The Norwegian childhood cancer biobank

Abstract Background The rapidly expanding era of “omics” research is highly dependent on the availability of quality‐proven biological material, especially for rare conditions such as pediatric malignancies. Professional biobanks provide such material, focusing on standardized collection and handling procedures, distinctive quality measurements, traceability of storage conditions, and accessibility. For pediatric malignancies, traditional tumor biobanking is challenging due to the rareness and limited amount of tissue and blood samples. The higher molecular heterogeneity, lower mutation rates, and unique genomic landscapes, however, renders biobanking of this tissue even more crucial. Aim The aim of this study was to test and establish methods for a prospective and centralized biobank for infants, children, and adolescents up to 18 years of age diagnosed with cancer in Norway. Methods Obtain judicial and ethical approvals and administration through a consortium, steering committee, and advisory board. Develop pipelines including SOPs for all aspects in the biobank process, including collection, processing and storing of samples and data, as well of quality controlling, safeguarding, distributing, and transport. Results The childhood cancer biobanking started at Oslo University Hospital in March 2017 and was from 2019 run as a national Norwegian Childhood Cancer Biobank. Informed consent and biological samples are collected regionally and stored centrally. Approximately 12 000 samples from 510 patients and have been included by January 1, 2021, representing a 96% consent and participation rate among our newly diagnosed patients. Conclusion A well‐functioning nationwide collection and centralized biobank with standardized procedures and national storage for pediatric malignancies has been established with a high acceptance among families.


| INTRODUCTION
Biobanks are repositories of biological samples with linked data. They are established to collect and harvest biological material during routine activities in an organized and standardized manner and therefore require pipelines for collection and facilities for storage of the biological specimens. 1,2 For pediatric oncology, the rapidly expanding era of Traditionally, tumor biobanking has been thematic and according to cancer type. 3,4 There are, however, strong arguments favoring the biobanking of pediatric malignancies as a collective entity. First, research shows that pediatric malignancies display distinct differences from adult cancers with higher molecular heterogeneity and lower mutation rates hence warranting separate research focus. 1 Second, pediatric malignancies are rare, and the possibility for focus on unique genomic landscapes in pediatric malignancies naturally disappears in larger groups of samples where pediatric cases are greatly outnumbered. Thirdly, the limited amount of tissue and blood samples challenging all biobanking procedures is even more pronounced in children, where methods like needle biopsies for tissue sampling are necessarily applied. 5 A national collection of samples for the whole entity of pediatric malignancies address these concerns by allowing for collection of larger sample sizes, and ensuring professional tracking, processing, storage of samples, and retrieval processes. Finally, there is an increasing demand for biological material for diagnostic purposes, clinical treatment protocols and research projects, making an F I G U R E 1 Structure of the Norwegian Childhood Cancer Biobank. The Norwegian Childhood Cancer Biobank is anchored in a national consortium and based on an agreement between the hospitals. Each consortium participant is responsible to legal set of agreements regarding joint ownership and use of biological material and data in the biobank. Oslo University Hospital is the responsible institution with the main juridical liability. Each university hospital has representatives in the steering committee, which is committed to follow the consortium statues and review application for use of samples and data from the biobank. In addition, it is established an advisory board, which gives their professional assessments and advice regarding research projects. The advisory board is composed of experienced researchers within the childhood cancer field and a user representative. The participants are invited by the steering committee to participate for 4 years, and the composition of the group aims to be a mix of basal medicine and clinical knowledge organizational structure advantageous, enabling reuse of material and data generated from the material. This will lead to reduced consent fatigue, ensure good governance, increase collaboration activities among research groups both nationally and internationally, and reduce the risk of using the limited precious material for multiple and identical types of analyses. 6 The Norwegian Childhood Cancer Biobank (NCCB) is a prospective biobank including infants, children, and adolescents from 0 to 18 years of age diagnosed with cancer in Norway. 7 The overall aim of the NCCB is to stimulate and facilitate basic and translational research within childhood cancer through a national pipeline for biobanking tumor, microbiotic, and germline tissue at all regional childhood cancer departments and from all children with newly diagnosed cancer in Norway, providing the basis for advanced childhood cancer research on a national and international basis.

| Organizational structure
The NCCB project was approved by the regional ethical committee

| Inclusion by informed consent
Each regional hospital is responsible for including their respective patients to the NCCB. The patient group encompasses children admitted with suspected, newly diagnosed, or relapsed childhood cancer.
For patients below age 16, both parents are required to sign the informed consent on behalf of the child. For patients between age 16 and 18, both patient and parents are required to sign. The NCCB use different consent forms to facilitate the information given based on the age of the child. All informed consent forms are approved by the ethical committee (REC 2016/943-1). Only patients with informed consent are included in the biobank. For each patient, a confidential biobank ID is generated. Data describing the biological material is registered in an electronic register ( Table 1). The key link between the biobank ID and the personal ID is kept in a separate safety system, stored on servers for sensitive information at the four regional centers. The participants may withdraw their consent at any time, and because the parents are signing the consent on behalf of the child, a renewed signed consent from the participant is required when he/she reaches the age of 18. If the participant chooses to withdraw the consent from the biobank, all biological material will be destroyed, but research already performed will be kept.  (Table 2).

| Sample processing, aliquoting, and transport of samples
The blood samples are handled within one hour after sampling in the laboratory according to standard operational procedures (SOP). Whole blood from the EDTA tube (Greiner Bio-One, Austria) is aliquoted into unique 0.5 ml matrix tubes (250 μl in each, Thermo Fisher Scientific, USA) and the rest of the blood is centrifuged at 2500Â g to collect 250 μl aliquots of plasma and 500 μl buffy coat. Serum is collected after coagulation for minimum 30 min at room temperature and centrifugation at 2500Â g. Urine, bone , and spinal fluid are aliquoted into 500 μl and 250 μl aliquots and frozen at À80 C.
Tumor biopsies are kept sterile and snap frozen preferably within 30-60 min after collection at the responsible Pathology Department.
The tumor tissues are stored in 1.8 ml barcoded matrix tubes (Thermo Fisher Scientific, USA) and frozen at À80 C.

| Storage
All biological samples and the extracted DNA and RNA samples are stored in monitored À80 C ultra-freezers located in monitored storage facilities at the Norwegian Institute of Public Health. The freezers are connected to external alarm systems and temperatures are logged routinely to assure stable storage temperature and good preservation of the quality of the samples. The freezers are connected to an emergency electrical system to provide backup power and the facility provides backup freezers, which constitutes 10% of the total freezer capacity.

| Quality assurance and quality control procedures
Each sample is handled according to SOPs, which are regularly reviewed and updated. Connected to every patient is a flowchart, F I G U R E 2 Norwegian Childhood Cancer Biobank work flow. Consent, inclusion, and sample collection according to Table 2

| Status to date
As of January 1, 2021, a total of 510 patients have been included and approximately 12 000 samples have been processed and stored in the biobank (Table 3) Table 3.

| Impact on research
Material from about one third of all consented donors has been involved in eight different research projects. Ongoing studies are continuously published on our web page, including the name, responsible PI and a short description of the project (https://www.ous-research. no/home/childhoodcancerbiobank/Projects/19154). The involved projects cover a wide range from basic to translational research studies (e.g. 8 ).
T A B L E 3 Diagnoses of the first 500 patients collected for NCCB  Table 3 In addition, NCCB facilitates storage and coordination of transporting samples to international collaborative childhood cancer treatment studies. As biological research is increasingly becoming part of international childhood cancer treatment studies, and approximately 50% of our children are included in such studies, the NCCB has become an important part of the infrastructure needed to enable participation in these crucial studies.

| DISCUSSION
Biobanking is an essential tool for medical research, in particular for  The NCCB is operating in compliance with current biobanking standards, but has not yet been formally certified according to ISO standards as the accreditation system for biobanks is still under revision. It is planned to implement ISO 20387:2018 standards for biobanking with accreditation for the specific biobank procedures in the future. This will be a confirmation of the competence of the biobank and state appropriate quality of both biological samples and data collections. 17 In conclusion, the NCCB provides a wide range of biological samples from all consenting childhood cancer patients in Norway, according to standardized procedures, ensuring proper quality and quantity of the stored material. In addition to collecting and storing samples for future research, the NCCB is actively supporting both translational projects as well as more basic research projects. All project using samples from NCCB are listed and described in further detail on the public webpage of NCCB (https://www.ous-research.no/barnekreftbiobank/).