the PAX7 locus, and 13q31,
which includes MIR17HG, are associated specifically with PAX7-FOXO1 tumors.
Author Manuscript

B. Fusion–Negative RMS
In contrast to PAX fusion–positive samples, tumors that do not harbor the fusion are
characterized by a more heterogeneous histology, complex karyotype, regions of loss of
heterozygosity, and an increased presence of single nucleotide point mutations. These
tumors display a wide range of causative mutations. The mutation most frequently occurs
within one of the Ras genes (NRAS > KRAS > HRAS), a receptor tyrosine kinase (FGFR4
≫ ERBB2), or the catalytic component (PIK3CA) of the phosphoinositide-3 kinase (PI3K)
complex. Other genes that are recurrently mutated include the ubiquitin ligase FBXW7, as
well as NF1, TP53, CTNNB1, and the transcriptional repressor BCOR28 (Table 2). In
addition, 2 recent studies have identified that point mutation of the myogenic muscle
differentiation transcription factor MYOD1 defines an aggressive subset of embryonal
RMS20 and adult spindle cell RMS.31
Author Manuscript

Perhaps the most unifying feature of fusion-negative tumors is the loss of heterozygosity at
the 11p15.5 locus,12 which occurs in a majority of fusion-negative tumors and also is
observed in the Beckwith-Wiedemann syndrome,33 hepatoblastoma,34 and Wilms tumor.35
The observed allelic loss of the maternal allele is frequently associated with duplication of
the remaining allele, resulting in paternal isodisomy.36 While many of the genes involved in
the region have been implicated in oncogenesis, H19, IGF2, and CDKN1C have been the

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 4

most extensively studied. Loss of imprinting at the IGF2 gene locus is associated with
Author Manuscript

massive overexpression of IGF2, which is a nearly universal finding in RMS.

Chromosome- and chromosome arm-level gains and losses are frequent events in fusion-
negative tumors. Multiple array studies have reported recurrent gains of chromosomes 2, 7,
8, 12, and 13.37–39 In addition, focal losses of 9q32-34, which includes CDKN2A, and 17p,
which includes the TP53 and NF1 loci, are observed. One recurrent focal amplification event
that occurs in fusion-negative tumors is the high copy gain of the 12q14-15 locus, containing
the MDM2 gene. Alteration of the MDM2 locus is a common event in soft-tissue
sarcomas,32 and the gene product is known to bind and inactivate TP53. In RMS, the MDM2
amplicon can overlap with the CDK4 amplicon, but more frequently the 2 alterations seem
to be mutually exclusive.

III. RMS EPIGENETICS

Author Manuscript

With the emergence of novel techniques to interrogate the epigenome, there have been
efforts to define the DNA modifications that affect transcription within these tumors.
Hypermethylation of 5′ regulatory regions of cancer genomes results in transcriptional
repression of tumor suppressors, and treatment of RMS cell lines with the DNA
demethylating agent 5-azacytadine results in a differentiation phenotype.40 Several groups
have used a candidate gene approach in RMS tumors to identify methylation changes at the
promoters of FGFR1, MYOD1, and PAX3.41–43 A more global approach using genome-
wide DNA methylation arrays was recently reported. The authors reported that both fusion-
positive and fusion-negative tumors have distinct methylation profiles, with the fusion-
positive subtype showing enriched methylation in genes targeted by the polycomb repressive
complex.44 In addition, they reported promoter methylation of IRX1, DNAJA4, and P4HTM
Author Manuscript

in cell lines and primary tumors that results in the silencing of these genes when compared
with normal skeletal muscle. The gene product of EZH2 is a critical component of the
polycomb repressive complex 2 (PRC2), which catalyzes trimethylation of histone H3 lysine
27 and recruits polycomb complexes, DNA methyltransferases, and histone deacetylases
(HDACs), resulting in transcriptional repression. Aberrant EZH2 activity, either as a result
of mutation or overexpression, is a common feature of cancer.45 In addition, EZH2
expression decreases and the PRC2 dissociates as myogenesis progresses toward mature
muscle development.46 While the critical genes that EZH2 modulates remain to be
elucidated, certainly EZH2 is highly upregulated in RMS cell lines and tumors.47 One
intriguing study found that the PRC2 in RMS may play a role in preventing the binding of
MYOD1 at muscle-specific genes.48 PAX3-FOXO1 itself is a fusion of 2 transcription
factors; as such, chromatin immunoprecipitation sequencing analysis using an antibody
Author Manuscript

specific to the fusion junction has been used to interrogate how the oncogene interacts with
the genome.49 Interestingly, the vast majority of PAX3-FOXO1 binding sites are located
more than 4 kb from a transcriptional start site and only infrequently (0.4%) within 1 kb
upstream of the transcription initiation site, making it much more likely that the fusion gene
exerts its effects through enhancer regions rather than at promoters. Enriched peaks included
PAX3 binding motifs and regions distal to the muscle development genes MYOD1 (Fig. 3)
and MYF5. In addition, Cao et al. demonstrated a strong association between chromatin

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 5

immunoprecipitation sequencing peaks and genes that are overexpressed in alveolar RMS
Author Manuscript

and confirmed that ALK, FGFR4, IGF1R, and MYCN are direct targets of PAX3-FOXO1.

IV. PATHOGENESIS AND BIOLOGY OF RMS

A. Fusion-Positive RMS
PAX3-FOXO1 clearly defines a distinct genotype, and given its role as the key prognostic
marker in RMS,50,51 multiple groups have attempted to characterize the effects of the fusion
gene on the cell. The translocations create a break within intron 7 of the PAX gene and
intron 1 of the FOXO1 gene, resulting in a chimeric transcript that encodes the N-terminal
DNA-binding domain of the PAX gene with the C-terminal activation domain of the FOXO1
gene.52,53 Expression of the fusion gene causes transformation and anchorage-independent
growth of fibroblasts.54 Knockdown of PAX3-FOXO1 decreased the proliferation rate in the
RMS cell line RH30 and the metastatic phenotype observed in the corresponding xenograft
Author Manuscript

model.55 In addition, conditional simultaneous biallelic PAX3-FOXO1 expression from the

PAX3 locus and homozygous deletion of either TP53 or CDKN2A in Myf6-expressing
maturing mouse myofibers leads to alveolar RMS development with 100% penetrance.56,57

Expression analysis has been the tool of choice to globally dissect the downstream effects of
the presence of the fusion gene. These studies revealed that the oncogene alters the
myogenic program of the cell, inducing or repressing a large set of muscle development
genes, including MYOD1, MYOG, and SIX1.59,59 Expression of the fusion protein also
massively upregulates several receptor tyrosine kinase molecules important for cell growth,
including FGFR4,60 ALK,61 and MET,62 which may provide a feed-forward loop driving
proliferation. Universally, these studies have demonstrated a common signature that is
associated with a tumor’s fusion status and that can be used for diagnosis and prognosis.51,63
Author Manuscript

B. Fusion-Negative RMS as an “RAS-opathy”

As discussed above, the most common causative single nucleotide variant in fusion-negative
RMS is an oncogenic mutation in one of the Ras isoforms, namely, NRAS, HRAS, or
KRAS. The role of Ras mutation as a prognostic marker in fusion-negative RMS is
emerging. In one recent study 75% of high-risk fusion-negative RMS tumors harbored a Ras
isoform mutation, in contrast to 45% of intermediate-risk and 0% of low-risk fusion-
negative RMS tumors with a Ras isoform mutation.19 A subset of fusion-negative RMS
tumors harbors mutations in the Ras GTPase-activating protein NF1, which also potentially
leads to aberrant Ras signaling in these tumors. Finally, activating mutations in known Ras
effectors such as BRAF and PIK3CA also have been identified in fusion-negative RMS
tumors; however, the signaling pathways downstream of activated Ras that are necessary for
Author Manuscript

tumorigenesis in fusion-negative RMS have yet to be fully characterized. Fusion-negative

RMS is unique in that mutations in all 3 of the major Ras isoforms may function as genetic
driver mutations.64 The functional consequences of individual Ras isoform mutations in
fusion-negative RMS tumors are not yet known.

The available in vitro and in vivo models of fusion-negative RMS confirm a central role for
aberrant Ras activity in fusion-negative RMS tumorigenesis. A knock-in model in which

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 6

oncogenic KRAS is conditionally expressed in the skeletal muscle of adult mice deficient in
TP53 leads to the development of pleomorphic RMS.65 In addition, human postnatal skeletal
Author Manuscript

muscle myoblasts engineered to overexpress large T oncoprotein, small t oncoprotein,

human telomerase reverse transcriptase, and oncogenic HRAS show anchorage-independent
growth and form tumors capable of local invasion and distant metastasis when implanted in
immunodeficient mice.66 Most of the established human fusion-negative RMS cell lines
currently in use harbor oncogenic mutations in one of the Ras isoforms.67 Finally, zebrafish
embryos injected with oncogenic KRAS at the one cell stage develop tumors that
histologically resemble fusion-negative RMS.68 In sum, the available next-generation
sequencing and model system data indicate that the major driver of fusion-negative RMS
tumorigenesis is oncogenic Ras.

Mutation of FGFR4 has been identified in approximately 7% of fusion-negative RMSs.30

Interestingly, FGFR4 is expressed in myoblasts during normal development and in
Author Manuscript

regenerating muscle following injury, but not in mature skeletal muscle. Based on
microarray-based gene expression analysis, this gene has been reported to be the most
differentially expressed gene in RMS tumors.59,63,69 These observations led to the
hypothesis that overexpression or mutational activation of this gene may be involved in the
tumorigenesis of RMS. Taylor et al. found that suppression of the wild-type FGFR4 in RMS
led to reduced growth and lung metastasis.16 Mutations in the tyrosine kinase domain were
predicted and confirmed to be activating and resulted in increased growth and reduced RMS
cell death, and enhanced the ability of RMS cells to metastasize. The investigators found
that the mutations lead to the activation of an oncogenic pathway involving STAT3.30
Subsequent studies have shown that stimulation of wild-type FGFR4 in fusion-positive RMS
cell lines leads to activation of the RAS-RAF-MEK-ERK mitogen-activated protein kinase
pathway, indicating that RMS tumors expressing activating mutations in FGFR4 may
Author Manuscript

phenocopy tumors with activating mutations in Ras isoforms.70

Insulin-like growth factor (IGF) 2 promotes myoblast proliferation and nutrient uptake. Loss
of imprinting at the IGF2 locus is associated with massive overexpression of IGF2 at the
messenger RNA and protein levels in fusion-negative RMS cell lines, and expression of
IGF2 is also induced by PAX3-FOXO1.60 The cellular effects of IGF2 are mediated by the
type I IGF receptor (IGF1R), which also is expressed on RMS cells. IGF2 is secreted by
RMS cell lines and is able to act as a mitogen in an autocrine manner in this model
system.71 Mouse C2C12 myoblasts expressing IGF2 in combination with PAX3-FOXO1 are
transformed in vitro and form undifferentiated tumors in immunodeficient mice.72

C. Evidence for a Commonly Disrupted Pathway in Fusion-Positive and Fusion-Negative

Author Manuscript

Tumors
Our genomic characterization of RMS tumors identified some interesting overlap between
the genes mutated in fusion-negative tumors and the genes that are under the control of the
PAX3-FOXO1 fusion gene. The results demonstrate that both alveolar RMS and embryonal
RMS tumors hijack the common receptor tyrosine kinase/RAS/PIK3CA axis through
alternative mechanisms: either mutation or translocation. Up to 93% of RMS tumors have
genetic evidence indicating alteration of this axis.18 With the proliferation of approved

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 7

clinical agents that target these pathways, these findings provide a molecular basis for the
Author Manuscript

rapid movement of these agents into clinical trials of RMS.

D. Alteration of Developmental Programs in RMS

Anatomic location of RMS tumors within skeletal muscle and the characteristic expression
of muscle markers such as myogenin73 and MYOD174 provide evidence that RMS tumors
reflect a disordered or corrupted muscle development program. The process of normal
myogenic differentiation is driven by sequential expression of myogenic regulatory factors
that include the basic helix-loop-helix transcription factors MYOD1, MYF5, MYOG, and
MYF6 (reviewed in refs. 75 and 76). The paired box transcription factors PAX3 and PAX7
in turn regulate MYOD1 and MYF5.77 Forced expression of the PAX3-FOXO1 fusion alters
a myogenic program including upregulation of MYOD1, MYOG, SIX1, and IGF2 and
induces myoblast-like cells.60 Collectively, these findings indicate that in RMS the
Author Manuscript

oncogenic damage to a muscle precursor cell leads to a persistent or static developmental

state that drives both the survival and proliferation signals in the tumor.

V. POTENTIAL NEW THERAPEUTIC OPTIONS

A. Signaling Inhibitors, Including Combination Strategies
Perhaps the most immediate translational clinical opportunity that can be derived from the
molecular and genomic study of RMS is that these tumors result from alteration of signaling
and growth pathways, many of which can be targeted with small-molecule inhibitors or
biological agents (Fig. 4).

The nearly universal alteration of the insulin signaling pathway in RMS tumors has made it
an intense focus for novel therapies. Cixutumumab, a human immunoglobulin G monoclonal
Author Manuscript

antibody directed against IGF1R, the receptor for IGF2, showed promising single-agent
activity in xenograft models of RMS.78 Based on these results, 20 pediatric patients with
RMS were treated in a phase II clinical trial of cixutumumab as a single agent. In that study,
1 patient had a partial response to anti-IGF1R therapy, 1 patient had prolonged stable
disease, and 2 patients had short-term stable disease.79 The efficacy of cixutumumab in
combination with intensive multiagent, interval, compressed cytotoxic chemotherapy was
studied in metastatic RMS (www.clinicaltrials.gov identifier NCT01055314). An additional
anti-IGF1R antibody, R1507, also showed promising results as a single-agent therapy in
patients with RMS: Of 36 patients with RMS treated in the study, 1 patient had a partial
response and 6 patients had stable disease.80 BMS-754807, a small-molecule, ATP-
competitive inhibitor of IGF1R, has shown promising activity as a single agent in RMS cell
lines in vitro and is currently under investigation in phase I clinical trials for adults with
Author Manuscript

solid tumors.78

FGFR4 signaling is altered in both fusion-positive (by overexpression) and fusion-negative

(by mutation) RMS, making FGFR4 an attractive candidate for targeted therapy. Recent
work demonstrated that the tyrosine kinase inhibitor ponatinib potently inhibited FGFR4
signaling in cell lines expressing either wild-type or mutant FGFR4. This drug also inhibited

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 8

growth of RMS cell lines in vitro, induced apoptosis in RMS cell lines, and inhibited tumor
growth in xenografts of cell lines expressing mutant FGFR4.81
Author Manuscript

The ALK receptor, a member of the insulin receptor family of receptor tyrosine kinases,
activates the signal transducer and activator of transcription 3, PI3K/AKT, and Ras/ERK
pathways, and is highly expressed in both fusion-positive and fusion-negative RMS. This
high level of protein expression can be the result of ALK gene copy number gain. In
addition, ALK gene expression is enhanced by PAX3-FOXO1.61 Genomic gains or
amplifications of ALK also occur in pediatric tumor neuroblastoma, as well as non-small-
cell lung cancer. Small-molecule inhibitors of ALK (crizotinib, ceritinib) are currently being
studied in these tumor types (www.clinicaltrials.gov identifier NCT01742286) and may
prove to be beneficial in the treatment of RMS. Additional receptor tyrosine kinases, such as
MET, epidermal growth factor receptor, and vascular endothelial growth factor receptor also
are overexpressed in RMS compared with normal muscle, and small-molecule inhibitors or
Author Manuscript

antibody-based therapies directed against these receptor tyrosine kinases could also be
developed as effective RMS therapies.82

RMS likely represents a malignant tumor of myoblast-like cells failing to exit the cell cycle
and differentiate. The cell cycle exit and differentiation of myoblasts into myotubes are
mediated, in part, by downregulation of cyclin D1 and a decrease in CDK4/CDK6 activity.
Genetic amplification of CDK4 and genetic loss of the CDK4/6-specific inhibitor p16Ink4a
(CDKN2A locus) frequently occur in RMS, making CDK4 an attractive target in RMS.
Treatment of RMS cell lines with the CDK4/6 inhibitor palbociclib (PD-0332991) leads to
G1 arrest and induces the expression of muscle-specific markers. This inhibitor is currently
in early phase clinical trials in adults and may represent a therapeutic option for patients
with RMS.83 In addition, as discussed above, the MDM2 locus also is frequently amplified
Author Manuscript

in RMS. An inhibitor of MDM2–TP53 interaction, MI-63, decreases proliferation and

increases apoptosis in RMS cell lines expressing wild-type TP53.84 This compound is
currently awaiting phase I testing.

Because Ras isoforms also are commonly mutated in fusion-negative RMS, targeting Ras
effectors such as PI3K and BRAF is a logical strategy. Several BRAF (veumurafenib,
dabrafenib) and MEK (trametinib) inhibitors have gained US Food and Drug Administration
(FDA) approval for the treatment of other Ras-driven cancers, such as metastatic melanoma.
Recent work has shown that the small-molecule inhibitors of MEK and PI3K—U0126 and
PI103, respectively—have a synthetic lethal interaction in RD, a fusion-negative RMS cell
line harboring an activating mutation in NRAS.85 Further studies have shown that growth of
RD is dependent on the RAS-RAF-MEK-ERK signaling pathway because an MEK
Author Manuscript

inhibitor, AZD244 (selumetinib), and an ERK2 inhibitor, VX-11e, inhibit proliferation of

these cells.86 Finally, treatment with the MEK inhibitor PD-0352901 leads to differentiation
of RD.87

Ultimately, single-agent targeted therapy for RMS seems unlikely to provide durable
responses. The mechanisms of resistance to therapy are relatively unstudied in RMS;
however, some evidence exists that the mechanism likely includes genetic selection of a
minor clone that is present at the time of diagnosis.19 Given the evidence for altered

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 9

signaling in RMS through the RAS signaling pathway and the insulin growth signaling
Author Manuscript

pathway, one therapeutic strategy might be to target both the mitogen-activated protein
kinase as well as the AKT pathways. This strategy is bolstered by a variety of evidence from
adult tumor models showing extensive cross-talk between the 2 pathways. One exciting
preclinical study using AZD8055, a mammalian target of rapamycin inhibitor, and
AZD6244, an MEK inhibitor, demonstrated significant synergy in both fusion-positive and
fusion-negative cell lines both in vitro and in vivo.88 With the explosion of clinical trials
examining similar combinations in adult solid tumors, it seems possible that these results
could rapidly inform novel therapies for RMS. Combinations of signaling inhibitors similar
to those described above might also be efficacious.

B. Modulating the Epigenome

The convergence point for abnormal signaling in cancer is transcriptional regulation.
Author Manuscript

Therefore, novel mechanisms to target the epigenome might provide new therapeutic
modalities for the treatment of RMS. HDACs are critical regulators of gene expression and
linked to key oncogenic events in a variety of tumor types, including colon, breast, and lung
tumors and leukemia.89 In preclinical xenograft models of both fusion-positive and fusion-
negative RMS, HDAC inhibitors inhibited growth and induced apoptosis.90 Also, in
preclinical models, HDAC inhibition radiosensitized RMS tumors.91 Finally, in the
therapeutically challenging fusion-positive subtype, the combination of HDAC inhibition
with the multikinase inhibitor PKC412 released the transcriptional repression of p21,
resulting in a synergistic therapeutic combination.92

Inhibiting the epigenetic silencing of myogenic genes involved in normal skeletal

differentiation by pharmacologic inhibition of EZH2 has restored myogenic differentiation
of the embryonal cell line RD in both culture as well as xenograft. Ciarapica et al. 93 used
Author Manuscript

the catalytic inhibitor MC1945 and demonstrated antiproliferative effects as well as

increased expression of markers of terminal muscle differentiation compared with placebo.
Given the pursuit of EZH2 inhibitors for the treatment of diffuse large B-cell lymphoma,
these results provide an exciting new therapeutic avenue in fusion-negative RMS.

C. Directly Targeting the Fusion

A fusion protein that occurs specifically in tumor tissue while being absent in normal tissue
theoretically presents an ideal opportunity for a “precision” therapy. In fusion-positive RMS
this strategy is further enhanced by the observation that targeted knockdown of PAX394 or
the PAX3-FOXO1 gene product95 induces apoptosis and inhibition of proliferation.
Unfortunately, unlike the BCR-ABL or EML4-ALK fusion oncogenes that occur in adult
cancers, which involve a targetable tyrosine kinase, the translocations observed in pediatric
Author Manuscript

solid tumors almost uniformly involve transcription factors. While it is generally thought
that specific inhibition of the transcriptional machinery is difficult,96 there has been recent
success inhibiting the EWS-FLI1 translocation in Ewing sarcoma97 and the SS18-SSX
translocation in synovial sarcoma.98 Similar efforts have been completed in PAX3-FOXO1-
driven RMS, with interesting results. Using a luciferase reporter placed downstream of the
promoter of a PAX3-FOXO1-induced gene (TFAP2B), Martin and colleagues99 screened a
small-molecule library and identified the synthetic retinoid fenretinide as a specific repressor

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 10

of PAX3-FOXO1 at both the messenger RNA and protein levels, which induced apoptosis of
Author Manuscript

RMS cell lines both in vitro and in vivo. A second drug screen using a similar approach
identified that fascaplysin, an inhibitor of CDK4, worked by abrogating the phosphorylation
and subsequent subcellular localization of PAX3-FOXO1.100

D. Immunotherapy
Antibodies or immune cells engineered against specific antigens expressed by cancer cells
have been increasingly used as therapeutic agents either alone or in combination with
chemotherapeutic drugs.101,102 Following the revolutionary success of rituximab targeting
CD20 on B cells as an FDA-approved drug for non-Hodgkin lymphoma, a number of
monoclonal antibodies have been developed and are being used as approved drugs in the
clinic or are currently in various phases of clinical trials for the treatment of
leukemias,103–106 as well as solid tumors including mesothelioma107 and
Author Manuscript

neuroblastoma.108,109 Most recently, chimeric antigen receptor–based therapies have shown

stunning successes in refractory pediatric cancers.110 Given their unique expression pattern,
including FGFR4, RMS tumors present a unique opportunity for immunotherapy.111 A
consortium funded by a StandUp2Cancer and a St. Baldrick’s grant is actively pursuing this
novel therapeutic modality.

VI. FUTURE PERSPECTIVES

Clear progress has been made in the understanding of the molecular and genetic causes that
are the basis of RMS oncogenesis. This groundwork is ushering in a new era in which
molecular knowledge will inform risk stratification and clinical decisions in real time. While
this goal will be challenging in cases of a relatively rare pediatric tumor, the growing
knowledge of the oncogenic and survival mechanisms underlying RMS give clinicians
Author Manuscript

remarkable insights into their patients’ disease. Given the mortality associated with high risk
and relapsed disease, priority should be given to innovative treatment modalities for these
patients. While determining a statistically significant clinical improvement in such a small
patient population is daunting, many of the genetic and molecular features of RMS overlap
with alterations that occur in more common tumors. Previously established, FDA-approved
drugs might provide significant benefit to these patients. In addition, these patients can
provide crucial preliminary information for candidate therapies before expanding their use in
the intermediate-risk patient cohort. Proper design of these trials should include a tumor
biopsy before, during, and upon relapse so that the genomic and proteomic informations can
be used to properly link the patient with the appropriate therapy and evaluate how the tumor
responds to the treatment. During the same procedure, adequate tissue should be collected so
that banking cell lines and in vivo tumor grafts can be generated, allowing the physician and
Author Manuscript

researcher to fully evaluate the tumor’s response to the drug. These generated model systems
would serve as critical tools to guide the development of novel therapies.

Acknowledgments
The authors thank Berkley Gryder for his help in the preparation of this manuscript. The reviewers are supported by
the Intramural Research Program of the National Institutes of Health, National Cancer Institute, Center for Cancer
Research. The content of this publication does not necessarily reflect the views or policies of the Department of
Health and Human Services, nor does mention of trade names, commercial products, or organizations imply

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 11

endorsement by the US government. J.F.S. receives additional grant support from the Sarcoma Research Alliance
for Collaboration and the St. Baldrick’s Foundation.
Author Manuscript

ABBREVIATIONS
FDA US Food and Drug Administration

HDAC histone deacetylase

IGF insulin-like growth factor

IGF1R type I insulin-like growth factor receptor

PI3K phosphoinositide-3 kinase

PRC2 polycomb repressive complex 2

Author Manuscript

RMS rhabdomyosarcoma

References
1. Ognjanovic S, Linabery AM, Charbonneau B, Ross JA. Trends in childhood rhabdomyosarcoma
incidence and survival in the United States, 1975–2005. Cancer. 2009; 115:4218–26. [PubMed:
19536876]
2. Parham DM, Barr FG. Classification of Rhabdomyosarcoma and its molecular basis. Adv Anat
Pathol. 2013; 20:387–97. [PubMed: 24113309]
3. Pappo AS, Shapiro DN, Crist WM, Maurer HM. Biology and therapy of pediatric
rhabdomyosarcoma. J Clin Oncol. 1995; 13:2123–39. [PubMed: 7636557]
4. Malempati S, Hawkins DS. Rhabdomyosarcoma: review of the Children’s Oncology Group (COG)
Soft-Tissue Sarcoma Committee experience and rationale for current COG studies. Pediatr Blood
Cancer. 2012; 59:5–10. [PubMed: 22378628]
Author Manuscript

5. Pappo AS, Lyden E, Breitfeld P, Donaldson SS, Wiener E, Parham D, Crews KR, Houghton P,
Meyer WH. Children’s Oncology Group. Two consecutive phase II window trials of irinotecan
alone or in combination with vincristine for the treatment of metastatic rhabdomyosarcoma: the
Children’s Oncology Group. J Clin Oncol. 2007; 25:362–9. [PubMed: 17264331]
6. Arndt CA, Stoner JA, Hawkins DS, Rodeberg DA, Hayes-Jordan AA, Paidas CN, Parham DM, Teot
LA, Wharam MD, Breneman JC, Donaldson SS, Anderson JR, Meyer WH. Vincristine,
actinomycin, and cyclophosphamide compared with vincristine, actinomycin, and
cyclophosphamide alternating with vincristine, topotecan, and cyclophosphamide for intermediate-
risk rhabdomyosarcoma: Children’s Oncology Group Study D9803. J Clin Oncol. 2009; 27:5182–8.
[PubMed: 19770373]
7. Pappo AS, Anderson JR, Crist WM, Wharam MD, Breitfeld PP, Hawkins D, Raney RB, Womer RB,
Parham DM, Qualman SJ, Grier HE. Survival after relapse in children and adolescents with
rhabdomyosarcoma: areport from the intergroup rhabdomyosarcoma study group. J Clin Oncol.
1999; 17:3487–93. [PubMed: 10550146]
8. Li FP, Fraumeni JF. Rhabdomyosarcoma in children: epidemiologic study and identification of a
Author Manuscript

familial cancer syndrome. J Natl Cancer Inst. 1969; 43:1365–73. [PubMed: 5396222]
9. Sung L, Anderson JR, Arndt C, Raney B, Meyer WH, Pappo AS. Neurofibromatosis in children
with rhabdomyosarcoma: a report from the intergroup Rhabdomyosarcoma Study IV. J Pediatr.
2004; 144:666–8. [PubMed: 15127010]
10. Steenman M, Westerveld A, Mannens M. Genetics of Beckwith-Wiedemann syndrome-associated
tumors: common genetic pathways. Gene Chromosome Cancer. 2000; 28:1–13.
11. Philip NM, Sigaudy S, Lacombe D, Vittu G, David A, Vigneron J, Moncla A, Flori E. Costello
syndrome: report of eight patients including one with a rhabdomyosarcoma. Am J Hum Genet.
1999; 65:A338-A.

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 12

12. Scrable H, Cavenee W, Ghavimi F, Lovell M, Morgan K, Sapienza C. A model for embryonal
rhabdomyosarcoma tumorigenesis that involves genome imprinting. Proc Natl Acad Sci U S A.
Author Manuscript

1989; 86:7480–4. [PubMed: 2798419]

13. Taylor AC, Shu L, Danks MK, Poquette CA, Shetty S, Thayer MJ, Houghton PJ, Harris LC. P53
mutation and MDM2 amplification frequency in pediatric rhabdomyosarcoma tumors and cell
lines. Med Pediatr Oncol. 2000; 35:96–103. [PubMed: 10918230]
14. Stratton MR, Fisher C, Gusterson BA, Cooper CS. Detection of point mutations in N-ras and K-ras
genes of human embryonal rhabdomyosarcomas using oligonucleotide probes and the polymerase
chain reaction. Cancer Res. 1989; 49:6324–7. [PubMed: 2680062]
15. 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; 18:748–57. [PubMed: 22142829]
16. Taylor JG 6th, Cheuk AT, Tsang PS, Chung JY, Song YK, Desai K, Yu Y, Chen QR, Shah K,
Youngblood V, Fang J, Kim SY, Yeung C, Helman LJ, Mendoza A, Ngo V, Staudt LM, Wei JS,
Khanna C, Catchpoole D, Qualman SJ, Hewitt SM, Merlino G, Chanock SJ, Khan J. Identification
Author Manuscript

of FGFR4-activating mutations in human rhabdomyosarcomas that promote metastasis in

xenotransplanted models. J Clin Invest. 2009; 119:3395–407. [PubMed: 19809159]
17. Barr FG, Galili N, Holick J, Biegel JA, Rovera G, Emanuel BS. Rearrangement of the Pax3 paired
box gene in the pediatric solid tumor alveolar rhabdomyosarcoma. Nat Genet. 1993; 3:113–7.
[PubMed: 8098985]
18. Shern JF, Chen L, Chmielecki J, Wei JS, Patidar R, Rosenberg M, Ambrogio L, Auclair D, Wang J,
Song YK, Tolman C, Hurd L, Liao H, Zhang S, Bogen D, Brohl AS, Sindiri S, Catchpoole D,
Badgett T, Getz G, Mora J, Anderson JR, Skapek SX, Barr FG, Meyerson M, Hawkins DS, Khan
J. Comprehensive genomic analysis of rhabdomyosarcoma reveals a landscape of alterations
affecting a common genetic axis in fusion-positive and fusion-negative tumors. Cancer Discov.
2014; 4:216–31. [PubMed: 24436047]
19. Chen X, Stewart E, Shelat AA, Qu C, Bahrami A, Hatley M, Wu G, Bradley C, McEvoy J, Pappo
A, Spunt S, Valentine MB, Valentine V, Krafcik F, Lang WH, Wierdl M, Tsurkan L, Tolleman V,
Federico SM, Morton C, Lu C, Ding L, Easton J, Rusch M, Nagahawatte P, Wang J, Parker M, Wei
L, Hedlund E, Finkelstein D, Edmonson M, Shurtleff S, Boggs K, Mulder H, Yergeau D, Shapek
Author Manuscript

S, Hawkins DS, Ramierez N, Potter PM, Sandoval JA, Davidoff AM, Mardis ER, Wilson RK,
Zhang J, Downing JR, Dyer MA. St. Jude Children’s Research Hospital–Washington University
Pediatric Cancer Genome Project. Targeting oxidative stress in embryonal rhabdomyosarcoma.
Cancer Cell. 2013; 24:710–24. [PubMed: 24332040]
20. Kohsaka S, Shukla N, Ameur N, Ito T, Ng CK, Wang L, Lim D, Marchetti A, Viale A, Pirun M,
Socci ND5, Qin LX, Sciot R, Bridge J, Singer S, Meyers P, Wexler LH, Barr FG, Dogan S,
Fletcher JA, Reis-Filho JS, Ladanyi M. A Recurrent point mutation in MYOD1 defines a clinically
aggressive subset of embryonal rhabdomyosarcoma. Lab Invest. 2014; 94:20a–1a.
21. Davis RJ, Dcruz CM, Lovell MA, Biegel JA, Barr FG. Fusion of Pax7 to Fkhr by the variant
T(1,13)(P36,Q14) translocation in alveolar rhabdomyosarcoma. Cancer Res. 1994; 54:2869–72.
[PubMed: 8187070]
22. Sumegi J, Streblow R, Frayer RW, Dal Cin P, Rosenberg A, Meloni-Ehrig A, Bridge JA. Recurrent
t(2;2) and t(2;8) translocations in rhabdomyosarcoma without the canonical PAX-FOXO1 fuse
PAX3 to members of the nuclear receptor transcriptional coactivator family. Genes Chromosomes
Cancer. 2010; 49:224–36. [PubMed: 19953635]
Author Manuscript

23. Wachtel M, Dettling M, Koscielniak E, Stegmaier S, Treuner J, Simon-Klingenstein K, Bühlmann

P, Niggli FK, Schäfer BW. Gene expression signatures identify rhabdomyosarcoma subtypes and
detect a novel t(2;2)(q35;p23) translocation fusing PAX3 to NCOA1. Cancer Res. 2004; 64:5539–
45. [PubMed: 15313887]
24. Barr FG, Smith LM, Lynch JC, Strzelecki D, Parham DM, Qualman SJ, Breitfeld PP. Examination
of gene fusion status in archival samples of alveolar rhabdomyosarcoma entered on the intergroup
rhabdomyosarcoma study-III trial: a report from the Children’s Oncology Group. J Mol Diagn.
2006; 8:202–8. [PubMed: 16645206]

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 13

25. Barr FG, Duan FH, Smith LM, Gustafson D, Pitts M, Hammond S, Gastier-Foster JM. Genomic
and clinical analyses of 2p24 and 12q13-q14 amplification in alveolar rhabdomyosarcoma: a
Author Manuscript

report from the Children’s Oncology Group. Genes Chromosomes Cancer. 2009; 48:661–72.
[PubMed: 19422036]
26. Gordon AT, Brinkschmidt C, Anderson J, Coleman N, Dockhorn-Dworniczak B, Pritchard-Jones
K, Shipley J. A novel and consistent amplicon at 13q31 associated with alveolar
rhabdomyosarcoma. Gene Chromosome Canc. 2000; 28:220–6.
27. Schwab M. MYCN in neuronal tumours. Cancer Lett. 2004; 204:179–87. [PubMed: 15013217]
28. Paulson V, Chandler G, Rakheja D, Galindo RL, Wilson K, Amatruda JF, Cameron S. High-
resolution array CGH identifies common mechanisms that drive embryonal rhabdomyosarcoma
pathogenesis. Genes Chromosomes Cancer. 2011; 50:397–408. [PubMed: 21412928]
29. 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; 18:748–57. [PubMed: 22142829]
30. Li SQ, Cheuk AT, Shern JF, Song YK, Hurd L, Liao H, Wei JS, Khan J. Targeting wild-type and
Author Manuscript

mutationally activated FGFR4 in rhabdomyosarcoma with the inhibitor ponatinib (AP24534).

PLoS One. 2013; 8:e76551. [PubMed: 24124571]
31. Szuhai K, de Jong D, Leung WY, Fletcher CDM, Hogendoorn PCW. Transactivating mutation of
the MYOD1 gene is a frequent event in adult spindle cell rhabdomyosarcoma. J Pathol. 2014;
232:300–7. [PubMed: 24272621]
32. Leach FS, Tokino T, Meltzer P, Burrell M, Oliner JD, Smith S, Hill DE, Sidransky D, Kinzler KW,
Vogelstein B. P53 mutation and Mdm2 amplification in human soft-tissue sarcomas. Cancer Res.
1993; 53:2231–4. [PubMed: 8387391]
33. Ping AJ, Reeve AE, Law DJ, Young MR, Boehnke M, Feinberg AP. Genetic-linkage of Beckwith-
Wiedemann syndrome to 11p15. Am J Hum Genet. 1989; 44:720–3. [PubMed: 2565083]
34. Rainier S, Dobry CJ, Feinberg AP. Loss of imprinting in hepatoblastoma. Cancer Res. 1995;
55:1836–8. [PubMed: 7728748]
35. Besnard-Guérin C, Newsham I, Winqvist R, Cavenee WK. A common region of loss of
heterozygosity in Wilms’ tumor and embryonal rhabdomyosarcoma distal to the D11S988 locus
on chromosome 11p15.5. Hum Genet. 1996; 97:163–70. [PubMed: 8566947]
Author Manuscript

36. Zhan SL, Shapiro DN, Helman LJ. Activation of an imprinted allele of the insulin-like growth-
factor-II gene implicated in rhabdomyosarcoma. J Clin Invest. 1994; 94:445–8. [PubMed:
8040287]
37. Weber-Hall S, Anderson J, McManus A, Abe S, Nojima T, Pinkerton R, Pritchard-Jones K, Shipley
J. Gains, losses, and amplification of genomic material in rhabdomyosarcoma analyzed by
comparative genomic hybridization. Cancer Res. 1996; 56:3220–4. [PubMed: 8764111]
38. Bridge JA, Liu J, Qualman S, Suijkerbuijk R, Wenger G, Zhang J, Wan X, Baker KS, Sorensen P,
Barr FG. Genomic gains and losses are similar in genetic and histologic subsets of
rhabdomyosarcoma, whereas amplification predominates in embryonal with anaplasia and alveolar
subtypes. Genes Chromosomes Cancer. 2002; 33:310–21. [PubMed: 11807989]
39. Bridge JA, Liu J, Weibolt V, Baker KS, Perry D, Kruger R, Qualman S, Barr F, Sorensen P, Triche
T, Suijkerbuijk R. Novel genomic imbalances in embryonal rhabdomyosarcoma revealed by
comparative genomic hybridization and fluorescence in situ hybridization: an intergroup
rhabdomyosarcoma study. Genes Chromosomes Cancer. 2000; 27:337–44. [PubMed: 10719362]
Author Manuscript

40. Lollini PL, De Giovanni C, Del Re B, Landuzzi L, Nicoletti G, Prodi G, Scotlandi K, Nanni P.
Myogenic differentiation of human rhabdomyosarcoma cells induced invitro by antineoplastic
drugs. Cancer Res. 1989; 49:3631–6. [PubMed: 2471586]
41. Goldstein M, Meller I, Orr-Urtreger A. FGFR1 over-expression in primary rhabdomyosarcoma
tumors is associated with hypomethylation of a 5′ CpG wand and abnormal expression of the
AKT1, NOG, and BMP4 genes. Genes Chromosomes Cancer. 2007; 46:1028–38. [PubMed:
17696196]

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 14

42. Gastaldi T, Bonvini P, Sartori F, Marrone A, Iolascon A, Rosolen A. Plakoglobin is differentially

expressed in alveolar and embryonal rhabdomyosarcoma and is regulated by DNA methylation
Author Manuscript

and histone acetylation. Carcinogenesis. 2006; 27:1758–67. [PubMed: 16537559]

43. Chen B, Dias P, Jenkins JJ, Savell V, Parham DM. Methylation alterations of the MyoD1 upstream
region predict rhabdomyosarcoma histology. Modern Pathol. 1998; 11:167a-a.
44. Mahoney SE, Yao Z, Keyes CC, Tapscott SJ, Diede SJ. Genome-wide DNA methylation studies
suggest distinct DNA methylation patterns in pediatric embryonal and alveolar
rhabdomyosarcomas. Epigenetics. 2012; 7:400–8. [PubMed: 22419069]
45. Chase A, Cross NCP. Aberrations of EZH2 in cancer. Clin Cancer Res. 2011; 17:2613–8.
[PubMed: 21367748]
46. Marchesi I, Giordano A, Bagella L. Roles of enhancer of zeste homolog 2: from skeletal muscle
differentiation to rhabdomyosarcoma carcinogenesis. Cell Cycle. 2014; 13:516–27. [PubMed:
24496329]
47. Wang H, Garzon R, Sun H, Ladner KJ, Singh R, Dahlman J, Cheng A, Hall BM, Qualman SJ,
Chandler DS, Croce CM, Guttridge DC. NF-kappaB-YY1-miR-29 regulatory circuitry in skeletal
myogenesis and rhabdomyosarcoma. Cancer Cell. 2008; 14:369–81. [PubMed: 18977326]
Author Manuscript

48. Marchesi I, Fiorentino FP, Rizzolio F, Giordano A, Bagella L. The ablation of EZH2 uncovers its
crucial role in rhabdomyosarcoma formation. Cell Cycle. 2012; 11:3828–36. [PubMed: 22983009]
49. Cao L, Yu Y, Bilke S, Walker RL, Mayeenuddin LH, Azorsa DO, Yang F, Pineda M, Helman LJ,
Meltzer PS. Genome-wide identification of PAX3-FKHR binding sites in rhabdomyosarcoma
reveals candidate target genes important for development and cancer. Cancer Res. 2010; 70:6497–
508. [PubMed: 20663909]
50. Missiaglia E, Williamson D, Chisholm J, Wirapati P, Pierron G, Petel F, Concordet JP, Thway K,
Oberlin O, Pritchard-Jones K, Delattre O, Delorenzi M, Shipley J. PAX3/FOXO1 fusion gene
status is the key prognostic molecular marker in rhabdomyosarcoma and significantly improves
current risk stratification. J Clin Oncol. 2012; 30:1670–7. [PubMed: 22454413]
51. Skapek SX, Anderson J, Barr FG, Bridge JA, Gastier-Foster JM, Parham DM, Rudzinski ER,
Triche T, Hawkins DS. PAX-FOXO1 fusion status drives unfavorable outcome for children with
rhabdomyosarcoma: a Children’s Oncology Group report. Pediatr Blood Cancer. 2013; 60:1411–7.
[PubMed: 23526739]
52. Davis RJ, Bennicelli JL, Macina RA, Nycum LM, Biegel JA, Barr FG. Structural characterization
Author Manuscript

of the Fkhr gene and its rearrangement in alveolar rhabdomyosarcoma. Hum Mol Genet. 1995;
4:2355–62. [PubMed: 8634710]
53. Fitzgerald JC, Scherr AM, Barr FG. Structural analysis of PAX7 rearrangements in alveolar
rhabdomyosarcoma. Cancer Genet Cytogenet. 2000; 117:37–40. [PubMed: 10700864]
54. Scheidler S, Fredericks WJ, Rauscher FJ, Barr FG, Vogt PK. The hybrid PAX3-FKHR fusion
protein of alveolar rhabdomyosarcoma transforms fibroblasts in culture. Proc Natl Acad Sci U S
A. 1996; 93:9805–9. [PubMed: 8790412]
55. Kikuchi K, Tsuchiya K, Otabe O, Gotoh T, Tamura S, Katsumi Y, Yagyu S, Tsubai-Shimizu S,
Miyachi M, Iehara T, Hosoi H. Effects of PAX3-FKHR on malignant phenotypes in alveolar
rhabdomyosarcoma. Biochem Biophys Res Commun. 2008; 365:568–74. [PubMed: 18022385]
56. Keller C, Arenkiel BR, Coffin CM, El-Bardeesy N, De-Pinho RA, Capecchi MR. Alveolar
rhabdomyosarcomas in conditional Pax3:Fkhr mice: cooperativity of Ink4a/ARF and Trp53 loss of
function. Genes Devel. 2004; 18:2614–26. [PubMed: 15489287]
57. Nishijo K, Chen QR, Zhang L, McCleish AT, Rodriguez A, Cho MJ, Prajapati SI, Gelfond JA,
Author Manuscript

Chisholm GB, Michalek JE, Aronow BJ, Barr FG, Randall RL, Ladanyi M, Qualman SJ, Rubin
BP, LeGallo RD, Wang C, Khan J, Keller C. Credentialing a preclinical mouse model of alveolar
rhabdomyosarcoma. Cancer Res. 2009; 69:2902–11. [PubMed: 19339268]
58. Khan J, Bittner ML, Chen YD, Faller AJ, Saal LH, Azorsa DA, Teichman U, Pavan W, Trent JM,
Meltzer PS. Elucidation of the downstream targets of the PAX3-FKHR fusion oncogene found in
aveolar rhabdomyosarcoma using cDNA microarrays [abstract]. Pediatr Res. 1999; 45:148A.
[PubMed: 9890624]

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 15

59. Davicioni E, Finckenstein FG, Shahbazian V, Buckley JD, Triche TJ, Anderson MJ. Identification
of a PAX-FKHR gene expression signature that defines molecular classes and determines the
Author Manuscript

prognosis of alveolar rhabdomyosarcomas. Cancer Res. 2006; 66:6936–46. [PubMed: 16849537]

60. Khan J, Bittner ML, Saal LH, Teichmann U, Azorsa DO, Gooden GC, Pavan WJ, Trent JM,
Meltzer PS. cDNA microarrays detect activation of a myogenic transcription program by the
PAX3-FKHR fusion oncogene. Proc Natl Acad Sci U S A. 1999; 96:13264–9. [PubMed:
10557309]
61. van Gaal JC, Flucke UE, Roeffen MH, de Bont ES, Sleijfer S, Mavinkurve-Groothuis AM,
Suurmeijer AJ, van der Graaf WT, Versleijen-Jonkers YM. Anaplastic lymphoma kinase
aberrations in rhabdomyosarcoma: clinical and prognostic implications. J Clin Oncol. 2012;
30:308–15. [PubMed: 22184391]
62. Taulli R, Scuoppo C, Bersani F, Accornero P, Forni PE, Miretti S, Grinza A, Allegra P, Schmitt-
Ney M, Crepaldi T, Ponzetto C. Validation of met as a therapeutic target in alveolar and embryonal
rhabdomyosarcoma. Cancer Res. 2006; 66:4742–9. [PubMed: 16651427]
63. Khan J, Wei JS, Ringnér M, Saal LH, Ladanyi M, Westermann F, Berthold F, Schwab M,
Antonescu CR, Peterson C, Meltzer PS. Classification and diagnostic prediction of cancers using
Author Manuscript

gene expression profiling and artificial neural networks. Nat Med. 2001; 7:673–9. [PubMed:
11385503]
64. Pylayeva-Gupta Y, Grabocka E, Bar-Sagi D. RAS oncogenes: weaving a tumorigenic web. Nat Rev
Cancer. 2011; 11:761–74. [PubMed: 21993244]
65. Tsumura H, Yoshida T, Saito H, Imanaka-Yoshida K, Suzuki N. Cooperation of oncogenic K-ras
and p53 deficiency in pleomorphic rhabdomyosarcoma development in adult mice. Oncogene.
2006; 25:7673–9. [PubMed: 16785989]
66. Linardic CM, Downie DL, Qualman S, Bentley RC, Counter CM. Genetic modeling of human
rhabdomyosarcoma. Cancer Res. 2005; 65:4490–5. [PubMed: 15930263]
67. Hinson AR, Jones R, Crose LE, Belyea BC, Barr FG, Linardic CM. Human rhabdomyosarcoma
cell lines for rhabdomyosarcoma research: utility and pitfalls. Front Oncol. 2013; 3:183. [PubMed:
23882450]
68. Storer NY, White RM, Uong A, Price E, Nielsen GP, Langenau DM, Zon LI. Zebrafish
rhabdomyosarcoma reflects the developmental stage of oncogene expression during myogenesis.
Development. 2013; 140:3040–50. [PubMed: 23821038]
Author Manuscript

69. Baird K, Davis S, Antonescu CR, Harper UL, Walker RL, Chen Y, Glatfelter AA, Duray PH,
Meltzer PS. Gene expression profiling of human sarcomas: insights into sarcoma biology. Cancer
Res. 2005; 65:9226–35. [PubMed: 16230383]
70. Wachtel M, Rakic J, Okoniewski M, Bode P, Niggli F, Schafer BW. FGFR4 signaling couples to
Bim and not Bmf to discriminate subsets of alveolar rhabdomyosarcoma cells. Int J Cancer. 2014;
135:1543–52. [PubMed: 24550147]
71. Elbadry OM, Minniti C, Kohn EC, Houghton PJ, Daughaday WH, Helman LJ. Insulin-like growth
factor-II acts as an autocrine growth and motility factor in human rhabdomyosarcoma tumors. Cell
Growth Differ. 1990; 1:325–31. [PubMed: 2177632]
72. Wang W, Kumar P, Wang W, Epstein J, Helman L, Moore JV, Kumar S. Insulin-like growth factor
II and PAX3-FKHR cooperate in the oncogenesis of rhabdomyosarcoma. Cancer Res. 1998;
58:4426–33. [PubMed: 9766674]
73. Kumar S, Perlman E, Harris CA, Raffeld M, Tsokos M. Myogenin is a specific marker for
rhabdomyosarcoma: an immunohistochemical study in paraffin-embedded tissues. Mod Pathol.
Author Manuscript

2000; 13:988–93. [PubMed: 11007039]

74. Sebire NJ, Malone M. Myogenin and MyoD1 expression in paediatric rhabdomyosarcomas. J Clin
Pathol. 2003; 56:412–6. [PubMed: 12783965]
75. Keller C, Guttridge DC. Mechanisms of impaired differentiation in rhabdomyosarcoma. FEBS J.
2013; 280:4323–34. [PubMed: 23822136]
76. Saab R, Spunt SL, Skapek SX. Myogenesis and rhabdomyosarcoma: the Jekyll and Hyde of
skeletal muscle. Curr Top Dev Biol. 2011; 94:197–234. [PubMed: 21295688]

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 16

77. Buckingham M, Relaix F. The role of Pax genes in the development of tissues and organs: Pax3
and Pax7 regulate muscle progenitor cell functions. Annu Rev Cell Dev Biol. 2007; 23:645–73.
Author Manuscript

[PubMed: 17506689]
78. Kolb EA, Gorlick R, Lock R, Carol H, Morton CL, Keir ST, Reynolds CP, Kang MH, Maris JM,
Billups C, Smith MA, Houghton PJ. Initial testing (stage 1) of the IGF-1 receptor inhibitor
BMS-754807 by the Pediatric Preclinical Testing Program. Pediatr Blood Cancer. 2011; 56:595–
603. [PubMed: 21298745]
79. Weigel B, Malempati S, Reid JM, Voss SD, Cho SY, Chen HX, Krailo M, Villaluna D, Adamson
PC, Blaney SM. Phase 2 trial of cixutumumab in children, adolescents, and young adults with
refractory solid tumors: a report from the Children’s Oncology Group. Pediatr Blood Cancer.
2014; 61:452–6. [PubMed: 23956055]
80. Pappo AS, Vassal G, Crowley JJ, Bolejack V, Hogendoorn PC, Chugh R, Ladanyi M, Grippo JF,
Dall G, Staddon AP, Chawla SP, Maki RG, Araujo DM, Geoerger B, Ganjoo K, Marina N, Blay
JY, Schuetze SM, Chow WA, Helman LJ. A phase 2 trial of R1507, a monoclonal antibody to the
insulin-like growth factor-1 receptor (IGF-1R), in patients with recurrent or refractory
rhabdomyosarcoma, osteosarcoma, synovial sarcoma, and other soft tissue sarcomas: results of a
Sarcoma Alliance for Research Through Collaboration study. Cancer. 2014; 120:2448–56.
Author Manuscript

[PubMed: 24797726]
81. Li SQ, Cheuk AT, Shern JF, Song YK, Hurd L, Liao H, Wei JS, Khan J. Targeting wild-type and
mutationally activated FGFR4 in rhabdomyosarcoma with the inhibitor ponatinib (AP24534). PloS
One. 2013; 8:e76551. [PubMed: 24124571]
82. Ferguson M, Hingorani P, Gupta AA. Emerging molecular-targeted therapies in early-phase
clinical trials and preclinical models. Am Soc Clin Oncol Educ Book. 2013:420–4. [PubMed:
23714564]
83. Saab R, Bills JL, Miceli AP, Anderson CM, Khoury JD, Fry DW, Navid F, Houghton PJ, Skapek
SX. Pharmacologic inhibition of cyclin-dependent kinase 4/6 activity arrests proliferation in
myoblasts and rhabdomyosarcomaderived cells. Mol Cancer Ther. 2006; 5:1299–308. [PubMed:
16731763]
84. Canner JA, Sobo M, Ball S, Hutzen B, DeAngelis S, Willis W, Studebaker AW, Ding K, Wang S,
Yang D, Lin J. MI-63: a novel small-molecule inhibitor targets MDM2 and induces apoptosis in
embryonal and alveolar rhabdomyosarcoma cells with wild-type p53. Br J Cancer. 2009; 101:774–
Author Manuscript

81. [PubMed: 19707204]

85. Guenther MK, Graab U, Fulda S. Synthetic lethal interaction between PI3K/Akt/mTOR and
Ras/MEK/ERK pathway inhibition in rhabdomyosarcoma. Cancer Lett. 2013; 337:200–9.
[PubMed: 23684925]
86. Li Z, Zhang Y, Ramanujan K, Ma Y, Kirsch DG, Glass DJ. Oncogenic NRAS, required for
pathogenesis of embryonic rhabdomyosarcoma, relies upon the HMGA2-IGF2BP2 pathway.
Cancer Res. 2013; 73:3041–50. [PubMed: 23536553]
87. Chen EY, DeRan MT, Ignatius MS, Grandinetti KB, Clagg R, McCarthy KM, Lobbardi RM,
Brockmann J, Keller C, Wu X, Langenau DM. Glycogen synthase kinase 3 inhibitors induce the
canonical WNT/beta-catenin pathway to suppress growth and self-renewal in embryonal
rhabdomyosarcoma. Proc Natl Acad Sci U S A. 2014; 111:5349–54. [PubMed: 24706870]
88. Renshaw J, Taylor KR, Bishop R, Valenti M, De Haven Brandon A, Gowan S, Eccles SA, Ruddle
RR, Johnson LD, Raynaud FI, Selfe JL, Thway K, Pietsch T, Pearson AD, Shipley J. Dual
blockade of the PI3K/AKT/mTOR (AZD8055) and RAS/MEK/ERK (AZD6244) pathways
synergistically inhibits rhabdomyosarcoma cell growth in vitro and in vivo. Clin Cancer Res. 2013;
Author Manuscript

19:5940–51. [PubMed: 23918606]

89. West AC, Johnstone RW. New and emerging HDAC inhibitors for cancer treatment. J Clin Invest.
2014; 124:30–9. [PubMed: 24382387]
90. Kutko MC, Glick RD, Butler LM, Coffey DC, Rifkind RA, Marks PA, Richon VM, LaQuaglia MP.
Histone deacetylase inhibitors induce growth suppression and cell death in human
rhabdomyosarcoma in vitro. Clin Cancer Res. 2003; 9:5749–55. [PubMed: 14654560]
91. Blattmann C, Oertel S, Ehemann V, Thiemann M, Huber PE, Bischof M, Witt O, Deubzer HE,
Kulozik AE, Debus J, Weber KJ. Enhancement of radiation response in osteosarcoma and

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 17

rhabomyosarcoma cell lines by histone deacetylase inhibition. Int J Radiat Oncol. 2010; 78:237–
45.
Author Manuscript

92. Hecker RM, Amstutz RA, Wachtel M, Walter D, Niggli FK, Schafer BW. p21 Downregulation is
an important component of PAX3/FKHR oncogenicity and its reactivation by HDAC inhibitors
enhances combination treatment. Oncogene. 2010; 29:3942–52. [PubMed: 20453878]
93. Ciarapica R, Carcarino E, Adesso L, De Salvo M, Bracaglia G, Leoncini PP, Dall’agnese A,
Verginelli F, Milano GM, Boldrini R, Inserra A, Stifani S, Screpanti I, Marquez VE, Valente S,
Mai A, Puri PL, Locatelli F, Palacios D, Rota R. Pharmacological inhibition of EZH2 as a
promising differentiation therapy in embryonal RMS. BMC Cancer. 2014; 14:139. [PubMed:
24575771]
94. Bernasconi M, Remppis A, Fredericks WJ, Rauscher F Jr, Schafer BW. Induction of apoptosis in
rhabdomyosarcoma cells through down-regulation of PAX proteins. Proc Natl Acad Sci U S A.
1996; 93:13164–9. [PubMed: 8917562]
95. Kikuchi K, Tsuchiya K, Otabe O, Gotoh T, Tamura S, Katsumi Y, Yagyu S, Tsubai-Shimizu S,
Miyachi M, Iehara T, Hosoi H. Effects of PAX3-FKHR on malignant phenotypes in alveolar
rhabdomyosarcoma. Biochem Bioph Res Commun. 2008; 365:568–74.
Author Manuscript

96. Gibbs JB. Mechanism-based target identification and drug discovery in cancer research. Science.
2000; 287:1969–73. [PubMed: 10720316]
97. Grohar PJ, Woldemichael GM, Griffin LB, Mendoza A, Chen QR, Yeung C, Currier DG, Davis S,
Khanna C, Khan J, McMahon JB, Helman LJ. Identification of an inhibitor of the EWS-FLI1
oncogenic transcription factor by high-throughput screening. J Natl Cancer Inst. 2011; 103:962–
78. [PubMed: 21653923]
98. Kadoch C, Crabtree GR. Reversible disruption of mSWI/SNF (BAF) complexes by the SS18-SSX
oncogenic fusion in synovial sarcoma. Cell. 2013; 153:71–85. [PubMed: 23540691]
99. Martin DH, Boro A, Schafer BW. Cell-based small-molecule compound screen identifies
fenretinide as potential therapeutic for translocation-positive rhabdomyosarcoma. PloS One. 2013;
8(1):e55072. [PubMed: 23372815]
100. Liu LL, Wu J, Ong SS, Chen TS. Cyclin-dependent kinase 4 phosphorylates and positively
regulates PAX3-FOXO1 in human alveolar rhabdomyosarcoma cells. PloS One. 2013; 8:e55072.
[PubMed: 23372815]
101. Cheson BD. Ofatumumab, a novel anti-CD20 monoclonal antibody for the treatment of B-cell
Author Manuscript

malignancies. J Clin Oncol. 2010; 28:3525–30. [PubMed: 20458041]

102. Cheson BD, Leonard JP. Monoclonal antibody therapy for B-cell non-Hodgkin’s lymphoma. N
Engl J Med. 2008; 359:613–26. [PubMed: 18687642]
103. FitzGerald DJ, Wayne AS, Kreitman RJ, Pastan I. Treatment of hematologic malignancies with
immunotoxins and antibody-drug conjugates. Cancer Res. 2011; 71:6300–9. [PubMed:
21998010]
104. Kreitman RJ, Arons E, Stetler-Stevenson M, Fitzgerald DJ, Wilson WH, Pastan I. Recombinant
immunotoxins and other therapies for relapsed/refractory hairy cell leukemia. Leuk Lymphoma.
2011; 52(Suppl 2):82–6. [PubMed: 21599609]
105. Kreitman RJ, Tallman MS, Robak T, Coutre S, Wilson WH, Stetler-Stevenson M, Fitzgerald DJ,
Lechleider R, Pastan I. Phase I trial of anti-CD22 recombinant immunotoxin moxetumomab
pasudotox (CAT-8015 or HA22) in patients with hairy cell leukemia. J Clin Oncol. 2012;
30:1822–8. [PubMed: 22355053]
106. Wayne AS, Kreitman RJ, Findley HW, Lew G, Delbrook C, Steinberg SM, Stetler-Stevenson M,
Author Manuscript

Fitzgerald DJ, Pastan I. Anti-CD22 immunotoxin RFB4(dsFv)-PE38 (BL22) for CD22-positive

hematologic malignancies of childhood: preclinical studies and phase I clinical trial. Clin Cancer
Res. 2010; 16:1894–903. [PubMed: 20215554]
107. Hassan R, Cohen SJ, Phillips M, Pastan I, Sharon E, Kelly RJ, Schweizer C, Weil S, Laheru D.
Phase I clinical trial of the chimeric anti-mesothelin monoclonal antibody MORAb-009 in
patients with mesothelin-expressing cancers. Clin Cancer Res. 2010; 16:6132–8. [PubMed:
21037025]
108. Cheung NK, Cheung IY, Kushner BH, Ostrovnaya I, Chamberlain E, Kramer K, Modak S.
Murine anti-GD2 monoclonal antibody 3F8 combined with granulocyte-macrophage colony-

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 18

stimulating factor and 13-cis-retinoic acid in high-risk patients with stage 4 neuroblastoma in first
remission. J Clin Oncol. 2012; 30:3264–70. [PubMed: 22869886]
Author Manuscript

109. Cheung NK, Kushner BH, Yeh SD, Larson SM. 3F8 monoclonal antibody treatment of patients
with stage 4 neuroblastoma: a phase II study. Int J Oncol. 1998; 12:1299–306. [PubMed:
9592190]
110. Lee DW, Barrett DM, Mackall C, Orentas R, Grupp SA. The future is now: chimeric antigen
receptors as new targeted therapies for childhood cancer. Clin Cancer Res. 2012; 18:2780–90.
[PubMed: 22589486]
111. Orentas RJ, Yang JJ, Wen X, Wei JS, Mackall CL, Khan J. Identification of cell surface proteins
as potential immunotherapy targets in 12 pediatric cancers. Front Oncol. 2012; 2:194. [PubMed:
23251904]
Author Manuscript
Author Manuscript
Author Manuscript

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 19
Author Manuscript
Author Manuscript

FIG. 1.
Whole-genome sequencing has revealed that rhabdomyosarcoma tumors can be classified
into 2 distinct genotypes characterized by the absence (a) or presence (b) of a PAX gene
rearrangement. CIRCOS plots from representative tumors are presented (from the outside
circle in). Mutated genes: missense mutations (black), non-sense mutations and insertions/
deletions (red); genomic location: genome-wide copy number alterations (gray), lesser allele
frequency (green), loss of heterozygosity (dotted track), density of heterozygous single
nucleotide polymorphisms (SNPs) (orange), homozygous SNPs (blue); intrachromasomal
Author Manuscript

rearrangements (inner circle, gray) and interchromosomal rearrangements (inner circle, red).
Adapted from Shern et al.18
Author Manuscript

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 20
Author Manuscript
Author Manuscript

FIG. 2.
A summary of the genomic alterations frequently occurring in primary rhabdomyosarcoma
shows 2 distinct genotypes defined by the presence or absence of a PAX gene fusion and
recurrent mutation of RAS pathway genes in fusion-negative tumors. Adapted from Shern et
al.18
Author Manuscript
Author Manuscript

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 21
Author Manuscript
Author Manuscript
Author Manuscript

FIG. 3.
The interaction of PAX3-FOXO1 with genomic locations. As determined by chromatin
precipitation, the PAX3-FOXO1 fusion gene is typically associated with enhancer regions of
the genome. Presented here are the fusion gene binding sites in the MYOD1 enhancer region
(top panel) and its relationship to other epigenetic and transcriptional marks (bottom panel).
Author Manuscript

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 22
Author Manuscript
Author Manuscript
Author Manuscript

FIG. 4.
Summary of the potential therapeutic options outlined in this review. Adapted from Shern et
al.18
Author Manuscript

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 23

TABLE 1

Genetic Alterations Commonly Observed in PAX Gene Fusion–Positive Rhabdomyosarcoma

Author Manuscript

Alteration Type Chromosomal Locus Estimated Frequency References

PAX3-FOXO1 Translocation (2;13)(q35;q14) 59% of ARMS 17, 24

PAX7-FOXO1 Translocation with amplification (1;13)(p36;q14) 19% of ARMS 21, 24

PAX3-NCOA1 Translocation Alveolar Rare 23

PAX3-INO80D Translocation Alveolar Rare 18

CDK4 Amplification 12q13-14 12% 25

MYCN Amplification 2p24 20% 25

miR-17-92 Amplification 13q31-32 26

IGF2 locus Uniparental disomy 11p15.5 29% 18

ARMS, alveolar rhabdomyosarcoma.

Author Manuscript
Author Manuscript
Author Manuscript

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.
 Shern et al. Page 24

TABLE 2

Genetic Alterations Commonly Observed in PAX Gene Fusion–Negative Rhabdomyosarcoma

Author Manuscript

Alteration Type Chromosome Locus Estimated Frequency References

IGF2 Loss of heterozygosity 11p15.5 65% 18

NRAS Point mutation Chr1:115256530 7.5% 18

Chr1:115258745

KRAS Point mutation Chr12:25398284 4% 18

Chr12:25398281

HRAS Point mutation Chr11:534289 3% 18

NF1 Point mutation Multiple 3.4% 18

PIK3CA Point mutation Chr3:178952084-178952085 5.4% 18, 29

Chr3:178936094-178936096

FBXW7 Point mutation Chr4:153247287 4.8% 18

Chr4:153249456
Chr4:153251905
Author Manuscript

FGFR4 Point mutation Chr5:176522551 9.3% 30

BCOR Point mutation/indel Multiple 5.4% 18

CTNNB1 Point mutation Chr3:41266101 2% 18, 29

Chr3:41266124

MYOD1 Point mutation p.Leu122Arg 10% of ERMS 20, 31

MDM2 Amplification 12q15 10% 32

Aneuploidy Chromosome gain Typically 2, 7, 8, 11, 13 Common 18

Chromosome loss Typically 1p, 9, 16 Common 18

ERMS, embryonal rhabdomyosarcoma; indel, insertion/deletion.

Author Manuscript
Author Manuscript

Crit Rev Oncog. Author manuscript; available in PMC 2017 June 27.